Indication for Pterygium Removal
- Progression -> growth into the optical axis
- Wetting disturbance of the cornea -> punctate staining, dellen (Stocker's line)
- Astigmatism (excision before refractive surgery) -> pre- and postoperative topography
- Subjectively bothersome (irritation, interferes with contact lenses, cosmetic)
Differential Diagnosis
- Pseudopterygium (e.g. after trauma, surgery, ulcer) -> peripherally adherent, thinned cornea underneath
- Pinguecula (affects only the conjunctiva)
- Conjunctival intraepithelial neoplasia (CIN), limbal dermoid
- Pannus (flat, translucent)
Preparation
- Pentacam and slit-lamp photograph for documentation
- Informed consent -> see consent form for pterygium excision (incl. risk of recurrence/postoperative pain and inability to work for at least 1-2, up to 4 weeks in dusty or steamy working conditions
- Preoperative preparation
- Tetracaine SDU 1% eye drops 3x every 5 minutes
Surgical Materials
- Hibidil solution
- Round swabs x6
- Sterile drape
- Film scissors
- Bangerter lid speculum
- BSS solution
- Triangular swabs x10
- Lidocaine-epinephrine 2%/lidocaine 2% in a 5 ml syringe with a yellow needle
- Hockey knife (reusable)
- Colibri forceps
- Blunt Westcott scissors
- Suture forceps x2
- Battery cautery
- Monocular patch
A: Without self-pay services
- Needle holder
- 8-0 Vicryl Rapide
B: with self-pay services
- Tisseel 2 ml double-barrel syringe (warm to body temperature before use)
- Diamond burr (Alger brush, 3.5 mm, sterile; burr packaged in a sterile glove)
Surgical Procedure
See operative report
Postoperative
- Leave the pressure patch in place until the first follow-up visit,
- Dispense the Floxal eye ointment used during surgery
- Analgesia
- Dafalgan 500 mg tablet 4x/day
- Ponstan 500 mg tablet 3x/day
- As needed: Tramal 100 mg tablet at night (dispense 2x)
Management
- Day-1 check-up: remove the patch, check whether the graft is in place
- Floxal eye ointment up to 1 week postoperatively, then stop
- Day-4 check-up: remove contact lens if applicable (caution: carefully, from the temporal side with a cotton-tipped applicator or with fine anatomical forceps)
- Abrasion re-epithelialized: start with Dexafree UD eye drops 5x/day for 1 week, 4x for 1 week
- Persistent erosion: follow-up every two days until epithelial closure, only then start Dexafree UD eye drops
- 2-week check-up
- Dexafree UD eye drops 3x for 2 weeks, 2x for 2 weeks, 1x for 2 weeks
- 6-week check-up
- Topography (Pentacam)
- Dexafree UD eye drops per management or extend (caution: check IOP to rule out steroid response)
FAQs
Dehiscence between graft and conjunctiva
Watchful waiting, not an indication for reoperation.
Dislocation or loss of the graft
Watchful waiting; recurrence rate is increased, comparable to "bare sclera".
Pterygium recurrence
Repeat pterygium excision with extensive tissue dissection including looping of the extraocular muscle. Larger autograft for coverage
Special notes
Fixation of the autograft with fibrin glue (Tisseel) is not covered by health insurance, nor is keratectomy with a diamond burr to remove subepithelial corneal opacities beneath the pterygium head.
ONO: self-pay pterygium package CHF 400.-/eye (fibrin glue and diamond burr)
