|Year : 2015 | Volume
| Issue : 1 | Page : 1-4
Minimally invasive pterygium surgery versus air-assisted dissection technique for excision of primary pterygium
Hesham A Enany
Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||09-Jul-2014|
|Date of Acceptance||20-Aug-2014|
|Date of Web Publication||29-May-2015|
MD Hesham A Enany
Department of Ophthalmology, Faculty of Medicine, Zagazig University, Zagazig
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess and compare minimally invasive pterygium surgery with air-assisted dissection technique for excision of primary pterygium.
Patients and methods
This prospective randomized comparative study was carried out on 20 eyes of 16 patients with primary pterygium. The cases were randomly divided into two equal groups: group I included 10 eyes in which pterygia were excised with minimally invasive pterygium surgery, and group II included 10 eyes in which pterygia were excised with air-assisted dissection technique. Postoperative examination and follow-up for 3 months were carried out.
The mean age of the patients was 46.1±3.8 years. Successful dissection was recorded in 80% of cases in group I and in 70% of cases in group II. Recurrence occurred in 10% of cases in each group, with a follow-up duration of 3 months.
The minimally invasive pterygium surgery is superior to air-assisted dissection of pterygium as it keeps the tenon capsule intact.
Keywords: air-assisted dissection technique, minimally invasive ptrygium surgery, primary ptrygiam
|How to cite this article:|
Enany HA. Minimally invasive pterygium surgery versus air-assisted dissection technique for excision of primary pterygium. Delta J Ophthalmol 2015;16:1-4
|How to cite this URL:|
Enany HA. Minimally invasive pterygium surgery versus air-assisted dissection technique for excision of primary pterygium. Delta J Ophthalmol [serial online] 2015 [cited 2018 Jun 19];16:1-4. Available from: http://www.djo.eg.net/text.asp?2015/16/1/1/157771
| Introduction|| |
The prevalence rate of primary pterygium ranges between 0.7 and 31% in various regions around the world  .
There are numerous reports that explore the surgical treatment of pterygium; yet, medical treatment such as anti-inflammatory medications should be tried before resorting to surgery. Although the main objectives of surgical treatment are apparent, the indication and timing for surgery are not clearly defined. The most important point of pterygium surgery is to excise the pterygium and inhibit recurrence of the disease  .
Recurrence after pterygium excision remains a major challenge, as evidenced by the existence of multiple surgical methods that have evolved over the years to deal with this problem  .
Adjunctive therapies designed to reduce recurrences include application of antimetabolites, radiotherapy, conjunctival or limbal conjunctival autograft, and amniotic membrane graft; however, there is no established effective technique without significant side effects  .
Minimally invasive pterygium surgery had lower recurrence rate and fewer postoperative complications, preserving the tenon capsule and minimizing conjunctival excision in pterygium surgery  .
Air-assisted dissection technique removes the pterygium head and facilitates the establishment of a smooth and clear corneal surface without extrascraping or polishing  .
This study was designed to assess and compare minimally invasive pterygium surgery with air-assisted dissection technique for excision of primary pterygium.
| Patients and methods|| |
This prospective randomized comparative study included 20 eyes of 16 patients. This study was carried out on patients attending the outpatient clinics of Zagazig University during a period from February to November 2013.
Exclusion criteria included dry eye syndrome or wound healing problems such as ocular cicatricial pemphigoid, immunocompromised patients or use of immunosuppressive drugs. For pterygium excision all eyes were operated under local anesthesia using a combination of 2 ml subconjunctival (4%) xylocain and topical benoxinate hydrochloride (0.4%) eye drops. A microsponge impregnated with benoxinate was applied directly to the pterygium for 2 min for efficient topical anesthesia.
The cases were randomly divided into two equal groups:
Group I included 10 eyes with primary pterygia excised with minimally invasive pterygium surgery. This was carried out by making a limbal incision of the conjunctiva through the body of pterygium and removing the head of the pterygium by blunt dissection, keeping the adjacent tenon capsule. A small conjunctival autograft was performed to cover the epithelial defect [Figure 1]a-n.
|Figure 1: Minimally invasive pterygium surgery. (a) Primary pterygium. (b) Opened eye with speculum. (c) Local anaesthesia. (d) Incision at neck of pterygium. (e) Topical anaesthesia at limbus. (f) Exposed sclera. (g) Dissection of neck. (h) Clear cornea. (i) Cleaning of bare sclera. (j) Cautarization. (k) Bare sclera. (l) Auto graft. (m) Suturing the graft. (n) Repaired conjuctiva.|
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Group II included 10 eyes with primary pterygia excised with air-assisted dissection. Air was injected into the side of the cap of the pterygium head with a 30 G needle, to create a dissection plane between the pterygium head and the cornea. After blunt dissection and excision of the pterygium, the conjunctival autograft technique was applied [Figure 2].
|Figure 2: Air-assisted dissection technique. (a) Primary Pterygium. (b) Local anaesthesia. (c) After anaesthesia. (d) Balloned conjuctiva. (e) Air injected under Pterygium. (f) Air under Pterygium. (g) Dissection from apex. (h) Complete the dissection. (I) Dissection of neck. (j) Dissection of body. (k) Complete dissection. (l) Dissection of Tenon. (m) Excision of tenon. (n) Bared sclera.|
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Postoperative examinations included full ophthalmic evaluation with slit lamp examination, fluorescein corneal staining, intraocular pressure measurement and recording of any complications, postoperative smoothness and clarity of cornea, and recurrence rate with a follow-up of 3 months.
| Results|| |
This prospective randomized comparative study included 20 eyes of 16 patients with primary pterygia. There were 10 male (62.5%) and six female patients (37.5%), whose age ranged between 30 and 55 years (mean 46.1 ± 3.8 years) [Table 1].
Minimally invasive pterygium surgery was performed in 10 eyes (group I), and air-assisted dissection of pterygia was performed in the other 10 eyes (group II).
Chemosis was noticed in four cases (40%) in group I, whereas it was noticed only in three cases (30%) in group II.
Dissection was successfully performed in eight eyes (80%) in group I and air assisted dissection was performed successfully in seven eyes in group II (70%) [Table 2].
Scraping with a crescent blade had to be performed in two eyes (20%) in group 1 and in three eyes (30%) in group II.
Autograft was performed in all cases successfully. It was noted that autograft was easier to perform in minimally invasive surgery of pterygia.
Clear smooth corneas also were noted during postoperative follow-up in both groups except only one eye (10%) in each group a superficial opacity was noted.
Postoperative complications were reported for a follow-up of 3 months. No conjunctival irritation was noted; conjunctival granuloma was noted in only one eye (10%) in group I and in two eyes (20%) in group II, and no superficial keratitis was noted in either group. Recurrence rate was recorded during the first 3 months of follow-up in only one eye (10%) in group I and in one eye (10%) in group II [Table 3].
| Discussion|| |
The main challenge to successful surgical treatment of pterygium is recurrence, evidenced by fibrovascular growth across the limbus onto the cornea. Many surgical techniques have been used, although none of them has been universally accepted because of variable recurrence rates. Regardless of the technique used, excision of the pterygium is the first step for repair. Many ophthalmologists prefer to avulse the head from the underlying cornea. Advantages include quicker epithelialization, minimal scarring, and resultant smooth corneal surface  .
Air-assisted dissection is a safe, easy, and cheap method for removing the pterygium head from the corneal surface, which also facilitates the establishment of a clear and smooth corneal surface  .
In performing other pterygium excision techniques, the following had been observed:
- When the head of the pterygium is transected from its conjunctival body at the limbus, the bulbar conjunctiva appears to be on stretch and retracts to the limbus.
- The underlying tenon capsule and its insertion to the sclera appear morphologically normal.
- Large conjunctival excision is associated with increased healing and scarring response .
Minimally invasive pterygium surgery was designed to preserve tenon capsule, minimize conjunctival excision, and use a small conjunctival autograft  .
The aim of this study was to assess and compare minimally invasive pterygium surgery with air-assisted dissection of pterygium.
The present study included 20 eyes of 16 patients with primary pterygia, who were divided into two groups: group I was subjected to excision of pterygia by minimally invasive pterygium surgery, whereas group II was subjected to excision of pterygia by air-assisted dissection technique.
In the present study successful dissection was performed in eight eyes (80%) in group I and in seven eyes (70%) in group II.
Gulkillik et al.  in their study with air-assisted dissection of pterygia reported that successful dissection was achieved in 75% of the cases, whereas Bellini  in his study used the same technique with successful dissection in 33.3% of the cases providing a clear corneal surface.
Scraping with crescent blade was performed in two eyes (20%) in group I and in three eyes (30%) in group II. In the study by Gulkillik et al.  , scraping with crescent blade was performed in 25% of cases. However, in the study by Bellini  , air dissection was not completely successful in 66.7% and scraping with crescent blade had to be performed.
Postoperative chemosis was noted in four eyes (40%) in group I and in three eyes (30%) in group II. However, Salman et al.  , using other techniques, reported chemosis in 10-60% of cases.
The most common complication of pterygium surgery is postoperative recurrence; simple excision with bare sclera is associated with high recurrence rate, which may be as high as 80%  .
The use of conjunctival autografts or an amniotic membrane transplant at the time of excision can reduce the recurrence rate to between 2 and 35%  .
In our study, recurrence rate in the first group and in the second group was 10%. Bozkir et al.  reported a recurrence rate of 4.2% with minimally invasive pterygium surgery, and Gulkillik et al.  in their study reported a recurrence rate of 8.3% with air-assisted dissection technique. Bellini  used the air-assisted dissection with no recurrence rate during a maximum follow-up duration of 3 months.
| Conclusion|| |
The minimally invasive pterygium surgery is superior to air-assisted dissection technique of pterygium as it keeps the tenon capsule intact.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Detels R, Ohir SP. Pterygium: a geographic survey. Arch Ophthalmol 1967; 78:85.
Hirst LW. The treatment of pterygium. Surv Ophthalmol 2003; 48:145-148.
Solomon A, Pires RT, Tseng SC. Amniotic membrane transplantation after extensive removal of primary and recurrent pterygia. Ophthalmology 2001; 108:449-460.
Potério MB, Alves MR, Cardillo JA, José NK An improved surgical technique for pterygium excision with intraoperative application of mitomycin-C. Ophthalmic Surg Lasers 1998; 29:685-687.
Bozkir N, Yilmaz S, Maden A. Minimally invasive pterygium surgery: a new approach for prevention of recurrence. Eur J Ophthalmol 2008; 18:27-31.
Gulkilik G, Kocabora S, Taskapili M, Ozsutcu M. A new technique for pterygium excision: air-assisted dissection. Ophthalmologica 2006; 220:307-310.
Ardalan A, Ravi S, David L. Management of pterygium cornea
. 2nd ed. Philadelphia, PA: Elsevier Mosby; 2005. 1481.
Tsengsc G, Ghen JJY, Huang AIW, et al.
Classification of conjunctival surgeries for corneal diseases based on stem cell concept. Ophthalmol Chin N Am 1990; 3:595-610.
Bellini LP. A new technique for pterygium excision. Ophthalmologica 2008; 222:216.
Salman AG, Mansour DE. The recurrence of pterygium after different modalities of surgical treatment. Saudi J Ophthalmol 2011; 25:411-415.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]