Sutureless Amniotic Surgery for Pterygium

Abstract

P terygium is one of the oldest pathologies known to ophthalmologists. Surgery for this condition can range from simple excision to techniques with exotic detail and meticulous maneuvers with task-specific instruments beckoning an era of raised expectations and cosmetic outcomes in the field of ocular surface surgery itself. In my previous publications, I had emphasized on complete removal along with amniotic grafting as a key concept for success. The part of the pterygium that is visible is only the tip of the iceberg (iceberg concept). By removing only this visible portion, the main pathology with its tentacles is not addressed and remains hidden under the conjunctiva. Theories about the etiology of pterygia are diverse and range from hereditary, neurotrophic, angioplastic, and immunologic causes to ultraviolet light exposure. Regardless of the cause, the result is elastotic degeneration with vesiculation of Bowman’s membrane in the cornea and formation of epithelial islets (Fuchs patches) as cysts around the pterygium (seen as glove-finger appearance on histopathologic study). Anatomically, the pterygium is composed of several segments, including Fuchs patches and Stocker line (the iron line), the hood, the head, the body, and the superior and inferior edges. Having previously classified pterygia into 4 categories, I have continuously studied the presentations and the outcomes in improving the surgical approach and outcomes over the years to add an additional way to classify the pterygium based on the adhesion of the head to the ocular surface and vascularity along with the draw test on the cornea. Pterygia can therefore have the following: Head/neck adhesion. Peripheral or central adhesion. In cases of peripheral adhesion, the pterygium easily peels off the cornea. Vascularity. Engorged, tortuous vessels and simultaneous conjunctival fold contracture signifies a more aggressive pterygium. This same concept can be used to determine outcomes postoperatively. Draw test. On tugging on the cornea, some pterygia may be small but outright gritty and deep into the cornea resulting in thin cornea when removed. Preparation for this before surgery helps plan a smooth outcome (amniotic graft itself can be used as a lamellar fill). Also, removal of these pterygia is more difficult from the corneal surface. Amniotic membrane. The advantages of the commercially available membrane are that there is no immune reaction, and it has anti-inflammatory functions, is antiadhesive and antibacterial, encourages epithelial differentiation and growth, and has an antitissue growth factor effect.