Issue: July 10, 2020
Source/Disclosures
Disclosures: Desai reports he is a consultant for Bio-Tissue. John reports no relevant financial disclosures.
July 02, 2020
5 min read
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Tissue tuck technique provides alternative method of pterygium removal

Goals include minimizing trauma, diminishing inflammation, sealing the gap between the resected conjunctiva and Tenon's fascia, and re-creating the semilunar fold.

Issue: July 10, 2020
Source/Disclosures
Disclosures: Desai reports he is a consultant for Bio-Tissue. John reports no relevant financial disclosures.
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A pterygium consists of a triangular, thickened mass of conjunctival and subconjunctival fibrovascular tissue with elastotic degeneration that crosses the limbus and invades the cornea, possibly interfering with vision.

Global incidence of pterygium ranges from about 1% to 25% based on the population studied, with higher concentration in the tropical regions of the world. The association between ultraviolet light exposure and pterygium may to some extent explain the geographic variation in pterygium prevalence.

Thomas "TJ" John
Thomas "TJ" John

Visual compromise can be due to direct obstruction or secondary corneal distortions and irregular astigmatism. In addition to possible visual symptoms, a pterygium can be a cosmetic issue as well. In severe cases, ocular motility may be affected with possible diplopia. The main therapeutic approach is surgery. However, concern is often focused on the possible recurrence of pterygium after excision, and hence, various surgical approaches have been devised, without a single procedure being the go-to technique.

Surgical techniques have spanned a wide spectrum from bare sclera excision to conjunctival autograft, conjunctival transposition flap and amniotic membrane transplant. Additive techniques have included the use of mitomycin C, 5-fluorouracil, radiotherapy, anti-VEGF, topical cyclosporine A and fibrin glue, with or without the use of sutures.

In this column, Dr. Desai describes his surgical technique in the management of pterygium.

Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor

Neel R. Desai
Neel R. Desai

The primary goal of pterygium surgery is not simply to remove the pterygium, but rather to seal the gap between the conjunctiva and Tenon’s fascia from which the pterygium and any recurrence will originate. Failure to seal this gap invites the possibility of the fibrovascular root of the pterygium re-extending and ultimately causing a recurrence with even more scar tissue and an increased risk for restrictive diplopia, poor cosmesis and visual impact.

The secondary but equally important goal of pterygium surgery should be to reconstruct the semilunar fold. If this functional anatomy and redundancy of the fold is not restored, the gap will be forced open again upon abduction, subjecting the patient to pyogenic granulomas, scar tissue, muscle restriction, diplopia and pterygium recurrence.

Surgical methods

Conjunctival grafts have long been a popular choice for pterygium surgery, and many excellent surgeons still consider it their go-to procedure of choice. However, there are drawbacks to this method. Autograft procedures inherently sacrifice normal conjunctiva and create two wounds and arguably more inflammation, scar potential and discomfort. Furthermore, we cannot ignore the practical and economic disadvantages of autograft procedures as they take considerably more operative time (30 to 45 minutes on average), postoperative chair time and recovery time for patients. In the context of the current global health crisis and weighing the modest reimbursement for this procedure, we must be ever more attentive to the allocation of our and our patients’ most valuable resource — time.

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Tissue tuck technique

My concerns about the autograft method led me to evolve an alternative technique that reduces surgery time and facilitates superior cosmesis. This procedure, known as the tissue tuck technique, has four key goals: minimize surgical trauma, diminish iatrogenic and postoperative inflammation, seal the gap between the resected conjunctiva and Tenon’s fascia, and re-create the semilunar fold.

seal the gap
Figure 1. The primary goal of pterygium surgery is to seal the gap between the conjunctiva and Tenon’s fascia.

Source: Neel R. Desai, MD

With the sutureless tissue tuck technique, it is critical to have a tissue graft that can be easily manipulated and tucked into position without tearing. I use AmnioGraft (Bio-Tissue) cryopreserved amniotic membrane. AmnioGraft maintains intraoperative resilience, and because it retains the heavy chain hyaluronic acid/pentraxin 3 matrix, it minimizes inflammation and serves as an excellent platform for rapid conjunctival re-epithelialization without scar tissue.

Resection and recession
Figure 2. Resection and recession of underlying Tenon’s and fibrovascular tissue with eye in full traction (a). McPherson bipolar cautery to remaining Tenon’s and fibrovascular tissue (b). Placement of AmnioGraft over and beyond conjunctival edge, allowing excess for tissue tuck and re-creation of semilunar fold (c). Curved tying forceps used to sweep and tuck tissue into the gap, giving definition to semilunar fold (d). Excess glue is squeegeed anteriorly and excess amniotic membrane is trimmed (e). Immediate postoperative appearance with bandage contact lens in place (f).

The technique takes 10 to 12 minutes and is comprised of the following steps:

  • Place a traction suture so the eye is in full abduction to flatten the muscle against the globe, improve visualization and allow for functional reconstruction of the semilunar fold in maximal abduction.
  • Infiltrate 2% lidocaine with epinephrine in the subconjunctival space to promote anesthesia and hemostasis and facilitate dissection along separated tissue planes.
  • Resect the pterygium, leaving bare sclera and an intact muscle sheath.
  • Create a 2- to 3-mm perimeter of normal conjunctiva by pulling Tenon’s fascia and remaining fibrovascular tissue anteriorly from under the conjunctiva and resecting it.
  • Cauterize the band of Tenon’s, fibrovascular tissue and any prolapsed orbital fat in the posterior gap, hence tethering the fibrovascular root to Tenon’s and creating a barrier.
  • Bring the cryopreserved amniotic membrane into the field and trim to the general shape of the exposed bed, adding 3 mm to 4 mm to allow adequate tissue for tucking and re-creation of the semilunar fold.
  • Slide the graft over the bed, coating the stromal side with fibrin tissue adhesive (Tisseel, Baxter), and place it up, over and past the edge of the conjunctival rim and the intended semilunar fold.
  • Use curved tying forceps to sweep the tissue under the conjunctival rim and deep into the gap along the entire new semilunar fold. The membrane edge will fold upon itself, exposing its stromal side to the conjunctival stroma in a broad band of contact, forming a barrier in the gap and definition to the reformed semilunar fold.
  • Squeegee excess glue anteriorly only, so glue is not sequestered posteriorly in the gap.
  • Finally, trim any excess AmnioGraft and insert a bandage contact lens to protect the anterior edge of the tissue.

Because this is all done while the eye is still in abduction, when it returns to primary gaze, the wound margins are all hidden, the gap is well-sealed and hidden, and the chances of recurrences are extremely low. We have used this technique in almost 1,000 cases to date; I have had a 0% recurrence rate in my most recent 500 cases, and we have had less than 1% recurrence rate in my practice in our last 900 cases.

Nasal pterygium
Figure 3. Nasal pterygium. Three week postoperatively after the tissue tuck technique using AmnioGraft with reconstructed semilunar fold and excellent cosmesis.

Practical considerations

Because this technique is sutureless, it saves time and money and eliminates a potential source of inflammation. Patients report little or no discomfort postoperatively and do well with only a topical steroid and an antibiotic. Ultimately, the tissue tuck technique using cryopreserved amniotic membrane offers a pterygium repair solution that achieves excellent cosmesis, minimizes complications and recurrence, reduces surgical time and maximizes productivity.