Anterior Segment Surgery J. Alberto Martinez, M.D. Visionary Ophthalmology Rockville, Dec 7, 2014
Anterior Segment
Surgery
J. Alberto Martinez, M.D.
Visionary Ophthalmology
Rockville, Dec 7, 2014
Doente atado como preparação para
cirurgia a pterígio
OUTLINE
Pterygium
Conjunctivochalasis
Limbal stem cell
deficiency
Glaucoma
microimplants
PTERYGIUM
Pterygium
• Still a fascinating, mysterious
disease.
• Etiology still unknown
• Optimal management still very
controversial
• Management is still fraught with
complications
Pterygium:Etiology UVR?
THEORY:
• UVR>>
• Mutations>>
• Proliferation
PTERYS
Pterygium: Genetic
predispositionNew evidence: certain populations/families are
susceptible to pterygium
• Genetic polymorphism (DNA variability) analysis
Ethiology
• Most researchers feel pterygium is a
TUMOR
• P53, tumor suppression gene
mutations and decreased of P53
protein
• Pterygium can be a precursor of
Squamous Cell Carcinoma
Still a Mystery
• Many Cases with very little UVR
exposure and no family history
• WHY?
Pterygium:Pathology
Pterygium: Pathology
Pterygium: Pathology
State-of-the art…..20 years ago
Procedure 23 years ago
• Conjuntival autograft
• 9-0 prolene or 10-0 biosorb sutures
• Cauthery as needed
• No amniotic membrane
• MMC for recurrent only
• 2.16 % recurrence rate
Pterygiectomy: Current Procedure
• No cauterization
• TISSEEL Fibrin glue; No sutures
• Amniotic membrane
• Over donor site – single pterygium
• Over nasal defect – double pterygium
• Intraoperative Mitomycin-C (2 Min.)
• Temporal pterygium
• Recurrent pterygium
Pre-
Op12w Post-
Op
Double Pterigiae
Complications
• < 1% recurrence rate (Unpublished)
• 1-2 % Dellen
• Cornea limbal scarring
• Ptosis
• Sub-graft hematoma>>fenestration
• One corneal ulcer in close to 10000 pterygia
• 2 Upside down grafts (One necrosed, one
regrafted)
Patient KG, after 4
pterygiectomies in Florida.
Pterygium Study (2002-
2005)• Retrospective
• 500 Pterygiae (390 Patients)
• Same surgeon (JAM) in all cases
• Average f/u period: 8.9 mo
• Low Recurrence Rate (2.16%) in High Risk Population
• Higher Temporal Recurrence (4%)
Recurrence
Recurrence
• EVERYONE “CLAIMS” LOW RECURRENCE
• Published recurrence rates decreasing
• Most recurrences are unexpected (Risk Factors?)
• A genetic “recurrence” profile may help predict
who may reccur.
• Management would be modified. (i.e. MMC)
Pterygium Research at
VO
• Questions:
• What is our current recurrent rate?
(DEFINITION?)
• Does AMT on donor site decrease healing time?
• Does AMT on donor site increase PTOSIS
• What happens to goblet cells in donor/host sites
• What is the effect of surgery on the endothelium?
Pterygium research at VO
• Data collected in 90+ patients include:
• PREOP: Full exam, pentacam, ant seg OCT,
ECC, Osmolarity, external photos, Impression
cytology
• INTRAOP: Video recording, Surgical time,
speculum separation, size , bleeding rate
variations
• POSTOP: Blood under graft, graft coverage,
elevation, pain scores, ptosis, healing rate
COSMETIC OUTCOME!?
The 500 pound
gorilla in the room