|Year : 1975 | Volume
| Issue : 1 | Page : 18-21
Surgery of pterygium
Department of Ophthalmology, Medical College, Meerut, India
I N Raizada
Department of Ophthalmology, Medical College, Meerut
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Raizada I N. Surgery of pterygium. Indian J Ophthalmol 1975;23:18-21
Postoperative recurrence of pterygium is a universal problem as is evident by the fact that many operative techniques have been devised from time to time and more recently have been supplemented by such methods as beta-irradiation, use of thio-tepa, antimitotic drugs and cortisone preparations. Various authors have reported varying rates of recurrence after surgery. Some report a very low rate of recurrence, , while other report recurrence rate varying from 23% to as high as 69%. ,,, Trivedi et al and Sen  do not report any recurrence after surgery. The rate of recurrence depends upon the type of pterygium  , age and sex of the patient, geographical, climatic, meteorological  and occupational  conditions. Postoperatively they have been managed by the use of beta- irradiations, thio-tepa and antimitotic drugs because of the fear of recurrence. All these postoperative measures may mask the efficiency or inefficiency of the operative technique.
A comparative evaluation of the various surgical techniques in similar types of pterygia in the same age group and without any supplementary postoperative treatment does not exist in literature.
This study had been undertaken to evaluate the efficacy of various surgical techniques. The factors on which the recurrence depends have been kept more or less constant, i.e., the age group of the selected cases, sex and the type of the pterygium. Doherty  classified the pterygia on a morphologico-clinical basis into progressive type, mildly progressive type and regressive type. The mildly progressive type is characterized by a thin, pale and sparsely vascularized head with a cap of a smoother border and seldom presenting outriders. This is Doherty's type II. Only this type has been put to surgery.
| Material and Method|| |
During the period 1969-1972 100 cases of pterygium were operated in the ophthalmic department of L.L.R.M. Medical College, Meerut. Five different techniques were employed, viz. excision, transplantation into inferior fornix (McReynolds), McGavic's technique (bare sclera), mucous membrane grafting (lower lip) and Spaeth's rotating flap. Brief description of each operation is given below.
1. Excision:-The technique of Arlt, introduced over a century ago is well known and still has some advocates. The pterygium is totally excised to a point near the caruncle. The rhomboid defect remaining is covered by uniting the upper and lower edges by several interrupted sutures.
2. McReynold's transplant :-This technique needs no explanation [Figure - 1] and [Figure - 2] The apex of the pterygium is transplanted into the lower fornix.
3. McGavic "bare sclera" Technique :-The subconjunctival tissue is excised and the conjunctiva is recessed from the limbus. The conjunctiva alone is secured to the episclera by interrupted sutures placed about 2 mm apart and atleast 5 mm from the limbus. The bare area is allowed to epithelize. Three grades of "baring" can be performed : the one in which conjunctiva is not recessed beyond the vertical limits of the pterygium [Figure - 3]; another, in which the limbal incisions are made 3 mm above and below the attachment and conjunctiva is sutured to the sclera 5 mm from the entire limbal area [Figure - 4]: and the third [Figure - 5], in which the recession is done 5 mm above and below the corneal attachment of the growth, as well as 5mm towards the canthus. The sutures are removed on the tenth day. We have adopted grade II baring in our cases.
4. Mucous Membrane Grafts:-Mucous membrane grafts removed from the lower lip were used to replace the conjunctiva. The technique does not require elaboration.
5. Spaeth's rotation :-A rectangular area of the conjunctiva containing the pterygium is shaped and then the direction is changed 90 degrees, either up or down [Figure - 6] and [Figure - 7] After the head of the pterygium is torn from the cornea by a suture, three sides of the rectangle are outlined by incising the conjunctiva with sharp scissors. A suture is passed through each corner of this island and then anchored in the episclera and conjunctiva of the next corner of the defect in the direction the flap is to be rotated. The "island" is then completed by incising its lower margins, and the sutures are secured. The block is thus caused to rotate to the anchored corners.
| Discussion|| |
Pterygium is often relegated to the junior most man in the department of ophthalmology in many eye hospitals and teaching institutions in India. The commonest operation which he is taught to perform is the McReynolds transplantation or excision with a high percentage of recurrence.
The various operative techniques for pterygium can be divided in five different groups, i.e., excisions, transplantation's baresclera methods, rotations and grafting. The techniques chosen were excision, (Czermak) McReynolds (transplantation), Spaeth (Rotating flap), McGavic (bare-sclera) techniques and mucous membrane grafting (from lower lip)
| Analysis of the results based on past-operative recurrence|| |
Apart from the surgical techniques employed recurrence of pterygium depends upon age, sex, type of the pterygium and also upon the previous history of operation. In our series of cases all these factors have been more or less, kept constant. From [Table - 1], it is clear that the recurrence was the least with McGavic's technique (bare-sclera technique and highest with excisions (100%) and McReynolds technique (100%). This study thus substantiates the findings of Sen  who reported very good results by this particular technique. Trivedi et al  found no recurrence whatsoever in a series of 140 cases of primary pterygia and recurrent pterygia after mucous membrane grafting. Our results are at variance with them as twenty percent of our cases recurred after this technique. Cameron  and Gibson  are of the opinion that there is very little to choose between the various operative techniques as far as recurrence is concerned but we differ from them as McGavic's technique has produced the best results in our series.
| Analysis based on final cosmetic appearance|| |
In the age group of 20-30 years, one of the main concern which brought the patient to the hospital was the cosmetic appearance and so one of the important yardsticks to measure the success of the operative technique was the final cosmetic appearance. From [Table - 2], it is clear the best cosmetic appearance resulted after the McGavic's technique.
| Analysis based on time consumed|| |
The time consumed during operation is not a very important factor but never the less we noted that excisions and McReynold's transplantation could be done the fastest, Spaeth's rotating flap and mucous membrane grafting took the maximum time and McGavic's technique was in between.
The study showed that chances of recurrence were the minimum and cosmetic appearance was comparatively the best with McGavic's technique in comparison to other techniques.
| Summary|| |
The results of 100 cases of pterygium operated by five different techniques, i.e., excision, transplantation, McGavic's bare sclera technique, mucous membrane grafting and Spaeth's rotating flap have been evaluated. McGavic's technique has been found to be the best.
| References|| |
Cameron, M.E., 1965, Pterygium throughout the world., p.
141. Thomas Springfield, Illumf.
Doherty, W.B., 1941. Amer. J Ophthal. 24,
Escapinie, H., 1958, Amer. J. Ophthal. 45,
Fulgosi, A. and Frank, P , 1957. Ophthalmologica 134, 410.
Gibson, J.B.G., 1956, Trans. Ophthal. Soc. Australia, 16,
125, Quoted by H. Zauberman, 1967. Arner. J. Ophthal. 63.
Hanan Zauberman, 1967. Amer J. Ophthal. 63,
Hilgers, J.H., ch. 1959. Klein offset Drukerij, Poortpers, N.V., Quoted by H. Zauberman ; 1967, Amer. J. Ophthal. 63,
Saad, R.S., 1966. Personal Communication,
Quoted by Herbstein and Donovan, 1968. Brit. J. Opltthal. 52, 162.
Sen, D.K., 1970. Brit. J. Ophthal. 54,
Torres Estrada, 1958. Abstract Amer. J. Ophthal 45,
Trivedi, L.K., D.B.
Massey and Rajendra Rohatgi, 1969. Amer J. Ophtha!., 68,
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
[Table - 1], [Table - 2]