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   Table of Contents      
ARTICLES
Year : 1975  |  Volume : 23  |  Issue : 1  |  Page : 18-21

Surgery of pterygium


Department of Ophthalmology, Medical College, Meerut, India

Correspondence Address:
I N Raizada
Department of Ophthalmology, Medical College, Meerut
India
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Source of Support: None, Conflict of Interest: None


PMID: 1158417

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How to cite this article:
Raizada I N. Surgery of pterygium. Indian J Ophthalmol 1975;23:18-21

How to cite this URL:
Raizada I N. Surgery of pterygium. Indian J Ophthalmol [serial online] 1975 [cited 2020 Jun 5];23:18-21. Available from: http://www.ijo.in/text.asp?1975/23/1/18/31337

Table 2

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Table 2

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Table 1

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Table 1

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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, [3],[10] while other report recurrence rate varying from 23% to as high as 69%. [2],[4],[5],[7] Trivedi et al and Sen [9] do not report any recur­rence after surgery. The rate of recurrence depends upon the type of pterygium [6] , age and sex of the patient, geographical, climatic, meteorological [1] and occupational [8] 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 [2] 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 Top


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 Top


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 Top


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 [9] who reported very good results by this particular technique. Trivedi et al [11] 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 [1] and Gibson [5] 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 Top


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 Top


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 Top


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 Top

1.
Cameron, M.E., 1965, Pterygium throughout the world., p. 141. Thomas Springfield, Illumf.  Back to cited text no. 1
    
2.
Doherty, W.B., 1941. Amer. J Ophthal. 24, 790.  Back to cited text no. 2
    
3.
Escapinie, H., 1958, Amer. J. Ophthal. 45, 879.  Back to cited text no. 3
    
4.
Fulgosi, A. and Frank, P , 1957. Ophthalmologica 134, 410.  Back to cited text no. 4
    
5.
Gibson, J.B.G., 1956, Trans. Ophthal. Soc. Australia, 16, 125, Quoted by H. Zauberman, 1967. Arner. J. Ophthal. 63. 1780.  Back to cited text no. 5
    
6.
Hanan Zauberman, 1967. Amer J. Ophthal. 63, 1781  Back to cited text no. 6
    
7.
Hilgers, J.H., ch. 1959. Klein offset Drukerij, Poortpers, N.V., Quoted by H. Zauberman ; 1967, Amer. J. Ophthal. 63, 1780.  Back to cited text no. 7
    
8.
Saad, R.S., 1966. Personal Communication, Quoted by Herbstein and Donovan, 1968. Brit. J. Opltthal. 52, 162.  Back to cited text no. 8
    
9.
Sen, D.K., 1970. Brit. J. Ophthal. 54, 606.  Back to cited text no. 9
    
10.
Torres Estrada, 1958. Abstract Amer. J. Ophthal 45, 879.  Back to cited text no. 10
    
11.
Trivedi, L.K., D.B. Massey and Rajendra Rohatgi, 1969. Amer J. Ophtha!., 68, 353.  Back to cited text no. 11
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]
 
 
    Tables

  [Table - 1], [Table - 2]



 

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