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Corneal Physician Bulletin: Surgical Procedure for Pterygium Employs Tucked Tissue Graft

Surgical Procedure for Pterygium Employs Tucked Tissue Graft
   
A procedure called the Tissue Tuck Technique for pterygium excision is minimizing surgical trauma, diminishing iatrogenic and postoperative inflammation, sealing the gap between the resected conjunctiva and Tenon’s fascia, and recreating the semilunar fold, says Neel R. Desai, M.D., director of Cornea, Cataract, and Refractive Services at the Eye Institute of West Florida and medical director of the Lions Eye Institute for Transplant and Research, who’s been using it.
   “This technique requires a tissue graft that can be easily manipulated and tucked into position without tearing,” he explains. “With this is mind, I use the AmnioGraft  (BioTissue*) cryopreserved amniotic membrane because I have found it maintains intraoperative resilience, and because it retains the heavy chain hyaluronic acid/pentraxin 3 (HC-HA/PTX3) matrix, it minimizes inflammation and serves as an excellent platform for rapid conjunctival re-epithelialization without scar tissue.” 

“This technique fulfills all the criteria that, in my mind, define successful pterygium surgery: It’s efficient, reproducible, and not difficult,” he asserts. “It also has an excellent cosmetic result, and, most importantly, it has a low recurrence rate.”

   So, how, specifically, does the Tissue Tuck Technique work?
  • The eye is placed in full abduction, via a traction suture, to reconstruct the semi-lunar fold and ensure the gap is sealed post-operatively. 
  • A total of 2% lidocaine with epinephrine is used to basically infiltrate underneath the pterygium, and hydro-dissect the pterygium off the scleral bed.
  “This separates natural tissue planes to allow us to get down to a bare sclera very quickly and efficiently,” Dr. Desai points out. “It also provides a little bit of hemostasis, so we have a good, clear view of our surgical field. And of course, it provides the patient additional anesthesia, and paresthesia, so they don’t feel the discomfort during surgery or the traction suture.”
  • A 2 mm to 3 mm perimeter of normal conjunctiva is created by pulling Tenon’s fascia and any remaining fibrovascular tissue anteriorly from under the conjunctiva and resecting it.  
  • The band of Tenon’s, fibrovascular tissue and prolapsed orbital fat in the posterior and nasal aspects of the gap between Tenon’s capsule and the resected conjunctival rim are cauterized.
  • The cryopreserved amniotic membrane is trimmed to the general shape of the exposed bed, adding 2 mm to 3 mm to allow adequate tissue for tucking and re-creation of the semilunar fold.
  • The graft is slid over the bed, and the stromal slide is coated with a fibrin sealant and placed so that it overlaps the edge of the conjunctival rim and the intended semilunar fold. Curved tying forceps are used to tuck the tissue under the conjunctival rim and deep into the gap along the new semilunar fold. Additionally, these forceps are used to pinch the edge of the conjunctival rim to the folded and tucked tissue to seal and create a wide margin of contact. 
  • Excess glue is squeegeed away, so as not to push into the gap.
  • Excess graft is trimmed, and a bandage contact lens inserted to protect the tissue’s anterior edge.
    The entire process takes 10 to 12 minutes, Dr. Desai says. 
   “This technique fulfills all the criteria that, in my mind, define successful pterygium surgery: It’s efficient, reproducible, and not difficult,” he asserts. “It also has an excellent cosmetic result, and, most importantly, it has a low recurrence rate.”
— Dr. Desai is a consultant and speaker for BIO-TISSUE.