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The surgical treatment of Pterygium 

PAGE 32 DR SAFFIEDINE

This article contains the information about the reasons, conditions, results, risks and limitations of the surgical treatment of pterygium.

Pterygium is a benign, not cancerous, wing shaped (“petyrigion” is the ancient Greek word for “wing”) tumour of the conjunctiva (which is the superficial membrane that covers the surface of the eye). 

The body of the wing is easily visible as a slight redness on the “white” part of the eye, usually on the nasal side. The whitish, irregular, bulbous summit of the wing is directed to the centre of the cornea (the main, anterior, lens of the eye).

It is a very frequent tumour, particularly in adults living in hot and sunny areas as it is the case in south of Tenerife.

Congenital forms of this tumour are very aggressive and, fortunately, rare. The most frequent form is the one that develops in persons exposed to ultra-violet (UV) rays of the sun during leisure activities (beach, sunbathing, nautical water ski, surf, windsurf, kite surf, diving, rowing, delta plan, hiking, alpinism etc.) or for professional reasons (marine fishing, open air agriculture and constructions etc.). Trachoma (that is also a disease of sunny countries) and the exposition to infra-red (IR) rays produced by high degree heat (pastry cookers, bakers, pizzaïolos, firemen, welders, glaziers, workers in steel industry etc.) and to irritating products (natural or industrial dust, sand, cement etc. ) are also predisposing factors of this tumour.

UV and IR filtering sunglasses is a good prevention mean.

Why operate?

Left without treatment, the pterygium, initially limited to the conjunctiva, extends progressively towards the centre of the cornea and becomes annoying by its unaesthetic appearance and the occurrence of chronic mechanical irritation due to the increase of its thickness. The extension towards the centre of the cornea can lead to visual, sometimes disabling, defects.

Surgery is the only way to remove this tumour.

The operation

It is performed while the patient is installed on the back, in a sterile environment, under surgical microscope.

• Anaesthesia: it is done by an injection of anaesthetic near the lesion.

• Technical procedure: Its aim is the complete excision of the lesion. There is no opening of the eyeball.

Chronologically, the steps of the procedure are: Disinfection, anaesthesia with drops and injection in the area of the lesion and the graft, incision, removal of the tumour tissue with a security healthy tissue zone, debridement of the healthy tissue, use of medication reducing the risk of recurrence, reconstitution of the conjunctival plan by a graft of conjunctiva taken from the same eye, closure with absorbable sutures, disinfection, optional eye-pad or eye-cup.

The total duration of presence in the clinic is approximately 1 hour. The time spent in the operating theatre is one hour of which 40 minutes occur in the operating room.

The residues of stitches, if any, are removed 1 to 4 weeks later.

If the lesion has an unusual appearance, an analysis in the laboratory of pathology can be performed to determine its exact nature. It is the patient’s responsibility to contact later the laboratory in order to get the results.

Usual postoperative course

The postoperative routine is: Swelling of the eyelids, redness, discharge, watery eyes with a bit of blood, sensitivity to light, sensation of sand and, depending on the sensitivity of the patient, light to heavy pain. These inconveniences are especially encountered on the first 3 post-operative days and fade gradually over a week. The sensation of sand, due to the knots of the sutures, can last several weeks, until they are absorbed or are removed by your eye doctor. The redness fades gradually over the weeks following the disappearance of the sutures.

The complications of the operation

Although it is perfectly standardized and followed by good results, this type of operation is no exception to the general rule that there is no surgery without risk. It is not possible for any ocular surgeon to ensure formally the success of a surgical intervention.

The patient should be aware that

• During the anaesthesia and sometimes despite the anaesthesia, during the operation itself, there is a hazard of discomfort and pain. This risk depends on the patient’s responsiveness to the anaesthetic molecule. This risk is unpredictable.

• In any local anaesthesia and all surgical procedures, there is a hazard of local complications, bleeding and infection and general intolerance that can lead to a severe shock. The risk of these complications is unpredictable. It is so exceptional that it is impossible to quantify.

• After any surgery, there is a hazard of inadequate or excessive scarring, which can lead to unaesthetic scarring.

This risk is higher on dark skinned or regularly exposed to sunlight patients. It is not quantifiable.

• After removing a tumour, there is a hazard of recurrence leading to further surgery. This risk is unpredictable but has been estimated globally between 8 and 19%, depending on the geographic location. Sun exposure increases this risk. The risk of occurrence is high when the exposition to the above mentioned risk factors happens during childhood.

To what must the patient be careful to, before, during and after the operation?

THE EVENING BEFORE THE OPERATION:

Any make-up should be removed. The hair and face, especially the eyelids and eyelashes, and the whole body should be washed with shampoo or soap then rinsed generously. The same thorough washing and rinsing should be repeated then the whole body should be dried with a clean towel. The sleep should be done with clean nightclothes and bedding. It is advisable not to take any Aspirin and other blood fluidifying drugs the day before and the day of the operation. Aspirin and other blood fluidifying drugs may be taken the day after the operation. The matter of Aspirin and other blood fluidifying drug should be discussed with the patient’s General Practioner.

THE DAY OF THE OPERATION AND DURING THE WEEK FOLLOWING IT:

On the morning of the day of the operation, upon awakening, any make-up residues should be re-removed carefully. The thorough double shower, as described above, should be repeated. Clean underwear and clothes should be worn. The breakfast and regular medications, except Aspirin and other blood fluidifying drugs, should be taken. All regularly taken medications should be brought to the Eye Clinic.

During the operation, the patient is requested to keep calm and strictly follow the instructions given by the Eye Doctor.

After the operation, the Eye Doctor prescribes eye drops or eye ointment, to be put on the operated eye, usually during 7 days.

The presence of an aiding person is advised during the remainder day of the operation.

A little bleeding and swelling (haematoma) of the eyelid should not worry nor keep the patient from following the treatment.

In case of pain, one to three Paracetamol tablets per day, for up to three days, may be taken.

It is, as always, strongly advised not to rub the eyes.

If a protection is placed on the eye, it should be kept throughout night sleep or nap. The plasters should be changed after each application of ointment. The plasters stick best on a skin previously washed with soap or a gently rubbed with an alcoholic perfume.

Visual activities, professional and of leisure, are allowed as long as dirt and dust do not reach the eye.

Wearing sunglasses is, as always, advisable when exposed to sunlight.

The patient should contact the eye doctor immediately in case of

* Breathing difficulties.

* General malaise.

* Fever.

* Persistent bleeding.

* Continued strong pain lasting more than 2 hours.

By courtesy of Dr SAFFIEDINE, Eye Doctor in Playa De Las Américas.