Bnrtish3Journal ofOphthalmology, 1990,74,265-266 265 Simultaneous pterygium and intraocular surgery Br J Ophthalmol: first published as 10.1136/bjo.74.5.265 on 1 May 1990. Downloaded from

Brendan I Ibechukwu

Abstract into the conjunctival sac, and a pad and bandage Fifteen patients were treated with simultane- are applied. Postoperative medications are as for ous pterygium and intraocular surgery. Eleven ordinary cataract extraction. of them had pterygium excision with cataract extraction, while four had pterygium excision with trabeculectomy. There was no evidence Simultaneous pterygium excision and of increased risk of pterygium recurrence or trabeculectomy of complications following cataract operation Most of our glaucoma patients also have or trabeculectomy as a result of the com- pterygia. Whenever trabeculectomy is indicated, bined procedure. In an environment where I excise the pterygium at the same time if pterygium is endemic and medical facilities present. A limbus-based conjunctival flap is inadequate a combined procedure is recom- again adopted. The conjunctival incision is con- mended to save time and cost. tinued through the pterygium. After the sclera is cleared, the site of the Pterygium is a major ophthalmic problem in Jos, trabeculectomy is centred and demarcated with Northern Nigeria. It commonly occurs in eyes cautery at 11 o'clock for a nasal pterygium, at with surgically treatable intraocular conditions 1 o'clock for a temporal pterygium, and at 12 such as cataract and glaucoma. The definitive o'clock where nasal and temporal pterygia occur treatment of pterygium is its removal which can together. Blood vessels in the pterygium area are be done prior to or combined with most intra- cauterised. ocular operations. A simultaneous operation for The neck of the pterygium is isolated from the excision of pterygium and treatment of cataract rest of the conjunctival flap with radial incisions or glaucoma, when possible, is simple. The at its upper and lower borders. Removal of the techniques are presented and discussed here. pterygium is then completed with a superficial keratectomy. Superficial and deep scleral trabeculectomy Simultaneous pterygium excision and cataract flaps are now developed and the trabeculectomy extraction operation is carried out. After Tenon's capsule The commonest site of a pterygium is nasal, but has been restored, the conjunctiva over the http://bjo.bmj.com/ occasionally both nasal and temporal pterygia trabeculectomy is closed with continuous 5-0 occur in the same eye with cataract. The surgical catgut. The conjunctival margins bordering the procedure up to excision of the pterygium is the area of the pterygium are sutured to the sclera same no matter whether the pterygium is nasal, with close, interrupted 8-0 virgin silk sutures. temporal, or both, or whether the cataract Cyclopentolate 1% and chloramphenicol 05% extraction is intra- or extracapsular. drops are instilled into the conjunctival cul-de- A conjunctival incision is made 5 mm from the sac and pad and bandage applied. Postoperative on September 23, 2021 by guest. Protected copyright. limbus and is continued through the pterygium management is as for ordinary trabeculectomy. nasally or temporally or both depending on the' site of the pterygium. The conjunctival flap is reflected as usual towards the cornea throughout Discussion the extent of the incision to expose the limbus. Jos University Teaching Hospital (JUTH) has a The proximal conjunctiva in the area of the catchment area spanning four states of Nigeria pterygium is undermined and all subconjunc- where pterygium has a high frequency. tival pterygium tissue carefully excised. All Pterygium takes a significant proportion of our blood vessels are cauterised. Radial incisions are clinic and theatre times. For instance, in the made above and below the neck ofthe pterygium 12 months July 1987 to June 1988 pterygium isolating it from the rest of the conjunctival flap. accounted for 10-6% of all operations in the eye The head of the pterygium is then removed by a theatre. In the following 12 months, July 1988 superficial keratectomy. to June 1989, it accounted for 9 4% (Table). A corneoscleral incision is then developed to These figures are comparable with the overall the size appropriate for either intra- or extra- incidence of the disease as noted by Cameron' capsular cataract extraction. After removal ofthe and Youngson2 but higher than that noted by cataractous lens, the corneoscleral wound is Nworah.3 closed with interrupted 8-0 virgin silk sutures. If Department of the corneoscleral incision extends into the Ophthalmology, Jos Incidence ofpterygium in Jos University Teaching Hospital University Teaching pterygium area, the sutures are inserted closer eye theatre Hospital, PMB 2076, Jos, together there. Plateau State, Nigeria After the anterior chamber is reformed, the Total no. No. of Pterygium as B I Ibechukwu conjunctival flap is replaced and closed with of pterygia % oftotal no. Correspondence to: B I operations excised ofoperations Ibechukwu, FRCS. interrupted 8-0 virgin silk leaving a 3-4 mm bare July 1987-June 1988 625 66 10-6 Accepted for publication sclera in the region of the pterygium. Atropine July 1988-June 1989 692 65 9-4 8 December 1989 1% and chloramphenicol 0 5% drops are instilled 266 Ibechukwu

Combined pterygium excision and cataract has been recorded in the 15 patients (16 eyes) extraction or trabeculectomy as described above operated on and followed up so far. There has has some obvious advantages for both the been no aqueous leakage from the trabeculec- Br J Ophthalmol: first published as 10.1136/bjo.74.5.265 on 1 May 1990. Downloaded from hospital and the patient. It shortens the waiting tomy or cataract wounds despite the deficient list and theatre time. It cuts down costs for the conjunctival protection in the pterygium sites. patient through a unified operation charge and Four ofthe patients who had combined opera- fewer hospital visits. tions had trabeculectomies for open-angle The indications for simultaneous operation glaucoma, while 11 had cataract extractions. include all those for cataract or glaucoma surgery Their pterygia were among 86 excised by the plus those for pterygium excision. In this centre author during the 24 months July 1987 to June we are in complete agreement with Boruchoff 1989. One of the patients had bilateral naso- and Foulks4 on the major indications for removal temporal pterygia with mature cataracts. He had of a pterygium. These include a significantly simultaneous pterygium excision and cataract inflamed eye resistant to topical medications; extraction in both eyes. relentless progression of the pterygium towards One puzzling complication of pterygium the visual axis with associated corneal operation is the high rate of recurrence of astigmatism, both of which impair vision; and pterygium. This is borne out by the extreme the physical appearance of an eye that is diversity of surgical techniques and medical cosmetically unacceptable to the patient. adjuvants which have been used for its treat- Simultaneous operations should be done on ment. At this centre we use the 'bare sclera' quiet eyes selected for elective surgery rather technique, cautery, and one or other post- than on inflamed eyes and eyes suffering from operative medication. Of the 86 eyes that had injury or acute glaucoma. pterygium excision, only 60 returned for the The occurrence of pterygium with cataract accepted three-month minimum follow-up.6 creates some additional optical problems. Tight Overall there have been 23 recurrences, giving a closure of the cataract wound and pterygium recurrence rate of 38%. Youngson,2 who used a both create a with-the-rule astigmatism wound similar technique in Jerusalem, reported a recur- closure by steepening the vertical meridian and rence rate of 37%. Different recurrence rates pterygium by flattening the 180° axis.' Whereas have been reported in the literature. This may be the astigmatism induced by tight wound closure due to lack of uniformity in the duration of can be reduced by removing the offending follow-up, as the interval between treatment and stitches postoperatively, the pterygium induced recurrence varies considerably. For example, astigmatism can be eliminated only by careful within the first three months, only nine recur- excision ofthe pterygium. Ifthe pterygium is not rences (15%) were detected. The number rose to removed during the cataract operation, it can 15 (25%) within six months and to 20 (33-3%) in create such a degree of postcataract astigmatism 12 months. The true recurrence rate is therefore

that the visual result may be very poor.I more likely to be between 30 and 40%. http://bjo.bmj.com/ The following points in the surgical tech- niques should be noted: In both procedures, the pterygium excision is Conclusion completed before the eye is opened. Keratec- In our environment pterygium occurs in most tomy is difficult in a soft eye. patients requiring intraocular surgery. I During the cataract wound closure corneo- advocate that whenever there is no contraindica-

scleral sutures are inserted closer together within tion the pterygium should be removed just on September 23, 2021 by guest. Protected copyright. the bare sclera area to compensate for the loss of before the eye is opened for the intraocular conjuctival protection. operation. The simultaneous procedure is In the combined pterygium excision and beneficial to both the hospital and the patient and trabeculectomy, decentring of the trabeculec- makes for a better visual prognosis in patients tomy site in nasal or temporal pterygium plus the undergoing cataract extraction. additional virgin silk sutures round the bare sclera both prevent excessive drainage. 1 Cameron ME. Pterygium throughout the world. Springfield: Thomas, 1965: 10-21. 2 Youngson RM. Recurrence of pterygium after excision. Br J Ophthalmol 1972; 56: 120-5. Complications 3 Nworah PB. Prevalence of pterygium in Enugu, Nigeria. There have been no specific complications NigerianJ Ophthalmol 1986; 2: 94-8. 4 Boruchoff SA, Foulks GN. Corneal surgery. In: Spaeth GL, ed. attributable to the simultaneous procedures Ophthalmic surgery, principles and practice. Philadelphia: other than those postoperative problems associ- Saunders, 1982: 202. 5 Holladay JT, Lewis JW, Allison ME, et al. Pterygium as cause ated with cataract extraction, trabeculectomy, or of post-cataract with-the-rule astigmatism. J Am Intraocul pterygium excision. The keratectomy sites have Implant Soc 1985; 2: 176-9. 6 Van den Brenk HAS. Results of prophylactic postoperative healed within our normal five-day postoperative irradiation in 1300 cases of pterygium. AJR 1968; 103: 723- inpatient period. No recurrence of pterygium 33.