Amniotic membrane transplant key to pterygium surgical method Technique may provide a more prolonged antifibrotic effect and

a decreased recurrence rate, but further study is needed. by Thomas John, MD; John A. Hovanesian, MD, FACS; Andrew Behesnilian, BS Submit a Comment Introduction There is a continued search among ophthalmic surgeons for the optimal surgical technique for pterygium surgery. This is partly because pterygium surgery is associated with potential postoperative complications, including recurrence of pterygium. My guests in this corneal dissection column, John A. Hovanesian, MD, FACS, and Andrew Behesnilian, BS, describe their surgical technique of using amniotic membrane transplantation as a biologic implant beneath the normal conjunctiva surrounding the region where the pterygium is excised and replaced with a conjunctival autograft. They said the recurrence rate of 5% after pterygium surgery combined with conjunctival autograft is similar to the Thomas eyes receiving amniotic membrane transplantation in the region where the John pterygium is excised. The guests are of the opinion that placing the amniotic membrane graft in the surgically created subconjunctival space may provide a more prolonged antifibrotic effect, as compared with placing it on the ocular surface, and may contribute to a decreased recurrence rate of the pterygium. This technique must be further examined in larger studies to address all of the ocular effects of such a procedure. The preferred anesthesia for this technique is with a peribulbar block of bupivacaine and lidocaine 1% with epinephrine. Although subconjunctival infiltration of anesthetic agents is also effective for the procedure, this may result in more postoperative patient discomfort. Story continues below ADVERTISEMENT Step-by-step surgery Fibrin tissue adhesive (Tisseel, Baxter AG) is reconstituted according to the manufacturers instructions, but the components are not transferred to the supplied Duploject syringe. Instead, they are left in their original vials. The pterygium is excised along with an additional 1-mm margin of conjunctival tissue, thus exposing the bare sclera (Figure 1). Next, blunt Westcott scissors are used to create a potential space of about 5 mm beneath the healthy conjunctiva on the three sides surrounding the site of pterygium excision. This potential space should be superficial to most of Tenons fascia, the medial rectus muscle and tendon. Minimal cautery is used to establish hemostasis. Next, a thin conjunctival autograft similar in size to the conjunctival defect that was created after pterygium excision is prepared from the superior bulbar conjunctiva of the same eye. At this point, the graft is left attached (Figure 1) at the limbus superiorly, such that it is not misplaced during the subsequent surgical steps. Print E-mail

Schematic representation displaying the bare sclera after pterygium excision. Conjunctiva is shown in pink, with a yellow line on its epithelial side (upper left); The pterygium has been excised and the autograft prepared and reflected onto the cornea at the superior limbus (upper right); Freeze-dried human amniotic membrane is cut into a Cshaped graft (lower left); The amniotic membrane is placed in the subconjunctival region surrounding the site of pterygium excision. The location of the amniotic membrane graft is shown in red, surrounding the area where the conjunctival autograft will be placed (lower right). Images: Hovanesian JA Amniotic membrane preparation: Freeze-dried human amniotic membrane, namely AmbioDry2 (IOP Inc.), in its dry form is removed from the outer packaging, but it is left in its inner packaging. The amniotic membrane is then cut through the packaging into a Cshaped graft that is large enough to surround the conjunctival defect (Figure 1). Fibrin adhesive preparation: A sterile 1-cc syringe with an 18-gauge needle is used to aspirate 0.1 cc of the fibrinogen in a sterile fashion from the fibrin sealant vial (blue label). Similarly, 0.1 cc of thrombin is aspirated into a separate 1-cc syringe from the thrombin sealant vial (black label). Air entry into these syringes is minimized. Next, into the thrombinfilled syringe, 0.9 cc of balanced salt solution is added, and the syringe is inverted several times to facilitate mixing. The adhesive components are now ready for use. Amniotic membrane application: A few drops of sterile balanced salt solution are placed on the bare sclera that will allow for the subsequent hydration of the freeze-dried amniotic membrane and facilitate its sliding on the ocular surface. The cut-edge of the conjunctiva is lifted using 0.12 forceps, and a Paton spatula containing a small droplet of fibrinogen is introduced. The fibrinogen is applied to the undersurface of the conjunctiva that was tentedup. This fibrinogen will help keep the amniotic membrane in place upon its introduction into

this surgically created potential space in the subconjunctival region. Thrombin is not applied at this time. Attention is directed back to the amniotic membrane graft, which is removed from its packaging and placed on the bare sclera. Using non-toothed, smooth forceps, the amniotic membrane is then gently grasped and brought into the subconjunctival space (Figure 2). The amniotic membrane is evenly distributed in this space. However, some amniotic membrane folds may remain, which usually have no postoperative deleterious effects on the overall outcome of this surgical procedure. The goal is to create a subconjunctival amniotic membrane belt-way that surrounds the area of the bare sclera, not to cover the bare sclera (Figures 1 and 2). After placing the amniotic membrane in the subconjunctival space, the edges of the overlying conjunctiva are lifted and advanced toward the limbus to cover any remnants of amniotic membrane transplantation that are exposed. The presence of the fibrinogen, mixed with small amounts of thrombin in the patients own blood, will allow these edges to stay in place, covering all of the amniotic membrane transplantation.

The graft is tucked into the subconjunctival space to provide its antifibrotic effects to Tenons fascia, from which pterygium recurrence might arise (upper left); Amniotic membrane (red) does not cover the bare-scleral defect (upper right); From the superior limbus, the conjunctival autograft is cut free from the superior limbus (lower left); The free conjunctival autograft is inverted on the cornea (note yellow epithelial surface of graft shown against the corneal epithelium) and oriented limbus-to-limbus adjacent to the excision site (lower right). Application of conjunctival autograft: The conjunctival autograft, which remains attached to the superior limbus, is now reflected onto the cornea (epithelium to epithelium) and cut free from the superior limbus with scissors (Figure 2). The surgeon slides this graft across the cornea, orienting its limbal side to the limbus where the pterygium was excised (Figure 3). A

small droplet from the diluted thrombin syringe (black label) is applied to the bare sclera (Figure 3), and a small droplet from the fibrinogen (blue label) syringe is applied to the underside of the graft. The graft is then grasped with two MacPherson forceps and flipped onto the bare sclera. This allows the two adhesive components to mix, and the surgeon has about 30 seconds to manipulate and orient the graft appropriately, such that the edges of the graft are approximated with the cut-edges of the surrounding conjunctiva and the corneal margin is aligned with the limbus (Figure 3).

Thrombin (black label vial) diluted with balanced salt solution is placed on the excision site, and fibrinogen (blue label vial) is placed on the stromal side of the autograft (upper row); The conjunctival autograft is inverted, mixing the adhesive components, and smoothed to approximate the edges of conjunctiva (lower row). Surgical pearls and tips

Conservative use of cautery avoids postoperative pain and is usually sufficient, as the fibrin adhesive provides additional hemostasis. Dilution of one part thrombin with nine parts balanced salt solution slows the polymerization process with fibrin adhesive and allows more time for manipulation of the graft. Harvesting a thin conjunctival autograft is best accomplished by making a small opening in the conjunctiva distal to the limbus and then lifting the cut-edge of the conjunctiva (with minimal Tenons membrane) using toothed forceps. Blunt Westcott scissors can be inserted parallel to the conjunctival surface and then opened in the plane just below the conjunctiva to separate it away from the underlying tissues, namely most of Tenons membrane. The conjunctival autograft should match the size of the conjunctival opening after pterygium excision and should not be significantly oversized or contain excessive Tenons membrane to avoid any significant tissue swelling after surgery. Once the conjunctival autograft is in place covering the bare sclera with its edge properly approximated (as described above) and the two components of the fibrin glue

begin to mix, the surgeon should avoid unnecessary touching of the graft or surrounding conjunctiva, as this will usually weaken the bonds of the fibrin adhesive and may result in suboptimal attachment of the conjunctival autograft. During the postoperative follow-up period, a small gap at the nasal edge of the graft may occasionally occur. This does not increase the risk of recurrence of the pterygium.

Treatment Postoperative follow-up and drug regimen: Zymar ophthalmic solution (gatifloxacin, Allergan), one drop four times a day, and Xibrom (bromfenac ophthalmic solution, Ista Pharmaceuticals), one drop twice a day, are used for 1 week after surgery. Pred Forte 1% drops (prednisolone acetate, Allergan) are used four times a day for 2 weeks, and then tapered off over the following 2 weeks. For more information: John A. Hovanesian, MD, FACS, is a clinical instructor at the UCLA Jules Stein Eye Institute and is in private practice in Laguna Hills, Calif. He can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; e-mail: drhovanesian@harvardeye.com. Dr. Hovanesian is a consultant to Allergan, Baxter AG, IOP Inc. and Ista Pharmaceuticals. Thomas John, MD, is a clinical associate professor at Loyola University at Chicago and is in private practice in Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; e-mail: tjcornea@gmail.com. Dr. John has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.

References: Chui J, Di Girolamo N, Wakefield D, Coroneo MT. The pathogenesis of pterygium: Current concepts and their therapeutic implications. Ocul Surf. 2008;6:24-43. De la Hoz F, Montero JA, et al. Efficacy of mitomycin C associated with direct conjunctival closure and sliding conjunctival graft for pterygium surgery. Br J Ophthalmol. 2008;92:175-178. Hovanesian JA, Behesnilian A. Results of pterygium excision using amniotic membrane beneath the healthy conjunctiva surrounding a conjunctival autograft. Presented at: Annual Meeting of the American Society of Cataract and Refractive Surgery; 2008; Chicago. Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-1470. Ma DH, See LC, Liau SB, Tsai RJ. Amniotic membrane graft for primary pterygium: Comparison with conjunctival autograft and topical mitomycin C treatment. Br J Ophthalmol. 2000;84:973-978.

Memarzadeh F, Fahd AK, Shamie N, Chuck RS. Comparison of deepithelialized amniotic membrane transplantation and conjunctival autograft after primary pterygium excision. Eye. 2008;22:107-112.

Transplantasi membran amnion kunci untuk metode bedah pterygium Technique may provide a more prolonged antifibrotic effect and a decreased recurrence rate, but further study is needed. Teknik dapat memberikan efek antifibrotic lebih lama dan tingkat kekambuhan menurun, namun studi lebih lanjut diperlukan. by Thomas John, MD; John A. Hovanesian, MD, FACS; Andrew Behesnilian, BS oleh Thomas John, MD; John A. Hovanesian, MD, FACS, Andrew Behesnilian, BS Submit a Comment E-mail EPrint Cetak Kirim Komentar mail Introduction Pengenalan There is a continued search among ophthalmic surgeons for the optimal surgical technique for pterygium surgery. Ada pencarian lanjutan antara ahli bedah oftalmik untuk teknik bedah yang optimal untuk operasi pterygium. This is partly because pterygium surgery is associated with potential postoperative complications, including recurrence of pterygium. Hal ini sebagian karena operasi pterygium berhubungan dengan komplikasi pasca operasi potensial, termasuk kekambuhan pterygium. My guests in this corneal dissection column, John A. Hovanesian, MD, FACS, and Andrew Behesnilian, BS, describe their surgical technique of using amniotic membrane transplantation as a biologic implant beneath the normal conjunctiva surrounding the region where the pterygium is excised and replaced with a conjunctival autograft. Tamu saya dalam kolom ini diseksi kornea, John A. Hovanesian, MD, FACS, dan Andrew Behesnilian, BS, Thomas menjelaskan teknik bedah mereka menggunakan transplantasi membran John amnion sebagai "implan biologis" di bawah konjungtiva normal di sekitar Thomas wilayah di mana pterygium yang dipotong dan diganti dengan autograft John konjungtiva. They said the recurrence rate of 5% after pterygium surgery combined with conjunctival autograft is similar to the eyes receiving amniotic membrane transplantation in the region where the pterygium is excised. Mereka mengatakan tingkat kekambuhan dari 5% setelah operasi pterygium dikombinasikan dengan autograft konjungtiva mirip dengan mata menerima transplantasi membran amnion di wilayah mana pterygium yang dipotong. The guests are of the opinion that placing the amniotic membrane graft in the surgically created subconjunctival space may provide a more prolonged antifibrotic effect, as compared with placing it on the ocular surface, and may contribute to a decreased recurrence rate of the pterygium. Para tamu berpendapat bahwa menempatkan graft membran amnion dalam ruang subconjunctival pembedahan dibuat dapat memberikan efek yang lebih lama antifibrotic, dibandingkan dengan menempatkannya pada permukaan mata, dan dapat berkontribusi pada tingkat kekambuhan penurunan pterygium tersebut. This technique must be further examined in larger studies to address all of the ocular effects of such a procedure. Teknik ini harus diteliti lebih lanjut dalam penelitian yang lebih besar untuk mengatasi semua efek mata seperti prosedur. The preferred anesthesia for this technique is with a peribulbar block of bupivacaine and lidocaine 1% with epinephrine. Anestesi disukai

untuk teknik ini adalah dengan blok peribulbar bupivakain dan lidokain 1% dengan epinephrine. Although subconjunctival infiltration of anesthetic agents is also effective for the procedure, this may result in more postoperative patient discomfort. Meskipun infiltrasi subconjunctival agen anestesi juga efektif untuk prosedur ini, hal ini dapat mengakibatkan ketidaknyamanan pasca operasi lebih sabar. Story continues below Cerita berlanjut di bawah ini ADVERTISEMENT IKLAN Step-by-step surgery Langkah-langkah operasi Fibrin tissue adhesive (Tisseel, Baxter AG) is reconstituted according to the manufacturer's instructions, but the components are not transferred to the supplied Duploject syringe. Jaringan fibrin perekat (Tisseel, Baxter AG) adalah dilarutkan menurut petunjuk pabrik, tetapi komponen tidak ditransfer ke jarum suntik Duploject disediakan. Instead, they are left in their original vials. Sebaliknya, mereka yang tersisa di botol aslinya. The pterygium is excised along with an additional 1-mm margin of conjunctival tissue, thus exposing the bare sclera (Figure 1). Pterygium ini dipotong bersama dengan margin 1-mm tambahan jaringan konjungtiva, sehingga mengekspos sclera telanjang (Gambar 1). Next, blunt Westcott scissors are used to create a potential space of about 5 mm beneath the healthy conjunctiva on the three sides surrounding the site of pterygium excision. Selanjutnya, tumpul Westcott gunting digunakan untuk membuat ruang potensial sekitar 5 mm di bawah konjungtiva sehat pada tiga sisi sekitar lokasi eksisi pterygium. This potential space should be superficial to most of Tenon's fascia, the medial rectus muscle and tendon. Ini ruang potensial harus dangkal untuk sebagian besar fasia Tenon itu, otot rektus medial dan tendon. Minimal cautery is used to establish hemostasis. Kauterisasi minimal digunakan untuk membuat hemostasis. Next, a thin conjunctival autograft similar in size to the conjunctival defect that was created after pterygium excision is prepared from the superior bulbar conjunctiva of the same eye. Selanjutnya, autograft konjungtiva tipis ukurannya sama dengan cacat konjungtiva yang diciptakan setelah eksisi pterygium dibuat dari konjungtiva bulbar unggul dari mata yang sama. At this point, the graft is left attached (Figure 1) at the limbus superiorly, such that it is not misplaced during the subsequent surgical steps. Pada titik ini, korupsi dibiarkan terpasang (Gambar 1) di superior limbus, seperti bahwa itu tidak salah selama langkah bedah berikutnya.

Schematic representation displaying the bare sclera after pterygium excision. Skema representasi menampilkan sclera telanjang setelah eksisi pterygium. Conjunctiva is shown in pink, with a yellow line on its epithelial side (upper left); The pterygium has been excised and the autograft prepared and reflected onto the cornea at the superior limbus (upper right); Freeze-dried human amniotic membrane is cut into a Cshaped graft (lower left); The amniotic membrane is placed in the subconjunctival region surrounding the site of pterygium excision. Konjungtiva adalah ditampilkan dalam warna pink, dengan garis kuning di sisi epitel nya (kiri atas); pterygium telah dipotong dan autograft menyiapkan dan tercermin ke kornea di limbus unggul (kanan atas); beku-kering membran amnion manusia dipotong menjadi cangkok berbentuk C (kiri bawah); Membran ketuban ditempatkan di wilayah subconjunctival sekitar lokasi eksisi pterygium. The location of the amniotic membrane graft is shown in red, surrounding the area where the conjunctival autograft will be placed (lower right). Lokasi graft membran ketuban yang ditampilkan dalam warna merah, sekitar area dimana autograft konjungtiva akan ditempatkan (kanan bawah). Images: Hovanesian JA Gambar: Hovanesian JA Amniotic membrane preparation: Freeze-dried human amniotic membrane, namely AmbioDry2 (IOP Inc.), in its dry form is removed from the outer packaging, but it is left in its inner packaging. Persiapan membran ketuban: beku-kering membran amnion manusia, yaitu AmbioDry2 (TIO Inc), dalam bentuk kering yang dikeluarkan dari kemasan luarnya, tapi dibiarkan dalam kemasan dalamnya. The amniotic membrane is then cut through the packaging into a C-shaped graft that is large enough to surround the conjunctival defect (Figure 1). Membran ketuban kemudian dipotong melalui kemasan menjadi cangkok berbentuk C yang cukup besar untuk mengepung cacat konjungtiva (Gambar 1).

Fibrin adhesive preparation: A sterile 1-cc syringe with an 18-gauge needle is used to aspirate 0.1 cc of the fibrinogen in a sterile fashion from the fibrin sealant vial (blue label). Fibrin perekat persiapan: Sebuah jarum suntik 1-cc steril dengan jarum 18-gauge digunakan untuk aspirasi 0,1 cc fibrinogen dalam mode steril dari botol segel fibrin (label biru). Similarly, 0.1 cc of thrombin is aspirated into a separate 1-cc syringe from the thrombin sealant vial (black label). Demikian pula, 0,1 cc dari trombin disedot ke dalam alat suntik 1 cc terpisah dari botol segel trombin (label hitam). Air entry into these syringes is minimized. Udara masuk ke dalam jarum suntik diminimalkan. Next, into the thrombin-filled syringe, 0.9 cc of balanced salt solution is added, and the syringe is inverted several times to facilitate mixing. Selanjutnya, ke dalam alat suntik trombin-diisi, 0,9 cc larutan garam seimbang ditambahkan, dan alat suntik terbalik beberapa kali untuk memfasilitasi pencampuran. The adhesive components are now ready for use. Komponen perekat sekarang siap untuk digunakan. Amniotic membrane application: A few drops of sterile balanced salt solution are placed on the bare sclera that will allow for the subsequent hydration of the freeze-dried amniotic membrane and facilitate its sliding on the ocular surface. Aplikasi membran ketuban: Beberapa tetes larutan garam steril seimbang ditempatkan pada sclera telanjang yang akan memungkinkan untuk hidrasi berikutnya dari membran amnion kering-beku dan memfasilitasi meluncur pada permukaan mata. The cut-edge of the conjunctiva is lifted using 0.12 forceps, and a Paton spatula containing a small droplet of fibrinogen is introduced. Cuttepi konjungtiva diangkat menggunakan 0,12 forseps, dan spatula Paton mengandung tetesan kecil dari fibrinogen diperkenalkan. The fibrinogen is applied to the undersurface of the conjunctiva that was tented-up. Fibrinogen adalah diterapkan pada permukaan bawah konjungtiva yang tenda-up. This fibrinogen will help keep the amniotic membrane in place upon its introduction into this surgically created potential space in the subconjunctival region. Fibrinogen Ini akan membantu menjaga membran ketuban di tempat pada saat diperkenalkan ke dalam ruang potensial operasi dibuat di wilayah subconjunctival. Thrombin is not applied at this time. Trombin tidak diterapkan saat ini. Attention is directed back to the amniotic membrane graft, which is removed from its packaging and placed on the bare sclera. Perhatian diarahkan kembali ke graft membran amnion, yang dikeluarkan dari kemasannya dan ditempatkan pada sklera telanjang. Using non-toothed, smooth forceps, the amniotic membrane is then gently grasped and brought into the subconjunctival space (Figure 2). Menggunakan non-bergigi, forsep halus, selaput ketuban yang kemudian dengan lembut digenggam dan dibawa ke dalam ruang subconjunctival (Gambar 2). The amniotic membrane is evenly distributed in this space. Membran ketuban merata di ruang ini. However, some amniotic membrane folds may remain, which usually have no postoperative deleterious effects on the overall outcome of this surgical procedure. Namun, beberapa lipatan membran amnion mungkin tetap, yang biasanya tidak memiliki efek merusak pascaoperasi pada hasil keseluruhan prosedur bedah. The goal is to create a subconjunctival amniotic membrane belt-way that surrounds the area of the bare sclera, not to cover the bare sclera (Figures 1 and 2). Tujuannya adalah untuk menciptakan membran ketuban subconjunctival "sabukjalan" yang mengelilingi daerah sclera telanjang, bukan untuk menutupi sklera telanjang (Gambar 1 dan 2). After placing the amniotic membrane in the subconjunctival space, the edges of the overlying conjunctiva are lifted and advanced toward the limbus to cover any remnants of amniotic membrane transplantation that are exposed. Setelah menempatkan membran ketuban di ruang subconjunctival, tepi konjungtiva atasnya terangkat dan maju ke arah limbus untuk menutupi sisa-sisa membran ketuban transplantasi yang terkena. The presence of the fibrinogen, mixed with small amounts of thrombin in the patient's own blood, will allow these edges to stay in place, covering all of the amniotic membrane transplantation.

Kehadiran fibrinogen itu, dicampur dengan sejumlah kecil trombin dalam darah pasien sendiri, akan memungkinkan tepi-tepi ini untuk tinggal di tempat, meliputi semua transplantasi membran amnion.

The graft is tucked into the subconjunctival space to provide its antifibrotic effects to Tenon's fascia, from which pterygium recurrence might arise (upper left); Amniotic membrane (red) does not cover the bare-scleral defect (upper right); From the superior limbus, the conjunctival autograft is cut free from the superior limbus (lower left); The free conjunctival autograft is inverted on the cornea (note yellow epithelial surface of graft shown against the corneal epithelium) and oriented limbus-to-limbus adjacent to the excision site (lower right). Cangkok terselip ke dalam ruang subconjunctival untuk memberikan efek antifibrotic untuk fasia Tenon, dari yang kambuh pterygium mungkin timbul (kiri atas); membran amniotik (merah) tidak mencakup cacat telanjang-scleral (kanan atas); Dari limbus unggul , autograft konjungtiva dipotong bebas dari limbus superior (kiri bawah); Para autograft konjungtiva gratis terbalik pada kornea (epitel permukaan catatan kuning graft ditunjukkan terhadap epitel kornea) dan berorientasi limbus-ke-limbus berdekatan dengan situs eksisi (kanan bawah). Application of conjunctival autograft: The conjunctival autograft, which remains attached to the superior limbus, is now reflected onto the cornea (epithelium to epithelium) and cut free from the superior limbus with scissors (Figure 2). Aplikasi autograft konjungtiva: The autograft konjungtiva, yang tetap melekat pada limbus unggul, sekarang tercermin ke kornea (epitel pada epitel) dan memotong bebas dari limbus unggul dengan gunting (Gambar 2). The surgeon slides this graft across the cornea, orienting its limbal side to the limbus where the

pterygium was excised (Figure 3). Dokter bedah cangkok slide ini di kornea, orientasi sisi limbal untuk limbus mana pterygium itu dipotong (Gambar 3). A small droplet from the diluted thrombin syringe (black label) is applied to the bare sclera (Figure 3), and a small droplet from the fibrinogen (blue label) syringe is applied to the underside of the graft. Sebuah tetesan kecil dari jarum suntik trombin diencerkan (label hitam) diterapkan untuk sclera telanjang (Gambar 3), dan tetesan kecil dari fibrinogen (biru label) jarum suntik diterapkan untuk bagian bawah graft. The graft is then grasped with two MacPherson forceps and flipped onto the bare sclera. Cangkok tersebut kemudian digenggam dengan dua tang MacPherson dan membalik ke sklera telanjang. This allows the two adhesive components to mix, and the surgeon has about 30 seconds to manipulate and orient the graft appropriately, such that the edges of the graft are approximated with the cut-edges of the surrounding conjunctiva and the corneal margin is aligned with the limbus (Figure 3). Hal ini memungkinkan dua komponen perekat untuk campuran, dan ahli bedah memiliki sekitar 30 detik untuk memanipulasi dan mengarahkan korupsi tepat, sehingga tepi graft yang didekati dengan memotong-tepi konjungtiva sekitarnya dan margin kornea sejajar dengan limbus (Gambar 3).

Thrombin (black label vial) diluted with balanced salt solution is placed on the excision site, and fibrinogen (blue label vial) is placed on the stromal side of the autograft (upper row); The conjunctival autograft is inverted, mixing the adhesive components, and smoothed to approximate the edges of conjunctiva (lower row). Trombin (botol label hitam) diencerkan dengan larutan garam seimbang ditempatkan di situs eksisi, dan fibrinogen (botol label biru) ditempatkan pada sisi stroma dari (baris atas) autograft; ini autograft konjungtiva terbalik, pencampuran komponen perekat, dan merapikan untuk mendekati tepi konjungtiva (baris bawah). Surgical pearls and tips Bedah mutiara dan tips

Conservative use of cautery avoids postoperative pain and is usually sufficient, as the fibrin adhesive provides additional hemostasis. Menggunakan kauter konservatif

menghindari nyeri pasca operasi dan biasanya cukup, sebagai perekat fibrin menyediakan hemostasis tambahan. Dilution of one part thrombin with nine parts balanced salt solution slows the polymerization process with fibrin adhesive and allows more time for manipulation of the graft. Pengenceran satu bagian trombin dengan sembilan bagian solusi yang seimbang garam memperlambat proses polimerisasi dengan fibrin perekat dan memungkinkan lebih banyak waktu untuk manipulasi korupsi. Harvesting a thin conjunctival autograft is best accomplished by making a small opening in the conjunctiva distal to the limbus and then lifting the cut-edge of the conjunctiva (with minimal Tenon's membrane) using toothed forceps. Memanen autograft konjungtiva tipis paling baik dilakukan dengan membuat lubang kecil di konjungtiva distal ke limbus dan kemudian mengangkat potongan-tepi konjungtiva (membran Tenon dengan minim itu) menggunakan tang bergigi. Blunt Westcott scissors can be inserted parallel to the conjunctival surface and then opened in the plane just below the conjunctiva to separate it away from the underlying tissues, namely most of Tenon's membrane. Westcott gunting tumpul dapat dimasukkan sejajar dengan permukaan konjungtiva dan kemudian dibuka di pesawat tepat di bawah konjungtiva untuk memisahkan diri dari jaringan di bawahnya, yaitu sebagian besar membran Tenon itu. The conjunctival autograft should match the size of the conjunctival opening after pterygium excision and should not be significantly oversized or contain excessive Tenon's membrane to avoid any significant tissue swelling after surgery. Autograft konjungtiva harus sesuai dengan ukuran pembukaan konjungtiva setelah eksisi pterygium dan tidak harus secara signifikan besar atau mengandung membran Tenon berlebihan untuk menghindari pembengkakan jaringan yang signifikan setelah operasi. Once the conjunctival autograft is in place covering the bare sclera with its edge properly approximated (as described above) and the two components of the fibrin glue begin to mix, the surgeon should avoid unnecessary touching of the graft or surrounding conjunctiva, as this will usually weaken the bonds of the fibrin adhesive and may result in suboptimal attachment of the conjunctival autograft. Setelah autograft konjungtiva di tempat meliputi sclera kosong dengan benar diperkirakan tepi (seperti dijelaskan di atas) dan dua komponen lem fibrin mulai campuran, ahli bedah harus menghindari menyentuh yang tidak perlu dari korupsi atau konjungtiva sekitarnya, karena hal ini biasanya akan melemahkan "ikatan" dari perekat fibrin dan dapat mengakibatkan dalam lampiran suboptimal autograft konjungtiva. During the postoperative follow-up period, a small gap at the nasal edge of the graft may occasionally occur. Selama masa tindak lanjut pasca operasi, celah kecil di ujung hidung graft sesekali mungkin terjadi. This does not increase the risk of recurrence of the pterygium. Ini tidak meningkatkan risiko kekambuhan dari pterygium tersebut.

Treatment Pengobatan Postoperative follow-up and drug regimen: Zymar ophthalmic solution (gatifloxacin, Allergan), one drop four times a day, and Xibrom (bromfenac ophthalmic solution, Ista Pharmaceuticals), one drop twice a day, are used for 1 week after surgery. Tindak lanjut pasca operasi dan obat rejimen: Zymar oftalmik solusi (gatifloksasin, Allergan), satu tetes empat kali sehari, dan Xibrom (bromfenac oftalmik solusi, Ista Farmasi), satu tetes dua kali sehari, digunakan untuk 1 minggu setelah operasi. Pred Forte 1% drops (prednisolone acetate,

Allergan) are used four times a day for 2 weeks, and then tapered off over the following 2 weeks. Pred Forte tetes 1% (asetat prednisolon, Allergan) digunakan empat kali sehari selama 2 minggu, dan kemudian pergi meruncing selama 2 minggu berikutnya. For more information: Untuk informasi lebih lanjut: John A. Hovanesian, MD, FACS, is a clinical instructor at the UCLA Jules Stein Eye Institute and is in private practice in Laguna Hills, Calif. He can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; e-mail: drhovanesian@harvardeye.com . John A. Hovanesian, MD, FACS, merupakan instruktur klinis di UCLA Jules Stein Eye Institute dan dalam praktek swasta di Laguna Hills, California Dia dapat dihubungi di Harvard Associates Mata, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653, 949-9512020, faks: 949-380-7856, e-mail: drhovanesian@harvardeye.com . Dr. Hovanesian is a consultant to Allergan, Baxter AG, IOP Inc. and Ista Pharmaceuticals. Dr Hovanesian adalah konsultan untuk Allergan, Baxter AG, TIO Inc dan Ista Farmasi. Thomas John, MD, is a clinical associate professor at Loyola University at Chicago and is in private practice in Tinley Park and Oak Lawn, Ill. He can be reached at 708-429-2223; fax: 708-429-2226; e-mail: tjcornea@gmail.com . John Thomas, MD, adalah seorang profesor klinis di Universitas Loyola di Chicago dan dalam praktek swasta di Tinley Park dan Oak Lawn, Illinois Dia dapat dihubungi di 708-429-2223; fax: 708-429-2226, e- mail: tjcornea@gmail.com . Dr. John has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned. Dr John tidak memiliki kepentingan keuangan langsung dalam produk-produk yang dibahas dalam artikel ini, atau dia seorang konsultan dibayar untuk setiap perusahaan yang disebutkan.

References: Referensi: Chui J, Di Girolamo N, Wakefield D, Coroneo MT. Chui J, N Di Girolamo, Wakefield D, Coroneo MT. The pathogenesis of pterygium: Current concepts and their therapeutic implications. Ocul Surf . Patogenesis pterygium: konsep Lancar dan implikasi terapi mereka Surf Ocul.. 2008;6:2443. 2008; 6:24-43. De la Hoz F, Montero JA, et al. De la Hoz F, Montero JA, dkk. Efficacy of mitomycin C associated with direct conjunctival closure and sliding conjunctival graft for pterygium surgery. Br J Ophthalmol . Keampuhan mitomycin C terkait dengan penutupan konjungtiva langsung dan geser graft konjungtiva untuk operasi pterygium. Br J Ophthalmol. 2008;92:175-178. 2008; 92:175-178. Hovanesian JA, Behesnilian A. Results of pterygium excision using amniotic membrane beneath the healthy conjunctiva surrounding a conjunctival autograft. Hovanesian JA, Behesnilian A. Hasil eksisi pterygium menggunakan membran ketuban di bawah konjungtiva sehat mengelilingi autograft konjungtiva. Presented at: Annual Meeting of the American Society of Cataract and Refractive Surgery; 2008; Chicago. Disampaikan pada: Rapat Tahunan American Society of Katarak dan bias; 2008; Chicago.

Kenyon KR, Wagoner MD, Hettinger ME. Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-1470. Konjungtiva autograft transplantasi untuk pterygium maju dan berulang Ophthalmology 1985;. 92:1461-1470. Ma DH, See LC, Liau SB, Tsai RJ. Ma DH, Lihat LC, Liau SB, Tsai RJ. Amniotic membrane graft for primary pterygium: Comparison with conjunctival autograft and topical mitomycin C treatment. Br J Ophthalmol . Cangkok membran amnion untuk pterygium utama:. Perbandingan dengan autograft konjungtiva dan mitomycin pengobatan topikal C Br J Ophthalmol. 2000;84:973-978. 2000; 84:973-978. Memarzadeh F, Fahd AK, Shamie N, Chuck RS. Memarzadeh F, Fahd AK, Shamie N, Chuck RS. Comparison of de-epithelialized amniotic membrane transplantation and conjunctival autograft after primary pterygium excision. Eye . Perbandingan de-epithelialized transplantasi membran amnion dan autograft konjungtiva setelah eksisi pterygium primer. Mata. 2008;22:107-112. 2008; 22:107-112.

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