_surgery with sutured conjunctival autografts缝合结膜移植治疗翼状胬肉课件

Pterygium Surgery with Pterygium Surgery with Sutured Conjunctival Sutured Conjunctival AutograftsAutografts David S. Rootman, MD, FRCSCDavid S. Rootman, MD, FRCSC Associate Professor, University of Associate Professor, University of TorontoToronto Why Sutures When We Can Why Sutures When We Can Glue?Glue? l l More secure fixation of autograftMore secure fixation of autograft l l Less likely to dislocateLess likely to dislocate l l Stretches out a smaller autograftStretches out a smaller autograft l l Long track recordLong track record l l No bovine or foreign blood productsNo bovine or foreign blood products l l Less messyLess messy l l Good suturing practiceGood suturing practice l l Less expensiveLess expensive Disadvantages of SuturesDisadvantages of Sutures l l Takes longerTakes longer l l More difficultMore difficult l l Sutures irritate patientSutures irritate patient l l More likelihood of bleedingMore likelihood of bleeding l l May have to remove suturesMay have to remove sutures Seven Principles of ProcedureSeven Principles of Procedure 1.1.Smooth partial keratectomySmooth partial keratectomy 2.2.Release of Tenons capsule constrictionRelease of Tenons capsule constriction 3.3.Thin autograftThin autograft 4.4.Alignment of graft Alignment of graft 5.5.Secure suturing of graftSecure suturing of graft 6.6.Bandage contact lensBandage contact lens KeratectomyKeratectomy l l As described by Richard AbbottAs described by Richard Abbott l l 7-0 Silk fixation suture7-0 Silk fixation suture l l Inject under pterygium with 1% xylo with Inject under pterygium with 1% xylo with epiepi l l Angled cut at anterior edge of pterygiumAngled cut at anterior edge of pterygium l l Smooth dissection in anterior stromaSmooth dissection in anterior stroma l l Removal of all scar tissue on corneaRemoval of all scar tissue on cornea l l Similar to making a phaco scleral tunnelSimilar to making a phaco scleral tunnel KeratectomyKeratectomy Release of Tenons CapsuleRelease of Tenons Capsule l l Do not over dissectDo not over dissect l l Release medial rectus on both sidesRelease medial rectus on both sides l l Allow conjuctiva to slide back to caruncleAllow conjuctiva to slide back to caruncle l l Mark extent of excisionMark extent of excision l l Minimal removal of conjunctivaMinimal removal of conjunctiva l l Stay away from caruncle Stay away from caruncle Autograft harvestingAutograft harvesting l l Measure area of resectionMeasure area of resection l l Pull eye downwardPull eye downward l l Use Gentian violet to mark areaUse Gentian violet to mark area l l Central mark to help orientationCentral mark to help orientation l l Rhomboidal shape, wider at posterior Rhomboidal shape, wider at posterior edgeedge l l Make graft as thin as possibleMake graft as thin as possible Meaure autograftMeaure autograft Alignment of GraftAlignment of Graft l l Slide conjunctiva on cornea, Tenon upSlide conjunctiva on cornea, Tenon up l l Appose limbal cells to limbus at site of Appose limbal cells to limbus at site of excisionexcision l l Secure with 10-0 monofilament vicrylSecure with 10-0 monofilament vicryl l l Turn graft over after secured at limbusTurn graft over after secured at limbus Suturing of AutograftSuturing of Autograft l l Secure in all four corners with scleral biteSecure in all four corners with scleral bite l l Avoid medial rectus to minimize bleedingAvoid medial rectus to minimize bleeding l l Close nasal conjuntiva to conjunctiva of Close nasal conjuntiva to conjunctiva of graft, no scleral bite heregraft, no scleral bite here l l Close edge to edge superiorly and Close edge to edge superiorly and inferiorlyinferiorly l l No exposed Tenon capsule, prevents No exposed Tenon capsule, prevents granulomagranuloma l l Do not advise running sutureDo not advise running suture Bandage Contact lensBandage Contact lens l l Apply at end of procedureApply at end of procedure l l More comfort for patientMore comfort for patient l l No patch neededNo patch needed l l Leave on for 2 weeksLeave on for 2 weeks l l Lessens chance of DellenLessens chance of Dellen l l Steroids for 6 weeks qid or until eye whiteSteroids for 6 weeks qid or until eye white ComplicationsComplications l l RecurrenceRecurrence l l InflammationInflammation l l Melting (more common with Mito C)Melting (more common with Mito C) l l InfectionInfection l l BleedingBleeding l l DellenDellen l l GranulomaGranuloma RecurrenceRecurrence InflammationInflammation NecrosisNecrosis InfectionInfection DellenDellen ConclusionsConclusions l l Pterygium excision with conjunctival flap is Pterygium excision