Insert a 15 mm solid blades Speculum (K1-5014 Katena), apply Epinephrine (1:1000) for hemostasis and 2% lidocaine gel (Astra Zeneca) for Topical Anesthesia P.S. Avoid peribulbar anesthesia which may distort the tissue plane

Place 7-0 Vicryl Traction Suture at the superior and inferior limbal sclera for adequate exposure and fixation of the globe

Excise pterygium head and body:

Use 0.12 forceps to pick up the conjunctiva in front of the semilunar fold (Fig. 1), and use scissors to make a conjunctival peritomy vertically. Then pick up the fibrovascular pterygium tissue toward the surgeon while using scissors to truncate it from the fornix. Without damaging the muscle, excise the Tenon from the sclera that is superior and inferior to the muscle. Remove the head and body of the pterygium from the cornea surface (Fig. 2).

Apply MMC (0.02% to 0.04%):

Cut thin strips from a Weckcel’s slant edges, soak them in the MMC solution, and apply approximately 2-3 sponges to subconjunctival fibrovascular tissue close to the fornix and above the tenon (Fig. 3). Before application, use a Q-tip to dry the bare sclera (Fig. 4). Then apply MMC strips for 2 min for mild, for 3 min for moderate, and 4 min for severe pterygium. Irrigate the contact surface with half a bottle of BSS after the incubation.

Identify & Seal the gap between the Conjunctiva and Tenon:

Use two 0.12 forceps: one to grab the conjunctival edge and the other for the underlying Tenon, to evaluate the extent of the gap, especially at the caruncle (Fig. 5A). This gap allows reinvasion (hemiation) of the residual fibrovascular tissue, giving rise to recurrence if left open.

Use 8-0 Vicryl running sutures for primary pterygium and 9-0 Nylon for recurrent pterygium when “sealing the gap” from the superior to the inferior fornix. The natural traction of the Tenon posteriorly facilitates the conjinctiva bending away from the sclera, which will reform the shape of the caruncle (Fig 5B).

Transplant Cryopreserved Amnion Graft with Fibrin Glue:

nitrocellulose paper. Lay it on the bare sclera with the sticky/stromal surface facing down. Flip one half of the graft up to cover the other half revealing the bare sclera.

Apply the fibrinogen oily/cloudy solution to the bare sclera and/or the stromal side of the graft. Next, apply the thrombin/watery/clear solution to the same area.

Using two 0.12 forceps to flip back the graft to re-cover the bare sclera. Stretch and flatten the graft with two forceps at different areas for a total of 45 sec before final smoothening by a muscle hook. Repeat the above steps to the other half of the membrane. Trim any excess membrane and fibrin glue from around the defect and then tuck the graft underneath the conjunctival edge and seal the conjunctiva over the graft with fibrin glue placed in between (Fig. 6).

Always check the adhesion strength at the edge of the graft by 0.12 forceps. If the graft detaches, do “touch up” by applying fibrin glue to the unsecured areas.

Figure 6

Additional Points:

• Minimize cauterization to blood vessels to avoid inflammation or ischemia.
• Engorged vessels are intrinsically normal and invariably regress.
• Avoid isolation of recti muscles by hook.
• It is not necessary to cover superficial corneal epithelial defect with the graft or a contact lens.
• Inject Kenalog in the surrounding host conjunctiva if it is too inflamed at the end of surgery.

Dr. Tseng, received his MD from National Taiwan University Medical School in 1978, and his PhD from University of California San Francisco in 1981. He completed the ophthalmology residency at Johns Hopkins Hospital in 1984 and the cornea and external disease fellowship at Massachusetts Eye & Ear Infirmary, Harvard Medical School, in 1986. He then was as a Charlotte Breyer Rodgers chair professor at Bascom Palmer Eye Institute University of Miami School of Medicine until 2002, when he resigned to assume the position as medical director of the Ocular Surface Center and the Ocular Surface Research & Education Foundation. He served as the first President of International Ocular Surface Society from 2000 to 2004, ad hoc members of NIH study sections from 2002, and the editorial board of Ocular Surface Journal and Cornea Journal. He has given several named lecture such as Ulrich Ollendorff Lecture (1999), Marvin Henry MD Memorial Lecture (2003), Kersley Lecture (2004), Oliver H. Dabezies Jr. M.D. Lecture (2005), James E. McDonald, M.D. Keynote Lecture (2005), Susrata Lecture (2006), and 60 th Japanese Clinical Ophthalmology Congress Keynote Lecture (2006), and received several honors and awards such as Chancellor Award (2002), Senior Achievement Award (2004, and Secretariat Award (2005) from American Academy of Ophthalmology. Dr. Tseng is specialized in ocular surface diseases and reconstruction using new surgical techniques of epithelial stem cell transplantation and amniotic membrane transplantation. He is also the R & D Director, leading a research team of 12 people in Bio-tissue/TissueTech, the leading tissue engineering company in Ophthalmology in the USA.