Professor Lawrie Hirst
MBBS(QLD) DO(Melb) FRANZCO FRACS MD(QLD) MPH(Johns Hopkins)
CEO The Australian Pterygium Centre
Pterygia and pterygium surgery still remain problematic for many eye health-care providers. For optometrists, the question frequently is not whether the corneal lesion is a pterygium but rather, whether it needs to be removed. For general practitioners, the issue is often a matter of diagnosis with a pinguecula often being diagnosed as pterygium. For ophthalmologists, the issue is an ambivalence or uncertainty with respect to the results—especially how often the pterygium is likely to recur.
Most ophthalmologists do not follow their patients after pterygium surgery for long enough to have confidence in the end result.1 Our studies have shown that the patient must be followed for approximately one year to have a 97 per cent chance of picking up the earliest signs of recurrence.2 The average follow-up period by Queensland ophthalmologists is less than four months1 so that, at least in Queensland, most ophthalmologists cannot really state what their recurrence rate is.
As a result of these issues, it is no wonder that the patient is frequently confused by conflicting advice from the various eye health-care providers.
Over the past 10 years, this ‘murky’ situation has been clarified for optometrists who have been presented with pterygium patients in need of advice. The development of P.E.R.F.E.C.T. for PTERYGIUM3 has essentially been responsible for this clarification of issues.
With a recurrence rate of 1/1000 for primary pterygium removal,3 it is now possible to say with confidence to patients that they are very unlikely to develop a recurrence of their pterygium. Now that recurrence is no longer an issue, patients will want to know what the final appearance of the eye will be.
Positive results from studies
Two studies specifically addressing the post-operative cosmetic appearance of pterygium patients have revealed the following results.
In a masked study of nearly 300 eyes4—including a control set of unoperated eyes and eyes that have had a nasal primary pterygium removed using P.E.R.F.E.C.T. for PTERYGIUM—lay persons and corneal specialists used a specially-designed grading system to assess the appearance of subjects’ eyes. The graders looked at both operated and unoperated eyes and gave similar evaluations ranging from ‘normal appearance’ to ‘poor appearance’. Overall, nearly 95 per cent of the operated eyes were considered ‘fair’ or better, which is a grading that most patients would find cosmetically acceptable.
Even more impressive were the results of the second study.5 This study was designed to closely mimic a real-life situation where lay people were asked to look at a sequence of approximately 400 pairs of eyes—in other words, right and left eyes of the same patient where only one eye had a primary nasal pterygium removed. The lay people were able to tell which eye had had the surgery in fewer than 50 per cent of the pairs of eyes—no better than by chance. This strongly suggests that for most patients, the public cannot discern any difference in the cosmetic appearance of the eye that has had the surgery.
Figures 1A and 1B. Right eye and left eye before surgery
What does this mean for the practising optometrist?
It means that you can now have considerable confidence in sending your pterygium patient to a surgeon undertaking P.E.R.F.E.C.T. for PTERYGIUM.
In the past because of the high recurrence rate and the poor cosmetic appearance in many cases,6 referral was generally restricted to very large pterygia; pterygia restricting eye movement, pterygia with atypical appearances; very symptomatic pterygia unresponsive to drops; and pterygia affecting vision. To this list can now be added smaller pterygia that may be symptomatic but which are of significant cosmetic concern to the patient. Many of these patients are psychologically traumatised by the appearance of a constantly red eye. Not infrequently they are thought to be on drugs or hung over, which creates problems in the work place.
With P.E.R.F.E.C.T. for PTERYGIUM, these patients can now be given relief with the real expectation of an end result where their eye will look normal. In fact, frequently not only does it appear normal to the casual observer, but even at the slitlamp it may not be possible to identify that the eye has had surgery. If there are any residual changes at all at the slitlamp, it is most frequently a slight haze in the peripheral cornea underlying the original position of the corneal component of the pterygium, which cannot be avoided but is rarely perceptible to the naked eye.
Figures 2A and 2B. Right eye and left eye one year after P.E.R.F.E.C.T. for PTERYGIUM
Your first go is your best go
This surgery is not simple and it is not really possible to learn from reading a description alone or just watching a few surgeries—not dissimilar to phacoemulsification cataract surgery, which no-one in their wildest dreams would consider undertaking just by reading about it or even watching a few cases. So it is with P.E.R.F.E.C.T. for PTERYGIUM. Even experienced cataract surgeons will find this a serious undertaking with a steep learning curve. Proof of this is that an experienced cataract surgeon who may take 10 minutes for a phacoemulsification is likely to start off taking 90 minutes for their first P.E.R.F.E.C.T. for PTERYGIUM surgery.
The situation with recurrent pterygia is not as good. The recurrence rate is about 1/100, which is still far better than with any other surgery6 and the cosmetic result is not always as good. The moral of the story is ‘your first go is your best go’ and that surgery should be undertaken by a P.E.R.F.E.C.T. for PTERYGIUM surgeon.
- Sebban A, Hirst LW. Treatment of pterygia in Queensland. Aust N Z J Ophthalmol 1991; 19: 2: 123-127.
- Hirst LW, Sebban A, Chant D. Pterygium recurrence time. Ophthalmology 1994; 101: 4: 755-758.
- Hirst LW. Recurrence and complications after 1,000 surgeries using pterygium extended removal followed by extended conjunctival transplant. Ophthalmology 2012; 119: 11: 2205-2210.
- Hirst LW. Cosmesis after pterygium extended removal followed by extended conjunctival transplant as assessed by a new, web-based grading system. Ophthalmology 2011; 118: 9: 1739-1746.
- Hirst LW. Pterygium extended removal followed by extended conjunctival transplant: but on which eye? Cornea 2013; 32: 6: 799-802.
- Hirst LW. The treatment of pterygium. Surv Ophthalmol 2003; 48: 2: 145-80.