Introduction to pterygium
In order to understand about laser pterygium removal, one must first understand what a pterygium is. Pterygium is a common disease of the external surface of the eye, characterized by fibrovascular growth that emerges from the conjunctiva and extends toward the cornea. The prevalence rates of pterygium range between 3% and 19.5% depending on geographic location. There is a higher rate among men and in countries closer to the equator. Surgical removal of the pterygium is the main treatment.
Surgical methods for treating pterygium
The surgical techniques can be divided into three main types: (1) the bare sclera technique, in which no tissue transplantation is used after excision of the pterygium, (2) simple closure, and (3) the tissue transplantation technique. In the tissue transplantation technique, a conjunctival autograft, a limbal conjunctival autograft, or an amniotic membrane transplant is used to cover the area from which the pterygium was excised. The surgery is minimally invasive.
Recurrent pterygium – what are the chances?
The recurrence rate can reach 88% in certain populations and depends on the surgical technique. The risk of recurrence after pterygium surgery is influenced by several factors, including patient-related factors such as age, ethnicity and pterygium morphology, and surgeon-related factors such as surgical experience and the surgical techniques. A large meta-analysis study showed that the bare sclera technique increases the risk of recurrence after surgery by 6 to 25 times compared with the tissue transplantation technique. Among the tissue transplantation options, autograft transplantation is associated with a lower risk of recurrence than the use of an amniotic membrane, and patients with recurrent pterygium are at lower risk of recurrence when they receive an autograft than an amniotic membrane. The use of conjunctival autograft transplantation also lowers the chances of complications and gives a better cosmetic result. In addition to the chosen surgical technique, the activity of the conjunctival fibroblasts during wound healing after pterygium surgery is considered the main factor contributing to the development of recurrence, and hence minimal inclusion of Tenon's tissue, which is composed of fibroblasts, during creation of the autograft can minimize recurrence. However, the surgery of a Tenon-free autologous conjunctival graft is highly dependent on surgical skills and can take a long time, especially for beginner surgeons.
Is laser pterygium removal possible?
In order to answer this question, one must first understand which laser is being referred to. Femtosecond lasers are widely used in ophthalmology for refractive surgery (laser vision correction), cataract surgery, and for corneal transplantation. The use of a laser allows more precise capsulotomy in cataract surgery, more precise flaps in vision-correction surgery, and a stronger attachment during corneal transplants. Recently, several studies have described the use of the femtosecond laser in pterygium removal surgeries. In fact, a technique has been described in which a high-frequency, low-energy femtosecond laser is used for the step of preparing the autologous conjunctival graft in pterygium surgery. The results showed that the laser enabled precise and reliable preparation of the autologous conjunctival graft with an especially thin graft (ranging around 60 microns). The technique was independent of the surgeons' experience. In the studies in question, autologous grafts for surgery were obtained consistently, and no intraoperative complications such as holes or buttonholes in the tissue occurred. With the growing popularity of femtosecond lasers in anterior segment surgery of the eye, laser-assisted preparation of an autologous conjunctival graft with a femtosecond laser could be an additional application in centers already equipped with a laser.
Can laser pterygium removal be performed in Israel, and is it worthwhile?
The studies consistently show that in order to achieve the best cosmetic results and to lower the chance of recurrence, it is advisable to perform pterygium removal surgery combined with an autologous conjunctival graft. Harvesting the graft can be done with a laser or manually. Using a laser involves a higher cost that is probably not justified, since the conjunctival harvesting can be done manually as long as it is performed in skilled hands. There are no large, prospective studies that have examined the long-term results of using a laser for conjunctival graft harvesting, and therefore at this stage we recommend avoiding the unnecessary additional expense.
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