Slide 1 2003 By Default Contemporary Techniques in

Slide 1 © 2003 By Default! Contemporary Techniques in the Management of Primary and Recurrent Pterygium ALLAN R. SLOMOVIC , MA, MD, FRCS(C) *ASSOCIATE PROFESSOR, OPHTH, UNIVERSITY HEALTH NETWORK *RESEARCH DIRECTOR, CORNEA SERVICE, UHN *CHAIRPERSON, CONTINUING PROFESSIONAL DEVELOPMENT, CANADIAN OPHTHALMOLOGICAL SOCIETY A Free sample background from www. awesomebackgrounds. com

Slide 2 © 2003 By Default! TISSUE GLUE n THE AUTHOR HAS NO FINANCIAL INTEREST IN THE PRODUCTS DISCUSSED IN THIS PRESENTATION n Alcon – Paid consultant n Allergan- Paid consultant n Bausch and Lomb- Paid consultant n AMO – Research assistance A Free sample background from www. awesomebackgrounds. com

Slide 3 © 2003 By Default! 2 COMPELLING REASONS WHY IT IS IMPORTANT FOR THE COMPREHENSIVE OPHTHALMOLOGIST TO KNOW HOW TO MANAGE PTERYGIA n 1. IT IS A COMMON CONDITION, ESPECIALLY IN ISRAEL, WHICH CAN ADVERSELY EFFECT YOUR PATIENT’S QUALITY OF LIFE eg REDUCED VISION, CHRONIC OCULAR IRRITATION AND REDNESS n 2. EFFECTIVE SURGICAL MANAGEMENT IS AVAILABLE A Free sample background from www. awesomebackgrounds. com

Slide 4 © 2003 By Default! DEFINITION n “A TRIANGULAR-SHAPED GROWTH CONSISTING OF CONJUNCTIVAL EPITHELIUM AND HYPERTROPHIED SUBCONJUNCTIVAL CONNECTIVE TISSUE, OCCURRING MEDIALLY AND LATERALLY IN THE INTERPALPEBRAL FISSURE AND ENCROACHING ON THE CORNEA. ” – Mark Mannis- Ocular Surface Disease 2002 n A Free sample background from www. awesomebackgrounds. com Greek “pterygos” =a small wing

Slide 5 © 2003 By Default! DIFFERENTIAL DIAGNOSIS A Free sample background from www. awesomebackgrounds. com n PINGUECULA n SIMILAR IN HISTOLOGY AND PERHAPS A PRECURSOR. n DISTINGUISHED BY- 1. DOES NOT INVOLVE THE CORNEA 2. -THE UNDERLYING FIBROVASCULAR TISSUE ARE NOT RADIALLY ORIENTED TOWARDS THE CORNEAL APEX

Slide 6 © 2003 By Default! INFLAMMED PINGUCULA n RECURRENT BOUTS OF INFLAMMATI ON

Slide 7 © 2003 By Default! PSEUDOPTERYGIUM n A CONJUNCTIVAL FIBROVASCULAR SCAR OCCURRING 2 y TO – MECHANICAL OR CHEMICAL TRAUMA, – PERIFERAL DEGENERATIONS (EG, MOOREN’S ULCER) A Free sample background from www. awesomebackgrounds. com

Slide 8 © 2003 By Default! INDICATIONS FOR SURGERY: 1. ABSOLUTE 1. INVOLVES OR THREATENS THE VISUAL AXIS n 2. REDUCED VISION FROM REGULAR/ IRREGULAR ASTIGMATISM n 3. DIPLOPIA FROM TRACTION ON E. O. M. (ESP IN PRIMARY GAZE) n A Free sample background from www. awesomebackgrounds. com

Slide 9 © 2003 By Default! INDICATIONS FOR SURGERY: RELATIVE A Free sample background from www. awesomebackgrounds. com n 1. CHRONIC IRRITATION n 2. COSMETIC n 3. CONTACT LENS INTOLERANCE OR WISHING REFRACTIVE SURGERY

Slide 10 © 2003 By Default! OPERATIVE TECHNIQUE n Anaesthetic: topical tetracaine and subconj lidocaine n Traction suture, if necessary n Mark conjunctival portion pterygium A Free sample background from www. awesomebackgrounds. com

Slide 11 © 2003 By Default! OPERATIVE TECHNIQUE A Free sample background from www. awesomebackgrounds. com n 57 BEAVER BLADE IS USED TO DISSECT THE HEAD & NECK OF PTERYGIUM BACK TO LIMBUS n COMPLETE REMOVAL OF ALL PTERYGIUM TISSUE AT BOWMAN’S MEMBRANE WHICH HELPS TO MINIMIZE POSTOP SCARRING AND ASTIGMATISM

Slide 12 © 2003 By Default! OPERATIVE TECHNIQUE n A Free sample background from

Slide 13 © 2003 By Default! OPERATIVE TECHNIQUE n A Free sample background from

Slide 14 © 2003 By Default! OPERATIVE TECHNIQUE n A Free sample background from

Slide 15 © 2003 By Default! OPERATIVE TECHNIQUE A Free sample background from www.

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Slide 23 © 2003 By Default! 1 week 1 month 3 months A Free

Slide 24 © 2003 By Default! “Fibrin Glue Versus Sutures for Attaching the Conjunctival Autograft during Primary Pterygium Surgery” BJO 2008 S Srinivasan, M Dollin, P Mc. Allum, Y Berger, D S Rootman, A R Slomovic 40 eyes 40 patients 20 Tisseel; 20 10 -0 vicryl Results: n n n 1. 2. n – “ The degree of postoperative inflammation was significantly less in eyes undergoing pterygium surgery with fibrin glue at 1 and 3 mospotoperatively (p=0. 19) “ “Conjunctival grafts secured with fibrin glue were as stable as those obtained with sutures” Conclusion: “This is the 1 st prospective clinical study to demonstrate that the conjunctival graft secured with fibrin glue during pterygium surgery are not only as stable as those obtained with sutures, but also produce significantly less inflammation at 1 and 3 months postoperatively” A Free sample background from www. awesomebackgrounds. com

Slide 25 © 2003 By Default! Application of Fibrin Glue to Conjunctival Autograft During Primary Pterygium surgery. ASCRS 2007 Sathish Srinivasan, Allan Slomovic A Free sample background from www. awesomebackgrounds. com

Slide 26 © 2003 By Default! Results n Single center retrospective chart review Medical records of 65 eyes of 62 patients underwent primary pterygium surgery with fibrin glue over a 5 month period (between April to September 2005). n 30 / 62 (46%) were females. n The median age of this cohort was 53 years (range 31 -81 years). n The mean follow-up time was (range 9 to 14 months). A Free sample background from www. awesomebackgrounds. com 9. 5 months

Slide 27 © 2003 By Default! RESULTS n There were no intraoperative complications. n Post operatively conjunctival graft displacement was noted in 2/65 eyes (3. 1%). n At 9 ½ months followup there was no evidence of recurrence that required repeat surgery. A Free sample background from www. awesomebackgrounds. com

Slide 28 © 2003 By Default! Management of Recurrent Pterygium with Intraoperative Mitomycin C and Conjunctival Autograft with Fibrin Glue AJO in print Raneen Shehadeh Mashor, MD; Sathish Srinivasan , MD; Corey Boimer; Kenneth Lee ; Oren Tomkins, MD; Allan R Slomovic , MD, MA, FRCSC ----------------------------------28 eyes 28 patients with recurrent pterygia who underwent P. E. C. A. – 0. 02% MMC for 2 minutes – Tisseel to adhere the conj autograft Conclusion: 1. 1 st published report P. E. C. A. using fibrin glue combined with intraoperative MMC 0. 02% 2. Safe and effective surgical option for treating recurrent pterygium. 3. Recurrence rate =3. 5% A Free sample background from www. awesomebackgrounds. com

Slide 29 © 2003 By Default! RECURRENCE RATE TISSEEL (2005) – N=65 eyes 0/65 RECURRENCESprimary Pterygium n 3. 5%- Recurrent Pterygium (AJO 2011) n POSTOP COMPLICATIONS n – GRAFT DISPLACEMENT-2 EYES A Free sample background from www. awesomebackgrounds. com SUTURES (9 -0 VICRYL) (1995) n=95 eyes 4% (2/52 EYES)- 1 e PTERYGIA n 10% (4/41 EYES)RECURRENT PTERYGIA n POST OP COMPLICATIONS n • NECROTIC GRAFT -2 EYES • DELLEN-1 EYE

Slide 30 © 2003 By Default! EYE RUBBING CAUSING CONJUNCTIVAL GRAFT DEHISCENCE FOLLOWING PTERYGIUM SURGERY WITH FIBRIN GLUE Eye (2007), 1– 3 n n n 2 out of a cohort of 65 eyes Instructed not to remove the eye pad for 24 hrs and not to rub eye for the 1 st 2 days Both patients admitted to premature removal of the eye pad and to intense rubbing of the eye from day 1 A Free sample background from www. awesomebackgrounds. com

Slide 31 © 2003 By Default! Pt no: 30, male, 47 yrs, graft displacement noted on day 4 post op, repositioned and secured with interrupted 10 -nylon sutures. Pt no: 43, 51 yrs male, graft displacement noted on day 5, graft refloated with glue and secured with 2 anchoring episcleral sutures. A Free sample background from www. awesomebackgrounds. com

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Slide 34 © 2003 By Default! CONCLUSION: Application of Fibrin Glue to Adhere the Conjunctival Autograft During Pterygium surgeryn Safe and Effective Method of Managing Both Primary and Recurrent Pterygia n TISSEEL OFFERS SEVERAL ADVANTAGES OVER SUTURES: 1. 2. 3. 4. 5. DECREASED PATIENT PAIN (OPERATIVE AND POSTOPERATIVE), REDUCED SURGICAL TIME SIGNIFICANT REDUCTION IN POSTOP INFLAMMATION, RECURRENCE RATE=0% MINOR AND CORRECTABLE POSTOPERATIVE COMPLICATIONS • 2 CONJUNCTIVAL GRAFT DISLOCATION- BOTH REPAIRED W/O RECURRENCE A Free sample background from www. awesomebackgrounds. com

Slide 35 © 2003 By Default! n EXTRA SLIDES A Free sample background from

Slide 36 © 2003 By Default! Tisseel kit-2. Duplojet Injector Syringe A Free sample

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Tisseel Slide 38 A commercial human fibrin glue n Used in other areas of Medicine (neuro-surgery, cardiology, orthopedics, urology, ENT) and Ophthalmology (Glaucoma, Strabismus, Refractive Surgery) n Properties: sealing, gluing and hemostasis n – Compelling case for using Tisseel in pterygium management A Free sample background from www. awesomebackgrounds. com © 2003 By Default!

Slide 39 © 2003 By Default! TISSUE GLUE OFF LABEL USE n EVIDENCE-BASED INFORMATION IN PEER-REVIEWED JOURNALS HAVE DOCUMENTED THE ADVANTAGES OF USING TISSUE GLUE IN THE CONTEXT OF PTERYGIUM MANAGEMENT n A Free sample background from www. awesomebackgrounds. com

Slide 40 © 2003 By Default! ADVANTAGE OF USING TISSEEL IN PECA 1. LESS PAIN n INTRAOPERATIVENO SUTURES ARE PLACED n POSTOPERATIVE – NO NEED TO REMOVE SUTURES 2. FASTER 3. Less Inflammation… perhaps decreased recurrence rate A Free sample background from www. awesomebackgrounds. com

Slide 41 © 2003 By Default! Tisseel Glue Contains two of the components that makes the blood clot: Fibrinogen and Thrombin 1. Sealant protein composed of human plasminogen, fibrinonectin factor XIII reconstituted with human aprotinin. 2. Sealant setting solution composed of human thrombin reconstituted with calcium chloride. n A Free sample background from www. awesomebackgrounds. com

Slide 42 © 2003 By Default! Tisseel kit-2. Duplojet Injector Syringe A Free sample

Slide 43 © 2003 By Default! Safety Record of Tisseel n Human plasma pools are tested for presence of genome sequences of HIV, HBV and HCV n Tisseel is vapor-heated to inactivate viruses n No evidence of disease transmission » 33 YEARS OF USE » 50 COUNTRIES » 17 MILLION APPLICATIONS » 3500 PUBLICATIONS IN SURGICAL JOURNALS A Free sample background from www. awesomebackgrounds. com

Slide 44 © 2003 By Default! Tisseel - the kit n Choose SLOW setting time • 2 SETTING TIMES BASED ON THROMBIN CONCENTRATION n SLOW- allows 90 seconds placement and adjustment of the conjunctival graft, after tissue glue has been applied A Free sample background from www. awesomebackgrounds. com