Once potential sources of inflammation have been identified and treated, the sutureless TissueTuck Technique with AmnioGraft can be effectively utilized.
I’ve been using this technique for 3 years in more than 500 ocular surface cases, with a less than 1% recurrence rate. The technique is designed with four
key goals in mind:
- minimize surgical trauma
- minimize iatrogenic and postoperative inflammation
- seal the site of origination of recurrence in the potential space between resected conjunctiva and Tenon’s fascia (“the gap”)
- recreate the semi-lunar fold.
The technique is performed under topical and local anesthesia, using lidocaine jelly and an intraoperative subconjunctival injection of 2% lidocaine with
epinephrine to begin the case. The lido-epi solution is injected, starting just adjacent to the pterygium and directed under it to separate natural tissue
planes and lift the pterygium from sclera. This allows for easy blunt dissection down to bare sclera along these identifiable planes while minimizing
bleeding and trauma during pterygium removal. Liberal use of the lido-epi mixture also helps me to identify and avoid the rectus muscle, which I pull tight
to the globe by placing the globe in abduction with a corneal traction suture.
After the bulk of the head and body have been resected, leaving bare sclera and intact muscle sheath, attention is directed to the peripheral edges of the
bed and the remaining Tenon’s and fibrovascular tissue. With the goal of creating a clear 2-3 mm zone perimeter of normal conjunctiva, Tenon’s and
remaining fibrovascular tissue are pulled anteriorly from under the conjunctiva and completely resected. Since Tenon’s has the natural tendency to recess
itself, pulling the tissue forward, resecting and recessing will produce the desired clear perimeter of conjunctiva. Next, bipolar cautery is used to
cauterize the band of Tenon’s, fibrovascular tissue and prolapsed orbital fat in the posterior and nasal aspects of the so-called “gap” between Tenon’s and
the resected conjunctival rim. This gap is where the fibrovascular stalk of primary and recurrent pterygia originates. Cauterization produces further
contracture and sealing of the gap and further recession of fibrovascular tissue, essential steps to prevent recurrence. The contracture also creates a
clear rim for reconstruction of the semi-lunar fold, which is often obliterated and flattened by a pterygium. It’s important to avoid cauterization of the
muscle belly, overlying conjunctival rim or overly aggressive cauterization of the scleral bed, which might produce a scleral melt, particularly if
Mitomycin C is used. I selectively use Mitomycin C 0.02% for aggressive or recurrent pterygia or in cases in which the patient’s ethnicity or occupation
would make him or her prone to recurrence. In such cases, a trimmed soaked pledget is placed only in the gap for 20-30 seconds, avoiding unnecessary
exposure to the scleral bed. The eye is thoroughly rinsed with BSS.
At this point, the AmnioGraft membrane is brought into the field and trimmed to size. I start with a 15 x 20 mm graft and trim to the general shape of the
exposed bed, while aiming to oversize the graft by at least 2-3 mm to allow for adequate tissue for tucking and re-creation of the semi-lunar fold. The
graft can be peeled and placed stromal side down on the cornea so that it can easily be grasped by its edges, dragged and tucked into position once the
fibrin-thrombin glue is placed. When placing glue it is important to remember that less is more. Three drops of thrombin and three drops of fibrin are
usually sufficient to allow for tissue adherence. One wants to avoid excess glue, as this tends to accumulate in, and tent open, the very gap we aim to
seal, allowing for granuloma formation or recurrence. The graft is then slid over the bed to coat the stromal side with glue and placed overlapping the
edge of the conjunctival rim and intended semi-lunar fold. Curved tying forceps can then be used to tuck this tissue under the conjunctival rim and deep
into the gap. Once this “tissue tuck” has been performed along the entire new semi-lunar fold, the forceps are used to pinch the edge of conjunctival rim
to the folded and tucked tissue to seal and create a wide margin of contact. The glue should then be squeegeed only in an anterior direction toward the
limbus to avoid pushing glue into the gap. Excess glue and tissue can then be trimmed.
A bandage contact lens (BCL) is typically placed to protect the anterior edge of tissue. Subconjunctival injections of cefazolin and dexamethasone are
placed just adjacent to the surgical site. The entire procedure takes 10-15 minutes. My postoperative regimen typically includes difluprednate 0.05%
(Durezol, Alcon) QID for the first week and tapering over 4 weeks, and an antibiotic QID for the week until the BCL is removed. Contrary to prior
experiences using other techniques, patients report little to no pain and hence no NSAID is routinely prescribed.
Since this sutureless technique depends on careful and deliberate placement of tissue, it’s critical to have a tissue graft that can be easily manipulated
and tucked into position without tearing. I specifically prefer the cryopreserved tissue unique to AmnioGraft because it retains remarkable intraoperative
resilience and workability and preserves the key biologically active molecules in the amniotic membrane responsible for its pro-healing, anti-inflammatory,
anti-angiogenic and anti-fibrotic actions. Avoiding sutures and the use of autografts, the sutureless TissueTuck Technique aims for time-saving efficiency
while avoiding iatrogenic sources of irritation, inflammation and trauma.