1. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 1 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

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

3. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 3 2 COMPELLING REASONS WHY IT IS IMPORTANT FOR THE COMPREHENSIVE OPHTHALMOLOGIST TO KNOW HOW TO MANAGE PTERYGIA 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 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 2. EFFECTIVE SURGICAL MANAGEMENT IS AVAILABLE 2. EFFECTIVE SURGICAL MANAGEMENT IS AVAILABLE

4. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 4 DEFINITION “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.” “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 Greek “pterygos” =a small wing Greek “pterygos” =a small wing

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

6. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 6 INFLAMMED PINGUCULA RECURRENT BOUTS OF INFLAMMATI ON RESULT IN PTERYGIUM FORMATION RECURRENT BOUTS OF INFLAMMATI ON RESULT IN PTERYGIUM FORMATION

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

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

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

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

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

12. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 12 OPERATIVE TECHNIQUE UNDERMINE THE CONJUNCTIVAL PORTION OF THE PTERYGIUM WITH BLUNT WESCOTT SCISSORS UNDERMINE THE CONJUNCTIVAL PORTION OF THE PTERYGIUM WITH BLUNT WESCOTT SCISSORS

13. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 13 OPERATIVE TECHNIQUE SHARP DISSECTION OF CONJUNCTIVAL PORTION OF PTERYGIUM SHARP DISSECTION OF CONJUNCTIVAL PORTION OF PTERYGIUM

14. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 14 OPERATIVE TECHNIQUE POLISH/SMOOTH THE LIMBUS WITH BEAVER BLADE OR DIAMOND DUSTED BURR POLISH/SMOOTH THE LIMBUS WITH BEAVER BLADE OR DIAMOND DUSTED BURR

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

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24. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 24 “Fibrin Glue Versus Sutures for Attaching the Conjunctival Autograft during Primary Pterygium Surgery” BJO 2008 S Srinivasan, M Dollin, P McAllum, Y Berger, D S Rootman, A R Slomovic 40 eyes 40 patients 40 eyes 40 patients 20 Tisseel; 20 10-0 vicryl 20 Tisseel; 20 10-0 vicryl Results: Results: 1. “ The degree of postoperative inflammation was significantly less in eyes undergoing pterygium surgery with fibrin glue at 1 and 3 mospotoperatively (p=0.19) “ 2.“Conjunctival grafts secured with fibrin glue were as stable as those obtained with sutures” Conclusion: 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 post- operatively”

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

26. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 26 Results Single center retrospective chart review 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). 30 / 62 (46%) were females. 30 / 62 (46%) were females. The median age of this cohort was 53 years (range 31-81 years). The median age of this cohort was 53 years (range 31-81 years). The mean follow-up time was 9.5 months (range 9 to 14 months). The mean follow-up time was 9.5 months (range 9 to 14 months).

27. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 27RESULTS There were no intraoperative complications. There were no intraoperative complications. Post operatively conjunctival graft displacement was noted in 2/65 eyes (3.1%). Post operatively conjunctival graft displacement was noted in 2/65 eyes (3.1%). At 9 ½ months followup there was no evidence of recurrence that required repeat surgery. At 9 ½ months followup there was no evidence of recurrence that required repeat surgery.

28. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 28 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%

29. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 29 RECURRENCE RATE TISSEEL (2005) –N=65 eyes 0/65 RECURRENCES- primary Pterygium 0/65 RECURRENCES- primary Pterygium 3.5%- Recurrent Pterygium (AJO 2011) 3.5%- Recurrent Pterygium (AJO 2011) POSTOP COMPLICATIONS POSTOP COMPLICATIONS –GRAFT DISPLACEMENT-2 EYES SUTURES (9-0 VICRYL) (1995) n=95 eyes 4% (2/52EYES)- 1e PTERYGIA 4% (2/52EYES)- 1e PTERYGIA 10% (4/41 EYES)- RECURRENT PTERYGIA 10% (4/41 EYES)- RECURRENT PTERYGIA POST OP COMPLICATIONS POST OP COMPLICATIONS NECROTIC GRAFT -2 EYESNECROTIC GRAFT -2 EYES DELLEN-1 EYEDELLEN-1 EYE

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

31. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 31 Pt no: 30, male, 47yrs, 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.

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34. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 34 CONCLUSION : Application of Fibrin Glue to Adhere the Conjunctival Autograft During Pterygium surgery- Safe and Effective Method of Managing Both Primary and Recurrent Pterygia Safe and Effective Method of Managing Both Primary and Recurrent Pterygia TISSEEL OFFERS SEVERAL ADVANTAGES OVER SUTURES: TISSEEL OFFERS SEVERAL ADVANTAGES OVER SUTURES: 1.DECREASED PATIENT PAIN (OPERATIVE AND POSTOPERATIVE), 2.REDUCED SURGICAL TIME 3.SIGNIFICANT REDUCTION IN POSTOP INFLAMMATION, 4.RECURRENCE RATE=0% 5.MINOR AND CORRECTABLE POSTOPERATIVE COMPLICATIONS 2 CONJUNCTIVAL GRAFT DISLOCATION- BOTH REPAIRED W/O RECURRENCE2 CONJUNCTIVAL GRAFT DISLOCATION- BOTH REPAIRED W/O RECURRENCE

35. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 35 EXTRA SLIDES EXTRA SLIDES

36. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 36 Tisseel kit-2.Duplojet Injector Syringe

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

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

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

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

42. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 42 Tisseel kit-2.Duplojet Injector Syringe

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

44. © 2003 By Default! A Free sample background from www.awesomebackgrounds.com Slide 44 Tisseel - the kit Choose SLOW setting time Choose SLOW setting time 2 SETTING TIMES BASED ON THROMBIN CONCENTRATION2 SETTING TIMES BASED ON THROMBIN CONCENTRATION SLOW- allows 90 seconds placement and adjustment of the conjunctival graft, after tissue glue has been applied SLOW- allows 90 seconds placement and adjustment of the conjunctival graft, after tissue glue has been applied