performed include bare excision combined with adjunctive beta-irradiation, intraoperative or postoperative use of MMC, conjunctival autografting, and excision with amniotic membrane. The main goals of pterygium removal are to completely excise the pterygium and prevent its recurrence. Complications from the removal must be minimized as well, and thus there are numerous reports in the literature citing varying surgical techniques and their rates of associated recurrence and complications. We believe the technique of pterygium removal with conjunctival autograft over the bared sclera is the procedure that is associated with the lowest recurrence rate and has the least amount of complication. Recently, the use of a Þbrin adhesive to secure the graft, as opposed to sutures, has decreased operating time and minimized pain and foreign body sensation postoperatively [7Ð9].

Instrument list

1.Lidocaine (2%) with epinephrine on 27or 30-gauge syringe

2.Violet marking pen

3.Westcott scissor

4.Beaver blade

5.Toothed and non-toothed forceps

6.Fine-tipped needle holder

7.Tissell Þbrin glue kit

8.Lieberman lid speculum

4.3.3 Surgical Technique

The patient is brought to the operating suite following informed consent. Anesthesia may be subconjunctival only or a RBB may be administered. We prefer a RBB when removing large pterygia so as to minimize ocular motility and make the patient most comfortable. When a pterygium is extensive and the rectus muscles are involved, the muscles will need to be manipulated with a muscle hook during the case, and this can be uncomfortable for the patient. A RBB is most helpful.

Following the administration of RBB, the patient is prepped and draped in a sterile fashion, often with a solution of 5% povodine-iodine if there are no allergies. A Lieberman lid speculum, or any of the surgeonÕs preference, is inserted to retract the lids from the surgical Þeld. The surgeon usually sits superior for the duration of the case.

4.3.3.1 Removal of the Pterygium

The area of the pterygium is marked with a gentian violet marking pen. Two percent lidocaine with epinephrine in a 3-mL syringe with a 27or 30-gauge needle is injected under the pterygium to elevate it. The tips of the Westcott scissor are placed under the body of the pterygium and between the pterygium and underlying sclera in order to dissect and lift the pterygium away from the sclera. Care is taken not to involve the rectus muscle. A peripheral to central dissection of the pterygium is then carried out by Þrst making an incision across the body of the pterygium with the Westcott scissor and then reßecting the pterygium across the limbus. Often the pterygium can be peeled off the cornea with a toothed forcep as there is a plane above BowmanÕs layer that can be identiÞed. A blade of the surgeonÕs preference may be used to remove the remaining Þbrous tissue from the cornea that is atop BowmanÕs layer. The pterygium should be laid out ßat on a glove paper and placed in formalin and sent for histopathologic conÞrmation of the diagnosis. We then perform an extensive removal of tenonÕs layer superiorly, medially or laterally, and inferiorly, by grasping the excessive tenonÕs tissue with a toothed forcep and pulling the redundant tissue out from underneath uninvolved conjunctiva and excising it with a Westcott scissor. If the pterygium covers the medial or lateral rectus muscles, the muscle is identiÞed on a muscle hook and the pterygium dissected off the muscle using a wooden cotton-tip applicator and a rolling motion in the direction of the muscle Þbers to effect the dissection bluntly. Sometimes the semilunar fold must be extracted as well.

4.3.3.2 Harvesting the Conjunctival Autograft

The most successful step to successful autograft surgery is the careful harvesting of a thin, Tenon-free conjunctival graft of a large enough size to cover the defect following pterygium removal.

The globe is rotated inferiorly to expose the superior bulbar conjunctiva. An area of appropriate size conjunctiva is marked with the caliper and outlined with the gentian violet marker. It should be noted that some degree of graft retraction will occur and so the area marked should be 1 mm oversized in each diameter. The area chosen should be as far away from the