Common Eye Surgeries: Pterygium Surgery, Dcr and Lid Reconstruction Surgery

The eye is a small organ but has several small parts contributing to its smooth functioning. Any disturbance to these parts may require treatment and sometimes surgery.

This article will discuss three of the common eye surgeries performed worldwide.

Pterygium surgery

Pterygium surgery is a common procedure performed to remove an outgrowth of the eye called pterygium.

Figure 1: Close-up of a pterygium taken during an eye examination.

What is a pterygium?

A pterygium is a triangular-shaped pinkish outgrowth of the eye that grows over the transparent portion of the eye(cornea). It extends from the pink part of the eye (conjunctiva) and grows on to the cornea.

Commonly referred to as the “Surfer’s eye”, pterygium is a non-cancerous growth that may obstruct vision when it grows over the cornea. This condition is common in people who live in countries with a hot climate, especially if they spend a lot of time outdoors.

More commonly seen in young males, and it progressive. It arises from the inner corner of your eye and gives an appearance of redness in some cases. In most cases, when the pterygium is small, it does not lead to any symptoms and hence does not require any treatment.

In cases where the pterygium is large, patients usually complain of a gritty feeling in the eyes, itching, burning sensation and the red appearance of the eye. Once the pterygium intrudes into the cornea (the transparent layer of the eye), patients complain of blurred vision.

Pterygium causes an increase in the cylindrical power of the eye and may require spectacles to correct it.

How do we treat pterygium?

In the early stages of its growth, the patient is prescribed spectacles and is advised to wear sunglasses and wide-brimmed hats to protect the eyes from the sun. Eye drops are prescribed to soothe the eye from itching and other symptoms.

Pterygium surgery.

There are several techniques, but these are the most common. Regardless of the type of surgery, pterygium has to be excised first, and this step makes up the first step of treatment.

After excision, When the white part of the eye (sclera) is left bare after the excision, the chances of recurrence of the pterygium (up to 80 per cent). The following techniques are followed after removing the pterygium to avoid recurrence.

I. Conjunctival autograft technique —

After removing the pterygium, the surgeon will harvest a small part of the conjunctiva tissue (the filmy transparent part over the white region of the eye. ) from another part of the eye.

The harvested piece of the conjunctiva is fixed to the part of the eye left bare after removing the pterygium.
This procedure drops the recurrence rate to as low as 6.4% and is the usual treatment choice in most cases.

2. Amniotic membrane graft:

This procedure involves placing an amniotic membrane on the area of the eye where the pterygium was excised. The amniotic membrane is the innermost layer of the placenta, a body tissue essential for reproduction. This membrane enwraps the fetus during pregnancy.

The membrane gives a foundation for cells to grow over it, giving rise to a smooth surface of the eye. This membrane is retrieved from a licensed bank to proceed with the surgery. This technique is used mainly for large, recurrent and in pterygiums, with inflammation(redness)

This is a relatively new technique and has a fairly low recurrence rate. It is practised for better wound healing and to reduce inflammation, unwanted blood vessel formation and scarring.

Besides these two commonly practised techniques, adjunctive therapies such as the use of Mitomycin-c and beta radiation has also been known to reduce the chances of getting a pterygium again.

Risks and complications of pterygium surgery.

Like every surgery, pterygium surgery also involves certain risks are as follows:

• Recurrence of the pterygium
• Reduced vision
• Bleeding in the eye
• Double vision
• Injury to the eye during the time of surgery

Pterygium excision may also cause certain complications

• Eye pain
• Sensitivity to light
• Irritation of the eye
• Blurred vision
• Scarring of the conjunctiva and cornea
• Glaucoma
• Cataract — Clouding of the crystalline lens inside the eye
• Iritis — Inflammation of the Iris

Pterygium surgery aftercare — Dos and don’ts

• Once the surgery is completed, the surgeon will cover the eye with an eye patch. This eye patch must be left undisturbed until the next visit to the clinic on the following morning.
• Apply medications as directed by your surgeon. Artificial tears to reduce the discomfort and eye drops to reduce inflammation and infection chances will be prescribed. Continue other eye drops(glaucoma eye drops) as directed.
• Do not apply any eye make up after the first week of surgery. Avoid any environment that has a high amount of dust and chemicals.
• No heavy lifting, strenuous activity, swimming or air travel after the first three weeks of surgery.
• Do not rub the treated eyes.
• Wear protective sunglasses to cover your eyes during outdoor activities.
• Use soap or water with caution during the first week of surgery and avoid it from entering your eyes.
• In case of severe pain, report to your ophthalmologist immediately.
• Normal activities can be resumed whenever you are comfortable (including driving)

Dacryocystorhinostomy (DCR)

Dacrocystorhinosotomy, or DCR, is a surgical procedure performed to open blocked tear ducts. This procedure helps to create a bypass between the nose and the lacrimal sac to allow the free flow of tears into the nose. This is irrespective of the presence of the block in the nasolacrimal duct. It involves removing a bone near the lacrimal sac so that there is a free-flowing and low resistance passage of tears.

Figure 3: The lacrimal system

What is NLDO?

Nasolacrimal duct obstruction (NL DO) is a condition where there is an overflow of tears due to blockage in the eye’s drainage system. This system is called the lacrimal system.

NLDO can be caused by birth or other reasons like facial injury, allergy to any eye medications, longstanding sinus disease, conditions like dacryocystitis, etc.

Patients with NLDO often have watering (epiphora), matting and crusting of lashes in the morning, mucopurulent discharge(mucous+pus), pus accumulation in the corner of the eye(dacryocystitis), etc.

In adults, DCR surgery is recommended when the patient is diagnosed with a nasolacrimal duct obstruction

(NL-DO), presence of NLDO due to another condition like sinusitis, nasal surgery, facial injury, presence of microliths( Stones inside the lacrimal system)

Types of DCR:

External DCR:

External DCR is a conventional type of DCR surgery. This procedure has a high success rate (90-95%), but it leaves a visible scar on the nose.

Here, a small opening is made on the side of the nose to reach the tear canal of the eye. The bone between the tear sac and nose is removed, and a bypass is created to allow the free flow of tears. The bypass is kept in position with the help of some tubes that are taken out after 6-8 weeks in the clinic.

The opening on the side of the nose is stitched at the end. The surgeon removes the stitches approximately one week later.

Endonasal DCR:

This type of DCR involves using a telescope that travels up the nose and locates the position of the blockage. Once the blockage is located, it is surgically opened, and a tube is inserted to keep the passage open.

This method has a lower success rate than the conventional DCR (70 per cent), but its advantage is that it does not leave any scar after surgery.

This procedure is recommended in younger patients and patients with a long-term nasal condition like a deviated nasal septum.

Other types of DCR include transnasal DCR, etc. The type of DCR may be decided by the surgeon depending on several factors such as age, type of obstruction, presence of other abnormalities, etc.

The surgery is performed using anaesthesia to eliminate pain during surgery. Both local and general anaesthesia can be used depending on the surgeon’s decision.

The surgery would roughly take 60 minutes to complete. After the surgery, you might feel sore around the area of the surgery, and you may experience pain. The surgeon may call you back to the clinic after a few days to note the procedure’s success.

Risks and complications of DCR:

• Nose bleeds
• Swelling around the corner of the eyes
• Linear scar on the side of the nose
• Injection
• Internal healing with blockage leading to membrane formation
• Further surgery

DCR Surgery: Do’s and don’ts:

• Once the surgery is completed, the surgeon will cover the eye with an eye patch. This eye patch must be left undisturbed until the next visit to the clinic on the following day. The surgeon will remove it then if advised otherwise.
• Avoid drinking hot drinks 36 hours from the time of surgery to avoid any chances of nose-bleeding.
• No strenuous exercises for at least ten days from the day of surgery.
• No air travel and swimming for at least 2-3 weeks after surgery
• Avoid blowing your nose for at least two weeks after surgery. If sneezing is unavoidable, pressure mustn’t be allowed to build up in the nose.
• Use an extra pillow during sleep to keep the head elevated.
• To take medications as advised by the surgeon.
• Avoid rubbing your eyes, and the wound must be kept dry and uncovered.

Eyelid reconstruction surgery

Eyelid reconstruction surgery is a procedure performed to correct the shape of uneven eyelids. Defects in the eyelids are usually caused due to birth defects, injury to the eye or removal of the tumour in that region.

They are reconstructed to protect the eye and make the eyes look cosmetically appealing. In some cases, the other normal eyelid will need surgery to maintain the symmetry with the diseased eyelid. Depending on the area affected(i.e.) lower eyelid, upper eyelid, corner of the eyelids, etc. or multiple areas at once, the procedure is planned differently.

This procedure may be coupled with blepharoplasty as well if required. The blepharoplasty procedure is used to treat droopy eyelids and lift the eyelid.

What are the eyelids made up of?

Before we understand eyelid reconstruction, here’s a quick summary of what the eyelids are made up of.

• Skin — Eyelid skin is loose and thin
• Cartilage (Tarsal plate) — Cartilage present under the skin helps to add stiffness to the eyelid margins
• Muscles — This muscle is responsible for the movement of the eyelids and maintaining the tone of the eyelids.
• Mucosa (Conjunctiva) — This layer helps keep the eyes moist.
• Amongst these layers, the eyelids have blood vessels and nerves responsible for maintaining the nutrition and function of the eye, respectively.

Before surgery, the surgeon will decide the type of surgery, and it is customized depending on the following aspects:

• Age of the patient
• Size and position of the defect
• Nature of the eyelid
• Experience and preference of the surgeon

Through surgery, the surgeon will aim to produce the following results:

a. A stable eyelid margins
b. Cosmesis and symmetry
c. Adequate closure of the eyelids
d. Sufficient vertical height for the eyelids

The surgery is decided and performed based on the availability of donor tissues, technical expertise, best cosmesis. and the specific needs of the patient. Based on all these factors, the surgeon chooses a method appropriate to perform the lid reconstruction surgery.

Some Of the techniques practised for eyelid surgery are discussed below:

1. Straight-line closure technique – This procedure bridges two edges of an open wound and creates a straight-line scar. It is a commonly practised technique for eyelid margin disorders
2. Rotational flap technique — This technique requires bringing tissue near the wound area to cover the open wound. The surgeon performs another incision or opening to allow this tissue to be rotated.
3. Skin graft technique — A piece of skin is harvested from another area called the donor site and then placed on the wound. The skin graft is made to adhere to the open wound and is left as a skin covering over the defect.
4. Composite graft technique –Like the skin graft, the composite graft technique involves harvesting the underlying layer of mucosa, including the skin. This layer is made to adhere to the wound and fills up the area of the wound
5. Eyelid tendon tightening (canthopexy) or repositioning (canthoplasty) — This procedure is performed through an opening(incision) in the lower eyelid. The primary reason to perform this procedure is to create support for the eyelid after surgery. This helps prevent the complication of Ectropion (retraction of the eyelid away from the eyeball).

Risks and complications of lid reconstruction surgery:

Like every other procedure, lid reconstruction surgery also has some risks and complications. Though rare, it’s crucial to understand the complications

• Bleeding after surgery
• Infection
• Blurry or foggy vision
• Dry eye problems
• Ectropion
• Loss of eyelashes
• Scarring
• Injury to deeper structures of the eye during surgery
• Asymmetry between the eyelids
• Eye pain
• Allergic reactions
• Delayed wound healing
• Long term effects include tissue loss and scarring of the eyelid skin due to excessive sun exposure.
• Need for revision or more than one surgery for best results
• Skin contour changes and discolouration
• Change in eyelid skin sensation