(scroll down to see the full narrated surgical video)
In most patients who have both a pterygium and a cataract, the typical approach is to first do the pterygium surgery. This is because the pterygium can alter the keratometry of the eye and in particular, induce a significant degree of corneal astigmatism. The pterygium surgery should be given weeks to months to fully heal and let the keratometry stabilize. This will result in more accurate IOL power calculations since the keratometry value varies almost 1:1 with the IOL power.
This patient has previously had multiple pterygia surgeries over the past few decades due to recurrence. For the past few years his pterygia have been stable with no additional growth and fortunately, they do not affect his central cornea or his vision. For this reason, he is content to live with his pterygia and only wishes to have cataract surgery. We will respect his wishes and just do the cataract surgery alone.
The patient has both nasal and temporal pterygia and we will need to shift our phaco incision to do the cataract surgery. We can do a superior scleral tunnel to steer clear of the pterygia, or we can simply stick with the corneal-limbal incision and change the axis. We are operating on the patient’s right eye, so we will rotate our microscope to the 150 degree axis in order to avoid touching the temporal pterygium. If the phaco incision intersects the pterygium there will be bleeding and chemosis of the conjunctiva which will make surgery more challenging.
The paracentesis incision is also shifted and the phaco and microscope foot pedals are rotated to be in front of the surgeon. The pterygia can also block part of the view into the eye during surgery, but fortunately in this case, it is a minor issue. The rest of the cataract surgery is relatively routine and it goes well. The patient is expected to have a bit more inflammation than a typical patient and a longer course of post-operative cortico-steroids will be administered.
Figure: The phaco incision is shifted one clock hour to the 150 degree axis to avoid touching the temporal pterygium.
Watch the narrated video here:
