When Standard Becomes Strange: Managing An Unusual Foreign Implant In Pterygium Surgery.

We report an unusual case of a 46-year-old male who presented with complications following a left pterygium excision performed in Indonesia. The procedure involved the use of a plastic mesh, leading to a severe foreign body reaction with subsequent fusion of the mesh to the medial rectus muscle and sclera. This complication was successfully managed with staged surgical intervention, including conjunctival mesh removal, medial rectus resection and recession, and ocular surface reconstruction with an amniotic membrane graft and conjunctival autograft.

A 46-year-old male presented with a history of left eye pterygium excision performed in Indonesia in 2022. No detailed surgical records were available. The patient reported persistent redness, soreness, and the presence of a mesh-like graft on the medial aspect of the eye. He also described the intermittent discharge of a white substance but denied significant pain. His visual acuity at presentation was 6/6 in both eyes.

Initial examination findings:

• Mild conjunctival injection.
• Presence of blue and white plastic mesh integrated with nasal corneal scarring.
• No anterior chamber reaction or posterior segment abnormalities.

Over 18 months a medial rectus palsy and increasing discomfort developed. Visual acuity declined from 6/6 to 6/18. Examination revealed worsening nasal inflammation and scleritis-like appearance. Surgical excision of mesh with amniotic membrane grafting was decided.

During surgery we noted unexpected findings. The mesh had extenisvelty integrated with the sclera and medial rectus and was partially embedded in the medial rectus up to 3.5mm from its insertion.

Surgical Procedure:

• Left eye conjunctival resection and mesh excision: Conjunctiva was dissected, and mesh carefully excised from the sclera using a crescent knife. 
• Medial rectus resection and recession: The medial rectus was hooked and secured with 6/0 vicryl and detached.The affected segment of medial rectus (3.5mm) was resected and the remaining muscle reattached 3.5mm posterior to its initial insertion site.
• Ocular surface reconstruction: A conjunctival autograft from the supero-temporal conjunctiva was performed, then amniotic membrane graft applied. 

Results: Lab analysis confirmed a plastic mesh of unknown origin. Post operatively the patient had significant improvement in his diplopia: now only present on extreme gaze and absent in primary position. In addition, visual acuity improved from 6/18 to 6/6 over 6 months.

This case underscores the need for awareness of potential surgical complications related to foreign materials in pterygium surgery. The successful resolution with a combined surgical approach, including mesh removal, medial rectus resection/recession, and ocular surface reconstruction, resulted in an excellent functional and visual outcome. Increased caution regarding surgical graft materials can help prevent similar complications in the future.