DOI: 10.

18410/jebmh/2015/832

ORIGINAL ARTICLE
ASTIGMATISM IN PRIMARY PTERYGIUM AND ITS EFFECT ON
VISUAL ACUITY
Devika P1, Lakshmi K. S2, Rajani K3, Sudhir Hegde4, Asha Achar5, Ajay Kudva6
HOW TO CITE THIS ARTICLE:
Devika P, Lakshmi K. S, Rajani K, Sudhir Hegde, Asha Achar, Ajay Kudva. Astigmatism in Primary
Pterygium and its Effect on Visual Acuity. Journal of Evidence based Medicine and Healthcare; Volume 2,
Issue 38, September 21, 2015; Page: 6036-6040, DOI: 10.18410/jebmh/2015/832

ABSTRACT: BACKGROUND: Pterygium is a fairly common condition in a tropical country like

India with average incidence being 5.2%. Surgery being offered as a treatment for pterygium
does not, at present, have a universally accepted indication based on the size. This study was
done to make an attempt to define the indication for surgical exicision of pterygium. AIMS: To
find out an association between increasing size of pterygium and degree of induced corneal
astigmatism and to assess if corneal astigmatism induced by pterygium affects best corrected
visual acuity (BCVA) and thus making it an indication for pterygium excision surgery. SETTINGS
AND DESIGN: Hospital Out Patient Department (OPD) based prospective clinical cross sectional
study on patients with unilateral pterygium. METHODS AND MATERIAL: 33 patients were
included in this study who had unilateral pterygium of varying sizes. Evaluation was done using
slit-lamp beam for size of pterygium in millimetre from the limbus, ketatometry using Bausch and
Lomb keratometer, autorefractometer objective refraction readings, visual acuity and BCVA using
Snellens chart. STATISTICAL ANALYSIS USED: Chi-square-test, Karl-Pearson correlation
coefficient, Kruskal-Wallis-co-efficient using SPSS statistics 22.0. RESULTS: 33 people having
unilateral pterygium were divided into three groups on the basis of size of the pterygium- 2mm,
2.1-3mm, >3mm. The co-relation coefficient between the astigmatism induced to BCVA was
maximum for the 3rd group with pterygium size >3mm and was statistically significant.
CONCLUSION: Pterygium induces with the rule astigmatism. Surgery is indicated in patients of
pterygium size >3mm as the astigmatism induced affects the BCVA.
KEYWORDS: Pterygium, Unilateral, Astigmatism, BCVA.
INTRODUCTION: Clinically, pterygia are fleshy, vascularized, often triangular formations of
tissue that extend across the limbus and onto the cornea.[1] The histopathologic hallmark of
pterygia and pingueculae is elastotic degeneration of the collagen of the substantiapropria[2]
Pterygia are most common in southern latitudes and typically occur in patients who work
outdoors.[1,3] Pterygium is commonly seen in India, a part of the pterygium belt described by
Cameron.[4] Pterygium leads to a considerable effect on corneal refractive status which has been
previously measured in various studies by refraction,[5,6] keratometry[7] and corneal
topography.[8,9,10,11,12,13] In the present study, we assess the relationship between pterygium size
and induced corneal astigmatism and to observe whether astigmatism secondary to pterygium is
an indication for surgery.
MATERIALS AND METHODS: 33 patients of unilateral pterygium were included in the study.
The normal eye without pterygium had no abnormalities and had best corrected visual acuity of
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DOI: 10.18410/jebmh/2015/832

ORIGINAL ARTICLE
6/6 was taken as control to compare with the other eye having pterygium for change in
astigmatism pattern in relation to the size of pterygium.
Evaluation of pterygium was done using.
Slit-lamp beam measurements of size of pterygium (in millimeters) from the limbus.
Ketatometry using Bausch and lomb keratometer.
Auto refractometer objective refraction readings.
Visual acuity and best corrected visual acuity using snellens chart.
RESULTS: in our study of the 33 people having unilateral pterygium, of mean age 42.58
years11.096 years, 17 (51.5%) were males and 16 (48.5%) were females. The total subjects
(n=33) was divided into 3 groups on the basis of size of the pterygium

2
2.1-3
>3

Frequency
13
8
12

Percent
39.4
24.2
36.4

Table 1: Frequency distribution of subjects on the basis of size of petrygium

In 19 subjects (57.6%), right eye was affected and in 14(42.4%), left eye was affected.
32 patients had nasal pterygium and 1 had temporal pterygium. In our study, pterygium induced
with the rule astigmatism in all patients.
Mean of BCVA Standard deviation in BCVA
Group 1- <2mm
1
0
Group 2- 2.1-3mm
0.852
0.195
Group 3- >3mm
0.682
0.16
Table 2: Size of the pterygium in co-relation with BCVA
This table indicates that as the size of pterygium goes on increasing, the mean BCVA
keeps on decreasing.
Size of pterygium BCVA 6/6 BCVA <6/6
Total
<2
13(100%)
0
13(100%)
2.1-3
5(62.5%)
3(37.5%)
8(100%)
>3
2(16.67%) 10(83.33%) 12(100%)
total
20
13
33
Table 3: co-relation of the size of pterygium with BCVA
2 =18.2, P0.000001 indicates very highly significant difference in the BCVA in the 3rd
group with pterygium size >3mm as compared to those with <3mm.
Co-relation between astigmatism induced by pterygium of the 3 groups with BCVA: after
calculation co-relation co-efficient for each group between the BCVA and astigmatism calculated
by auto refractometer readings and K readings from Bausch and lomb keratometer.
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DOI: 10.18410/jebmh/2015/832

ORIGINAL ARTICLE
Group1: As the BCVA remains same in this group, indicates no co relation between astigmatism
induced by pterygium and BCVA.
Group 2: In this group, Co relation co-efficient is 0.1 which indicates very low positive corelation between astigmatism (both by AR readings and k values) and BCVA.
Group 3: In this group, Co relation co-efficient is 0.3 which indicates positive co-relation
between astigmatism (both by AR readings and k values) and BCVA.
This shows that if the size is >3mm, probability of BCVA being <6/6 is more as compared
to the pterygium size being 2.1 to 3 mm.
The difference in horizontal K readings of the affected and unaffected eye between the 3
groups was calculated and KruskalWallis H test applied to find if the values have statistical
significance. Calculated value was 11.9 with p value0.05 which shows that there is a statistically
significant difference in the horizontal corneal cuvature when compared between the affected and
unaffected eye from group 1 to group 3.
As the keratometry measures only central corneal curvature, the total astigmatism
measured by keratometry induced by the pterygium on the cornea is not accurate and forms one
of the drawbacks of our study. But as it is the change in central corneal curvature that affects the
vision and BCVA, keratometry can be used. In our study, p value suggests statistical significance
more in the group 3with pterygium size >3mm.
DISCUSSION: Pterygium is a worldwide disease which is particularly common in tropical and
sub-tropical regions.[14] Through its astigmatic impact it is often the cause of several subjective
visual complaints, which include decreased visual acuity or visual aberrations such as glare or
diplopia.[15]
The automated keratometer is readily available to the Ophthalmologist as compared to
the other instruments. Its utility in analyzing the astigmatic effects of pterygium and then
deciding whether to excise it or not is very convenient. The type of astigmatism that pterygium
causes in the majority of cases is with the rule. This astigmatism occurs by mechanical pull which
causes localized flattening of horizontal meridian of the cornea occurring up to the leading apex
of the pterygium.[16] However, pterygium also induces against the rule and oblique astigmatism.[3]
LIN and STERN found asignificant correlation between the pterygium size and corneal
astigmatism, they reported that pterygium induces significant degrees of corneal astigmatism
once it exceeded (>45%) of the radius of the cornea or within (3.2) mm of visual axis.[15] The
exact mechanism of flattening is not clear, it is thought that astigmatism is mainly caused by the
formation of tear meniscus between the corneal apex and the elevated pterygium causing
apparent flattening of the normal corneal curvature. [16,17]
A study done by Dr. Qasim Kadhim Farhood et al in Iraq showed that Pterygium induces
with the rule astigmatism and often leads to visual impairment more so if pterygium is more than
2 mm size from the limbus and they suggested pterygiumexicision surgery for the same.[18]

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ORIGINAL ARTICLE
Another study by Rahim Avisar et al from Israel found that pterygium induced visually
significant with the rule astigmatism if >1.1mm in size and suggested surgical exicision of
pterygium if >1mm in size.[19]
In this study, all our patients had a change towards with the rule astigmatism (100%) in
comparison with the normal eye without pterygium i.e, in 8 patients against the rule astigmatism
that decreased, 5 patients had with the rule astigmatism that increased and 20 patients had no
astigmatism that became with the rule astigmatism.
Our study showed that clinically significant astigmatism (astigmatism causing visual
impairment which could be corrected by glasses) is induced by pterygium of more than 3 mm size
from the limbus, this tends to increase significantly with increasing size of the pterygium and in
turn leads to impairment of vision. In other words, the extension of pterygium is significantly
correlated with the degree of corneal astigmatism with higher percentage of with the rule
astigmatism, therefore surgical intervention of pterygium is indicated when the size of the lesion
is more than 3 mm from the limbus.
CONCLUSION: Nasal pterygium is more common when compared to temporal pterygium.
Pterygium induces with the rule astigmatism. Surgery for pterygium is indicated in patients of
pterygium size >3mm as the astigmatism induced affects the BCVA to a maximum extent.
REFERENCES:
1. Eagle RC: Eye pathology: an atlas and basic text. Philadelphia, WB Saunders, 1999: 47, 7273.
2. Cameron ME: Histology of pterygium: an electron microscopic study. Br J Ophthalmol, 1983.
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3. William Tasman, Edward A. Jaeger. Duanes ophthalmology. London:Lippincott Williams &
Wilkins;2007.
4. Demartini DR, Vastine DW. Pterygium. In: Abbott RL, editor. Surgical interventions Corneal
and External diseases. Grune and Straton: Orlando, USA; 1987. p. 141.
5. Fong KS, Balakrishnan V, Chee SP, Tan DT. Refractive change following pterygium surgery.
CLAO J 1998; 24: 115-7.
6. Maheshwari S. Effect of pterygium excision on pterygium-induced astigmatism. Indian J
Ophthalmol 2003; 51: 187-8.
7. Hansen A, Norn M. Astigmatism and surface phenomena in pterygium. ActaOphthalmol
(Copenh) 1980; 58: 174-81.
8. Lin A, Stern G. Correlation between pterygium size and induced corneal astigmatism.
Cornea 1998; 17: 28-30.
9. Stern G, Lin A. Effect of pterygium excision on induced corneal topographic abnormalities.
Cornea 1998; 17: 23-7.
10. Tomidokoro A, Miyata K, Sakaguchi Y, Samejima T, Tokunaga T, Oshika T. Effects of
pterygium on corneal spherical power and astigmatism. Ophthalmology 2000; 107: 156871.

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11. Cinal A, Yasar T, Demirok A, Topuz H. The effect of pterygium surgery on corneal
topography. Ophthalmic Surg Lasers 2001; 32: 35-40.
12. Yagmar M, Altan A, Ozcan MD, Sari S, Ersoz RT. Visual acuity and corneal topographic
changes related with pterygium surgery. J Refract Surg 2005; 21: 166-70.
13. Oldenburg JB, Garbus J, McDonnell JM, McDonnell PJ. Conjunctival pterygia. Mechanism of
corneal topographic changes. Cornea 1990; 9: 200-4.
14. Kamil Z, Bokhari SA, Rizwi F. Comparison of conjunctival autograft and intraoperative
application of mitomycin-C in the treatment of primary pterygium. Pak J Ophthalmol 2011;
27: 221-5.
15. Jaffar S, Dukht U, Rizvi F. Impact of pterygium size on corneal topography. RMJ 2009;
34:145-7.
16. Lin A, Stern GA. Correlation between pterygium size and induced corneal astigmatism.
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17. Salih PM, Sharif AF. Analysis of pterygium size and induced corneal astigmatism. Cornea
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AUTHORS:
1. Devika P.
2. Lakshmi K. S.
3. Rajani K.
4. Sudhir Hegde
5. Asha Achar
6. Ajay Kudva
PARTICULARS OF CONTRIBUTORS:
1. Consultant, Department of
Ophthalmology, AJ Institute of Medical
Sciences, Mangalore.
2. Junior Resident, Department of
Ophthalmology, AJ Institute of Medical
Sciences, Mangalore.
3. Associate Professor, Department of
Ophthalmology, AJ Institute of Medical
Sciences, Mangalore.
4. Professor & HOD, Department of
Ophthalmology, AJ Institute of Medical
Sciences, Mangalore.

5. Assistant Professor, Department of

Ophthalmology, AJ Institute of Medical
Sciences, Mangalore.
6. Associate Professor, Department of
Ophthalmology, AJ Institute of Medical
Sciences, Mangalore.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Lakshmi K. S,
# 450, 6th Floor,
Staff Quarters,
AJ Institute of Medical Sciences,
Kuntikana, Mangalore-575004.
E-mail: lakshmimurthy1@gmail.com
Date
Date
Date
Date

of
of
of
of

Submission: 05/08/2015.
Peer Review: 06/08/2015.
Acceptance: 08/09/2015.
Publishing: 18/09/2015.

J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 38/Sept. 21, 2015 Page 6040