Pathogenesis

The pathogenesis of pterygium is closely linked to ultraviolet exposure. Dryness,

inflammation, wind, dust or other irritants into other factors.

Prevalence increases in the

region with dry and hot climate near the equator. UV radiation activates fibroblasts which
lead to the formation of pterygium. 2 Pathological changes that occur consist of degeneration
of collagen elastoid and the appearance of sub-epithelial fibrovaskular tissue. Ultraviolet B is
mutagenic factor for the P53 tumor suppressor gene in the basal stem cells in the limbus. This
resulted in the degeneration of collagen change and appearance of subepithelial fibrovaskular
tissue. Subconjunctival tissue becomes degeneration of elastoid (degeneration basophilic) and
proliferation of fibrovaskular granulation tissue underneath the epithelium namely the propria
substantia which eventually penetrate the cornea. Corneal damage contained in the Bowman
membrane layer is caused by fibrovaskular tissue growth and accompanied by mild
inflammation. Bowman membrane damage will produce the necessary substrate for the
growth of pterygium. Epithelium can be normal, thick or thin, and sometimes occurs
dysplasia. 1
Clinical Features
Pterygium is usually asymptomatic in the early stages, but can be characterized by dry
eyes such as burning sensation, itching, or tearing. Lesion can increase in size and becomes
more apparent when viewed that causes cosmetic complaint for the patient. Further growth
can impair vision due to astigmatism. 2
Diagnosis
Anamnesis:

1. Patient with pterygium appears with various eye complaints such as redness, swelling,
itching, irritation, or visual disturbance. 3
2. In the early stages of the disease, pterygium is usually asymptomatic. However, it can also
with eye complaints. As the development of the disease, the lesion increases in size and
becomes more apparent. This condition can be a cosmetic reason for patient. Further
pterygium growth can cause visual symptoms due to astigmatism. 4
Examination:
1. Thickening in the form of a triangular fold which grows into the cornea with a
triangular peak in the cornea, contains many blood vessels that lead to the peak of
pterygium. Generally, it is located in the side of the nasal and bilateral.

Pterygium

may be accompanied by Stocker lines (lines pigmented by iron) which can be seen at
the end of the pterygium.
2. Astigmatism can be found in the advanced stages of pterygium.

The degree of

pterygium growth are divided into four:

grade 1: pterygium is limited on the corneal limbus
grade 2: pterygium already passed the corneal limbus but not more than 2 mm
passed the cornea
grade 3: pterygium has been exceeded grade 2 but does not exceed the edge of the
pupil under normal light condition (normal pupil circumstance around 3-4 mm)
grade 4: pterygium growth through the pupil so that interfere with vision. 6
Supporting Examination
Histopathologic examination can be found damage of the corneal epithelium and Bowman
membrane. There are irregular epithelial and hyaline degeneration in stroma.
cornea bowman is replaced by the hyaline and elastic tissue.

Layer of the

Epithelium can be normal,

thick, or thin and usually occurs dysplasia. Pathological changes can consist of degeneration
of collagen elastoid and the appearance of sub-epithelial fibrovaskular tissue.1

Treatments
Pterygium treatment consists of conservative or surgical. In the early stage of disease,
given conservative treatment. Because UV radiation is believed to be an important risk factor,
clinicians should recommend the patient to wear protective glasses, especially for people who
work outdoors.

If the pterygium is inflamed, it can be given artificial tears or steroid.

Surgery is performed if there is visual impairment. 3 If the pterygium enlarges and extends to
the area of pupil, the lesion must be surgically removed with a small portion of superficial
corneal. There is a possibility that pterygium may grow back after surgery. 5
Pterygium Excision
Indications of pterygium excision: 1
1. Persistent discomfort.
2. The visual distortion.
3. The progressive and significant tumor growth (more than 3-4 mm) to the central of cornea
or axis visual.
4. Decreased eye movement.
Several surgical techniques that are used in the treatment of pterygium:
1. Bare sclera excision
Aims to reunite conjunctival to scleral surface. The disadvantage of this technique is
the high rate of recurrence after surgery, which reached 40-75% and not
recommended.1
2. Simple closure
Aims to unite directly the open side of the conjunctiva. This technique is done if the
injury of the conjunctiva is relatively small. 1
3. Sliding flap
L-shaped incision around the excision wound to allow placement of the flap. 1

4. Rotational flap
U-shaped incision around the excision wound to form like the tongue on the
conjunctiva which is then placed on the ex-excision. 1
5. Conjungtival graft
Using the free graft is usually taken from the superior of conjunctiva bulbi, excised
according to the size of the wound and then transferred and sutured or fixed with
adhesive tissue (eg Tisseel VH, Baxter Healthcare, Dearfield, Illinois). 1
6. Amniotic membrane
Grafting technique using amniotic membrane which is the innermost layer of the
placenta containing thick basement membrane and avascular stromal matrix. The
amniotic membrane is used as a draft and dressing for infection of the cornea and
ocular surface reconstruction for various procedures. 7
1. American Academy of Ophthalmology. Basic and Clinical Science Course. External
Disease and Cornea. Section 8. Singapore: Lifelong Education Ophthalmologist;
2011.
2. Caldwell M, Fajardo D, Hirst L, Woodward MA. Pterygium. Diakses dari
http://eyewiki.aao.org/Pterygium. 2015.
3. Ilyas S. Ilmu Penyakit Mata Edisi Ketiga. Jakarta: Balai Penerbit Fakultas Kedokteran
Universitas Indonesia; 2007.
4. 4. Aminlari A, Singh R, dan Liang D. Management of Pterygium. Diakses dari
5. http://eyewiki.aao.org/Amniotic_Membrane_Transplant. 2010.

6. Vaughan DG, Asbury T, dan Eva PR. Voughan & Asbury Oftalmologi Umum. Edisi
14. Jakarta : Widya Medika; 2000.
7. Laszuarni. Prevalensi Pterygium di Kabupaten Langkat. Tesis. Medan: Departemen
Ilmu Kesehatan Mata Fakultas Kedokteran Universitas Sumatera Utara; 2009.

8. Kozak A, Feldman BH, Fajardo D, Cason JB, Plumb RC. Amniotic Membrane
Transplant. Diakses dari http://eyewiki.aao.org/Amniotic_Membrane_Transplant.
2014.