See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/322680958

The Astigmatic Effect of Pterygium in a Tertiary Hospital in Kano, Nigeria

Article  in  Annals of African medicine · January 2018

DOI: 10.4103/aam.aam_13_17

CITATION READS

1 102

8 authors, including:

Sadiq Hassan Ebisikephilips Ifeanyichukwu

Bayero University, Kano Bayero University, Kano
8 PUBLICATIONS   15 CITATIONS    3 PUBLICATIONS   3 CITATIONS   

SEE PROFILE SEE PROFILE

Rabi Sani Shuaib Abdulsalam

London School of Hygiene and Tropical Medicine Aminu Kano Teaching Hospital
5 PUBLICATIONS   5 CITATIONS    7 PUBLICATIONS   7 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Diabetic Retinopathy: Knowledge, Attitude and Practice of Physicians in Northwestern Nigeria. View project

Traumatic cataract in children : causes and consequences of delayed clinic presentation View project

All content following this page was uploaded by Shuaib Abdulsalam on 09 February 2018.

The user has requested enhancement of the downloaded file.

ISSN 1596-3519

Volume 17 Issue 1 January-March 2018

www.annalsafrmed.org
Annals of African Medicine • Volume 17 • Issue 1 • January-March 2018 • Pages 1-***
 Original Article

The Astigmatic Effect of Pterygium in a Tertiary Hospital in

Kano, Nigeria
Abdu Lawan, Sadiq Hassan, Ebisike Philips Ifeanyichukwu1, Hadi Bala Yahaya2, Rabi Yahaya Sani, Saudat Garba Habib, Abdulsalam Shuaib, Okpo Eme1
Department of Ophthalmology, Faculty of Clinical Sciences, College of Health Sciences Bayero University Kano/Aminu Kano Teaching Hospital, 1Department of
Ophthalmology, Aminu Kano Teaching Hospital, 2Department of Ophthalmology, Murtala Mohammed Specialist Hospital, Kano, Nigeria

Abstract
Aim: This study aims to determine the effect of pterygium excision on the degree of corneal induced astigmatism and visual acuity.
Patients and Methods: This was a prospective interventional study conducted between September 2012 and June 2013. Consecutive
patients with pterygium who met the inclusion criteria were recruited into the study. They had a basic eye examination, and those with
existing comorbidity were excluded. Selected patients had pterygium excision using the bare sclera technique with intraoperative application
of Mitomycin C. Detailed pre‑  and post‑operative evaluation and refraction was done. Results: There were 45 eyes of 33  patients aged
28–75 years. The mean age was 56.12 + 12.38 years. Six eyes had Grade I, 29 eyes had Grade II and 10 eyes had Grade III pterygium. The
mean value for preoperative astigmatism was 2.12 ± 1.09 diopter cylinder (DC) while that for postoperative astigmatism was 0.72 ± 0.50
DC (P = 0.000). Surgery was associated with statistically significant increase in postoperative visual acuity. (P = 0.000).  Conclusion: This
study has shown that the degree of pterygium‑induced astigmatism reduces significantly following surgical excision. Pterygium excision was
associated with improvement in visual acuity.

Keywords: Astigmatism, pterygium, visual acuity

Résumé
But: Déterminer l’effet de l’excision du ptérygion sur le degré d’astigmatisme induit par la cornée et l’acuité visuelle.
Patients et méthodes: Il s’agissait d’une étude interventionnelle prospective réalisée entre septembre 2012 et juin 2013. Les patients consécutifs
atteints de ptérygion répondant aux critères d’inclusion ont été recrutés dans l’étude. Ils ont subi un examen oculaire de base et ceux qui
présentaient une comorbidité existante ont été exclus. Les patients sélectionnés ont eu une excision du ptérygion en utilisant la technique de
la sclère nue avec une application intra-opératoire de la mitomycine C. Une évaluation pré et post-opératoire détaillée et une réfraction ont
été effectuées. Résultats: Il y avait 45 yeux de 33 patients âgés de 28 à 75 ans. L’âge moyen était de 56,12 + 12,38 ans. Six yeux avaient un
grade I, 29 yeux avaient un grade II et 10 yeux avaient un ptérygion de grade III. La valeur moyenne de l’astigmatisme préopératoire était
de 2,12 ± 1,09 DC tandis que celle de l’astigmatisme postopératoire était de 0,72 ± 0,50 DC (valeur P = 0,000). La chirurgie était associée à
une augmentation statistiquement significative de l’acuité visuelle postopératoire. (P = 0,000). Conclusion: Le degré d’astigmatisme induit
par le ptérygion réduit significativement l’excision chirurgicale. L’excision du ptérygion était associée à une amélioration de l’acuité visuelle.

Mots‑clés: astigmatisme, ptérygion, acuité visuelle

Introduction Address for correspondence: Prof. Abdu Lawan,

Department of Ophthalmology, Aminu Kano Teaching Hospital,
A pterygium is a triangular fibrovascular degenerative
Kano, Nigeria.
bulbar conjunctival growth occurring in the palpebral E‑mail: lawal1966@yahoo.com
fissure and extending onto the cornea.[1] However, there

This is an open access article distributed under the terms of the Creative Commons
Access this article online Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
Quick Response Code: and build upon the work non‑commercially, as long as the author is credited and the
Website: new creations are licensed under the identical terms.
www.annalsafrmed.org
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Lawan A, Hassan S, Ifeanyichukwu EP, Yahaya HB,
10.4103/aam.aam_13_17 Sani RY, Habib SG, et al. The astigmatic effect of pterygium in a Tertiary
Hospital in Kano, Nigeria. Ann Afr Med 2018;17:7-10.

© 2018 Annals of African Medicine | Published by Wolters Kluwer - Medknow 7

 Lawan, et al.: Astigmatic effect-pterygium

is some evidence suggesting that it may be a proliferative
condition.[2] Pterygium is commoner in hot climates and
may be a response to persistent dryness and exposure to sun
(ultraviolet) light.[1]
Most pterygia are asymptomatic, but symptoms may include
redness, pain, discomfort, and reduced vision, which could
be attributed to induced astigmatism or occlusion of the
visual axis. A significant degree of corneal astigmatism can
be induced by encroachment of pterygium onto the cornea.[3]
There is a direct relationship between the size of pterygium
on the cornea and the astigmatic effect.[4] Pterygium leads to
significant changes in corneal refractive status, which increase
with the grade of pterygium and improves after surgery.[5]
The definitive treatment for pterygium at present is surgical
excision, for which there are various techniques. These include
the bare sclera, excision with conjunctival autografting or
amniotic membrane transplantation and beta irradiation.[2,6,7]
Conservative treatment could be adopted for temporary relief
of symptoms such as the use artificial tears or lubricants
and topical anti‑inflammatory agents. [6] The effect of
pterygium on corneal refractive status may be measured by
refraction, keratometry, corneal topography, and computerized
video‑keratoscopy.[8] The aim of this study was to determine the
effect of pterygium excision on the degree of corneal‑induced
astigmatism and visual acuity.
Pterygium excision was done using the bare sclera technique
with the application of 0.2 mg/ml Mitomycin C soaked in a
cotton pledget for 5 min and the eye irrigated with 50 ml of
normal saline. The same surgeon performed all the surgeries.
Pre‑ and post‑operative visual acuity with subjective refraction
was recorded to detect if there was any demonstrable change
in astigmatism.
Data analysis
Data were analyzed using the statistical software Minitab
version  12.0, Minitab Inc, Pennsylvania, United States of
America. Paired t‑test was used to compare the mean values
of visual acuity and change in cylindrical power before and
after surgery. P <0.05 was considered statistically significant.
Results
There were 45 eyes of 33 patients aged 28–75 years with a
mean age of 56.42 ± 12.38 years. There were 21 males (63.6%)
and 12  females  (36.4)  (M:F  =1.75:1). The age and gender
and occupation of the patients studied are shown in Table 1.
The patients were predominantly outdoor workers. Six eyes
had Grade I, 29 eyes had Grade II and 10 eyes had Grade III
pterygium. Pterygium was unilateral in 19 eyes of which 11
were in the right eye and 8 in the left eye. It was bilateral
in 26 eyes. The astigmatism was with the rule in 31 eyes,

Table 1: Age, gender, and occupation of patients

Patients and Methods
Age (years) Sex n (%)
The study adhered to the tenets of the Helsinki Declaration.
Ethical approval was obtained from the Ethics Review Board of Male Female
Aminu KanoTeaching Hospital. This prospective observational 20-29 1 0 1 (3.0)
intervention study was carried out from September 2012 to 30-39 2 1 3 (9.1)
June 2013. Consecutive patients that fulfilled the inclusion 40-49 5 1 6 (18.2)
criteria were recruited. Criteria for inclusion include consent 50-59 4 3 7 (21.2)
to be participate, age above 20 years, the presence of a primary ≥60 9 7 16 (48.5)
pterygium with astigmatism of at least 1 Diopter cylinder (DC) Total 21 12 33 (100)
and normal fundus on direct ophthalmoscopy. Participants that Occupation n (%)
did not give consent, those aged 20 or less, evidence of previous Farming 13 (39.4)
ocular surgery, those with a recurrent pterygium, involvement Trading/artisan 8 (24.2)
of the pupillary area (Grade IV pterygium), participants known Commercial motorcyclist 1 (3.0)
to be using spectacle correction, and other ocular surface Civil servant 4 (12.1)
diseases were excluded from the study. Mechanic 2 (6.1)
Homemaker 5 (15.2)
Information obtained included age, sex, occupation, visual Total 33 (100)
acuity before and after surgery, laterality of disease, position
of pterygium on the cornea  (nasal, temporal, or both) and
retinoscopic findings before and after surgery. Patients had Table 2: Pre‑ and post‑operative visual acuity of patients
unaided and pinhole visual acuity tested at a distance of 6
Visual acuity Before surgery After surgery
m using Snellen’s or tumbling “E” charts. Anterior segment
6/6 2 16
examination was done using a slit lamp biomicroscope.
6/9 5 11
The pterygium was graded based on the extent of corneal 6/12 14 9
involvement. Grade I: crossing the limbus, Grade II: midway 6/18 12 5
between the limbus and the pupil, Grade III: at the pupillary 6/24 5 3
margin and Grade  IV: crossing the pupillary margin.[9] All 6/36 5 1
patients had streak retinoscopy at a working distance of 6/60 2 0
two‑third of a meter preoperatively and 6 weeks after surgery. Total 45 45

8 Annals of African Medicine  ¦  Volume 17  ¦  Issue 1  ¦  January-March 2018


20
15
Axis Title
10
5 to that reported in other studies.[2,20] Evidence has shown that
0
x6/6 x6/9 x6/12 x6/18 x6/24 x6/36 x6/60
Figure 1: Visual acuity of patients before and after pterygium excision
Table 3: Pre- and post-operative visual acuity and
refractive astigmatism
Mean±SD
Preoperative Postoperative
BCVA 4.82±2.37 2.58±1.74 14.37 0.001
Astigmatism (DC) 2.12±1.09 0.72±0.50 14.06 0.001
SD=Standard deviation, BCVA=Best corrected visual acuity, DC=Diopter
cylinder
against the rule in 13 eyes and mixed in one eye. The change
in visual acuity after surgery is shown in Table 2 and Figure 1.
The mean value of cylindrical correction was 2.12 ± 1.09 DC
preoperatively, while that for the best corrected visual acuity
of all the patients was 4.82 ± 2.37. Table 3 shows the mean
values of pre‑ and post‑operative visual acuity and refractive
astigmatism.
Discussion
The presence of a pterygium can induce astigmatism which
may be associated with reduced visual acuity and other
symptoms such as irritation, redness, diplopia and glare.[8] A
pterygium flattens the cornea along the horizontal meridian
thereby leading to with the rule astigmatism. The vertical
corneal meridian is steep in younger adults. This reduces with
age and tends to give rise to against the rule astigmatism in
later years.[10] The study consisted of older patients, and this
might explain the presence of against the rule astigmatism The
length of pterygium on the cornea has a statistically significant
relationship with the amount of refractive astigmatism.[4]
There is the possibility that some of the patients although not
using spectacle correction could have had against the rule
astigmatism not related to the pterygium. Surgical excision
reduces astigmatism, leading to improvement in visual
acuity and also ameliorates other associated symptoms.[11]
The prevalence of pterygium was found to be higher with
increasing age of participants similar to findings reported in
studies carried out in Saudi Arabia and Indonesia.[12‑14] This
may be attributable to prolonged exposure to risk factors
associated with pterygium in older individuals.[15] Our study
showed that the number of male patients was almost twice
that of females similar to other studies.[14,16‑19] This could be
explained by the fact that males tend to engage in more outdoor
activities compared to females.[2] Ultraviolet light exposure
in addition to hot, dry and dusty environmental conditions
has been found to play a role in the development of pterygia.
Annals of African Medicine  ¦  Volume 17  ¦  Issue 1  ¦  January-March 2018
Lawan, et al.: Astigmatic effect-pterygium
Farmers and laborers and other outdoor workers with increased
exposure are at a higher risk of developing this condition.[20,21]
The highest prevalence of cases of pterygium in this study
Before surgery
was seen in farmers and other outdoor workers; this is similar
After surgery
most cases of pterygium result in with the rule astigmatism
as shown in our study and other similar studies.[7,11] Our study
demonstrated improvement in visual acuity and reduction in
induced astigmatism after pterygium excision. These findings
were found to be statistically significant. Surgical excision
of pterygia has been shown to have significant effects on
corneal refractive status with improvement in spherical
power, astigmatism, and irregularity of the surface of the
Paired P
t-test cornea. These lead to a significant improvement in visual
acuity.[8] Improvement in pterygium induced astigmatism
following surgical excision was seen in a study carried out
in Pakistan.[8] A study that assessed the effect of pterygium
excision on induced astigmatism showed that surgical excision
reduces pterygium‑induced astigmatism with improvement
in visual acuity.[9] A study using videokeratography showed
reduction in corneal astigmatism from 4.4  +  3.64 to
1.55 + 1.63 diopters (P < 0.001) following surgery.[5] A study
that investigated the effect of the technique of surgery on
postoperative astigmatism in pterygium surgery concluded
that pterygium results in high corneal astigmatism which
decreases significantly following excision.[22] Findings of this
study support other studies which have shown that surgical
excision of pterygium leads to improvement in pterygium
induced astigmatism and visual acuity.[5,23,24] Surgical excision
of pterygia is recommended in view of the associated benefits
of improvement in vision and other associated symptoms.
A limitation of this study includes the possibility that some
patients have preexisting uncorrected astigmatism and lack
of long‑term follow‑up which would have helped determine
recurrence and change in astigmatism over time.
Conclusion
The degree of pterygium induced astigmatism reduces
significantly following surgical excision. Pterygium excision
was associated with improvement in visual acuity.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Kanski  JJ, Bowling  B. Conjunctiva. In: Clinical Ophthalmology:
A  Systematic Approach. 7th  ed. Edinburgh: Elsevier Saunders; 2011.
p. 163‑4.
2. Makkar B, Agrawal I, Ahuja A, Shah HK. Comparison of preoperative
and postoperative astigmatism following pterygium excision with
conventional conjunctival graft and amniotic membrane graft. Sch J
Appl Med Sci 2015;3:1477‑82.
3. Lindsay RG, Sullivan L. Pterygium‑induced corneal astigmatism. Clin
Exp Optom 2001;84:200‑3.
9
 Lawan, et al.: Astigmatic effect-pterygium
4. Ashaye AO. Refractive astigmatism and size of pterygium. Afr J Med
Med Sci 2002;31:163‑5.
5. Maheshwari S. Pterygium‑induced corneal refractive changes. Indian J
Ophthalmol 2007;55:383‑6.
6. Mohammed I. Treatment of pterygium. Ann Afr Med 2011;10:197‑203.
7. Ayanniyi  AA, Badmos  KB, Olatunji  FO, Owoeye  JF, Sanni  TO.
Blindness caused by pterygium ‑ A case report. Sierra Leone J Biomed
Res 2011;3:60‑2.
8. Khan FA, Khan Niazi SP, Khan DA. The impact of pterygium excision
on corneal astigmatism. J Coll Physicians Surg Pak 2014;24:404‑7.
9. Maheshwari  S. Effect of pterygium excision on pterygium induced
astigmatism. Indian J Ophthalmol 2003;51:187‑8.
10. American Academy of Ophthalmology. Basic and Clinical Science
Course. Sec. 3. San Francisco: American Academy of Ophthalmology;
2013. p. 114‑7.
11. Shelke E, Kawalkar U, Wankar R, Nandedkar V, Khaire B, Gosavi V.
Effect of pterygium excision on pterygium induced astigmatism and
visual acuity. Int J Adv Health Sci 2014;1:1‑3.
12. Liu L, Wu J, Geng J, Yuan Z, Huang D. Geographical prevalence and
risk factors for pterygium: A systematic review and meta‑analysis. BMJ
Open 2013;3:e003787.
13. Alqahtani  JM. The prevalence of pterygium in Alkhobar:
A hospital‑based study. J Family Community Med 2013;20:159‑61.
14. Tan  CS, Lim  TH, Koh  WP, Liew  GC, Hoh  ST, Tan  CC, et al.
Epidemiology of pterygium on a tropical island in the Riau Archipelago.
Eye (Lond) 2006;20:908‑12.
15. Monsudi  KF, Azonobi  IR, Olatunji  FO, Saka  ES. Prevalence of
pterygium in a tertiary hospital in North‑Western Nigeria. J  Chitwan
10 Annals of African Medicine  ¦  Volume 17  ¦  Issue 1  ¦  January-March 2018
View publication stats
Med Coll 2015;5:46‑51.
16. Cajucom‑Uy H, Tong L, Wong TY, Tay WT, Saw SM. The prevalence
of and risk factors for pterygium in an urban Malay population: The
Singapore Malay Eye Study (SiMES). Br J Ophthalmol 2010;94:977‑81.
17. Liang QF, Xu L, Jin XY, You QS, Yang XH, Cui TT, et al. Epidemiology
of pterygium in aged rural population of Beijing, China. Chin Med
J (Engl) 2010;123:1699‑701.
18. Shiroma H, Higa A, Sawaguchi S, Iwase A, Tomidokoro A, Amano S,
et al. Prevalence and risk factors of pterygium in a Southwestern Island
of Japan: The Kumejima study. Am J Ophthalmol 2009;148:766‑10.
19. Sherwin  JC, Hewitt  AW, Kearns  LS, Griffiths  LR, Mackey  DA,
Coroneo MT, et al. The association between pterygium and conjunctival
ultraviolet autofluorescence: The Norfolk Island Eye Study. Acta
Ophthalmol 2013;91:363‑70.
20. Rohatgi  S. Pterygium: An epidemiological study in India. Intern J
Healthc Biomed Res 2013;4:297‑301.
21. Mackenzie FD, Hirst LW, Battistutta D, Green A. Risk analysis in the
development of pterygium. Ophthalmology 1992;99:1056‑61.
22. Altan‑Yaycioglu R, Kucukerdonmez C, Karalezli A, Corak F, Akova YA.
Astigmatic changes following pterygium removal: Comparison of 5
different methods. Indian J Ophthalmol 2013;61:104‑8.
23. Popat KB, Sheth HK, Vyas VJ, Rangoonwala MM, Sheth RK, Shah JC.
A study on changes in keratometry readings and astigmatism induced by
pterygium before and after pterygium excision surgery. J Res Med Dent
Sci 2014;2:37‑42.
24. Yousuf  M. Role of pterygium excision in pterygium induced
astigmatism. JK Pract 2005;12:91‑2.