MANAGEMENT FOR PTERYGIUM

MEDICAL TREATMENT:
Symptomatic patient : Tear substitutes
Inflammation: Topical steroids
Sunglasses: To reduce UV exposure and
decrease growth stimulus.
INDICATION FOR SURGERY:
Extension to the visual axis and induced
astigmatism.
Recurrent irritation.

SURGICAL TECHNIQUE:
Pterygium Excision
1. Goal: Achieve a normal, topographically
smooth ocular surface
2. Dissect a smooth plane toward the limbus
3. Some surgeons prefer specialized blunt
pterygium blades (Tooke or Gills) while
others prefer sharp blades
4. Preferable to dissect down to bare sclera at
limbus
5. Bare sclera = remove loose Tenons layer
and leave episcleral vessels intact


Some surgeons avoid medial dissection to
avoid bleeding from trauma to adjacent
muscle tissue while other remove
excessive fibrovascular tissue medially
Light thermal cautery is applied for
hemostasis



Pterygium Recurrence
Growth of fibrovascular tissue across the
limbus onto cornea after initial removal
Excludes persistence of deeper corneal
vessels and scarring which may remain
even after adequate removal
Bunching of conjunctiva and formation of
parallel loops of vessels, which aim almost
like an arrowhead at the limbus, usually
denotes a conjunctival recurrence

Proposed Recurrence Grading
System:
Grade 1 normal appearing operative
site
Grade 2 fine episcleral vessels in the site
extending to the limbus
Grade 3 additional fibrous tissues in site
Grade 4 actual corneal recurrence

Wound Closure Options:
Bare sclera
Simple closure
Sliding flap
Rotational flap
Conjunctival graft

Bare Sclera Closure
No sutures or fine, absorbable sutures used
to appose conjunctiva to superficial sclera
in front of rectus tendon insertion
Leaves area of bare sclera
Relatively high recurrence rate with
variable techniques of 5 68 % with
primary / 35 82 % with recurrent)
Simple Closure
Free edges of conjunctiva secured
together
Effective only if defect is very small
Can be used for pingueculae removal
Reported recurrence rates from 45 69
% (one report of barest sclera, N=800
of 2 %)
Few complications (dellen)

Sliding Flap Closure
An L-shaped incision is made adjacent to
the wound to allow conjunctival flap to
slide into place
Reported recurrence rates from 0.75 5.6
% (poorly designed, retrospective)
Few complications (flap retraction / cyst
formation)
Rotational Flap Closure
A U-shaped incision is made adjacent
to the wound to form tongue of
conjunctiva that is rotated into place
Reported recurrence of 4 %
Few complications
Conjunctival Graft Closure
A free graft, usually from superior
bulbar conjunctiva, is excised to
correspond to wound and is then
moved and sutured into place
Can be performed with inferior
conjunctiva to preserve superior
conjunctiva
Harvested tissue should be approximately 0.5
1 mm larger than defect
Most important aspect in harvesting is to
procure conjunctival tissue with only minimal
or no Tenons included
Graft is transferred to recipient bed and
secured with or without incorporating
episclera
Some surgeons harvest limbal stem cells along
with graft and orient graft to place stem cells
adjacent to site of corneal lesion excision

Topical antibiotic-corticosteroid ointment
used for 4 6 weeks post-operatively until
inflammation subsides (compliance with this
regimen decreases recurrence)
Used when extensive damage or destruction
of limbal epithelial stem cells is NOT present
Reduces recurrence to 2 5 % (up to 40 % in
some reports)
Ameliorates the restriction of extraocular
muscle function

Limbal Conjunctival Autograft
Reported recurrence rates are variable
(between 0 40 %)
Few complications
Further prospective studies in primary and
recurrent pterygia are needed

Lamellar Corneal Transplant
Wound closed with piece of lamellar sclera or
cornea
Reported recurrence rates of 6 30 %
Not performed often
Can be used in conjunction with AMT for
multiply recurrent pterygia with corneal
scarring and limited available conjunctiva
Method involves increased surgical
complexity, the requirement of donor tissue,
and risk of infectious disease transmission


Adjunctive Beta Irradiation
Most common dosage is 15 Gy in single or
divided doses
Reasonably acceptable recurrence rates
(from 0 50 % with bare sclera or simple
conj closure)
Risk of corneal or scleral necrosis and
endophthalmitis

Adjunctive Thiotepa
Most common dose is 1:2000 thiotepa
given up to every 3 hours for approx. 6
weeks
Usually used with bare sclera method
Low reported recurrence rates of 0 16 %
(poor study quality)
Minimal complications (2 cases of scleral
thinning)

Adjunctive Mitomycin C
Used with bare sclera or conj closure
Most common dose is 0.02 % applied for 3
min during surgery
Risk of aseptic scleral necrosis /
perforation and infectious sclerokeratitis
Used more often for recurrent cases
Rate of recurrence between 3 25 % for
intra-op / 5 54 % for post-op with most
studies showing < 10 % recurrence

Amniotic Membrane Graft
Closure
Useful for very large conjunctival defects
as in primary double-headed pterygium
or to preserve superior conjunctiva for
future glaucoma surgeries
Requires costly donor tissue
Reported recurrence rate between 3 64
% for primary cases and 0 37.5 % for
recurrent cases


Conclusions:
There is no clear-cut superior single treatment
Bare scleral and simple conjunctival closure
without adjunctive therapy have relatively high
but variable recurrence rates
Use of beta irradiation and antimetabolites can be
used with appropriate caution
Conjunctival transplants and flaps appear to have
overall lower rate of recurrence but require more
surgical time and unnecessary conj destruction
Other treatment options need further adequate
study prior to widespread implementation