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Disease Entity

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Pterygium, from the Greek pterygos meaning wing, is a common ocular surface lesion originating in
the limbal conjunctiva within the palpebral fissure with progressive involvement of the cornea. The
lesion occurs more frequently at the nasal limbus than the temporal with a characteristic wing-like
appearance.

Disease

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Etiology

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The etiology is unknown. An increased incidence is noted in latitudes nearer the equator and in
individuals with a history of increased UV exposure. Some studies have shown a slightly higher
incidence in males than females, which may only reflect a higher rate of UV radiation.

Risk Factors

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UV radiation, proximity to the equator, dry climates, outdoor lifestyle.

General Pathology

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Histologically, pterygia are an accumulation of degenerated subepithelial tissue which is basophilic


with a characteristic slate gray appearance on H&E staining. Vermiform or elastotic degeneration

refers to the wavy worm-like appearance of the degenerate fibers. Destruction of Bowmans layer by
fibrovascular ingrowth is typical. The overlying epithelium is usually normal, but may be acanthotic,
hyperkeratotic, or even dysplastic and often exhibits areas of goblet cell hyperplasia.

Pterygium histopathology. H&E stain exhibiting elastotic degeneration.

Pathophysiology

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The large number of theories that exist to explain the pathogenesis of pterygium growth underscores
the uncertainty of the etiology. The increased prevalence in hot dry climates and regions nearer to
the equator suggest a role of environmental factors such as UV radiation and dryness. Actinic
changes seen on histopathology similar to actinic keratoses on the skin also supports the role of UV
radiation. It has been suggested that radiation activated fibroblasts may result in excessive
production of material resulting in pterygia. Other proposed theories include choline deficiency, an
inflammatory disorder, disregulation of angiogenesis, immune system abnormalities, tear film
abnormalities, as well as the possible role of a viral stimulus.
Recurrent pterygia appear to be more related to surgical trauma than UV radiation as avoidance of
UV radiation has not been shown to affect the incidence of recurrence. The actinic damage noted
histologically on primary pterygia is characteristically absent from recurrent pterygia, supporting this
theory.

Primary prevention

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As UV radiation is believed to play an important role in the pathophysiology, avoidance of UV


exposure is probably important to primary prevention. Ocular surface lubrication may also help.

Diagnosis

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The diagnosis is made by slit-lamp examination of the typical limbal growth at the characteristic
location within the palpebral fissure. The diagnosis is most often clear clinically, but histopathologic
confirmation is performed routinely.

History

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Physical examination

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A complete eye exam should be performed on all patients with apparent pterygia focusing on
assessment of visual and refractive impact as well as the exclusion of less common alternate
diagnoses.

Visual acuity with current correction and manifest refraction

External examination (lids, lashes, lacrimal apparatus)

Examination of bulbar and palpebral conjunctiva as well as fornices

Slit lamp biomicroscopy of the ocular surface and anterior segment

Keratometry

Corneal Topography

Motility Exam

The remainder of a comprehensive eye exam to include pupil exam, visual fields, intraocular
pressure, and dilated funduscopic exam

Signs

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The diagnosis of pterygium is based on the clinical appearance of the lesion. Typical findings include

Fibrovascular conjunctival growth within the palpebral fissure extending onto the corneal
surface
triangular shape with the apex, or head, extending onto the cornea

vascular straightening in the direction of the advancing head of the pterygium on the corneal
surface.

May be a thin translucent membrane or significantly thickened with an elevated mound of


gelatinous material.

It may affect the nasal and temporal limbus of both eyes or only a single location.

raised lesion, white to pink in color depending on vascularity

ranges from a fine transparent area with very mild elevation, few vessels, and minimal
corneal involvement in the early stages to a thick opaque vascular growth extending to the visual
axis in later stages
Pinguecula are often present in the ipsilateral or contralateral eye
A pigmented epithelial iron line (Stockers line) adjacent to a pterygium is evidence of
chronicity.

It is unusual for pterygia to deviate from the characteristic locations of three and nine oclock within
the palpebral fissure. Pterygioid lesions in other locations should elevate suspicion for alternate
diagnoses.

Symptoms

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Though frequently asymptomatic, pterygia can become inflamed and cause ocular surface irritation.
Many patients will disclose their dislike of the appearance of the pterygium when questioned directly.
As the lesion progresses vision may be affected by induction of astigmatism or obscuration of the
visual axis.

Clinical diagnosis

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Diagnosis is based on the typical clinical appearance

Diagnostic procedures

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Assessment of visual acuity, changes in manifest refraction, and corneal topography can aid in
determining the visual impact of pterygia. Histopathologic confirmation is routine for excised lesions
and can be important in verifying atypical cases.

Laboratory test

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Differential diagnosis

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Pannus

Conjunctival Intraepithelial Neoplasia (CIN)

Terriens marginal degeneration

Symblepharon secondary to chemical, thermal, or mechanical injury

Stevens Johnson Syndrome

Limbal dermoid

Neurotrophic keratitis

Management

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General treatment

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A number of potential therapeutic options exist for the management of pterygia ranging from
conservative management with lubrication to surgical excision with conjunctival autografts. Due to
the potential for recurrence of a more aggressive lesion, as well as other surgical risks, the surgical
removal of pterygia should not be undertaken casually.

Medical therapy

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Inflamed pterygia may cause irritation, foreign body sensation, and tearing which, in many cases,
can be alleviated with over the counter vasoconstrictor drops, lubricating drops and ointments.

Medical follow up

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Initially, the corneal extension of the pterygium should be measured and followed every 1 to 2 years
to determine the rate of growth toward the visual axis.

Surgery

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Excision: simple excision or simple conjunctival closure will result in a recurrence rate as high as
80% and is now considered unacceptable.
Excision together with adjunctive therapies such as radiotherapy, mitomycin and 5FU: the use of
these adjunctive agents will reduce the 80% recurrence of simple excision to about 10% but bring
with them some visually threatening complications. The only real advantage of these methods is the
simplicity and speed of the surgery.
Conjunctival Flap/Graft : this is considered the Gold Standard of care and carries an approximate
rate of recurrence of 5-10% with minimal complications. However, it is a lengthier procedure and
technically slightly more complicated than those methods above. Recently a major modification of a
routine autograft, known as P.E.R.F.E.C.T. for PTERYGIUM, has reduced the recurrence rate to
1/1000 and results in a cosmetic result where the appearance of the eye after this procedure is
indistinguishable from that of a normal eye.

Surgical follow up

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Intensive postoperative topical steroids may be required. Patients need to be followed for one year if
a recurrence is to be identified. 97% of all recurrences occur in the first year after surgery.

Complications

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Recurrence

Corneal scarring

Corneal perforation

Strabismus

Non-healing epithelial defect (esp with mitomycin C)

Scleral melt (esp with mitomycin C)

Prognosis

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Recurrence rate can be as low as 1/1000 with complications being very uncommon.

Additional Resources

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References

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1: Hirst LW. Recurrent pterygium surgery using pterygium extended removal followed by extended
conjunctival transplant: recurrence rate and cosmesis. Ophthalmology. 2009 Jul;116(7):1278-86.
2: Hirst LW, Axelsen RA, Schwab I. Pterygium and associated ocular surface squamous neoplasia.
Arch Ophthalmol. 2009 Jan;127(1):31-2.
3: Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal
followed by extended conjunctival transplantation. Ophthalmology. 2008 Oct;115(10):1663-72. Epub
2008 Jun 16.
4: Hirst LW. Mitomycin C in the treatment of pterygium. Clin Experiment Ophthalmol. 2006
Apr;34(3):197-8.
5: Troutbeck R, Hirst L. Trends in beta irradiation for pterygium in Queensland. Clin Experiment
Ophthalmol. 2003 Dec;31(6):545.
6: Hirst LW. The treatment of pterygium. Surv Ophthalmol. 2003 Mar-Apr;48(2):145-80. Review.

Jaros PA, DeLuise VP. Pingeculae and pterygia. Survey of Ophthalmology 1988;33:41-49.
Nemesure B, Wu S, Henis A, Leske MC, Barbados Eye Studies Group. Nine-year incidence and risk
factors for pterygium in the Barbados Eye Studies. Ophthalmology 2010;115:2153-2158.
Detorakis ET, Spandidos DA. Pathogenetic mechanisms and treatment options for opthalmic
pterygium: Trends and perspectives (Review). International Journal of Molecular Medicine
2009;23:439-447.
The Wills Eye Manual, 5th Edition. Ehlers and Chirag. Lippincott, 2008.