Pterygium

http://emedicine.medscape.com/article/1192527-overview#showall

Background
A pterygium is an elevated, superficial, external ocular mass that usually forms over the
perilimbal conjunctiva and extends onto the corneal surface. Pterygia can vary from small,
atrophic quiescent lesions to large, aggressive, rapidly growing fibrovascular lesions that can
distort the corneal topography, and, in advanced cases, they can obscure the optical center of
the cornea.[1, 2]

Pathophysiology
The pathophysiology of pterygia is characterized by elastotic degeneration of collagen and
fibrovascular proliferation, with an overlying covering of epithelium. Histopathology of the
abnormal collagen in the area of elastotic degeneration shows basophilia with hematoxylin and
eosin stain. This tissue also stains with elastic tissue stains, but it is not true elastic tissue, in
that it is not digested by elastase.[1, 2]

Epidemiology
Frequency
United States

Occurrence within the United States varies with geographical location. Within the continental
United States, prevalence rates vary from less than 2% above the 40th parallel to 5-15% in
latitudes between 28-36. A relationship is thought to exist between increased prevalence and
elevated levels of ultraviolet light exposure in the lower latitudes.[3, 4]

International

Internationally, the relationship between decreased incidence in the upper latitudes and
relatively increased incidence in lower latitudes persists.

Mortality/Morbidity
Pterygia can cause a significant alteration in visual function in advanced cases. They also can
become inflamed, resulting in redness and ocular irritation.

Sex
Pterygia are reported to occur in males twice as frequently as in females.
Age
It is uncommon for patients to present with pterygia prior to age 20 years. Patients older than 40
years have the highest prevalence of pterygia, while patients aged 20-40 years are reported to
have the highest incidence of pterygia.

History
Patients with pterygia present with a variety of complaints, ranging from no symptoms to
significant redness, swelling, itching, irritation, and blurring of vision associated with elevated
lesions of the conjunctiva and contiguous cornea in one or both eyes.

Physical
A pterygium can present as any of a range of fibrovascular changes on the surface of the
conjunctiva and the cornea. It is more common for the pterygium to present on the nasal
conjunctiva and to extend onto the nasal cornea, although it can present temporally, as well as
in other locations.

The clinical presentation can be divided into 2 general categories.

One group of patients with pterygium can present with minimal proliferation and a relatively
atrophic appearance. The pterygia in this group tend to be flatter and slow growing and have a
relatively lower incidence of recurrence following excision.

The second group presents with a history of rapid growth and a significant elevated
fibrovascular component. The pterygia in this group have a more aggressive clinical course and
a higher rate of recurrence following excision.

Causes
Risk factors for pterygium include (1) increased exposure to ultraviolet light, including living in
subtropical and tropical climates,[5] and (2) engaging in occupations that require outdoor
activities.

A genetic predisposition to the development of pterygia appears to exist in certain families.

A predilection exists for males to develop this condition in significantly higher numbers than
females, although this finding may represent an increased exposure to ultraviolet light in this
portion of the population.[5]

Diagnostic Considerations
Consider pseudopterygia (eg, chemical or thermal burn, trauma, marginal corneal disease) in
the differential diagnoses.
 Consider neoplasia (eg, carcinoma in situ, squamous cell carcinoma, other neoplastic diseases)
in the differential diagnoses.

Pingueculae (ie, actinic lesions confined to the perilimbal conjunctiva that do not extend onto the
cornea) should also be considered in the differential diagnoses.[6]

Pingueculae are commonly occurring, generally small and asymptomatic (often yellow) raised
nodules appearing on the bulbar surface of the conjunctiva. They are found more commonly on
the nasal side, but they can also present either on the temporal conjunctiva or on both the nasal
and temporal conjunctiva in the eyes of some patients.

Pingueculae are thought to be associated with actinic (sunlight) exposure in susceptible

individuals.

Pingueculae can occasionally be subject to some inflammation with symptoms of itching,

burning, or mild pain. In the absence of inflammation or of significant cosmetic complaints,
pingueculae are generally ignored (by patient and physician alike). If mildly symptomatic, like
pterygia, they can be treated with artificial tears.

On rare occasions, ocular anti-inflammatory drops may be required. On even more infrequent
occasions, surgical excision may be of benefit in the management of pingueculae.

Histopathologically, pingueculae show mild-to-moderate focal thickening of the conjunctival

stroma with elastotic degeneration of collagen.

Differential Diagnoses
Squamous Cell Carcinoma, Conjunctival

Imaging Studies
Corneal topography can be very useful in determining the degree of irregular astigmatism
induced by advanced pterygia.

External photography can assist the ophthalmologist in following the progression of the
pterygium.

Procedures
Multiple different procedures have been advocated in the treatment of pterygia. These
procedures range from simple excision to sliding flaps of conjunctiva with and without adjunctive
external beta radiation therapy and/or use of topical chemotherapeutic agents, such as
mitomycin C (MMC).[7, 8]

Using free grafts of conjunctiva (with or without limbal tissue) at the same time as primary
excision of the lesion has been widely advocated as the preferred treatment modality for
aggressive pterygia. For moderate-to-severe pterygia, some corneal surgeons use amniotic
membrane transplants. Both the conjunctival autografts and the amniotic membrane transplants
may be sutured onto adjacent conjunctiva and subjacent cornea. Some corneal surgeons seal
the graft tissue onto the underlying sclera with the aid of fibrin tissue glue rather than with
sutures.[9, 10, 11, 12, 13, 14]

A study by Kheirkhah et al found that conjunctival inflammation was much more common with
amniotic membrane transplantation than with conjunctival autograft after pterygium surgery.
However, with control of such inflammation and intraoperative application of mitomycin C, both
techniques brought about similar final outcomes.[15]

Medical Care
Patients with pterygia can be observed unless the lesions exhibit growth toward the center of
the cornea or the patient exhibits symptoms of significant redness, discomfort, or alterations in
visual function. Pterygia can be removed for cosmetic reasons, as well as for functional
abnormalities of vision or discomfort.[16]

Surgical Care
Surgery for excision of pterygia is usually performed in an outpatient setting under local or
topical anesthesia with sedation, if necessary.

A prospective, randomized, interventional study by Kheirkhah et al assessed 56 patients who

underwent pterygium excision with MMC application and an amniotic graft.[17] Of those 56
patients, 28 received MMC on the perilimbal bare sclera from 1-5 minutes, whereas 28 other
patients received MMC under the conjunctiva. Endothelial cell studies revealed loss of 3.4% of
cells in the bare sclera group compared with 4.8% in the subconjunctival group at 6 months. No
complications were observed in either group; however, the study was small.

A prospective, nonrandomized study by Bahar et al examined the risk of endothelial cell loss in
43 subjects following pterygium surgery with MMC and conjunctival autograft.[18] The study
included a control group who had a primary pterygium excision without MMC. Although the
number of patients in each group was small, the patients who received MMC experienced a 4%
reduction in endothelial cells at 3 months, compared with no loss in the control group. This
suggests that MMC can affect the endothelial cell counts in patients undergoing pterygium
excision.

Despite the relatively small sample sizes, both studies reported statistically significant
decreases in corneal endothelial cell counts (P values 0.05) as long as 3 months after surgery.
The authors note that placement of MMC at the limbus can be a risk factor for scleral melts.
Thus, the authors advise placement of MMC only in the area of the fibrovascular conjunctival
tissue.

Hirst initiated a prospective nonrandomized study of an evolution of previous pterygium surgical

techniques involving extensive excision of overlying conjunctiva and underlying Tenon fascia in
the vicinity of the pterygium, combined with a large, limbal-sparing autograft harvested from the
superior conjunctival surface.[19] Hirst subsequently published his longer-term results after more
than 1000 surgeries, including 806 primary pterygia and 194 recurrent pterygia. The author had
a follow-up of longer than 1 year in 99% of those patients, with a mean follow-up of 616 days.
The author reported only one recurrence among those 1000 patients, significantly lower than
has been previously reported for both primary and secondary pterygium surgeries. [20]

This technique did not require the use of antimetabolites and it spared limbal stem cells at the
site of conjunctival autograft harvesting. In addition to a reduction in expected recurrences, Hirst
also reported a lower rate of postoperative complications with fewer than expected
postoperative granulomas and fewer than expected conjunctival inclusion cysts.

Postoperatively, the eye is generally patched overnight, and it is treated subsequently with
topical antibiotics and anti-inflammatory drops and/or ointments.

Medication Summary
Medical therapy of pterygia consists of over-the-counter (OTC) artificial tears/topical lubricating
drops (eg, Refresh Tears, GenTeal drops) and/or bland, nonpreserved ointments (eg, Refresh
P.M., Hypo Tears), as well as occasional short-term use of topical corticosteroid anti-
inflammatory drops (eg, Pred Forte 1%) when symptoms are more intense. In addition, the use
of ultraviolet-blocking sunglasses is advisable to reduce the exposure to further ultraviolet
radiation.

Artificial tears (topical lubricating drops)

Class Summary
To lubricate the ocular surface and to fill in defects in the tear film.

View full drug information

Artificial tears (Refresh Tears, GenTeal [OTC])

Artificial tears provide topical ocular surface lubrication in patients with irregular corneal
surfaces and irregular tear films. These conditions are very common in the setting of pterygium.

Topical lubricating ointments

Class Summary
A more viscous lubricant of the ocular surface.

View full drug information

Artificial tears (Hypo Tears, Refresh P.M. [OTC])

A relatively more viscous lubricant for the ocular surface. These thicker preparations tend to blur
the vision temporarily; therefore, they are generally used at night, except in patients with severe
discomfort.

Anti-inflammatory drops
 Class Summary
To reduce inflammation on the ocular surface and other ocular tissues. Corticosteroids can be
helpful in the management of inflamed pterygia by reducing the swelling of the inflamed tissues
of the ocular surface adjacent to the lesions.

View full drug information

Prednisolone ophthalmic (Pred Forte 1%)

A topical corticosteroid suspension used to reduce inflammation in the eye. Use should be
limited to eyes with significant inflammation not relieved by topical lubricants.

Further Outpatient Care

Postoperatively, after pterygium excision, the topical steroids are slowly tapered. Patients on
topical steroids need to be observed to avoid problems, such as elevated intraocular pressure
and cataracts.[21]

Inpatient & Outpatient Medications

See Medication.

Deterrence/Prevention
Theoretically, minimizing exposure to ultraviolet radiation should reduce the risk of development
of pterygia in susceptible individuals. Patients are advised to use a hat or a cap with a brim, in
addition to ultraviolet-blocking coatings on the lenses of glasses/sunglasses to be used in areas
of sun exposure. This precaution is even more important for those patients living in tropical or
subtropical areas or for those patients who are engaged in outdoor activities with a high risk of
ultraviolet exposure (eg, fishing, skiing, gardening, outdoor construction work).

Complications
Complications of pterygia include the following:

Distortion and/or reduction of central vision

Redness
Irritation
Chronic scarring of the conjunctiva and the cornea
Extensive involvement of the extraocular muscles may restrict ocular motility and contribute
to diplopia. In patients who have not yet undergone surgical excision, scarring of the medial
rectus muscle is the most common cause of diplopia In patients with pterygia who have
previously undergone surgical excision, scarring or disinsertion of the medial rectus muscle is
the most common cause of diplopia.
 In patients with significantly elevated pterygia, focal drying and subsequent thinning of the
adjacent cornea may rarely occur.

Postoperative complications of pterygium repair can include the following:

Infection
Reaction to suture material
Diplopia
Conjunctival graft dehiscence [22]
Corneal scarring
Perforation of the globe, vitreous hemorrhage, or retinal detachment (all rare)
Late postoperative complications of beta radiation of pterygia can include scleral and/or corneal
thinning or ectasia, which can present years or even decades after treatment. Some of these
cases can be quite difficult to manage.

In some cases, adjunctive use of topical MMC at and after pterygium surgery has been reported
to cause similar ectasia or melting of the sclera and/or the cornea.[7, 23, 24]

The most common complication of pterygium surgery is postoperative recurrence. Simple

surgical excision has a high recurrence rate of approximately 50-80%. The rate of recurrence
has been reduced to approximately 5-15% with use of conjunctival/limbal autografts or amniotic
membrane transplants at the time of excision.[13, 25, 26, 27]

On rare occasion, malignant degeneration of epithelial tissue overlying an existing pterygium

can occur.

Prognosis
The visual and cosmetic prognosis following excision of pterygia is good. The procedures are
well tolerated by patients, and, aside from some discomfort in the first few postoperative days,
most patients are able to resume full activity within 48 hours of their surgery. Those patients
who develop recurrent pterygia can be retreated with repeat surgical excision and grafting, with
conjunctival/limbal autografts or amniotic membrane transplants in selected patients.[28, 29]

Patient Education
Patients who are at high risk of the development of pterygia because of a positive family history
of pterygia or because of extended exposure to ultraviolet irradiation need to be educated in the
use of ultraviolet-blocking glasses and other means of reducing ocular exposure to ultraviolet
light.