PTERIGIUM

D R . P U R N A M A N I TA S YA W A L , S P M , M A R S
OUTLINE

• SKILL 3 A

• DEGENERATIVE CONDITION IN THE CONJUNCTIVA

– PTERIGIUM
– PSEUDOPTERIGIUM
– PINGUECULA
PTERYGIUM
• Pterygium (L. Pterygion = a wing) is a wing-shaped fold of conjunctiva
encroaching upon the cornea from either side within the
interpalpebral fissure
 ETIOLOGY
PATHOLOGY
• Not definitely known.
• The primary causative factor of • Pterygium is a
the pterygium is excess degenerative and
exposure to UV-B radiation hyperplastic condition
exposure is cumulative and dose- of conjunctiva.
related
• Response to prolonged effect of • The corneal epithelium,
environmental factors such as Bowman's layer and
exposure to sun (ultraviolet superficial stroma are
rays), dry heat, high wind and destroyed.
abundance of dust.
• More common in people living in
hot climates.
PATHOGENIC THEORIES AND
MOLECULAR MECHANISMS
• A fully developed pterygium
consists of three parts:
i. Head (apical part present on
the cornea),
ii. Neck (limbal part), and
iii. Body (scleral part) extending
between limbus and the
canthus.
TYPE 2. REGRESSIVE
1. PROGRESSIVE
❖pterygium is thin,
❖ pterygium is thick, ❖atrophic,
❖ fleshy and attenuated with very little
❖vascularity.
❖invascular with a few infiltrates
the cornea, in front of the
head of the pterygium (called
❖There is no cap.
Ultimately it becomes
❖membranous
cap of pterygium). but never
disappears.
CLASSIFICATION OF PTERYGIUM
PRIMARY ACTIVE
(CLASS IA)
• Highly vascular, inflamed,
symptomatic lesion with or
without an iron line, corneal
edema at the head ; no prior
surgery.
PRIMARY PASSIVE
(CLASS IB)
• Raised, hyalinized,
degenerative, fibrosis with or
without pigmentation and tear
film defect; little or no vascular
channels.
CLASSIFICATION OF PTERYGIUM
SECONDARY ACTIVE SECONDARY PASSIVE
(CLASS IIA) (CLASS IIB)

• Raised, vascular, symptomatic • Flat, avascular, asymptomatic

regrowth with 2 mm or more re-growth with 2 mm or more
corneal involvement; corneal involvement; atrophic.
recurrence.
CLINICAL STAGING OF PTERYGIUM
STAGE I: EXPOSURE
CONJUNCTIVITIS
• Increase in size & number of
conjunctival vessels; mild to
moderate congestion
coinciding with periods of
exposure, signs & symptoms of
dryness; no formed lesion.
STAGE II: CONJUNCTIVAL
PINGUECULUM AND
PTERYGIUM
• Presence of a distinct raised
lesion in the bulbar conjunctiva,
with or without abnormal
vascularization and inflammation;
symptoms of burning and itching;
foreign body sensation.
 CLINICAL STAGING OF PTERYGIUM
STAGE III : LIMBAL STAGE IV: CORNEAL
PTERYGIUM PTERYGIUM

• Leading edge of the lesion • Lesion is 2 mm or more onto and

(head) is on or across the into the cornea; may be
limbus, with or without an iron degenerative or vascular;
line at the conjunctival-corneal granulation tissue invades the
interface, vascularization and cornea; a zone of dellen, edema or
fibrous proliferation; symptoms iron staining cells may be present;
more pronounced. can be painful as it affects the
corneal nerves directly or due to
inflammation.
 CLINICAL STAGING OF PTERYGIUM
STAGE V: COMPOUND PTERYGIUM

• Lesion has extended through

Bowman’s membrane into the
corneal stroma; astigmatism is
induced and vision is
compromised; symptoms more
frequent & more severe;
secondary recurrences and
rapidly progressive traumatic
and chemical lesions.
CLINICAL SIGN
• More common in elderly males doing outdoor work.
• Can be unilateral or bilateral.
• It presents as a triangular fold of conjunctiva encroaching the cornea
in the area of palpebral aperture, usually on the nasal side, but may
also occur on the temporal side.
• Deposition of iron seen sometimes in corneal epithelium anterior to
advancing head of pterygium is called stocker's line.
SYMPTOMS
• Asymptomatic condition in the early stages, except for cosmetic
intolerance.
• Visual disturbances occur
– when it encroaches the pupillary area or
– due to corneal astigmatism induced
– due to fibrosis in the regressive stage.
• Occasionally diplopia may occur due to limitation of ocular
movements.
COMPLICATIONS

• Like cystic degeneration and

• Infection are infrequent.
• Rarely, neoplastic change to epithelioma, fibrosarcoma or malignant
melanoma, may occur.
 DIFFERENTIAL DIAGNOSIS.
1. PINGUECULA
2. PSEUDOPTERIGIUM
3. CONJUNCTIVAL HEMANGIOMA : irregular cluster of blood
vessels in the subconjunctival layer

CONJUNCTIVAL
HEMANGIOMA

PSEUDOPTERYGIUM
DIFFERENTIAL DIAGNOSIS
4. FOREIGN BODY : Foreign body in the conjunctiva ,especially at the
limbus elicits an inflammation response with the rapid proliferation
of fibrovascular tissue which is pterygious in appearance

5. PAPILLOMA: It resembles a bunch of grapes but is hiding a very

vascular core. It usually has a pedicle.
DIFFERENTIAL DIAGNOSIS
6. GRANULOMA: smooth lesion that arises rapidly following a history
of recent surgery or injury.

7. PHLYCTENULE: a flat, fibrovascular, thin, characterized by a history

of infection, usually appears in childhood or infancy & associated
with a hypersensitivity reaction.
DIFFERENTIAL DIAGNOSIS
8. NODULAR EPISCLERITIS : superficial, hyperemic, flat, rounded
lesion consisting of irregular conjunctival & episcleral vessels which
blanch with the application of decongestants, often associated with
localized pain (early stages).
LIMBAL CATARRH

NODULAR EPISCELITIS

9. LIMBAL CATARRH : known as vernal keratoconjunctivitis in

temperate zones & associated with allergy & atopy. The follicles are
usually arranged around the limbus and are often in the palpebral
fissure associated with exposure.
DIFFERENTIAL DIAGNOSIS
10. DERMOID : It has a history of congenital origin, is yellowish-red in
color and has no abnormal blood vessels.

DERMOID CYST SQUAMOUS CELL C A

11. SQUAMOUS CELL CARCINOMA: It is the most common

neoplasm mistaken for pterygium. It often has irregular tiers and
hard white calcifications
Conjunctival and corneal intraepithelial neoplasma (CCIN)
• Late adult life, with ocular irritation or mass
• Uncommon, unilateral
• Slow progressive (low malignant potential)
• Risk factor: UV Exposure, human papilloma virus and AIDS
• Clinical features:

1. En plaque 2. Papillomatous
3. Diffuse CCIN

• Treatment : excision
MANAGEMENT PTERYGIUM
• EARLY DISEASE :
– USE PROTECTIVE EYEWEAR
– LUBRICANT (ARTIFICIAL TEAR EYEDROPS)
• PREOPERATIVE
– TOPICAL DECONGESTANTS (ex NAPHAZOLINE 0.012% AND
TETRAHYDROZALIN )
– TOPICAL ANTI INFLAMMATION MEDICATIONS (ex
DEXAMETHASONE PHOSPHATE 0.1% OR LOTEPREDNOL
EYEDROPS), FOR 7-10 DAYS
– VITAMIN C 300-500 MG ( POSITIVE ROLE IN WOUND HEALING)
– OMEGA-3 1000 MG, 500 MG OF GINGER & 700 MG OF TURMERIC
TO REDUCE AND/OR PREVENT INFLAMMATION PREOPERATIVELY.
MANAGEMENT PTERYGIUM
• SURGICAL EXCISION, may be indicated for:
a. cosmetic reasons,
b. continued progression threatening to encroach onto the pupillary area
c. diplopia due to interference in ocular movements.
• TEHNIQUE:
1. simple excision
2. bare sclera technique
3. Free conjunctival membrane graft
4. Limbal conjunctival autograft trans- plantation (LLAT)
• ADJUNCTIVE THERAPY:
1. Mitomycin C (MMC)
2. Beta irradiation
3. Anti VEGF
Postoperative Management
The routine medications include
-topical antibiotics,
-lubricants, and
- analgesics in the immediate postoperative period.
 COMPLICATIONS AFTER PTERYGIUM EXCISION
IMMEDIATE COMPLIC ATIONS
• Excessive bleeding due to
reactionary hemorrhage can be
noted in the immediate
postoperative period
• Conjunctival chemosis
• Graft edema
• Localized epithelial defect is
seen in almost all patients on
postoperative day-1 (will heal
within 24 hours).
LATE COMPLIC ATION
• Suture-Related Inflammation
• Tenon’s Cyst
• Diplopia and Strabismus
• Scleral Complications
• Corneal Perforation
• Graft Reversal
• Lens Changes
• Ptosis, symblepharon, and iris
atrophy (after pterygium
excision with irradiation).
RECURRENCE PTERYGIUM
• Recurrence after surgical excision problem (30-50%).
• Can be reduced by any of the following measures:
1. Postoperative use of antimitotic drugs such as mitomycin-C or
thiotepa.
2. Surgical excision with free conjunctival graft taken from the same eye
or other eye is presently the preferred technique.
3. In recurrent recalcitrant pterygium, surgical excision should be
coupled with lamellar keratectomy and lamellar keratoplasty.

Primary pterygium Recurrent pterygium

PREVENTION PTERYGIUM
• UV PROTECTION
• MAINTAINING A HEALTHY TEAR FILM
• CONTROLLING INFLAMMATION
• NEW MEDICAL TREATMENT : ANTI VEGF
• PREOPERATIVE MANAGEMENT OF
PTERYGIUM USING SURGEON’S
PREFERENCES : Topical decongestants like
naphazoline 0.012% and tetrahydrozaline, tear
film substitutes
PSEUDO-PTERYGIUM
 PSEUDO PTERYGIUM
1. Pseudo- pterygium
• A fold of bulbar conjunctiva attached to the cornea, grow outside of the 3-
and 9-o’clock positions
• Can be trigger :
– by ocular trauma,
– previous surgery or
– chemical exposure (chemical burns)
• Formed due to adhesions of chemosed bulbar conjunctiva to the marginal
corneal ulcer.
• Suggest may be related to keloids,
DD
PINGUECULA
PINGUECULA
• Pinguecula is an extremely common degenerative condition of the
conjunctiva resemblance to fat, which means pinguis.
• Characterized by formation of a yellowish white patch on the bulbar
conjunctiva near the limbus
Etiology : not known exactly.
• It has been considered as an age-change, occurring more commonly in
persons exposed to strong sunlight, dust and wind.
• It is also considered a precursor of pterygium.
PINGUECULA

Pathology.
• An elastotic degeneration of collagen fibres of the substantia propria of
conjunctiva, coupled with deposition of amorphous hyaline material in the
substance of conjunctiva.
Clinical features.
• Bilateral, usually stationary condition, presenting as yellowish- white
triangular patch near the limbus.
• Apex of the triangle is away from the cornea.
• Affects the nasal side first and then the temporal side.
• When conjunctiva is congested, it stands out as an avascular prominence.
PINGUECULA
Complications

• inflammation,
• intraepithelial abscess formation and
• rarely conversion into pterygium.
Treatment

• No treatment is required for pinguecula.

• May be excised, if desired
REFEREENCE:
1. Pterygium: A Practical Guide to Management © 2009, Jaypee
Brothers Medical Publishers
2. Pterygium : technqiues and technologies for surgical success /
[edited by] John A. Hovanesian.,2012
3. Kanski, clinical ophthalmology.
4. Comprehensive ophthalmology, AK. Khurana. Published by New Age
International (P) Ltd., Publishers,2007
TH ANK Y OU
FOR
ATTENTION