Ophthalmic Epidemiology

ISSN: 0928-6586 (Print) 1744-5086 (Online) Journal homepage: http://www.tandfonline.com/loi/iope20

Pterygium: prevalence, demography and risk

factors

Seang-Mei Saw & Donald Tan

To cite this article: Seang-Mei Saw & Donald Tan (1999) Pterygium: prevalence, demography and
risk factors, Ophthalmic Epidemiology, 6:3, 219-228, DOI: 10.1076/opep.6.3.219.1504

To link to this article: https://doi.org/10.1076/opep.6.3.219.1504

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 Review article

Ophthalmic Epidemiology Pterygium: prevalence, demography and

0928-6586/99/US$ 15.00
risk factors
Ophthalmic Epidemiology
– 1999, Vol. 6, No. 3, Seang-Mei Saw1
pp. 219-228
© Æolus Press 1999 Donald Tan2
Accepted 11 September 1998 1
Department of Community, Occupational & Family Medicine,
National University of Singapore, and
2
Singapore National Eye Centre, Singapore

Abstract Pterygium is not just a degenerative disease, but may be Correspondence and
a proliferative disorder of the ocular surface. The etiology of pterygia reprint requests to:
has intrigued researchers for centuries. Several surveys have consis- Dr. Seang-Mei Saw
tently shown that countries nearer the equator have higher rates of Dept. Community, Occupational
and Family Medicine
pterygia. A possible reason for this geographic variation is that (ultra-
Faculty of Medicine, MD3
violet) UV B light may be a risk factor for the development of pterygia.
National Univ. of Singapore
UV B radiation may induce cellular changes in the medial limbus of 16 Medical Drive
the cornea. Several case-control and cross-sectional studies have attempt- Singapore 117597
ed to accurately quantify UV light exposure and document its relation- Tel.: +65 874 4976
ship with pterygia. Genetic attributes and other lifestyle behaviors may Fax: +65 779 1489
also contribute to the development of pterygia. However, further re- E-mail: cofsawsm@nus.edu.sg
search efforts are needed to enable us to better understand the relative
contribution of the different risk factors and how each risk factor may
be linked to pterygium formation. In addition, the underlying mecha-
nism of the effects of UV radiation needs to be further evaluated. By
readdressing these unresolved issues in a newly proposed epidemiolog-
ical study, new measures might be taken to reduce incidences and
improve clinical managements of diseases, in addition to preventing
UV exposure by eliminating other contributory factors. Meanwhile,
preventive measures such as protection of the eyes by the wearing of
sunglasses with UV B protective lenses and brimmed hats outdoors are
recommended.

Key words Pterygium; ultraviolet radiation; risk factors; epidemi-

ology

Introduction Pterygium management dates back to the time that

Susruta recorded the removal of a pterygium lesion in 1000 BC.1 Even
in ancient times, the recurrent nature of pterygium after surgical re-
moval was noted. Rosenthal remarked that pterygium lesions have been
“incised, removed, split, transplanted, excised, cauterized, grafted, in-
verted, galvanized, heated, dissected, rotated, coagulated, repositioned,
and irradiated.” Also, he adds that it has been “analyzed statistically,
geographically, etiologically, microscopically, and chemically, yet it

Epidemiology of pterygium 219

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 grows onward, primarily and secondarily. We look with interest to its
future”.2 Pterygium is one of the most common eye conditions and
pterygium surgery is widely practised. In 1965, Cameron in his book
‘Pterygium throughout the world’ reviewed the geographic distribution,
risk factors and management of pterygium.3 However, little is known
about the prevalence of pterygium based on population-based surveys
and the relative importance of the different risk factors that contribute
to the onset and recurrence of pterygium. The objective of this review
is to provide an update of the prevalence, demography and pathogen-
esis of pterygia and how the observed risk factors may relate to the
etiology of the disease. Important issues that will be addressed are: 1)
Pterygium is not just a degenerative but a proliferative disease; 2) The
underlying mechanism for the fact that ultraviolet radiation leads to
pterygium formation; 3) The role of genetic and other environmental
factors in pterygium pathogenesis; 4) Directions for the conduct of
further epidemiologic studies that may causally link potential risk fac-
tors to the development of pterygium.

The histology and pathogenesis of pterygium A ptery-

gium (the Greek word pterygos means ‘wing’) has been described clas-
sically as a degenerative or inflammatory process. A pterygium may be
derived from a pingueleculum which is a yellowish growth on the
corneal limbus.1,4 There are several theories on the occurrence of ptery-
gium, which include chronic infection and thrombosis of the conjunc-
tival veins resulting in the development of pterygia.5,6 However, these
theories do not provide a good explanation for the wing-like shape and
location of pterygia. Electron microscopic findings by Cameron showed
that pterygium may be due to invasion of the cornea by subconjunctival
fibroblasts.3,7 There may be a pterygium angiogenesis factor that at-
tracts blood vessels onto the cornea.4 Vessel ingrowth and the develop-
ment of pterygium may occur as a result of this factor. An immunolog-
ic mechanism may also contribute to the development of pterygium as
there is infiltration of small lymphocytes and plasma cells into the
pterygium.8 Type I hypersensitivity may also contribute to the develop-
ment of pterygium.8
More recent findings suggest that pterygia may be a proliferative
disorder rather than a degenerative process.5,6 There is new evidence to
support the claim that pterygium is a proliferative ocular condition.
Pterygia often recur after surgical excision and the treatment modalities
such as wide excision, antimitotic chemotherapy and irradiation mimic
the treatment for neoplasms. Histologic findings reveal that pterygia
may invade locally and sometimes show mild dysplasia or even carci-
noma-in-situ. Recent findings of p53 in the epithelium of pterygium
specimens is further evidence that pterygium is a growth disorder rather
than a degenerative process.9 p53 is a tumor suppressor gene that acts
as a transcription factor that activates or represses the expression of
growth controlling genes. This gene has been shown to be abnormally
expressed in a wide variety of human cancers.

Prevalence and demography Several surveys of pterygium

eyes have been conducted in various countries (Table I). However,

220 S.M. Saw & D. Tan

3212.p65 220 7/6/99, 8:51 PM

 table 1. Summary of the prevalence
Country Study Population Sample size Age Prevalence of pterygium in selected studies.
ref. no.) based ? (years) (%)

Solomon Verlee Yes 512 1 to 89 0.3

Islands (13)
South Africa Hill et al. Yes 1,519 all ages 0.5
(Transkei) (6)
Denmark Norn Yes 810 all ages 0.7
(Copenhagen) (14)
Australia Moran et al. Yes 64,314 all age 3.4 in
(12) Aborigines groups Aborigines
40,799 1.1 in
non- non-
Aborigines Aborigines
Greenland Norn et al. Yes 659 all ages 8.6
(14)
Australia Kerkenezov No 287 10 and 9.6
(New South (20) (clinic above
Wales) patients)
Jordan Norn et al. No, soldiers 127 10 and above 12
(14) and hospital
patients

most surveys are hospital or clinic-based rather than population-based

studies. Therefore, patients with asymptomatic pterygium or those who
seek advice from primary health care physicians and from practice
based ophthalmologists may not be included in such surveys. In hospi-
tal surveys, the total number of pterygium surgeries is often reported
but not pterygium cases seen at the clinic, which leads to a significant
underestimation of pterygium prevalence rates in the hospital. The age
structure of different populations may vary and age-standardized prev-
alence rates are preferred when comparing rates in different countries.
On the other hand, pterygium is an easily recognized condition and
diagnostic procedures are fairly standard across international bound-
aries.
Cameron noted that pterygium rates were higher in countries that
were hot, dusty and dry and especially in countries between 37 degrees
north and south of the Equator.3 A relative ‘pterygium belt’ may exist
where the UV radiation intensity is strongest. Most of the studies re-
viewed were a mixture of institutional surveys, community surveys and
surgical audits. The reason for this interesting geographic variation
could be that sunlight exposure may be associated with the develop-
ment of pterygium. Ringland Anderson first noticed that the prevalence
of pterygium operations was highest in the northern parts of Australia.10
A survey of pterygium operations from the main hospital in each State
in the United States of America was performed by Dimitry in 1937.11
The rate calculated was pterygium operations as a percentage of all eye
surgery. This figure varies with the pattern of operations in each hos-

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 pital but general comparisons of rates show that cities in the South,
including Los Angeles and New Orleans, have higher percentages (11-
13% compared to the overall average of 2.9%). We must be cautious
in the interpretation of this data as individual measurements of sunlight
exposure were not conducted.
Population-based surveys have been conducted in several countries.
In Australia, ophthalmologists examined 64,314 Aborigines, which
covers 50% of the aboriginal population, and the prevalence rate was
3.4%. In 40,799 non-aboriginal volunteers, the rate was 1.1%.12 Popu-
lation-based surveys of the islands in the Pacific Ocean show preva-
lence rates ranging from 29% in the Samoa Islands to 6.75% in the
Cocos Islands and 0.3% in the Solomon Islands.13 In South Africa, only
seven of 1519 people (0.5%) surveyed in Transkei had a pterygium
lesion.6 Only 1% of 189 Japanese in Kyoto had a pterygium in the eye
(latitude 35 degrees North).14 Examinations by Norn using a similar
apparatus showed that the prevalence of pterygium was 12% in Jordan,
9% in Greenland and 1% in Copenhagen.15,16 There have been few
population-based surveys conducted to identify the prevalence rates of
pterygia. The surveys have used different instruments to examine the
patients for pterygia and are often limited by sample size.6,15,16 Thus, it
is difficult to compare the rates of pterygia in different countries.
Other surveys have been conducted in hospitals, physician practices
and among selected occupational groups. The age-adjusted prevalence
rates for 110 male sawmill workers in Thailand was 27% compared to
2% for 164 white male sawmill workers in British Columbia.17 Hospi-
tal-based surveys show prevalence rates that vary from 31% in Lima,
Peru to 4% in the ophthalmologic department of a hospital in Kigali,
Rwanda.18,19 The prevalence of pterygia was 12.3% in several physician
practices in Brisbane, and was 9.6% in the far northern coast of New
South Wales.3,20 The heterogeneity of the study populations limit the
comparability of prevalence rates across studies. The prevalence rates
from these surveys are biased as the study population is not represen-
tative of the population as a whole. Selected population groups may
have certain characteristics leading to higher or lower rates of pterygia
than in the general population.
The prevalence of pterygium increases with age.6,12,16,21 No sex pre-
ponderance has been noted except in the non-aboriginal population of
Australia where the prevalence for women was 0.65% compared to
1.5% in men.3 There is a possibility that different sunlight exposure and
occupation patterns in males and females in certain countries may
contribute to differences in pterygium rates.
The most striking feature of the distribution of pterygium is the high-
er rates found in countries nearer the equator. However, there are still
gaps in our knowledge of the distribution of pterygium in certain parts
of the world. Population-based surveys that are a random sample of the
general population with high participation rates are needed to quantify
pterygium age-adjusted prevalence rates in countries at different lati-
tudes. It is also important that experienced ophthalmologists conduct
the clinical examinations and that uniform criteria are maintained for
diagnosis and grading.

222 S.M. Saw & D. Tan

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 Risk factors

ultraviolet radiation The major environmental risk factor for

the development of pterygium is exposure to UV light.21 Age-related
cataract, age-related macular degeneration, climatic droplet kerato-
pathy and eyelid malignancies are also postulated to be related to UV
light.22-24 Other sunlight-related conditions such as basal cell carcino-
ma, polymorphous light eruption and xeroderma pigmentosum are of-
ten associated with pterygium.21 When UV radiation is divided into UV
A (400 to 320 nm), B (320 to 290 nm), and C (290 to 100 nm) accord-
ing to the wavelength, UV A causes sun tanning, UV B causes sunburn
and skin cancer, and UV C does not reach the earth’s surface.25 The
depletion of the ozone layer in recent decades may result in increased
ultraviolet radiation and a subsequent increase in sunlight-related con-
ditions such as pterygium.26
UV light absorbed by the cornea and conjunctiva promotes cellular
damage and hence subsequent proliferation. Experiments in mice showed
that UV radiation results in degeneration of Bowman’s membrane and
epithelial hyperplasia.27 One theory proposed by Coroneo et al. is that
UV light enters from the temporal side and is focused on the nasal side
resulting in the formation of a nasal pterygium.28,29 Albedo, or reflected
solar radiation, is responsible for most of the light rays that strike the
corneal surface and is the major factor that determines focal UV B
exposure (295 to 320 nm) of the eye.
There are several theories about the mechanism whereby UV radia-
tion may result in pterygia formation. There may be a modification of
the ocular immune system which may contribute to pterygium forma-
tion. UV radiation at the medial limbus may cause a depletion of Langer-
hans cells which may result in the conjunctival cells not recognizing
the junction between the cornea and conjunctiva, leading to a growth
of conjunctival epithelium into the corneal zone.5,30 Recent evidence
indicates that pterygium is a proliferative disease and that maximum
mitosis may occur when the cornea is exposed to UV radiation. There
is evidence that the extracellular matrix of pterygia is not normal and
UV radiation may alter the synthesis of protein, resulting in degener-
ation of the limbal region. In summary, UV light may have an actinic
effect on the mitosis of cells resulting in pterygium formation.
The amount of UV light that reaches the surface of the cornea is
affected by local and external factors. Local factors such as corneal
curvature, anterior chamber depth, length of eye lashes, and ocular
prominence may determine the fall of light on the nasal portions of the
eye. The exposure to albedo UV light also varies with external factors
such as latitude, ambient conditions, reflective terrain, time of day spent
outdoors, prescription eyewear, and protective equipment such as hats.28
The reflectance of the terrain is an important determinant of UV B
radiation with the greatest reflectance from fresh snow, followed by
sand and concrete pavements.31 The average transmission for UV B
light to the cornea as measured using a radiometer32 was highest for
soft contact lenses, followed by glass spectacle lenses, hard contact
lenses and plastic spectacle lenses.
The evidence from epidemiologic studies for UV radiation as a cause

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 for the onset of pterygia is not conclusive. Most epidemiologic studies
do not directly measure the exposure to UV radiation in each individual
and deductions are made from selected population groups. The studies
are also limited by sample size, lack of a clear delineation of the tem-
poral relationship between UV light exposure and pterygium formation,
and the fact that potential confounders are often not examined. Several
preliminary studies have been conducted that suggest that UV light
may play a role in the pathogenesis of pterygia.
There are several observations that support the hypothesis that UV
light promotes pterygia formation. In a study by Jensen, the results
showed that pterygium usually occurs first in the dominant eye which
is held open when facing the sun.33 The non-dominant eye remains
closed and the intensity of the incident albedo radiation decreases.
Pterygium rates increase with age which may be related to the cumu-
lative effects of ultraviolet radiation.22 Another observation is that se-
lected occupations with higher exposure to UV light have higher rates
of pterygium. Occupational studies have shown that welders and saw-
mill workers have a higher prevalence of pterygium.17,34,35 A study of
217 male welders in Copenhagen showed that 57% of welders had
pingueculae and 5% had pterygium. The prevalence increased with a
higher welding exposure.35 Pterygium was also associated with certain
outdoor occupations such as stockmen, station hands, and laborers in
the Aboriginal population.36 However, other possible confounding fac-
tors were not adjusted for and direct measures of UV exposure were
not made. The exposure to UV light for different members of the same
profession may not be uniform.
For example, a higher prevalence of pterygium was noted in coun-
tries at a higher latitude and with fewer hours of sunlight per day.3 In
350 Aborigines in Australia, the odds ratio for pterygium for those
exposed to more than 9.5 hours of sunshine per day was 1.9.37 A pos-
itive correlation was also found for latitude and pterygium. A case-
control study by Darrell showed a higher frequency of pterygium in
veterans living in the South of the United States compared to the North,
in those with outdoor occupations, and in rural areas.38 Deductions may
be made from ecologic studies in which the prevalence of pterygium in
64,314 Aborigines in Australia was 3.4% compared to 1.1% in 40,799
non-Aborigines.12 Male and female aborigines in Australia spend more
time outdoors compared to their non-aboriginal counterparts. Selection
bias may have occurred as the non-aboriginal population was self-re-
ferred.
Accurate measurements of UV light exposure are needed to reduce
misclassification of exposure in epidemiologic studies. Often, ambient
light levels of sunlight are used as surrogates of personal ocular expo-
sure. However, only crude estimates of UV light exposure are some-
times obtained. Global UV light exposure measurements may lead to
serious errors that may distort exposure-disease relationships. More
precise estimates of ultraviolet light exposure were made in the follow-
ing studies. A study of 135 cases and 687 age-matched controls of
watermen who worked on Chesapeake Bay found a strong association
between ocular exposure to a wide band of UV radiation and ptery-
gium.21,23 The odds ratio of pterygium in those with doubling of cumu-

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 lative blue light exposure is 1.85 (1.43 to 2.38). The odds ratio for
average annual exposure to UV-B light in the upper quartile was 3.06
(1.77-5.31) compared to the lowest quartile and a dose-response rela-
tionship was seen. A combination of interview data that combined work
and leisure time histories, history of spectacle and eyeglass wear as
well as laboratory and field measurements were made by interviewers
masked to the status of the cornea. Ocular exposure was quantified by
UV- sensitive film badges placed near the eye.39 After exposure of the
film badge to UV light, the spectrophotometer was used to measure
absorbance. A slit-lamp examination of the cornea was made to diag-
nose pterygia. In a hospital in Brisbane, in an interview study using a
standard questionnaire from the watermen study, 278 cases and a sim-
ilar number of age, sex and race matched controls were compared.40,41
The odds ratio was 44.3 for pterygium for patients living at latitude less
than 30 degrees and 14.1 for spending more than 50% of the time
outdoors in the first five years of life. However, selection bias may
have occurred as hospital controls may have different living patterns
compared to the general population.
The above studies have consistently shown a strong association of
UV light and pterygium formation. UV radiation levels may increase as
the ozone layer is gradually depleted. Despite the fact that there is a
biologically plausible model for the action of UV light, most of the
studies do not establish a well-defined temporal relationship and the
latency period, nor explore effects of the duration of UV light expo-
sure, peak exposure or cumulative exposure. To establish causality,
future studies should include a well-defined temporal sequence of events
and document the nature of the dose-response relationship. A pre-tested
and reliable questionnaire that measures ultraviolet light exposure and
other potential confounders is essential in analytic studies of the causes
of pterygia. Future cohort studies of a representative population with a
wide range of ocular exposures to UV light may provide us with valu-
able data on the incidence of pterygia in those with greater ocular
exposures to UV light compared to those with less ocular exposure. A
well-designed cohort study ideally should have a sufficient length of
follow-up to accrue a good number of new cases of pterygia and there
should be intensive efforts to decrease the number of participants who
are lost to follow-up (migrated, uncontactable, refused to participate).
A large number of subjects lost to follow-up will decrease the sample
size and introduce bias if the participants lost to follow- up have a
different exposure-disease relationship.
If the incidence of pterygium is low in the population, a case-control
design may be more efficient and the odds ratio may be used to esti-
mate the relative risk. However, a case-control study is often limited by
selection and information biases. Measures must be taken to limit the
problem of biases in such studies. Based on our present knowledge
from epidemiologic studies, we would still advise the protection of the
eyes from excessive sunlight exposure by the use of eyewear or protec-
tive clothing.

genetic factors Hereditary factors may play an important role in

the pathogenesis of pterygia. The p53 oncogene may be a possible

Epidemiology of pterygium 225

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 marker for the pterygium gene. Although case reports have described
clusters of family members with pterygium,42-44 the importance of he-
reditary factors in pterygium onset is still unknown. An interesting
study that was conducted to examine familial risk factors is a hospital-
based case-control study of 100 pterygium cases and 100 controls in
Australia. The odds ratio for a family history of pterygium was 4.7545
However, no eye examination of family members was conducted.
Another clue that genetics may play a role is that pterygium is associ-
ated with several syndromes such as the multiple pterygium syndrome
(autosomal dominant or recessive). 46 Nevertherless, there is little evi-
dence from twin studies, migration studies or segregation analysis stud-
ies on the exact nature of genetic inheritance. Familial clusters of the
disease may also arise as a result of a common environment or occu-
pation. Further research is needed to evaluate the nature of any genetic
transmission or interaction of genetic and environmental factors.

dry eyes It is possible that abnormalities in the tear film may cause
drying and predisposition to new growth. Thus, proliferation of cells
leading to the formation of pterygia may occur. The evidence for dry
eyes as a causative agent for pterygia is, however, limited to a few
studies. Aborigines with pterygium were found to have a disruption of
the marginal tear strip compared to aborigines without pterygium.47 A
hospital case-control study in Johannesburg did not show any correla-
tion between dry eyes in the Bantu and pterygium.48 However, only 43
cases and 23 controls were evaluated. When the tear film break-up time
(BUT) was studied in 56 eyes of patients with pterygium and compared
with 50 normal eyes in India, there was a significantly reduced BUT in
cases with pterygium.49 Biedner et al. found that in 60 patients with
unilateral pterygia that were examined, there was no Schirmer test
evidence for dryness.50 However, in this study, there were no compar-
isons with a control group.

other environmental risk factors The attributable risk of pte-

rygium for UV light exposure is not known. Are there other factors that
may contribute independently or interact with UV light exposure? Oth-
er observations have suggested that low humidity or microtrauma from
particulate material such as smoke or sand may play a role.21,48 The role
of genetics is not well explored. Researchers have raised the question
of whether dietary deficiencies may contribute to the formation of ptery-
gium.51 In a small case-control study by Taylor, alcohol intake, previ-
ous ocular trauma and severity of trachoma were not related to ptery-
gium.52 Other studies have raised the possibility of HPV infection
contributing to the development of pterygium.53 At present, there is no
proven evidence from epidemiologic studies on other possible genetic
or environmental risk factors for pterygium.

Conclusion Pterygium is one of the most obvious eye disorders

and the removal of pterygium one of the most commonly performed
operations in Asia. However, the nature and etiology of pterygia has
eluded many researchers for decades. New evidence has shown that
pterygium is a proliferative rather than just a degenerative disease. UV

226 S.M. Saw & D. Tan

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 radiation could be a major risk factor for pterygia and UV radiation
may have an actinic effect on cell mitosis resulting in pterygia forma-
tion. It is unlikely that there is a sole risk factor for pterygia and the
other possible contributing factors include age, hereditary factors, and
dry eyes. There may also be interaction between the different factors.
We would like to suggest directions for future epidemiologic research.
Population-based studies with adequate sample size would be useful in
defining the prevalence of pterygium in different countries. Future stud-
ies on the incidence of pterygium in a well-defined cohort would pro-
vide a clearer picture of the events surrounding disease onset.
Several studies over the past few decades suggest that UV radiation
may be associated with pterygium.12,21,23,29 Accurate exposure estima-
tions of ocular UV light exposure combining interview and field data
are essential to decrease the misclassification bias. Further studies would
determine whether any factors are causally related to pterygium as well
as the attributable risk of each factor. Several previous studies have
quantified sunlight exposure, which is a rather crude estimate of ultra-
violet light; thus, future studies should include accurate measures of
ultraviolet light exposure. Cohort and case-control studies with accu-
rate estimates of the various risk factors for pterygia would shed further
light on the causes of pterygia. Present evidence from case-control
studies suggests that UV B light is the predominant risk factor for
pterygium formation. Most light that reaches the eye is reflected solar
radiation (albedo). Conventional sunglasses may not protect the eye
from UV light as reflected light, which may strike the eye from the
side. Protection of the eyes by wearing wrap-around sunglasses with
UV B-absorbing lenses and brimmed hats outdoors has thus been rec-
ommended.41

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