Pterygium Surgery
Technique and Complication
Management
Arie L Marcovich MD
Director of Cornea Service
Kaplan Medical Center, Rehovot, Israel
No financial interest
Pterygium Surgery - Anesthesia

Subpterygial Lidocaine 2% infiltration

Addition if needed
Excision with conjunctival graft
Extensive resection vs minimal approach

Hirst advocates large conjunctival resection and
extensive tenonectomy.
He reported a series of 2000 consecutive primary
pterygia and 250 consecutive recurrent pterygia
without a single recurrence
Hirst LW. Prospective study of primary pterygium surgery using
pterygium extended removal followed by extended conjunctival
transplantation. Ophthalmology 2008;115:1663–1672
Hirst LW. Recurrent pterygium surgery using pterygium extended
removal followed by extended conjunctival transplant: recurrence
rate and cosmesis. Ophthalmology 2009;116:1278–1286

Others advocate limited tenonectomy, small
conjunctival resection and a small conjunctival graft
Massaoutis P et al. Clinical outcome of a modified surgical technique
for pterygium excision. Can J Ophthalmol 2006;41:704-708

Limited tenonectomy creates less bleeding, avoids
rectus muscle involvement. It simplifies surgery and
reduces surgical time
Amniotic membrane vs conjunctival graft

Amniotic membrane was less efficient than
conjunctival graft in preventing recurrence
Prabhasawat P et al. Comparison of conjunctival grafts,
amniotic membrane and primary closure for pterygium
excision. Ophthalmology 1997;104:974-985

Cosmetic results with amniotic membrane were
inferior to conjunctival grafts
Luanratanakorn P et al. Randomised controlled study of
conjunctival autograft versus amniotic membrane graft in
pterygium excision. Br J Ophthalmol 2006;90:1476–1480

Amniotic membrane advantageous in large
pterygia and scarred conjunctiva, or glaucoma
patients who need filtration surgery
Post operative management:

Bandage contact lens for 10 - 30 days

Prolonged topical steroid treatment

Careful follow up
Nasal & temporal pterygia

Simultaneous excision: 1 month post-op
Sup conj healed
Complications
Dellen

Patch with antibiotic ointment

Bandage contact lens

Tarsorrhaphy
Treat aggressively to avoid thinning and
inflammation and reduce risk of recurrence
Scleromalacia
M.A. 59 year-old man pterygium OS
Excision bare sclera, MMC 0.02% drops bid - 3 days
5 years P/O
Operation:
Lamellar
corneal graft &
conjunctival
graft from
fellow eye
7 years P/O
9 years P/O
3 months P/O
Infection
V.Y. 66 year-old man pterygium OD
Excision bare sclera, MMC 0.02% applied for 3 min

Avascular
sclera

Corneoscleral
ulcer

Pseudomonas
aeruginosa

Melting &
perforation
1 month P/O
1 year P/O
Recurrence management

Usually occurs within 6 months

More common in younger patients

Persistent inflammation increases risk

Premature cessation of topical steroids
may lead to recurrence
Recurrence management

Recurrence OS
after excision
with
intraoperative
MMC 0.02%

Op: limbal
transplantation
from OD
Young AL et al. A randomised trial comparing 0.02% MMC
and limbal conjunctival autograft after excision of primary
pterygium. Br J Ophthalmol. 2004;88:995–997.
Recurrence OS Op: limbal transplantation from OD
OS
OD
1 m post limbal
harvesting
1 m post pterygium excision
& limbal conjunctival graft
OD
OS
1 year postoperatively
Recurrence management

OD: pterygium recurred twice

Limbal conjunctival graft from superior limbus

No recurrence
Invasion of pseudopterygium at harvest site
Pterygium – astigmatism

Induces
astigmatism
with-the-rule

Excise pterygium before refractive surgery
Pterygium surgery & cataract

Pterygium excision increases spherical power of
cornea and reduce astigmatism

K values stabilize after 1 month

Important with premium IOLs
Tomidokoro A et al. Effects of pterygium on corneal spherical power
and astigmatism. Ophthalmology 2000;107:1568-71.
Recurrent pterygium – astigmatism

Avascular scarring post pterygium
excision may induce high astigmatism

This scarring can be misdiagnosed as
corneal opacification
Pterygia as cause of post-cataract with-the-rule
astigmatism. Holladay JT et al.
J Am Intraocul Implant Soc 1985;11(2):176-9
The effect of recurrent pterygium on corneal topography.
Walland, Stevens, Steele. Cornea 1994; 13(5):463-4
Astigmatism M.K. 79 year old male pterygium OD
Excision bare sclera, MMC 0.02% applied for 3 min
UCVA RE: 20/200 BCVA 20/40 - 6 + 10 X 70
1 m P/O UCVA 20/40 BCVA 20/25 – 2 + 0.5 X 90
Astigmatism post pterygium surgery
 Non
removal of leading edge
 Recurrence
 Scarring
 Deep
excision
Stocker’s line
Pterygium – surgical approach

Gentle corneal scraping

Minimal conjunctival and Tenon excision

Avoid Mitomycin C

Bandage contact lens for 10-30 days

Prolonged topical steroid treatment

Limbal transplantation for recurrent cases