Management of Pterygium
Dr VIDYASHANKAR G K
Shekar Nethralaya
Bangalore
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4/8/2015
Pterygium
Defn : An Elastotic Degenerative condition of conjunctiva with a
wing like encroachment of conjunctiva on to the Cornea.
Pathogenesis –
 Environmental causes- UV exposure, dust heat , wind exposure
 Heredity
 Coroneo Effect -Nasal segment of cornea gets highest UV exposure effect
 Limbal Stem cell defect with Fibroblast Activation
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4/8/2015
Pterygium - Classification
 Primary Pterygium
Body
Neck
 Recurrent Pterygium
Head
 Atrophic Pterygium
Older pts, thin translucent body with thin vessels
 Pogressive Pterygium
Thick fleshy growth seen in Younger pts
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Pterygium
Grading of pterygium helps for management
Depending on SizeGrade 1
Grade 2
Grade 3
Variants
 Cystic degeneration
 Bidirectional
 Pseudo pterygium – present anywhere, neck bridges limbus
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4/8/2015
Pterygium- Management
 Observation
Asymptomatic , grade 1 pterygium
 Medical Management
Symptomatic Grade 1 and 2 pterygium
Eye drops – Tear substitutes, Decongestants
Local injections – anti VEGFs, Steroid
 Surgical Management
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4/8/2015
Pterygium -Surgical Management
Indications Symptomatic patients
- recurrent irritation, redness and watering
 Visual need
- covering visual axis or threatening visual axis
- causing irregular astigmatism
- Grade 2 and 3 Pterygium
 Cosmetic
 Therapeutic
- suspected associated neoplastic degeneration
- motility restriction
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4/8/2015
Pterygium -Surgical Management
Different Procedures have been described
 Excision
- Bare sclera technique
 Excision and direct suturing of cut ends of conjunctiva
 Excision of Head +Rotation and burial of body in inferior fornix
 Excision + Conj Auto graft (CAG) - most preferred
 Excision + MMC + Conj Auto graft
 Excision + AMG + Conj Auto graft
 Excision + MMC + AMG + Conj Auto graft
For recurrent pterygium
 Excision + Conjunctivolimbal Auto graft
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4/8/2015
Pterygium -Surgical Management
Excision
Either from medial conjunctival side or from head
Peeling off pterygium from corneal surface
Smoothening of Corneal surface with 15 no Blade or diamond Burr
Conjuntiva sutured with 8-0 Vicryl suture
Limbal apposition - can be done by 10-0 nylon Monofilament suture
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4/8/2015
Pterygium -Surgical Management
Adjuvants – to reduce recurrence
Mitomycin C- For recurrent pterygia
Intra op or post op
Uncommonly used
Late Scleral necrosis & melt
Thiotepa – used post op
Beta radiation with Strontium 90
High complications
Excimer Laser in PTK mode – for corneal smoothening
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4/8/2015
Pterygium- Surgical Complications
 Graft contration
 Recurrence
 Graft edema
 Corneal scaring
 Graft necrosis
 Ocular motility restriction
 Granuloma formation
 Surgical induced Necrotising
 Excessive cautery- scleral
necrosis
 Infection
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Scleritis (SINS)
4/8/2015
Pterygium- Surgical Complications
Graft contraction – insufficient size of graft
- more chance for granuloma
- watch for recurrence
Graft edema – almost all cases at 1 wk post op
- no intervention
- can be associated with Dellen formation
Graft necrosis – if graft is placed upside down ( reverse)
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4/8/2015
Pterygium- Surgical Complications
Recurrence – most common complication
-More in Young pts,
-Surgery for progressive & recurrent perygium
-In bare sclera method
Granuloma – more common
-with bare sclera technique
-in young patients
- can be seen at donor site also
® - increase Steroids
- excision if no response
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4/8/2015
Pterygium- Surgical Complications
Sterile Surgical induced Necrotising Scleritis (SINS)
-more common with MMC usage
- systemic work up for Autoimmune vasculitic disorders
- steroids in high dosage
- long term systemic immunosuppression
- may need Scleral Patch Graft
Excessive cauteryScleral necrosis in Bare sclera method
No inflammation, no pain
AMG or Conj graft
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4/8/2015
Pterygium- Surgical Complications
Ocular motility restriction –
- Extensive excision causing Symblepharon formation
- Intra op Medial Rectus muscle damage
- Diplopia in post op period
Corneal scaring –
- Poor visual acuity and quality of vision due to
irregular astigmatism
- PTK Excimer laser may help
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4/8/2015
Pterygium- Surgical Complications
Microbial Infection
- rare
- Identify organism
- culture and sensitivty
- antibiotics / antifungals
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4/8/2015
Pterygium - Management
Recent Advances
Local Injections
 Anti VEGF agents- Bevacizumab (Avastin) 0.25 mg (0.1 ml)
For both primary & recurrent pterygia
 Steroids –Triamcinolone Acetonide (0.1 ml- 2 mg)
For recurrent pterygia
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4/8/2015
Pterygium - Management
Recent Advances
Fibrin Glue Tisseal glue (Baxter Pharma) use for
 Conj Auto graft & Amniotic membrane fixation
 Less Surgical time
 Less post op irritation
 Faster recovery
 ? More recurrence
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4/8/2015