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, as follows: 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]

Differentials
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. 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.
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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.
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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.
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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.[19]

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[20] Corneal scarring

Rare complications may include perforation of the globe, vitreous hemorrhage, or retinal detachment. Late postoperative complications of beta radiation of pterygia can include the following:

Scleral and/or corneal thinning or ectasia 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, 21, 22] 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, 23, 24, 25] 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.[26, 27]

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.

References
1. Coroneo MT, Di Girolamo N, Wakefield D. The pathogenesis of pterygia. Curr Opin Ophthalmol. Aug 1999;10(4):282-8. [Medline]. 2. Elliot R. The aetiology of pterygium. Trans Ophthalmol Soc NZ. 1961;13:22. 3. Saw SM, Tan D. Pterygium: prevalence, demography and risk factors. Ophthalmic Epidemiol. Sep 1999;6(3):219-28. [Medline]. 4. Threlfall TJ, English DR. Sun exposure and pterygium of the eye: a dose-response curve. Am J Ophthalmol. Sep 1999;128(3):280-7. [Medline]. 5. Blum HF. Carcinogenesis by Ultraviolet Light. Princeton University Press; 1959. 6. Cogan DG, Kuwabara T, Howard J. The nonelastic nature of pingueculas. Arch Ophthalmol. 1959;61:388.

7. Anduze AL. Pterygium surgery with mitomycin-C: ten-year results. Ophthalmic Surg Lasers. Jul-Aug 2001;32(4):341-5. [Medline]. 8. McDonald JE, Wilson FM. Ocular therapy with beta particles. Trans Am Acad Ophthalmol Otolaryngol. 1959;63:468. 9. Bahar I, Weinberger D, Gaton DD, Avisar R. Fibrin glue versus vicryl sutures for primary conjunctival closure in pterygium surgery: long-term results. Curr Eye Res. May 2007;32(5):399-405. [Medline]. 10. Cohen RA, McDonald MB. Fixation of conjunctival autografts with an organic tissue adhesive. Arch Ophthalmol. Sep 1993;111(9):1167-8. [Medline]. 11. Jain AK, Bansal R, Sukhija J. Human amniotic membrane transplantation with fibrin glue in management of primary pterygia: a new tuck-in technique. Cornea. Jan 2008;27(1):94-9. [Medline]. 12. Kheirkhah A, Casas V, Sheha H, Raju VK, Tseng SC. Role of conjunctival inflammation in surgical outcome after amniotic membrane transplantation with or without fibrin glue for pterygium. Cornea. Jan 2008;27(1):56-63. [Medline]. 13. Oguz H. Amniotic membrane grafting versus conjunctival autografting in pterygium surgery. Clin Experiment Ophthalmol. Aug 2005;33(4):447-8. [Medline]. 14. Uy HS, Reyes JM, Flores JD, Lim-Bon-Siong R. Comparison of fibrin glue and sutures for attaching conjunctival autografts after pterygium excision. Ophthalmology. Apr 2005;112(4):667-71. [Medline]. 15. Kheirkhah A, Nazari R, Nikdel M, et al. Postoperative conjunctival inflammation after pterygium surgery with amniotic membrane transplantation versus conjunctival autograft. Am J Ophthalmol. Nov 2011;152(5):733-8. [Medline]. 16. Kamel S. The Pterygium: its etiology and treatment. Am J Ophthalmol. 1954;38:682. 17. Kheirkhah A, Izadi A, Kiarudi MY, Nazari R, Hashemian H, Behrouz MJ. Effects of mitomycin C on corneal endothelial cell counts in pterygium surgery: role of application location. Am J Ophthalmol. Mar 2011;151(3):488-93. [Medline]. 18. Bahar I, Kaiserman I, Lange AP, Slomovic A, Levinger E, Sansanayudh W, et al. The effect of mitomycin C on corneal endothelium in pterygium surgery. Am J Ophthalmol. Mar 2009;147(3):447-452.e1. [Medline].

19. Singh G, Wilson MR, Foster CS. Long-term follow-up study of mitomycin eye drops as adjunctive treatment of pterygia and its comparison with conjunctival autograft transplantation. Cornea. Oct 1990;9(4):331-4. [Medline]. 20. Srinivasan S, Slomovic AR. Eye rubbing causing conjunctival graft dehiscence following pterygium surgery with fibrin glue. Eye. Jun 2007;21(6):865-7. [Medline]. 21. Raiskup F, Solomon A, Landau D, Ilsar M, Frucht-Pery J. Mitomycin C for pterygium: long term evaluation.Br J Ophthalmol. Nov 2004;88(11):1425-8. [Medline]. 22. Rubinfeld RS, Pfister RR, Stein RM, Foster CS, Martin NF, Stoleru S, et al. Serious complications of topical mitomycin-C after pterygium surgery. Ophthalmology. Nov 1992;99(11):1647-54. [Medline]. 23. Miyai T, Hara R, Nejima R, Miyata K, Yonemura T, Amano S. Limbal allograft, amniotic membrane transplantation, and intraoperative mitomycin C for recurrent pterygium. Ophthalmology. Jul 2005;112(7):1263-7. [Medline]. 24. Ti SE, Chee SP, Dear KB, Tan DT. Analysis of variation in success rates in conjunctival autografting for primary and recurrent pterygium. Br J Ophthalmol. Apr 2000;84(4):385-9. [Medline]. 25. Yao YF, Qiu WY, Zhang YM, Tseng SC. Mitomycin C, amniotic membrane transplantation and limbal conjunctival autograft for treating multirecurrent pterygia with symblepharon and motility restriction. Graefes Arch Clin Exp Ophthalmol. Feb 2006;244(2):232-6. [Medline]. 26. Fernandes M, Sangwan VS, Bansal AK, Gangopadhyay N, Sridhar MS, Garg P, et al. Outcome of pterygium surgery: analysis over 14 years. Eye. Nov 2005;19(11):1182-90. [Medline]. 27. Starck T, Kenyon KR, Serrano F. Conjunctival autograft for primary and recurrent pterygia: surgical technique and problem management. Cornea. May 1991;10(3):196-202. [Medline]. 28. Fuchs E. Uber das Pterygium. Albert von Graefes Arch Klin Exp Ophthalmol. 1892;38:1.