12/6/2016 Pterygium - Asia Pacific - American Academy of Ophthalmology

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NOV 2015

Pterygium - Asia Pacific

Asia Pacific

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EPIDEMIOLOGY
Global Information
The prevalence of pterygium was found to be 10.2% in the world, with highest prevalence in low
altitude regions (Liu et al, 2013).
Increased incidence of pterygium is noted in the tropics and in an equatorial zone between 30
north and south latitudes (Liu et al, 2013).
Higher incidence is associated with chronic sun exposure (ultraviolet light), older age, male sex,
and outdoor activity (Liu et al, 2013).

Regional Information (ASIA-PACIFIC)

Studies in Asia have shown that higher prevalence is significantly associated with a rural versus
an urban population.
A study done in Victoria, Australia measured the prevalence in the general population more than
40 years old (1.2%), nursing home residents (1.7%), and rural residents (6.2%) (McCarty et al,
2000).
See Table 1 for additional prevalence data.

Table 1. Prevalence of Pterygium in the Asia-Pacific Region

Source Country Prevalence (%)

Lu et al, 2007; China

14.4933.01
Ma et al, 2007; Rural
2.9
Wu et al, 2002 Urb an

Cajucom et al, 2010 Singapore 12.3

Durkin et al, 2008 Myanmar 19.6

Shiroma et al, 2009 Japan 30.8

Gazzard et al, 2002 Indonesia 10. 0

DIFFERENTIAL DIAGNOSIS
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DIFFERENTIAL DIAGNOSIS
Pseudopterygium (Figure 1)
Pingeucula (Figure 2)
Pannus (Figure 3)
Episcleritis, sclerokeratitis
Conjunctival and corneal intraepithelial neoplasm (CIN) (Figure 4)
Limbal dermoid (Figure 5)

PATHOPHYSIOLOGY / DEFINITION

Chart 1. Pterygium pathophysiology. See Image Library for figure.

Pterygium comes from the Greek word meaning wing, pterygos.

Pterygium is a triangular fibrovascular growth that extends from the conjunctiva toward the
cornea.
It is more common in the interpalpebral fissure area and may occur nasally or temporally or
both. The nasal location is more common.
Although the pathophysiology is not clearly understood, ultraviolet (UV) light is identified as the
most important risk factor.
UV light forms free radicals that induce damage in DNA, RNA, and the extracelluar matrix of
cells.
Ultraviolet-B (UVB) induces expression of cytokines and growth factors in pterygial epithelial
cells.
Polymorphisms of the DNA break repair gene Ku70 have been associated with genetic
predisposition to pterygia development.
Increased levels of T-cells and inflammatory markers have also been noted in pterygial tissue
compared to normal conjunctival tissue.

Risk Factors
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Ultraviolet exposure (single most significant risk factor)

Exposure to irritants (dust, sand, wind)
Inflammation
Dry ocular surface

SIGNS/SYMPTOMS
Signs
Wedge-shaped, translucent membrane with apex extending onto cornea (Figure 6)
White to pink in color, depending on vascularity
Vascular straightening in the direction of the advancing head of the pterygium
Stocker line: iron line on cornea at leading edge of pterygium (Figure 7)
Regular or irregular astigmatism
Degenerative changes such as cystic changes

Symptoms
May be asymptomatic
Redness
Irritation
Decreased vision

Diagnosis
Diagnosis is made clinically based on slit-lamp examination and typical appearance of the lesion
(Figure 1).

MANAGEMENT
Prevention
Wearing eye protection, sunglasses, goggles, and/or a brimmed hat is recommended when one
is exposed to sunlight or dust.
Sunglasses that block 99%100% of both UVA and UVB rays are preferred.

Medical Management
Small pterygia without visual impairment can be treated symptomatically with artificial tears and
ocular lubricants.
Medical treatment (artificial tears and lubricants) does not decrease progression or cause
regression of pterygia.

In patients with irritative symptoms, preservative-free artificial tears are recommended for mild
inflammation and topical steroids are recommended for moderate inflammation.

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Monitoring pterygia at 612 months is reasonable.

Surgical Management
Surgical removal is considered for the following conditions:

Decrease in visual acuity due to astigmatism or encroachment onto visual axis

A cosmetically significant pterygium
When it interferes with contact lens wear
Symptomatic degenerative changes like cystic changes
Restriction of extraocular movements

Surgical techniques include the following:

Simple excision (without transplantation, aka bare sclera) is associated with a higher recurrence
rate and hence it has been supplemented with conjunctival transplantation.
Adjuvant therapies including mitomycin C (MMC), 5-fluorouracil (5-FU), ethanol,
irradiation, and anti-angiogenic agents, among others, are used to reduce recurrence rate,
but there is insufficient evidence that one is superior (Kaufman et al, 2013).

The ideal treatment recommended involves excision of pterygium with conjunctival autograft
(CAG) supplementation. Alternatively, if there is not enough conjunctiva, then amniotic
membrane transplant (AMT) may be glued or sutured into place (Figure 8).
Procedures using fibrin glue take about half the time as surgeries using sutures and
patients often report less postoperative surgical pain and discomfort (Marticorena,
Joaquin et al, 2006).
However, fibrin glue is more expensive and can be difficult to obtain in some countries.
The glue is a blood-derived product and carries the risk (however minimal) of viral and
prion disease.
Another approach is autoblood graft fixation, a technique also known as suture- and glue-
free autologous graft. This approach affixes the graft into place with the patients own
blood, eliminating the concern of disease transmission.

Postoperative Management
Patch/shield overnight
Drops: Steroid antibiotic combination 4 times a day for 1 month

Complications of Pterygium Surgery

Intraoperative:

Buttonhole of the conjunctival autograft

Injury to extraocular muscles

Postoperative (immediate):

Graft slippage
Graft retraction
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Donor site granuloma formation

Long-term complications:

The most common complication is recurrence after removal.

The recurrence rate is as high as 50% within 4 months and 97% recurrence rate within 12
months without autograft or amniotic membrane transplant (Hirst LW, 2003).
The recurrence rate is higher with fleshy, nontranslucent pterygia and increased postoperative
inflammation. It is often dependent on the surgical procedure.
The recurrence rate is decreased to 5%10% with conjunctival flap/graft supplementation.
Other complications include corneal scarring, corneal perforation, strabismus, nonhealing defect
(especially with mitomycin C), scleral melt (especially with mitomycin C), and scleral dellen
(Figure 9) (Kaufman, SC et al, 2013).
If scleral dellen are present, aggressive lubrication with artificial tear ointment every 2
hours.
Scleral graft patch is placed in severe cases of scleral thinning. (Tsai et al, 2002)

CASE STUDY

History of Present Illness

A 45-year-old patient presented with hyperemia, foreign body sensation, and itchiness in her right eye
without improvement after artificial tears. Her family history is significant for diabetes. Eyelids of the
right eye were within normal limits. The right eye had mild conjunctival hyperemia and a 23 mm
temporal pterygium without involvement of the papillary area (Figure 10). Ocular examination of the left
eye was normal.

Treatment
Resection of pterygium plus conjunctival autograft in right eye. One week after surgery, there is mild
conjunctival hyperemia and chemosis with complete resection of the pterygium (Figure 11).

IMAGE LIBRARY
Differential Diagnosis

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Figure 1. Pseudopterygium. (Courtesy Dr. N. Nenkatesh Prajna.)

Figure 2. Pinguecula. ( 2015 American Academy of Ophthalmology, www.aao.org.)

Figure 3. Pannus. ( 2015 American Academy of Ophthalmology, www.aao.org.)

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Figure 4. Conjunctival intraepithelial neoplasia. A. Papilliform. B. Gelatinous. C. Leukoplakic. (

2015 American Academy of Ophthalmology, www.aao.org.)

Figure 5. Limbal dermoid. ( 2015 American Academy of Ophthalmology, www.aao.org.)

Signs/Symptoms

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Figure 6. Slit-lamp image of a pterygium. (Reproduced, with permission, from Reidy, JJ, Basic and
Clinical Science Course, Section 8: External Disease and Cornea. American Academy of
Ophthalmology, 20102011).

Figure 7. Stocker line (arrow). (Courtesy Dr. N. Nenkatesh Prajna.)

Management

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Figure 8. Immediate postoperative photograph showing a suture conjunctival autograft after pterygium
excision. (Reproduced from Ward M. Pterygium excision with conjunctival autograft. EyeRounds
Online Atlas of Ophthalmology.)

Figure 9. Scleral dellen. (Reproduced from Garcia-Medina JJ et al. Severe scleral dellen as an early
complication of pterygium excision with simple conjunctival closure and review of the literature. Arq
Bras Oftalmol. 2014;77[3].)

Case Study

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Figure 10. A 23 mm temporal pterygium without involvement of the papillary.

Figure 11. One week after resection of the pterygium and placement of temporal conjunctival
autograft.

REFERENCES
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Alqahtani JM. The prevalence of pterygium in Alkhobar: A hospital-based study. J Family Community
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Bueno-Gimeno I, Monts-Mic R, Espaa-Gregori E, et al. Epidemiologic study of pterygium in a

Saharan population. Ann Ophthalmol. 2002;34(1):436.

Cajucom-Uy H, Tong L, Wong TY, et al. The prevalence of and risk factors for pterygium in an urban
Malay population: the Singapore Malay Eye Study (SiMES). Br J Ophthalmol. 2010;94(8):97781.

Chan TC, Wong RL, Li EY, et al. Twelve-year outcomes of pterygium excision with conjunctival
autograft versus intraoperative mitomycin c in double-head pterygium surgery. J Ophthalmol.
2015;2015:891582.

Durkin SR, Abhary S, Newland HS, et al. The prevalence, severity and risk factors for pterygium in
central Myanmar: the Meiktila Eye Study. Br J Ophthalmol. 2008;92(1):259.
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External Disease and Cornea. Basic and Clinical Science Course, Section 8, 20152016. San
Francisco: American Academy of Ophthalmology; 2015.

Eze BI, Maduka-okafor FC, Okoye OI, Chuka-okosa CM. Pterygium: a review of clinical features and
surgical treatment. Niger J Med. 2011;20(1):714.

Fotouhi A, Hashemi H, Khabazkhoob M, Mohammad K. Prevalence and risk factors of pterygium and
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Kaufman S C, Jacobs D S, Lee WB, Deng SX, Rosenblatt MI, Shtein RM. Options and adjuvants in
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Kumah DB, Oteng-Amoako AO, Apio H. Prevalence of pterygium among kitchen staff in senior high
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Liu L, Wu J, Geng J, Yuan Z, Huang D. Geographical prevalence and risk factors for pterygium: a
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Lu P, Chen X, Kang Y, Ke L, Wei X, Zhang W. Pterygium in Tibetans: a population-based study in

China. Clin Experiment Ophthalmol. 2007;35(9):82833.

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Ophthalmol Clin. 2010;50(3):4761.

Marticorena, Joaqun, et al. "Pterygium surgery: conjunctival autograft using a fibrin

adhesive." Cornea 25.1 (2006): 34-36.

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Shiroma H, Higa A, Sawaguchi S, et al. Prevalence and risk factors of pterygium in a southwestern
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EPIDEMIOLOGY

Glob al Information

Regional Information (ASIA-PACIFIC)

DIFFERENTIAL DIAGNOSIS

PATHOPHYSIOLOGY / DEFINITION

Risk Factors

SIGNS/SYMPTOMS

Signs

Symptoms

Diagnosis

MANAGEMENT

Prevention

Medical Management

Surgical Management

Postoperative Management

Complications of Pterygium Surgery

CASE STUDY

History of Present Illness

Treatment

Differential Diagnosis

Signs/Symptoms

Management

Case Study

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