Management of Pterygium

Dr VIDYASHANKAR G K
Shekar Nethralaya
Bangalore

04/05/16

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

2

04/05/16

Pterygium - Classification
Primary Pterygium

Body

Neck

Recurrent Pterygium
Hea
d

Atrophic Pterygium
Older pts, thin translucent body with thin vessels

Pogressive Pterygium
Thick fleshy growth seen in Younger pts

04/05/16

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

04/05/16

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

04/05/16

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

04/05/16

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

For recurrent pterygium

Excision + MMC + AMG + Conj Auto graft

Excision + Conjunctivolimbal Auto graft
7

04/05/16

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
Limbal apposition -

with 8-0 Vicryl suture

can be done by 10-0 nylon

Monofilament suture

04/05/16

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

High complications
Beta radiation with Strontium 90
Excimer Laser in PTK mode for corneal smoothening

04/05/16

Pterygium- Surgical
Complications
Graft contration
Graft edema

Recurrence
Corneal scaring

Graft necrosis
Granuloma formation

Ocular motility

Excessive cautery-

scleral necrosis
Infection

10

restriction
Surgical induced
Necrotising
Scleritis (SINS)

04/05/16

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)
11

04/05/16

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

12

04/05/16

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
13

04/05/16

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
14

04/05/16

Pterygium- Surgical
Complications
Microbial Infection
- rare
- Identify organism
- culture and sensitivty
- antibiotics / antifungals

15

04/05/16

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

16

04/05/16

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

17

04/05/16

18

04/05/16