Pterygium

A pterygium is a wing-shaped growth of conjunctiva and fibrovascular tissue on the superficial cornea
(Fig 12-2). As with a pinguecula, the pathogenesis of a pterygium is strongly correlated with UV-light
exposure, although environmental traumas such as exposure to dust, wind, or other irritants that cause
chronic inflammation may also be factors.

The predominance of pterygia on the nasal side in the interpalpebral zone is theorized to result from
light passing medially through the cornea, focusing on the nasal limbus area, while the shadow of the
nose reduces the intensity of light transmitted to the temporal limbus.

The prevalence of pterygia increases steadily with proximity to the equator and is more common in men
than women, in persons 20–30 years of age (the most common age of onset), and in people who work
outdoors.

The histopathology of pterygia is similar to that of pingueculae, only it involves subepithelial

fibrovascular tissue. Further discussion of the histopathology of both pingueculae and pterygia can be
found in BCSC Section 4, Ophthalmic Pathology and Intraocular Tumors.

Pterygia are nearly always preceded by pingueculae, although why some patients develop pterygia
whereas others have only pingueculae is not known.

Regular and irregular astigmatism, as well as corneal scarring, occurs in proportion to pterygium size. A
pigmented iron line (called a Stocker line) may be seen at the central anterior edge of the pterygium on
the cornea. A pterygium must be differentiated from a pseudopterygium, which may occur after trauma
or secondary to inflammatory corneal disease.

Treatment with artificial tears can alleviate associated irritation, but as with pingueculae, long-term use
of topical corticosteroids is contraindicated.

Excision is indicated if the pterygium approaches the visual axis, exhibits rapid growth, causes chronic
irritation, or is cosmetically unacceptable. See Chapter 14 for discussion of the surgical treatment of
pterygium.

Pterygium Excision

Indications for pterygium excision include persistent discomfort, vision distortion and induction of
irregular astigmatism, significant (>3–4 mm) and progressive growth toward the corneal center/visual
axis, and restricted ocular motility. The aim of microsurgical excision of a pterygium is to achieve a
normal, topographically smooth ocular surface. The procedure is performed on an outpatient basis using
topical anesthesia and, in some cases, peribulbar or retrobulbar anesthetic, especially in recurrent cases
complicated by scarring. A traction suture (eg, 6-0 silk or polyglycolic acid on a spatulated needle) placed
at the 12 o’clock position, which can then be clamped down in various positions to the surgical drape,
facilitates maximal exposure of the pterygium and the graft site. A common surgical technique is to
remove the pterygium using a flat blade or an angled crescent blade, which allows a smooth plane of
dissection toward the limbus. Although it is preferable to dissect down to bare sclera at the limbus, the
surgeon should be careful when dissecting Tenon tissue medially, as doing so can sometimes lead to
bleeding and later scarring from inadvertent trauma to subjacent muscle tissue and muscle check
ligaments. After excision, light cautery is usually applied to the sclera for hemostasis. It is important to
remove as much of the fibrovascular scar tissue as possible. If the medial rectus muscle is restricted, it
must be isolated and carefully freed of all scar tissue. A smooth surface at the site of dissection is a
desirable endpoint. With the eye rotated to expose the involved quadrant, the size of the defect is
measured with calipers. Options for wound closure include the following (Fig 14-2; Table 14-2 lists the
recurrence rate of pterygium with some of these options): Bare sclera. No sutures or fine, absorbable
sutures are used to appose the conjunctiva to the superficial sclera in front of the rectus tendon
insertion, leaving an area of exposed sclera. Note that this technique has an unacceptably high
recurrence rate and is therefore strongly not recommended. Simple closure. The free edges of the
conjunctiva are secured together (effective only when the conjunctival defect is very small). Sliding flap.
An L-shaped incision is made adjacent to the wound to allow a conjunctival flap to slide into place.
Rotational flap. A U-shaped incision is made adjacent to the wound to form a tongue of conjunctiva that
is rotated into place. Autologous conjunctival transplantation. As mentioned previously, this is a free
graft, usually from the superior bulbar conjunctiva. The graft is excised to correspond to the size of the
wound and is then moved and either sutured into place or fixated with a tissue adhesive (fibrin sealant
made from pooled human plasma). This technique is described in more detail below. Autologous
conjunctival–limbal transplantation. This is also a free graft, but it includes limbal stem cells in addition
to the conjunctival graft. (See below for surgical technique.) Amniotic membrane transplantation. A free
amniotic membrane graft may be an alternative to conjunctival autograft, although free conjunctival
grafting is still more successful and is the preferred technique. Amniotic membrane is indicated
particularly when there is a shortage of autologous conjunctiva. These grafts may be most useful with
large pterygia, where a wide excision is needed. There are insufficient data to comment on the efficacy
of amniotic membrane grafting as an adjuvant in pterygium surgery.

If autologous conjunctival transplantation is to be performed, then the eye is turned down to expose the
superior bulbar conjunctiva, and the area to be harvested is marked with a surgical pen. The most
important aspect of the harvesting is to procure conjunctival tissue with only minimal or no Tenon
included. This may be facilitated by injection of a small amount of anesthetic between the

with focal applications of cautery approximately 2 mm posterior to the limbus. The initial incision is
made superficially within clear cornea using a disposable knife. E, The bulbar conjunctival portion of the
graft is undermined and thinly dissected from its limbal attachment. F, The limbal grafts are transferred
to their corresponding sites in the recipient eye and are secured with interrupted sutures, 10-0 nylon
suture at the corneal edge and 8-0 polyglycolic acid suture at the conjunctival margin. (Reproduced by
permission from Kenyon KR, Tseng SC. Limbal autograft transplantation for ocular surface disorders.
Ophthalmology. 1989;96(5):709–723.)

conjunctiva and Tenon capsule. Some surgeons make a special point of harvesting limbal stem cells
along with the conjunctiva and orienting the donor material in the host bed so that the stem cells are
adjacent to the site of corneal lesion excision. It is best to allow a little extra tissue for grafting, so the
harvested tissue should be approximately 0.5–1.0 mm larger than the size of the defect in the area of
the excised pterygium. The donor site is usually left bare. After the graft is freed, it is transferred to the
recipient bed and secured to adjacent conjunctiva (with or without incorporating episclera) with 7-0 to
10-0 polyglycolic acid (absorbable) or nylon (nonabsorbable) suture or with tissue adhesive. Many
authors have described the use of commercially available fibrin tissue adhesive to fixate the conjunctival
autograft, thereby eliminating the need for suture fixation. Elimination of sutures decreases
postoperative pain and reduces surgical time as well as the recurrence rate, compared with bare sclera
techniques (see Table 14-2). Fibrin tissue adhesive mimics natural fibrin formation, ultimately resulting
in the formation of a fibrin clot. Several fibrin sealants have been approved by the US Food and Drug
Administration (FDA) and are commercially available and distributed by US companies, including Tisseel
Fibrin Sealant (Baxter Healthcare Corporation, Westlake Village, CA), Evicel Fibrin Sealant (Ethicon, Inc,
Somerville, NJ), and BioGlue Surgical Adhesive (CryoLife, Inc, Kennesaw, GA). There is also the CryoSeal
FS System (ThermoGenesis Corp, Rancho Cordova, CA), which can be used in the automated preparation
of fibrin sealant from the patient’s own plasma. Currently, use of these products in pterygium surgery is
considered off-label. Also, because both pooled human plasma and bovine products are used to obtain
some components of these products, careful consideration should be given to the potential for disease
transmission with their use. If the defect created following dissection of scar tissue is considerably larger
than what can be covered with an autologous conjunctival graft, then an amniotic membrane graft may
be used in conjunction with a conjunctival graft to cover the entire area of resection. Several authors
have noted that this decreases postoperative inflammation and speeds reepithelialization of the surface.
There is evidence that the use of mitomycin C (MMC) with conjunctival autografting reduces the
recurrence rate of pterygium after surgical excision (see Table 14-2). However, further studies are
necessary to determine the optimal route of administration and dose for MMC, as well as the duration
of treatment with MMC and its long-term effects. In studies, the concentration of intraoperative MMC,
administered locally for 3 to 5 minutes, varies from 0.002% to 0.04%. The concentration of
postoperative MMC eyedrops, administered 2–4 times a day, varies from 0.02% to 0.04%. It is Figure 14-
2 Surgical wound closures following pterygium excision. A, Bare sclera. B, Simple closure with fine,
absorbable sutures. C, Sliding flap that is closed with interrupted and/or continuous suture. D,
Rotational flap from the superior bulbar conjunctiva. E, Conjunctival autograft that is secured with
interrupted and/or continuous suture. (Reproduced with permission from Gans LA. Surgical treatment of
pterygium. Focal Points: Clinical Modules for Ophthalmologists. San Francisco: American Academy of
Ophthalmology; 1996, module 12. Illustration by Christine Gralapp.)

important to note that any use of topical MMC can be toxic and may cause visually significant
complications such as aseptic scleral necrosis and infectious sclerokeratitis. These complications may
occur months, or even years, after use of the drug. If surgery is being performed in a case of recurrent
pterygium and MMC use is being considered, it is safer to apply this agent intraoperatively than to give
it to the patient for postoperative topical application; in the latter case, overuse may be a problem.
Postoperatively, topical antibiotic–corticosteroid eyedrops are administered frequently for
approximately 4–6 weeks, until inflammation subsides. The surgeon should emphasize to the patient
that adherence to this regimen will minimize the chance of recurrence. The use of bevacizumab in
primary pterygium excision apparently has no effect on the recurrence rate of this condition.