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MANAGEMENT OF PTERYGIUM
Delhi J Ophthalmol
INTRODUCTION
• Genetic predisposition
Decreased Apoptosis
Increased TGF- β
Increased Growth
• Triad of features characteristic of limbal stem cell deficiency-
1) Conjunctivalisation
2) Vascularisation
3) Chronic inflammation
• Thus with the loss of limbal stem cell barrier the conjunctival
vasculature can invade the cornea.
EPIDEMIOLOGY
Type 1-
Pterygium extends less than
2mm onto the cornea
A deposit of iron (Stocker’s
line) may be seen in the
corneal epithelium anterior to
the advancing head of the
pterygium
Usually asymptomatic but
may get intermittently
inflamed and may cause
irritation.
• Type 2-
Involves upto 4mm of
cornea and may be primary
or recurrent following
surgery.
• Nasal
• Temporal
• Double
• Bilateral
RECURRENT PTERYGIUM
• Pseudopterygium
• Papilloma
• Corneal macropannus
• surgery is technically
complicated with
suboptimal cosmesis
CONJUNCTIVAL AUTOGRAFT
• A small incision is made in the conjunctiva just medial to the head of the
pterygium
• The head of the pterygium is left attached to the cornea, enabling easier
dissection of the conjunctiva
• The corneal epithelium 2 mm ahead of the head of the pterygium is
scraped off with a hockey-stick knife
• The body of the pterygium with the involved Tenon’s capsule and
cicatrix is then excised, taking care to ensure the safety of the
underlying medial rectus muscle and the overlying conjunctiva
• The size of the conjunctival graft required to resurface the
exposed scleral surface is determined using Castroviejo
calipers
• The graft is smoothened out in its bed taking care to avoid any folding of the
edges
• The medial edge of the graft is sutured with 2-4 additional sutures, preferably
including episclera
• The donor area is covered by pulling the forniceal conjunctiva forward and
anchoring it to the limbal episcleral tissue with 2 interrupted 10-0 nylon
sutures.
• 0.5cc dexamethasone is injected subconjunctivally at the
conclusion of the procedure and the eye is patched firmly
with antibiotic eye ointment
• In this situation, Tan et al have suggested that the use of free conjunctival
grafts may have equivalent outcomes.
• This technique may also be advantageous when surgery is
performed in a patient with a subsequent risk of glaucoma and the
need to preserve the superior bulbar conjunctiva
• the tissue is replaced and sutured in the bare scleral bed, with the
limbal aspect of graft now facing the fornix and vice versa
• limitations
– need for donor corneal tissue
– risks of graft rejection
– transmission of infection
– increased complexity of the procedure
Scleral melt after pterygium surgery After lamellar corneal graft
SPLIT GRAFT FOR DOUBLE PTERYGIA
• Recurrence
• Medial rectus damage
• Graft dislodgement / necrosis
• Corneal scarring
• Limbal deficiency at donor site
• Corneal or scleral infection
• Graft infection
• Scleral necrosis
• Dellen
• Episcleral pyogenic granuloma
FUTURE PROSPECTS
Bevacizumab
• Studies are underway to try Bevacizumab as an adjuvant in
pterygium surgery to prevent recurrence.
• Mitomycin C has been used topically after surgical removal of
pterygia to prevent recurrences