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CURRENT CONCEPTS IN

MANAGEMENT OF PTERYGIUM

Delhi J Ophthalmol
INTRODUCTION

• Pterygium was first


described in 1000 BC by
Sushruta

• The word pterygium is


derived from latin word
Pterygion which means “a
wing”
Pterygium is triangular, wing shaped, hyperplastic
proliferative fibrovascular subepithelial growth of
degenerative bulbar conjunctival tissue over the sclera
onto the cornea

It is located horizontally in the


inter-palpebral fissure on either
nasal or temporal side of
the cornea or on both sides
(Double pterygium)
ETIOLOGY
• Prolonged exposure to UV light

• Dry heat, high wind or dust

• Genetic predisposition

• mutations in p53 tumor suppressor gene

• Recent studies have suggested that human papilloma virus


may also be implicated in pterygium pathogenesis

• Matrix metalloproteinases (MMPs) and tissue inhibitors of


MMPs (TIMPs) at the advancing edge may be responsible for
inflammation, tissue remodeling, destruction of Bowman’s
layer and pterygium invasion into the cornea
PATHOGENESIS

• The above aetiological factors result in parental limbal


epithelial basal stem cell damage (p53 mutations within limbal
epithelial cells) giving rise to a zone of motile daughter stem
cells, the pterygium cells.

• These cells migrate as a group centripetally along the corneal


basement membrane dissolving Bowman’s layer.

• The pterygium cells are followed by normal conjunctival cells


and fibrovascular tissue.
UV-B radiation

Limbal stem cell p53


mutation

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

• Prevalence rates vary in different parts of world

• Highest in “Pterygium belt” described by Cameron between


latitudes 370 north and south of equator

• Prevalence in India ranges from 9.5 to 13% ,more common in


rural parts of the country

• Age:more common in elderly

• Use of hats and sunglasses is protective


• Sex: twice as common in males as in females

• Heredity: AD inheritance with low penetrance(it is not the


actual lesion that is transmitted but the tendency of eye to
react to environmental factors)

• it is most of the times bilateral


PARTS OF PTERYGIUM

• Cap or gray zone- is an arcuate, gray-white, sub-epithelial


corneal opacity that is at the leading edge of the pterygium

• With choricity abnormal tear pooling in advance of the cap


leads to the deposition of a corneal epithelial Iron line
(Stocker’s line)
Elevated whitish opacities (“islets of Vogt”) and an iron
deposition line (“Stocker”) may delineate the head of the
pterygium on the cornea.
• Head of pterygium- is the elevated white mass that forms a
firm adhesion to the globe on the cornea

• Neck- Limbal part

• Body- Scleral part extending between limbus and the canthus.


It is a fleshy fibrovascular mass that is demarcated from
normal conjunctiva superiorly and inferiorly by sharp folds
HISTOPATHOLOGY

Subepithelial elastotic degeneration of collagen and destruction


of Bowmans membrane

Histopathologically, pterygium is a fibrovascular proliferation of


conjunctival tissue onto clear cornea
The abnormal collagen tissue is
aggregated into a coiled and
fibrillated pattern, similar to
elastic tissue

Unlike elastic tissue it is not


digested by elastase and
therefore is called elastotic
degeneration

congested blood vessels are


dispersed between
hypertrophied collagen fibres &
richly supply this degenerative
tissue
Head of pterygium: grows into a plane between bowmans
membrane and basement membrane of overlying corneal
epithelium

At this plane a row of fibroblasts advances in front of the apex


and prepares a path for head of pterygium to invade the cornea.

Bowmans membrane is pushed posteriorly and eventually


fragments and makes openings for fibrovascular tissue to grow
into underlying superficial stroma of cornea that makes
pterygium firmly adherent to cornea.
• Body of pterygium: incorporates underlying tenons but
spares episclera. Therefore it is not adherent to sclera and
can be easily mobilized

• but at limbus , absence of tenons makes neck of pterygium


adherent to underlying episclera and sclera

• Body contains some tubular glands and larger spaces lined


with epithelium- cysts may form

• lymphocytic infiltration consisting predominantly of T cells is


also present.
Histopathology of recurrent pterygium:

• It consists of fibrovascular tissue in the absence of elastotic


degeneration

• It involves underlying episclera, sclera, rectus muscle sheath


and corneal stroma and is firmly adherent to underlying
structures throughout its extent

• It is highly vascularised tissue


CLASSIFICATION
DEPENDING UPON THE PROGRESSION-

• Progressive pterygium is • Regressive pterygium is


actively growing, thick, pale, thin, papery, gray,
fleshy, vascular and anemic, membranous and
inflammed looking with few attenuated looking with
infiltrates in the cornea, in very little vascularity.
front of head of pterygium
There is no cap.
called cap of pterygium.

• It is also called pterygium • Ultimately it becomes


carassum, vasculosum or membranous but never
carnosum. disappears.
Gerundo classified three stages as:
 Proliferative papillomatous
 Fibromatous
 Atrophic sclerotic respectively

Townsend classified into 5 groups on their risk of recurrence:


 Actively growing
 Fleshy
 Slowly growing
 Stationary
 Atrophic pterygia.
CLINICAL CLASSIFICATION

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.

Interferes with precorneal


tear film and induces
astigmatism.
• Type 3-
Invades more than 4mm of
cornea and involves visual
axis.
Extensive lesions associated
with subconjunctival
fibrosis extending to the
fornices cause restriction in
ocular motility.
• Pseudopterygium is caused
by a band of conjunctiva
adhering to an area of
compromised cornea at its
apex.
• forms as a response to an
acute inflammatory episode
such as
– chemical burn
– corneal ulcer (esp
marginal),
– trauma
– cicatrizing conjunctivitis
DEPENDING ON SITE

• Nasal
• Temporal
• Double
• Bilateral
RECURRENT PTERYGIUM

• Regrowth of pterygium after primary excision is called


recurrent pterygium (40%)

• Recurred lesions grow more aggressively than primary lesions

• Recurrent pterygia – lack elastotic degeneration and are more


accurately classified as an exuberant granulation tissue
response
CLINICAL FEATURES
 Asymptomatic if it is small

 Eye irritation, foreign body sensation, dryness, epiphora,


pruritus

 Patients who wear contact lenses may develop symptoms of


irritation at an earlier stage due to edge lift

 Cosmesis may be a significant problem

 May get inflamed intermittently and cause symptoms

 A pterygium of significant size induces astigmatism

 If encroaches pupillary area causes gross diminution of vision


DIFFERENTIAL DIAGNOSIS
• Pinguecula

• Pseudopterygium

• Papilloma

• Conjunctival intra epithelial neoplasia

• Squamous cell conjunctival carcinoma

• Corneal macropannus

• Terrien's marginal degeneration


PINGUECULA-

 Is a small, elevated, yellowish mass


confined to the limbus and bulbar
conjunctiva in the intrapalpebral
fissure and may occasionally become
inflamed

 This condition is termed pinguecula,


because of its resemblance to fat,
which means pinguis

 May be mistaken for early pterygium

 It grows away from limbus and


usually does not involve cornea

 It may act as a precursor for


pterygium.
PSEUDOPTERYGIUM

• It is due to some abnormality of cornea due to which


conjunctiva comes and seals over it.

• Causes- Chemical burns, Corneal perforation, Long


standing corneal ulcers.

• Can occur at any age, any site and always stationary.


Pseudo pterygium
Clues leading to diagnosis of pseudo pterygium-

• Any anatomic location other than interpalpebral fissure


• Diffuse corneal involvement in multiple locations.
• History of past significant ocular inflammatory event.
• Lack of anatomic configuration (head & body) typical of
pterygium.
• bridges the limbus so that a probe can be passed underneath
the body at the limbus.
• Presence of corneal thinning
MANAGEMENT
MEDICAL MANAGEMENT

• The lesion starts as a small elevation at the limbus, often in the


interpalpebral region- ‘roundlet’

• Can be asymptomatic, or prone to recurrent episodes of


inflammation with redness and irritation

• Treatment includes the use of ultraviolet filters in glasses and


lubricant tear drops

• The use of steroid eye drops to manage the inflammation is also


described - little data available on efficacy of this approach
INDICATIONS FOR SURGERY

• Most patients present with corneal involvement and in these


patients, surgery is recommended for various reasons –

– A documented history of progression


– Astigmatism causing poor vision
– Proximity to the visual axis
– Poor cosmesis
– Recurrent inflammation
– Concern about malignant change
• The earliest described surgical approach for pterygium was
simple excision leaving the scleral bed bare

• The recurrence rates range from 30 to 80%

• postoperative cosmesis is poor, resulting in this procedure


being abandoned

• Various modifications in technique have been reported and


with current approaches
• It is speculated that pterygium may represent an area of
localized limbal stem cell deficiency, with result invasion of
the adjacent cornea by the conjunctiva

• Surgical techniques that fail to address these pathophysiologic


causative factors, (the bare sclera technique) appear to be
associated with highest rates of recurrence

• Since a recurrence is more aggressive than primary lesion in


speed and extent of corneal invasion, it is important to choose
the primary procedure that has highest rate of success
Pterygium invading visual axis Pterygium crossing visual axis
EVOLUTION OF APPROACHES TO
MANAGEMENT OF PTERYGIUM
BARE SCLERA TECHNIQUE
• Involves surgical excision of
the pterygium with the
exposed sclera left bare

• a quick and easy procedure,


often performed in the
office with topical or
subconjunctival anesthesia

• High recurrence rate


ranging from 30-80 %-
seldom used now
• Other variations of this approach were tried to mitigate the
high recurrence rate

• These procedures include –


– primary closure of the defect
– splitting the head of the pterygium
– Mac Reynold’s operation- head is sutured under body
itself
– Kehr’s operation- head is sutured in inferior fornix

• While these modifications did improve the results,


recurrences were still common, and the technical complexity
of these procedures limited their use
CONJUNCTIVAL FLAP

• Sliding conjunctival flaps


harvested from the inferior
or superior bulbar
conjunctiva were used to
close the scleral defect

• recurrence rate reported is


1-5%

• surgery is technically
complicated with
suboptimal cosmesis
CONJUNCTIVAL AUTOGRAFT

• Described by Kenyon in 1985

• In their landmark paper, the authors used a free conjunctival-


limbal graft with the same dimensions as the scleral bed,
harvested from the superior bulbar conjunctiva, and sutured
this in the scleral bed
• The graft is preferably taken from the superior temporal
bulbar conjunctiva, because

– technical difficulty in harvesting a graft from the inferior


bulbar conjunctiva

– The inferior limbus and inferior bulbar conjunctivae are


more exposed to UV radiations, compared to superior
limbus and superior temporal bulbar conjunctiva which are
shielded by upper lid
• recurrence rates ranges from 0 to 15%

• In a series from India, Rao et al reported the outcomes of this


procedure in 53 eyes with 36 primary and 17 recurrent
pterygia, with a mean follow-up of 18.9 + 12.1 months

• The recurrence rate was 3.8%


STEPS OF THE TECHNIQUE
• A wire speculum is used to separate the lids

• A superior rectus bridle suture is inserted

• The suture is used to abduct the eye maximally (assume nasal


pterygium) by clipping it to the drapes adjacent to the lateral canthus

• A small incision is made in the conjunctiva just medial to the head of the
pterygium

• Beginning here, the conjunctiva is progressively dissected from the body


of the pterygium towards the caruncle

• 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

• Once the plane is defined, the pterygium head is easily avulsed


using a combination of blunt dissection and traction

• Residual fibrous tissue on the cornea is removed by sharp


dissection with a No. 15 Bard-Parker blade

• 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 measured dimensions are marked onto the


superotemporal conjunctiva

• Using a Pierse-Hoskins forceps and Westcott scissors, the graft


is excised starting at the forniceal end

• Care is taken to obtain as thin a graft as possible without


button-holing
• Once the limbus is reached the graft is flipped over onto the
cornea and the Tenon’s attachments at the limbus were
meticulously dissected

• The flap is then excised using a Vannas scissors, taking care to


include the limbal tissue

• After excision, the conjunctivallimbal graft is slid onto the


cornea Without lifting the tissue off the cornea, it is rotated
and moved onto its scleral bed with fine non-toothed forceps
• A limbus-limbus orientation is maintained- helps avoid inadvertent scrolling of
the graft with resultant inversion of the surfaces

• The graft is smoothened out in its bed taking care to avoid any folding of the
edges

• The graft is secured using interrupted 10-0 nylon sutures


• The four corners of the graft are anchored with episcleral bites to maintain
position

• 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

• Postoperatively, topical betamethasone eye drops are used


every 2 hours for the first operative week and then tapered
over the next 5-6 weeks

• Antibiotic ointment is used 3 times daily for the first 2 weeks.


Any retained sutures are removed at 6 weeks
Pterygium before surgery Close up post opereative
After pterygium excision with
picture of the same eye
conjunctival autograft
Recurrent pterygium After conjunctival autograft Ocular surface squamous neoplasia

Pseudo pterygium after After excision of pseudo


excision of the neoplasia pterygium with conjunctival
autograft
P.E.R.F.E.C.T SURGERY

• Dr Hirst from Australia reported a recurrence rate of 0.5% with a


technique he called P.E.R.F.E.C.T. which stands for ‘Pterygium
Extended Removal Followed by Extended Conjunctival Transplant’

• He did an extensive conjunctival autografting of about 15mm by 12


mm

• Advantages are less recurrence and better cosmetic outcome as


graft edge and the surgical scars are hidden in the fornices and
caruncle

• Limitation is that it is time consuming and technically challenging


procedure
FREE CONJUNCTIVAL AUTOGRAFT
• It has been suggested that including limbal stem cells in the conjunctival
autograft (limbal–conjunctival graft)

• acts as a barrier to conjunctival cells migrating onto the corneal surface


and helps prevent recurrence

• The limbal–conjunctival graft includes approximately 0.5mm of the limbus


and peripheral cornea

• The recurrence rates range from 0 to 15%

• In some situations, where there has been previous surgery, or limbal


damage due to other causes, surgical manipulations when removing a
limbal graft may promote further damage to stem cells

• 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

• it is possible that limbal–conjunctival autografts are more effective


than conjunctival autografts for recurrent pterygium

• In some patients with an existing superior conjunctival bleb, other


superior conjunctival pathology, or in anticipation of the need to
perform glaucoma surgery superiorly, it may be feasible to perform
the surgery, using tissue from the inferior bulbar conjunctiva

• The results of this approach were reported by Rao et al R, with an


acceptable recurrence rate of 18.2 %
CONJUNCTIVAL ROTATION AUTOGRAFT SURGERY
• first described by Tan et al

• requires the removal of conjunctiva over the body of the pterygium

• This tissue is stored in saline, while rest of the Pterygium is removed

• the tissue is replaced and sutured in the bare scleral bed, with the
limbal aspect of graft now facing the fornix and vice versa

• useful where it is not possible or desirable to use the superior


conjunctiva as a donor source, such as with excision of extensive
pterygium, (insufficient conjunctival tissue), double pterygium,
glaucoma surgery etc
• Recurrence rate is 4%.
AMNIOTIC MEMBRANE TRANSPLANTATION

• Amniotic membrane transplantation -recently proposed as a


treatment option to prevent recurrences
• Amniotic membrane advantages -
– Possess anti-scarring, antiangiogenic and anti-inflammatory
properties

– removes the need for harvesting large autografts, thereby


minimizing iatrogenic injury to rest of conjunctival surface

• Recurrence rate ranges from 12 to 40 %.

• Delayed vascularization of amniotic membrane is thought to be


responsible for the delayed recurrence after pterygium surgery
CULTIVATED CONJUNCTIVAL TRANSPLANTATION
• A novel method of closing the surgical defect involves the use
of an ex-vivo expanded conjunctival epithelial sheet on an
amniotic membrane substrate

• the efficacy of this approach was studied in the management


of Pterygium surgery, comparing it to standard amniotic
membrane transplantation

• a recurrence rate of 23 % was noted

• Further studies are needed to evaluate the success of this


approach in pterygium surgery.
ADJUNCTIVE METHODS FOR
PREVENTION OF RECURRENCE
RADIATION

• Radiation of the bare sclera with Strontium 90 is largely given


up due to patients developing scleral necrosis at the site

• It has been replaced by other safer adjuvants


MITOMYCIN C (MMC)
• The adjunctive use of Mitomycin C during pterygium surgery has
been shown to decrease the recurrence rate

• MMC is used in two forms, intra-operative application to the bare


scleral bed and post operative drops.

• The reported recurrence rates associated with intraoperative


mitomycin C use range from 10.5 to 38%.

• Increasing the duration of intra operative exposure to MMC


reduces recurrences
• complications of MMC
– Infectious scleritis
– Severe secondary glaucoma
– Corneal edema
– Corneal perforation
– Corectopia
– Iritis
– Sudden onset mature cataract
– Scleral calcification and incapacitating photophobia and
pain

• These complications have been reported both with intra


operative use of MMC and post operative mitomycin eye
drops.
CORTICOSTEROIDS

• The postoperative use of subconjunctival triamcinolone


seems to benefit patients having risk factors like conjunctival
inflammation, hemorrhage, granuloma and fibrovascular
proliferation by preventing recurrences

• Post-operative topical corticosteroid eye drops also decrease


the incidence of recurrences by reducing the inflammation
OTHERS

• Daunorubicin, doxorubicin and 5 fluorouracil (5FU)


OTHER ADVANCES FOR EASE OF
SURGERY
FIBRIN GLUE

• used as an alternative to sutures for securing conjunctival grafts

• shortens operating times, AND less postoperative discomfort

• success rates are comparable to sutured grafts

• heal with minimal inflammation

• Concerns -cost and the potential risk of transmitted infection like


HIV, hepatitis B or C or prionmediated disease
AUTOLOGOUS SERUM

• Patients own blood is used as a bio adhesive in pterygium


surgery
• recurrence rate - similar to fibrin glue

• cost effective with no risk of transmission of infections.

• Complications- graft displacement and graft retraction are


more common
COMPLICATED CASES AND APPROACH
TO THEIR MANAGEMENT
LAMELLAR KERATOPLASTY
• used to replace the thinning and corneal scarring seen after
pterygium excision

• No special advantage in preventing pterygium recurrence

• used to treat recurrent pterygium to restore corneal


thickness in thinned, scarred corneas or corneal opacity in the
visual axis

• 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

• used to cover large conjunctival defects created in double-


head pterygium

• the conjunctival graft including the limbal tissue is


transplanted nasally, as the nasal limbus is reported to be
more exposed to the UV radiation by internal reflection from
the temporal limbus.
A double headed pterygium
COMBINATION OF APPROACHES

• Conjunctival autografting with amniotic membrane grafting


has been used in recurrent pterygium with restriction of
movements

• In these cases, amniotic membrane is used to cover the


muscle to prevent fibrosis and restriction of movements while
the conjunctival autograft is used to close the defect from the
pterygium surgery.
COMPLICATIONS OF PTERYGIUM SURGERY

• 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

• Hayasaki and co-workers studied 99 eyes of 80 patients

• All had surgical removal of their primary pterygia and


postoperative application of topical corticosteroids and
antibiotics
• Mitomycin C, 0.02% in 0.9% NaCl, twice per day for the first 5
postoperative days, significantly reduced the recurrence of
pterygia (7% in 29 eyes)

• The 31 eyes not receiving mitomycin C had a 32% recurrence


rate.

• Reduced recurrence rates were achieved by 2000-cGy


radiation (15%) and mitomycin C, 0.04%, three times per day
for 1 week (11%) however they were not superior to that of
the 0.02% solution of mitomycin C

• Intraoperative application of 0.04% mitomycin C was found


significantly more effective than 2160 cGy radiation
• Singh and co-workers using 0.04% and 0.1% solutions of
mitomycin after pterygium surgery found it effective

• 1% solution caused some epithelial breakdown, irritation and


lacrimation

• Mitomycin C 0.02%, applied for 5 minutes on a sponge, and


leaving the sclera bare provided a significantly lower
recurrence rate, 4%, than removal using only a bare sclera,
46.7%

• conjunctival autograph was just as effective as drops of 0.02%


mitomycin C, twice daily for 5 days in preventing recurrence

• Applying mitomycin C intraoperatively seems to be as


effective as using drops postoperatively
• In recurrent pterygia, treatment after tumor excision with
either a conjunctival autograft or a sponge containing 0.02%
mitomycin C for 3 minutes, provided similar recurrence rates

• Intraoperative application and postoperative eye drops of


mitomycin C after pterygium removal have been associated
with severe scleral melting
• UV rays -most accepted risk factor for the occurrence of pterygium

• UV cause mutations in genes such as the p53 tumor suppressor


gene, resulting in abnormal pterygial epithelium

• Recent studies have suggested that human papilloma virus may


also be implicated in pterygium pathogenesis

• These findings suggest that pterygium is not just a degenerative


lesion, but could be a result of uncontrolled cell proliferation

• Matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs


(TIMPs) at the advancing pterygium edge may be responsible for
the inflammation, tissue remodeling, destruction of Bowman’s
layer and pterygium invasion into the cornea
SURGICAL TECHNIQUES
• Avulsion
• Excision (Bare Sclera)
• Excision with
Primary closure
Conjunctival flap formation
Conjunctival autograft
Amniotic membrane transplantation
• Limbal Autograft
• Lamellar or Penetrating Keratoplasty
• Transplantation operations
• Mucus membrane/ split skin grafts
Bare sclera closure Simple Closure
Sliding Flap Closure Rotational Flap Closure
Conjunctival Autograft

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