Dr VIDYASHANKAR G K

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Management of Pterygium

• Dr VIDYASHANKAR G K
• Shekar Nethralaya
• Bangalore

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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

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Pterygium - Classification

• Primary Pterygium
• Recurrent Pterygium
• Atrophic Pterygium
• Older pts, thin translucent body with thin
  vessels
• Pogressive Pterygium
• Thick fleshy growth seen in Younger pts

Body
Neck
Head
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Pterygium

• Grading of pterygium helps for management
• Depending on Size-
• Grade 1 Grade 2
  Grade 3
• Variants
• Cystic degeneration
• Bidirectional
• Pseudo pterygium present anywhere, neck bridges
  limbus

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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

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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

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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
• Excision MMC AMG Conj Auto graft
• Excision Conjunctivolimbal Auto graft

For recurrent pterygium
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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 with 8-0 Vicryl suture
• Limbal apposition - can be done by 10-0 nylon
  Monofilament suture

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

High complications
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Pterygium- Surgical Complications

• Graft contration
• Graft edema
• Graft necrosis
• Granuloma formation
• Excessive cautery- scleral necrosis
• Infection

• Recurrence
• Corneal scaring
• Ocular motility restriction
• Surgical induced Necrotising
• Scleritis (SINS)

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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)

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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

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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 cautery-
• Scleral necrosis in Bare sclera method
• No inflammation, no pain
• AMG or Conj graft

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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

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Pterygium- Surgical Complications

• Microbial Infection
• - rare
• - Identify organism
• - culture and sensitivty
• - antibiotics / antifungals

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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

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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

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