eMedicine Specialties > Ophthalmology > Conjunctiva

Pterygium

Jerome P Fisher, MD, FACS, Volunteer Assistant Professor, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine
William B Trattler, MD, Ophthalmologist, The Center for Excellence in Eye Care; Volunteer Assistant Professor of Ophthalmology, Bascom Palmer Eye Institute

Updated: Jan 12, 2009

Introduction

Background

A pterygium is an elevated, superficial, external ocular mass that usually forms over the perilimbal conjunctiva and extends onto the corneal surface. Pterygia can vary from small, atrophic quiescent lesions to large, aggressive, rapidly growing fibrovascular lesions that can distort the corneal topography, and, in advanced cases, they can obscure the optical center of the cornea.

Pathophysiology

The pathophysiology of pterygia is characterized by elastotic degeneration of collagen and fibrovascular proliferation, with an overlying covering of epithelium. Histopathology of the abnormal collagen in the area of elastotic degeneration shows basophilia with hematoxylin and eosin stain. This tissue also stains with elastic tissue stains, but it is not true elastic tissue, in that it is not digested by elastase.

Frequency

United States

Occurrence within the United States varies with geographical location. Within the continental United States, prevalence rates vary from less than 2% above the 40th parallel to 5-15% in latitudes between 28-36°. A relationship is thought to exist between increased prevalence and elevated levels of ultraviolet light exposure in the lower latitudes.

International

Internationally, the relationship between decreased incidence in the upper latitudes and relatively increased incidence in lower latitudes persists.

Mortality/Morbidity

Pterygia can cause a significant alteration in visual function in advanced cases. They also can become inflamed, resulting in redness and ocular irritation.

Sex

Pterygia are reported to occur in males twice as frequently as in females.

Age

It is uncommon for patients to present with pterygia prior to age 20 years. Patients older than 40 years have the highest prevalence of pterygia, while patients aged 20-40 years are reported to have the highest incidence of pterygia.

Clinical

History

Patients with pterygia present with a variety of complaints, ranging from no symptoms to significant redness, swelling, itching, irritation, and blurring of vision associated with elevated lesions of the conjunctiva and contiguous cornea in one or both eyes.

Physical

A pterygium can present as any of a range of fibrovascular changes on the surface of the conjunctiva and the cornea. It is more common for the pterygium to present on the nasal conjunctiva and to extend onto the nasal cornea, although it can present temporally, as well as in other locations.

• The clinical presentation can be divided into 2 general categories, as follows:
  • One group of patients with pterygium can present with minimal proliferation and a relatively atrophic appearance. The pterygia in this group tend to be flatter and slow growing and have a relatively lower incidence of recurrence following excision.
  • The second group presents with a history of rapid growth and a significant elevated fibrovascular component. The pterygia in this group have a more aggressive clinical course and a higher rate of recurrence following excision.

Causes

• Risk factors for pterygium include the following:
  • Increased exposure to ultraviolet light, including living in subtropical and tropical climates
  • Engaging in occupations that require outdoor activities
• A genetic predisposition to the development of pterygia appears to exist in certain families.
• A predilection exists for males to develop this condition in significantly higher numbers than females, although this finding may represent an increased exposure to ultraviolet light in this portion of the population.

Differential Diagnoses

Squamous Cell Carcinoma, Conjunctival

Other Problems to Be Considered

• Pseudopterygia (eg, chemical or thermal burn, trauma, marginal corneal disease)
• Neoplasia (eg, carcinoma in situ, squamous cell carcinoma, other neoplastic diseases)
• Pingueculae (ie, actinic lesions confined to the perilimbal conjunctiva that do not extend onto the cornea)
  • Pingueculae are commonly occurring, generally small and asymptomatic (often yellow) raised nodules appearing on the bulbar surface of the conjunctiva. They are found more commonly on the nasal side, but they can also present either on the temporal conjunctiva or on both the nasal and temporal conjunctiva in the eyes of some patients.
  • Pingueculae are thought to be associated with actinic (sunlight) exposure in susceptible individuals.
  • Pingueculae can occasionally be subject to some inflammation with symptoms of itching, burning, or mild pain. In the absence of inflammation or of significant cosmetic complaints, pingueculae are generally ignored (by patient and physician alike). If mildly symptomatic, like pterygia, they can be treated with artificial tears.
  • On rare occasions, ocular anti-inflammatory drops may be required. On even more infrequent occasions, surgical excision may be of benefit in the management of pingueculae.
  • Histopathologically, pingueculae show mild-to-moderate focal thickening of the conjunctival stroma with elastotic degeneration of collagen.

Workup

Imaging Studies

• Corneal topography can be very useful in determining the degree of irregular astigmatism induced by advanced pterygia.
• External photography can assist the ophthalmologist in following the progression of the pterygium.

Procedures

• Multiple different procedures have been advocated in the treatment of pterygia. These procedures range from simple excision to sliding flaps of conjunctiva with and without adjunctive external beta radiation therapy and/or use of topical chemotherapeutic agents, such as mitomycin C.
• Using free grafts of conjunctiva (with or without limbal tissue) at the same time as primary excision of the lesion has been widely advocated as the preferred treatment modality for aggressive pterygia. For moderate-to-severe pterygia, some corneal surgeons use amniotic membrane transplants. Both the conjunctival autografts and the amniotic membrane transplants may be sutured onto adjacent conjunctiva and subjacent cornea. Some corneal surgeons seal the graft tissue onto the underlying sclera with the aid of fibrin tissue glue rather than with sutures.

Treatment

Medical Care

Patients with pterygia can be observed unless the lesions exhibit growth toward the center of the cornea or the patient exhibits symptoms of significant redness, discomfort, or alterations in visual function. Pterygia can be removed for cosmetic reasons, as well as for functional abnormalities of vision or discomfort.

Surgical Care

Surgery for excision of pterygia is usually performed in an outpatient setting under local or topical anesthesia with sedation, if necessary.
 
Postoperatively, the eye is generally patched overnight, and it is treated subsequently with topical antibiotics and anti-inflammatory drops and/or ointments.

Medication

Artificial tears (topical lubricating drops)

To lubricate the ocular surface and to fill in defects in the tear film.

Artificial tears/topical lubricating drops (Refresh Tears, GenTeal [OTC])

Artificial tears provide topical ocular surface lubrication in patients with irregular corneal surfaces and irregular tear films. These conditions are very common in the setting of pterygium.

Dosing

Adult

1 gtt in affected eye(s) qid and prn for irritation

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

If symptoms persist despite continued use, reevaluate patient

Topical lubricating ointments

A more viscous lubricant of the ocular surface.

Topical lubricating ointments (Hypo Tears, Refresh P.M. [OTC])

A relatively more viscous lubricant for the ocular surface. These thicker preparations tend to blur the vision temporarily; therefore, they are generally used at night, except in patients with severe discomfort.

Dosing

Adult

Apply to inferior cul-de-sac in affected eye(s) hs

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Patients using ocular ointments will have temporary blurring of vision and should avoid activities that require clear vision until the blurring subsides

Anti-inflammatory drops

To reduce inflammation on the ocular surface and other ocular tissues. Corticosteroids can be helpful in the management of inflamed pterygia by reducing the swelling of the inflamed tissues of the ocular surface adjacent to the lesions.

Prednisolone acetate (Pred Forte 1%)

A topical corticosteroid suspension used to reduce inflammation in the eye. Use should be limited to eyes with significant inflammation not relieved by topical lubricants.

Dosing

Adult

1 gtt qid in affected eye(s) for a limited time, usually only 1-2 wk of continuous therapy

Pediatric

Not applicable, as pterygia are very rare in pediatric age group

Interactions

None reported

Contraindications

Documented hypersensitivity; patients with a history of herpes simplex dendritic keratitis or steroid responsive glaucoma

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Can be absorbed systemically but systemic adverse effects are generally not seen in patients using topical prednisolone acetate drops; can be excreted in the milk of women who are breastfeeding

Follow-up

Further Outpatient Care

• Postoperatively, after pterygium excision, the topical steroids are slowly tapered. Patients on topical steroids need to be observed to avoid problems, such as elevated intraocular pressure and cataracts.

Inpatient & Outpatient Medications

• See Medication.

Deterrence/Prevention

• Theoretically, minimizing exposure to ultraviolet radiation should reduce the risk of development of pterygia in susceptible individuals. Patients are advised to use a hat or a cap with a brim, in addition to ultraviolet-blocking coatings on the lenses of glasses/sunglasses to be used in areas of sun exposure. This precaution is even more important for those patients living in tropical or subtropical areas or for those patients who are engaged in outdoor activities with a high risk of ultraviolet exposure (eg, fishing, skiing, gardening, outdoor construction work).

Complications

• Complications of pterygia include the following: 
  • Distortion and/or reduction of central vision
  • Redness
  • Irritation
  • Chronic scarring of the conjunctiva and the cornea
  • Extensive involvement of the extraocular muscles may restrict ocular motility and contribute to diplopia.
    • In patients who have not yet undergone surgical excision, scarring of the medial rectus muscle is the most common cause of diplopia.
    • In patients with pterygia who have previously undergone surgical excision, scarring or disinsertion of the medial rectus muscle is the most common cause of diplopia.
• In patients with significantly elevated pterygia, focal drying and subsequent thinning of the adjacent cornea may rarely occur.
• Postoperative complications of pterygium repair can include the following:
  • Infection
  • Reaction to suture material
  • Diplopia
  • Conjunctival graft dehiscence
  • Corneal scarring
  • Rare complications may include perforation of the globe, vitreous hemorrhage, or retinal detachment.
• Late postoperative complications of beta radiation of pterygia can include the following:
  • Scleral and/or corneal thinning or ectasia can present years or even decades after treatment.
  • Some of these cases can be quite difficult to manage.
• In some cases, adjunctive use of topical mitomycin-C at and after pterygium surgery has been reported to cause similar ectasia or melting of the sclera and/or the cornea.
• The most common complication of pterygium surgery is postoperative recurrence. Simple surgical excision has a high recurrence rate of approximately 50-80%. The rate of recurrence has been reduced to approximately 5-15% with use of conjunctival/limbal autografts or amniotic membrane transplants at the time of excision.
• On rare occasion, malignant degeneration of epithelial tissue overlying an existing pterygium can occur.

Prognosis

• The visual and cosmetic prognosis following excision of pterygia is good. The procedures are well tolerated by patients, and, aside from some discomfort in the first few postoperative days, most patients are able to resume full activity within 48 hours of their surgery. Those patients who develop recurrent pterygia can be retreated with repeat surgical excision and grafting, with conjunctival/limbal autografts or amniotic membrane transplants in selected patients.

Patient Education

• Patients who are at high risk of the development of pterygia because of a positive family history of pterygia or because of extended exposure to ultraviolet irradiation need to be educated in the use of ultraviolet-blocking glasses and other means of reducing ocular exposure to ultraviolet light.

Miscellaneous

Medicolegal Pitfalls

• As in any surgical procedure, careful informed consent must be obtained from the patient prior to surgery. While this procedure is fairly common with a very good visual prognosis in most patients, any ocular procedure can be associated with infection, perforation of the globe, vitreous hemorrhage, endophthalmitis, retinal detachment, or diplopia.
• Patients should be informed that redness and irritation may persist for longer than a month postoperatively.
• Patients should be informed about the chance of recurrence.
• The surgeon should check all biopsy results after excision of pterygium to rule out the possibility of an atypical presentation of a malignancy masquerading as a benign pterygium.

References

1. Anduze AL. Pterygium surgery with mitomycin-C: ten-year results. Ophthalmic Surg Lasers. Jul-Aug 2001;32(4):341-5. [Medline].

2. Bahar I, Weinberger D, Gaton DD, Avisar R. Fibrin glue versus vicryl sutures for primary conjunctival closure in pterygium surgery: long-term results. Curr Eye Res. May 2007;32(5):399-405. [Medline].

3. Blum HF. Carcinogenesis by Ultraviolet Light. Princeton University Press; 1959.

4. Cogan DG, Kuwabara T, Howard J. The nonelastic nature of pingueculas. Arch Ophthalmol. 1959;61:388.

5. Cohen RA, McDonald MB. Fixation of conjunctival autografts with an organic tissue adhesive. Arch Ophthalmol. Sep 1993;111(9):1167-8. [Medline].

6. Coroneo MT, Di Girolamo N, Wakefield D. The pathogenesis of pterygia. Curr Opin Ophthalmol. Aug 1999;10(4):282-8. [Medline].

7. Elliot R. The aetiology of pterygium. Trans Ophthalmol Soc NZ. 1961;13:22.

8. Fernandes M, Sangwan VS, Bansal AK, Gangopadhyay N, Sridhar MS, Garg P, et al. Outcome of pterygium surgery: analysis over 14 years. Eye. Nov 2005;19(11):1182-90. [Medline].

9. Fuchs E. Uber das Pterygium. Albert von Graefes Arch Klin Exp Ophthalmol. 1892;38:1.

10. Jain AK, Bansal R, Sukhija J. Human amniotic membrane transplantation with fibrin glue in management of primary pterygia: a new tuck-in technique. Cornea. Jan 2008;27(1):94-9. [Medline].

11. Kamel S. The Pterygium: its etiology and treatment. Am J Ophthalmol. 1954;38:682.

12. Kheirkhah A, Casas V, Sheha H, Raju VK, Tseng SC. Role of conjunctival inflammation in surgical outcome after amniotic membrane transplantation with or without fibrin glue for pterygium. Cornea. Jan 2008;27(1):56-63. [Medline].

13. Lee JS, Oum BS, Lee SH. Mitomycin c influence on inhibition of cellular proliferation and subsequent synthesis of type I collagen and laminin in primary and recurrent pterygia. Ophthalmic Res. May-Jun 2001;33(3):140-6. [Medline].

14. McDonald JE, Wilson FM. Ocular therapy with beta particles. Trans Am Acad Ophthalmol Otolaryngol. 1959;63:468.

15. Miyai T, Hara R, Nejima R, Miyata K, Yonemura T, Amano S. Limbal allograft, amniotic membrane transplantation, and intraoperative mitomycin C for recurrent pterygium. Ophthalmology. Jul 2005;112(7):1263-7. [Medline].

16. Oguz H. Amniotic membrane grafting versus conjunctival autografting in pterygium surgery. Clin Experiment Ophthalmol. Aug 2005;33(4):447-8. [Medline].

17. Raiskup F, Solomon A, Landau D, Ilsar M, Frucht-Pery J. Mitomycin C for pterygium: long term evaluation. Br J Ophthalmol. Nov 2004;88(11):1425-8. [Medline].

18. Rubinfeld RS, Pfister RR, Stein RM, Foster CS, Martin NF, Stoleru S, et al. Serious complications of topical mitomycin-C after pterygium surgery. Ophthalmology. Nov 1992;99(11):1647-54. [Medline].

19. Saw SM, Tan D. Pterygium: prevalence, demography and risk factors. Ophthalmic Epidemiol. Sep 1999;6(3):219-28. [Medline].

20. Singh G, Wilson MR, Foster CS. Long-term follow-up study of mitomycin eye drops as adjunctive treatment of pterygia and its comparison with conjunctival autograft transplantation. Cornea. Oct 1990;9(4):331-4. [Medline].

21. Srinivasan S, Slomovic AR. Eye rubbing causing conjunctival graft dehiscence following pterygium surgery with fibrin glue. Eye. Jun 2007;21(6):865-7. [Medline].

22. Starck T, Kenyon KR, Serrano F. Conjunctival autograft for primary and recurrent pterygia: surgical technique and problem management. Cornea. May 1991;10(3):196-202. [Medline].

23. Tan D. Conjunctival grafting for ocular surface disease. Curr Opin Ophthalmol. Aug 1999;10(4):277-81. [Medline].

24. Threlfall TJ, English DR. Sun exposure and pterygium of the eye: a dose-response curve. Am J Ophthalmol. Sep 1999;128(3):280-7. [Medline].

25. Ti SE, Chee SP, Dear KB, Tan DT. Analysis of variation in success rates in conjunctival autografting for primary and recurrent pterygium. Br J Ophthalmol. Apr 2000;84(4):385-9. [Medline].

26. Uy HS, Reyes JM, Flores JD, Lim-Bon-Siong R. Comparison of fibrin glue and sutures for attaching conjunctival autografts after pterygium excision. Ophthalmology. Apr 2005;112(4):667-71. [Medline].

27. Yao YF, Qiu WY, Zhang YM, Tseng SC. Mitomycin C, amniotic membrane transplantation and limbal conjunctival autograft for treating multirecurrent pterygia with symblepharon and motility restriction. Graefes Arch Clin Exp Ophthalmol. Feb 2006;244(2):232-6. [Medline].

Keywords

pterygia, ocular mass, ocular lesion, corneal surface, corneal topography, diplopia, double vision, vision loss

Contributor Information and Disclosures

Author

Jerome P Fisher, MD, FACS, Volunteer Assistant Professor, Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine
Jerome P Fisher, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Medical Association, and Florida Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

William B Trattler, MD, Ophthalmologist, The Center for Excellence in Eye Care; Volunteer Assistant Professor of Ophthalmology, Bascom Palmer Eye Institute
William B Trattler, MD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Cataract and Refractive Surgery
Disclosure: Nothing to disclose.

Medical Editor

Fernando H Murillo-Lopez, MD, Senior Surgeon, Unidad Privada de Oftalmologia CEMES
Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, Pennsylvania Medical Society, and Philadelphia County Medical Society
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)