Dr VIDYASHANKAR G KShekar Nethralaya

Bangalore

Management of Pterygium

04/19/231

PterygiumDefn : 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

04/19/232

Pterygium - Classification

Primary PterygiumRecurrent Pterygium

Atrophic PterygiumOlder pts, thin translucent body with thin vessels

Pogressive PterygiumThick fleshy growth seen in Younger pts

Head

NeckBody

04/19/233

PterygiumGrading 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

04/19/234

Pterygium- ManagementObservation

Asymptomatic , grade 1 pterygium

Medical ManagementSymptomatic Grade 1 and 2 pterygiumEye drops – Tear substitutes, DecongestantsLocal injections – anti VEGFs, Steroid

Surgical Management

04/19/235

Pterygium -Surgical ManagementIndications-

Symptomatic patients - recurrent irritation, redness and watering

Visual need- covering visual axis or threatening visual axis- causing irregular astigmatism - Grade 2 and 3 Pterygium

CosmeticTherapeutic

- suspected associated neoplastic degeneration- motility restriction

04/19/236

Pterygium -Surgical ManagementDifferent 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

04/19/237

Pterygium -Surgical ManagementExcision

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

04/19/238

Pterygium -Surgical ManagementAdjuvants – to reduce recurrenceMitomycin 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

04/19/239

Pterygium- Surgical Complications

Graft contration Graft edema Graft necrosis Granuloma formation Excessive cautery-

scleral necrosis Infection

Recurrence Corneal scaring Ocular motility

restriction Surgical induced

NecrotisingScleritis (SINS)

04/19/2310

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)

04/19/2311

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

04/19/2312

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 methodNo inflammation, no painAMG or Conj graft

04/19/2313

Pterygium- Surgical ComplicationsOcular 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

04/19/2314

Pterygium- Surgical ComplicationsMicrobial Infection

- rare- Identify organism- culture and sensitivty - antibiotics / antifungals

04/19/2315

Pterygium - ManagementRecent 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

04/19/2316

Pterygium - ManagementRecent 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

04/19/2317

04/19/2318