1. Management of Pterygium
Dr VIDYASHANKAR G K
Shekar Nethralaya
Bangalore
4/19/2017

2. 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
4/19/2017

3. 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
4/19/2017

4. Pterygium Grading of pterygium helps for management Variants
Depending on Size-
Grade Grade Grade 3
Variants
Cystic degeneration
Bidirectional
Pseudo pterygium – present anywhere, neck bridges limbus
4/19/2017

5. 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
4/19/2017

6. 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
4/19/2017

7. 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
4/19/2017

8. 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
4/19/2017

9. 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
4/19/2017

10. 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)
4/19/2017

11. 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)
4/19/2017

12. 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
4/19/2017

13. 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
4/19/2017

14. 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
4/19/2017

15. Pterygium- Surgical Complications
Microbial Infection - rare - Identify organism - culture and sensitivty - antibiotics / antifungals
4/19/2017

16. 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
4/19/2017

17. 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
4/19/2017

18. THANK YOU
4/19/2017