Major reviewThe Treatment Of Pterygium☆
Section snippets
History of Pterygium Therapy
There are numerous early reports that explore the treatment of pterygium. Celsus described a treatment that consisted of lifting the pterygium with a hook, pushing a needle underneath it, tying it with a thread, and dissecting it off the cornea with a knife,63 while the Chinese discussed the importance of applying medications which would inhibit the formation of blood vessels in a pterygium such as rhemania, akebia, licorice, and ginseng.63 The School of Hippocrates describes the pterygium but
Reported indications
There are a number of generally accepted reasons for removing pterygium. Few people would argue that a pterygium that extends close to the visual axis and appears to be active should be removed. This is based on the understanding that whenever a pterygium is removed, there will be some scarring in the cornea as a result. If the scarring extends close to the visual axis, irregular astigmatism and reduced vision may occur.
There would also be little disagreement that pterygia that restrict eye
Surgical Outcomes
The major endpoints of pterygium removal relate to recurrence, which may be corneal or conjunctival, visual, and cosmetic appearance. There are other minor less common endpoints such as ocular motility, tear outflow, and so forth.
The most common endpoint determined by scientific studies is the recurrence of the pterygium, which is usually defined as a corneal recurrence that is evidenced by growth of fibrovascular tissue across the limbus onto the cornea. This usually excludes the persistence
Current Methods of Treatment
In an endeavor to give an overview of the existing literature, most of the recent articles (last 20 years) in the peer-reviewed English literature have been included in the following brief summaries of the different methods of treatment and are listed in the accompanying tables. It should be noted that where varying methods of treatment have been compared in a single study, the studies will be referred to more than once under the appropriate tables of the different individual methods of
Adjunctive Therapies
There are four principal adjunctive therapies that continue to gather active interest: beta irradiation postoperatively, thiotepa postoperatively, intraoperative mitomycin, and postoperative mitomycin.
Anesthesia
Although there is a common perception that pterygium surgery can be safely undertaken in the office, and although this provides an efficient time and cost basis under which to remove pterygia, it tends to prevent the maintenance of a sterile field and mitigates against an appropriate form of anesthesia, as will be discussed shortly.
If all that is to be undertaken is a stripping of the pterygium head and an excision with scissors, it can be fully understood how this might be performed under
Surgical Skills
In the past, pterygium has been treated as a relatively innocuous and frequently occurring disease which, if it required treatment, could be undertaken at the lowest level of expertise and at the simplest and easiest accessible location. In one series,126 this has meant that the training eye doctor in the first few weeks of training would be shown one method of removal and thereafter a clinic to treat subsequent pterygia would be undertaken by the training eye doctor in an outpatient setting.
Operative Complications
Operative complications during pterygium removal are extremely rare and interestingly are virtually not reported in any of the scientific literature. Therefore, the types of complications can only be mentioned in generalities. They including excessive thinning of the cornea during pterygium head removal, reversing the conjunctival autograft with the epithelial surface down, or reversal with respect to limbal edge to limbus. More serious complications are transection of the medial rectus,
Postoperative Complications
The principal complications of the treatment of pterygium are recurrence and visual disturbance or loss (Table 13).
As most methods of treatment will successfully, even if albeit temporarily, remove the pterygium, the recurrence of a pterygium is an undesirable result of surgery and must be considered a complication. Recurrences may be trivial or quite significant and yet few of the studies describe, or differentiate the type of recurrence. Recurrence of the pterygium where there is bunching of
Risk Factors for Recurrence
There have been virtually no studies that attempt to identify preoperative morphologic appearance, epidemologic status, or surgical factors that influence recurrence rate. This is an area which is desperately in need of research so that better counseling of patients preoperatively may be undertaken.
A description of the morphologic appearance of the pterygium prior to pterygium surgery has been studied as a correlate for recurrence.134
Prevention
No discussion of the treatment of pterygium would be complete without briefly mentioning the importance of prevention. There are many studies now that relate the association between UVB92, 125 exposure and the development of pterygium. Of greatest importance is the recent understanding that exposure to UVB in the first 10 years of life92 is critical in the later development of pterygium. Until there is a better understanding of the pathogenesis of pterygium and a uniformly effective method of
Discussion
There are a number of issues which can remain as questions with respect to the treatment of pterygium.
Summary
It would seem that one satisfactory method of removing pterygium, which has minimal complications and a very low recurrence rate, say less than 5%, that can deal with any form or grade of pterygium has not yet been identified. Follow-up of at least 1 year is required to identify at least 95% of all recurrences.66 Either additional controlled studies will need to be undertaken on the current methods of treatment and long-term follow-up applied to identify serious long-term complications, such as
Method of Literature Search
The Medline database was searched electronically for any article with pterygium in its title for the last 20 years. These were then manually searched for those with any relationship to treatment, using references in the English language only.
Outline
I. History of ptergium therapy
II. Indications for treatment
A. Reported indications
B. Problems to be resolved
III. Surgical outcomes
IV. Current methods of treatment
A. Bare scleral closure
B. Simple conjunctival closure
C. Sliding conjunctival flaps
D.
References (152)
Surgery of pterygium by conjunctival pedicle flap
Am J Ophthalmol
(1967)Surgery, thio-tepa, and corticosteroid in the treatment of pterygium
Am J Ophthalmol
(1972)- et al.
Postoperative beta radiation treatment of pterygium
Int J Radiat Oncol Biol Phys
(1983) - et al.
Precarved lyophilized tissue for lamellar keratoplasty in recurrent pterygium
Am J Ophthalmol
(1986) - et al.
Single intraoperative application versus postoperative mitomycin C eye drops in pterygium surgery
Ophthalmology
(1995) - et al.
A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium
Am J Ophthalmol
(1995) - et al.
Development of scleral ulceration and calcification after pterygium excision and mitomycin therapy
Am J Ophthalmol
(1991) - et al.
Beta irradiation of recurrent ptergiaresults and complications
Int J Radiat Oncol Biol Phys
(1992) - et al.
The use of low-dose mitomycin C for prevention of recurrent pterygium
Ophthalmology
(1994) - et al.
Intraoperative application of topical mitomycin C for pterygium surgery
Ophthalmology
(1996)
Limbal-conjunctival autograft transplantation for the treatment of recurrent pterygium
Ophthalmology
The management of pterygia. A third report on a combined surgical- irradiation technique
Am J Ophthalmol
Cataract formation following beta-ray radium therapy
Am J Ophthalmol
Pterygium recurrence time
Ophthalmology
A quantitative analysis of astigmatism induced by pterygium
J Biomech
Reirradiation for recurrent pterygia
Int J Radiat Oncol Biol Phys
Conjunctival rotation autograft for pterygium. An alternative to conjunctival autografting
Ophthalmology
Incidence of pterygium recurrence
Am J Ophthalmol
Conjunctival autograft transplantation for advanced and recurrent pterygium
Ophthalmology
A randomized trial of conjunctival autografting for pterygium in the tropics
Ophthalmology
Risk analysis in the development of pterygia
Ophthalmology
Sliding conjunctival flap for the treatment of primary pterygium
Ophthalmology
Triethylene thiophosphoramide. In the prevention of pterygium recurrence
Am J Ophthalmol
Treatment of pterygium in Lagos, Nigeria
East Afr Med J
Measures for preventing recurrence after pterygium surgery
Cornea
The use of postoperative beta radiation in the treatment of pterygia
Ophthalmic Surg
Pterygium excision with conjunctival autograftingan effective and safe technique
Br J Ophthalmol
Scleritis and Streptococcus pneumoniae
Cornea
Pterygium staging in the Caribbean
Ann Ophthalmol
Merest sclera technique for primary pterygium surgery
Ophthalmic Surg
Pterygiumclinical classification and management in Virgin Islands
Ann Ophthalmol
Pterygium in Ibadan
West Afr J Med
Scleral necrosis and infection 15 years following pterygium excision
Singapore Med J
Long-term complications of beta-radiation therapy in ophthalmology
Trans Am Ophthalmol Soc
Pterygiasingle-fraction postoperative beta irradiation
Radiology
Pterygium removalknife excision versus modified evulsion technique
Ophthalmic Surg
Pterygiumresection plus beta irradiation
Trans Ophthalmol Soc NZ
Pterygiumsurgery plus beta-irradiation
Trans Ophthalmol Soc Aust
Preventable complications of pterygium excision with beta-irradiation
Br J Ophthalmol
Beta-irradiation of pterygia. Comparison of different areas treated
Br J Ophthalmol
Recurrent pterygiaresults of postoperative treatment with Sr-90 applicators
Radiology
Prospective trial of intraoperative mitomycin C in the treatment of primary pterygium
Br J Ophthalmol
Radiation scleral necrosis simulating early scleromalacia perforans
Br J Ophthalmol
The inhibition of pterygium recurrence by thio-tepa
Am J Ophthalmol
Pterygium treatment with triethylene thiophosphoramide
Aust NZ J Ophthalmol
Postoperative mitomycin-C eye drop and beta radiation in the treatment of pterygia
J Med Assoc Thai
Treatment of pterygia with and without thiotepa
Trans Ophthalmol Soc NZ
Postoperative irradiation of pterygiaten more years of experience
Radiology
Beheading the pterygium
Ophthalmic Surg
The pathogenesis of pterygia
Curr Opin Ophthalmol
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The author reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.