Elsevier

Survey of Ophthalmology

Volume 48, Issue 2, March–April 2003, Pages 145-180
Survey of Ophthalmology

Major review
The Treatment Of Pterygium

https://doi.org/10.1016/S0039-6257(02)00463-0Get rights and content

Abstract

The treatment of pterygium is still quite controversial, with various treatments being advocated in the scientific literature. Unfortunately, there are very few well-conducted controlled clinical trials of treatments. However, years of anecdotal and noncontrolled studies have confirmed that some methods, such as bare scleral closure, are no longer acceptable in the treatment of pterygium and that other methods are likely to be more useful. In the future it will be important to develop a grading system, and surgeons will need to be conservative in the treatment of pterygium until such time as a single treatment provides a lower recurrence rate and complication rate.

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.

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    The author reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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