Update on Pterygium Therapy

Jay C. Bradley, MD
David L. McCartney, MD
January Grand Rounds
From the BCSC: Basics
Often bilateral
Almost always situated at the nasal or temporal
limbus within palpebral fissure
Associated with prolonged UV exposure
UV-B limbal stem cell p53 mutation apoptosis / TGF- growth

May be associated with dryness, inflammation,
and exposure to wind and dust or other irritants
Prevalence increases with proximity to equator
Difficult to determine if race is independent risk
factor due to confounding variables
Albedo Hypothesis
Researcher: MT Coroneo (Australia)
Pterygia occur secondary to albedo concentration
in the anterior eye
Light entering the temporal limbus at 90 degrees is
concentrated onto the medial limbus
Related to corneal curvature
Explains predominance of medial pterygia

Ophthalmic surg. 1990 Jan;21(1):60-6.
From BCSC: Basics
Encroaches on cornea in wing-like fashion
Overlying epithelium often thinned, but can be
hyperplastic or dysplastic
Nearly always preceded by pingueculae
Induces astigmatism (usually with-the-rule)
proportional to size
Excision indicated if persistent irritation, vision
distortion, significant (> 3-4 mm) and progressive
growth toward visual axis, restricted ocular
motility, and atypical appearance
From the BCSC: Basics
Elastotic degeneration fragmentation and
breakdown of stromal collagen





Destruction of Bowmans layer by advancing
fibrovascular tissue resulting in corneal scarring
From BCSC: Basics
Recurrent pterygia lack elastotic degeneration
and are more accurately classified as an exuberant
granulation tissue response
Stockers line a pigmented iron line in advance
of pterygium
Pterygium Excision
Goal: Achieve a normal, topographically smooth
ocular surface
Dissect a smooth plane toward the limbus
Some surgeons prefer specialized blunt pterygium
blades (Tooke or Gills) while others prefer sharp
blades
Preferable to dissect down to bare sclera at limbus
Bare sclera = remove loose Tenons layer and
leave episcleral vessels intact
Some surgeons avoid medial dissection to avoid
bleeding from trauma to adjacent muscle tissue
while other remove excessive fibrovascular tissue
medially
Light thermal cautery is applied for hemostasis


Pterygium Recurrence
Growth of fibrovascular tissue across the limbus
onto cornea after initial removal
Excludes persistence of deeper corneal vessels and
scarring which may remain even after adequate
removal
Bunching of conjunctiva and formation of parallel
loops of vessels, which aim almost like an
arrowhead at the limbus, usually denotes a
conjunctival recurrence
Proposed Recurrence Grading
System
Grade 1 normal appearing
operative site
Grade 2 fine episcleral
vessels in the site extending
to the limbus
Grade 3 additional fibrous
tissues in site
Grade 4 actual corneal
recurrence
Wound Closure Options:
Bare sclera
Simple closure
Sliding flap
Rotational flap
Conjunctival graft
Bare Sclera Closure
No sutures or fine, absorbable
sutures used to appose
conjunctiva to superficial
sclera in front of rectus
tendon insertion
Leaves area of bare sclera
Relatively high recurrence
rate with variable techniques
of 5 68 % with primary / 35
82 % with recurrent)
Simple Closure
Free edges of conjunctiva
secured together
Effective only if defect is very
small
Can be used for pingueculae
removal
Reported recurrence rates
from 45 69 % (one report of
barest sclera, N=800 of 2 %)
Few complications (dellen)

Sliding Flap Closure
An L-shaped incision is made
adjacent to the wound to allow
conjunctival flap to slide into
place
Reported recurrence rates from
0.75 5.6 % (poorly designed,
retrospective)
Few complications (flap
retraction / cyst formation)
Rotational Flap Closure
A U-shaped incision is made
adjacent to the wound to form
tongue of conjunctiva that is
rotated into place
Reported recurrence of 4 %
Few complications
Conjunctival Graft Closure
A free graft, usually from
superior bulbar conjunctiva,
is excised to correspond to
wound and is then moved
and sutured into place
Can be performed with
inferior conjunctiva to
preserve superior
conjunctiva
Harvested tissue should be approximately 0.5 1
mm larger than defect
Most important aspect in harvesting is to procure
conjunctival tissue with only minimal or no
Tenons included
Graft is transferred to recipient bed and secured
with or without incorporating episclera
Some surgeons harvest limbal stem cells along
with graft and orient graft to place stem cells
adjacent to site of corneal lesion excision
Conjunctival Graft Closure
Conjunctival Graft Closure
Topical antibiotic-corticosteroid ointment used for
4 6 weeks post-operatively until inflammation
subsides (compliance with this regimen decreases
recurrence)
Used when extensive damage or destruction of
limbal epithelial stem cells is NOT present
Reduces recurrence to 2 5 % (up to 40 % in
some reports)
Ameliorates the restriction of extraocular muscle
function
Limbal Conjunctival Autograft
Reported recurrence rates are variable (between 0
40 %)
Few complications
Further prospective studies in primary and
recurrent pterygia are needed
Lamellar Corneal Transplant
Wound closed with piece of lamellar sclera or
cornea
Reported recurrence rates of 6 30 %
Not performed often
Can be used in conjunction with AMT for
multiply recurrent pterygia with corneal scarring
and limited available conjunctiva
Method involves increased surgical complexity,
the requirement of donor tissue, and risk of
infectious disease transmission

Adjunctive Beta Irradiation
Most common dosage is 15 Gy in single or
divided doses
Reasonably acceptable recurrence rates
(from 0 50 % with bare sclera or simple
conj closure)
Risk of corneal or scleral necrosis and
endophthalmitis
Adjunctive Thiotepa
Most common dose is 1:2000 thiotepa given
up to every 3 hours for approx. 6 weeks
Usually used with bare sclera method
Low reported recurrence rates of 0 16 %
(poor study quality)
Minimal complications (2 cases of scleral
thinning)
Adjunctive Mitomycin C
Used with bare sclera or conj closure
Most common dose is 0.02 % applied for 3 min
during surgery
Risk of aseptic scleral necrosis / perforation and
infectious sclerokeratitis
Used more often for recurrent cases
Rate of recurrence between 3 25 % for intra-op /
5 54 % for post-op with most studies showing <
10 % recurrence
Amniotic Membrane Graft
Closure
Useful for very large conjunctival
defects as in primary double-
headed pterygium or to preserve
superior conjunctiva for future
glaucoma surgeries
Requires costly donor tissue
Reported recurrence rate between
3 64 % for primary cases and 0
37.5 % for recurrent cases

Other Methods:
Pterygium head transplantation
Split skin grafts
Ruthenium adjunctive therapy
Laser or thermal cautery
Excimer laser treatment
PDT (one report, N = 10)
Intraoperative doxorubicin / daunorubicin
5-FU
Serum-free derived cultivated conjunctival graft
Recombinant epidermal growth factor
****Few studies with limited numbers of
patients, poor follow-up, and variable
recurrence rates
Primary Pterygium
Metanalysis
Includes 5 studies with N=290 (BS+Mito=257/CAG=33)

Comparison Odds Ratio 95 % CI

Bare sclera: mito C 25:1 9.0 66.7
Bare sclera: CAG 6:1 1.8 18.8
Sanchez-Thorin JC et al. Br J Ophthalmol 82:661-5, 1998.
Conclusions:
There is no clear-cut superior single treatment
Bare scleral and simple conjunctival closure without
adjunctive therapy have relatively high but variable
recurrence rates
Use of beta irradiation and antimetabolites can be
used with appropriate caution
Conjunctival transplants and flaps appear to have
overall lower rate of recurrence but require more
surgical time and unnecessary conj destruction
Other treatment options need further adequate study
prior to widespread implementation
Any Questions?