What are the treatment options for pterygium?

Treatment Options for Pterygium

Surgery is the main treatment for pterygium, with conjunctival autografting being the preferred surgical technique due to its lower recurrence rate compared to other methods. 1

Non-Surgical Management

For early or asymptomatic pterygium, conservative management may be appropriate:

• Lubricating eye drops/artificial tears: Help manage mild symptoms of irritation and dryness
• UV protection: Sunglasses to prevent progression
• Topical anti-inflammatory medications: For temporary relief of inflammation

Surgical Management

Surgery is indicated when the pterygium:

• Causes visual disturbance (astigmatism or encroachment on visual axis)
• Produces significant discomfort
• Grows rapidly
• Creates cosmetic concerns
• Limits ocular motility

Surgical Techniques (in order of preference)

1. Conjunctival Autograft

   • Involves excision of pterygium followed by transplantation of patient's own conjunctival tissue
   • Lowest recurrence rate among surgical techniques
   • Can be secured with sutures or tissue adhesives

2. Amniotic Membrane Graft

   • Alternative when conjunctival tissue is limited
   • Provides good coverage and healing properties

3. Limbal Conjunctival Autograft

   • Includes limbal stem cells which may help prevent recurrence
   • Particularly useful for recurrent cases

4. Rotational Conjunctival Flap

   • Uses adjacent conjunctiva to cover the defect
   • Moderate recurrence rates

5. Bare Sclera Technique

   • Simple excision without grafting
   • Highest recurrence rate (not recommended without adjunctive therapy)

Adjunctive Therapies

These are used to reduce recurrence rates following surgery:

• Mitomycin C (MMC)

  • Applied intraoperatively (0.02% for 15-60 seconds)
  • Significantly reduces recurrence rates 2
  • Caution: Potential complications include delayed epithelialization, scleral thinning, and corneal perforation

• 5-Fluorouracil

  • Alternative antimetabolite
  • Lower risk profile than MMC but possibly less effective

• Topical corticosteroids

  • Used postoperatively to reduce inflammation
  • Typically administered for 1-3 months with tapering

• Anti-VEGF agents (e.g., bevacizumab)

  • Emerging adjunctive therapy
  • May reduce vascularization and recurrence

Recurrent Pterygium

For recurrent cases, management is more challenging:

1. Conjunctival autograft with MMC is the preferred approach
2. Amniotic membrane transplantation with MMC
3. P.E.R.F.E.C.T. technique (Pterygium Extended Removal Followed by Extended Conjunctival Transplantation)

Postoperative Care

• Topical antibiotics for 1-2 weeks
• Topical corticosteroids with tapering schedule over 1-3 months
• Regular follow-up to monitor for recurrence
• UV protection with sunglasses

Complications to Monitor

• Recurrence (most common complication)
• Graft dehiscence or failure
• Corneal dellen (thinning)
• Scleral thinning (with MMC)
• Infection
• Granuloma formation
• Corneal scarring

Clinical Decision Algorithm

1. Asymptomatic, non-progressive pterygium: Observation, UV protection, lubricants
2. Symptomatic or progressive pterygium: Surgical excision with conjunctival autograft
3. High risk for recurrence (young age, fleshy pterygium, previous recurrence): Add adjunctive MMC
4. Recurrent pterygium: Conjunctival autograft with MMC or amniotic membrane with MMC

The recurrence rate with bare sclera technique alone is unacceptably high (up to 88.9%), while conjunctival autografting with or without MMC reduces this to approximately 2-15% 3, 1.