What are the treatment options for pterygium?

Treatment Options for Pterygium

Surgical excision with conjunctival autografting is the recommended treatment for pterygium that threatens or affects the visual axis, causes significant astigmatism, or is cosmetically concerning. 1

Understanding Pterygium

Pterygium is a wing-shaped, fleshy, vascularized growth on the conjunctiva that can progressively grow toward the visual axis and affect vision. Unlike pinguecula (a yellowish, non-vascular lesion), pterygium often requires intervention due to its potential to affect visual function 1.

Treatment Algorithm

Conservative Management

• For small, non-progressive pterygium with minimal symptoms:
  • Artificial tears for lubrication
  • Topical anti-inflammatory drops (e.g., indomethacin 0.1%)
  • UV protection with sunglasses

Surgical Intervention

Indications for surgery include:

• Pterygium threatening or affecting the visual axis
• Significant astigmatism caused by pterygium
• Cosmetic concerns
• Persistent irritation unresponsive to conservative measures

Surgical Techniques (in order of effectiveness)

1. Conjunctival Autografting (preferred method)

   • Involves excision of pterygium followed by transplantation of patient's own conjunctival tissue
   • Lowest recurrence rates (5-10%)
   • Best cosmetic outcome

2. Amniotic Membrane Grafting

   • Alternative when conjunctival tissue is limited
   • Moderate recurrence rates

3. Bare Sclera Technique

   • Not recommended as standalone procedure
   • High recurrence rates (30-89%)

Adjunctive Therapies to Reduce Recurrence

• Mitomycin C (MMC)

  • Applied intraoperatively (0.02% for 15-60 seconds)
  • Reduces recurrence rates significantly
  • Caution: potential for delayed complications (scleral thinning)

• 5-Fluorouracil

  • Alternative to MMC
  • Lower risk profile but possibly less effective

• Anti-VEGF Agents

  • Emerging adjunctive therapy
  • May reduce vascularization and recurrence

• Beta-irradiation

  • Typically 30 Gy in three fractions within 24 hours of surgery
  • Effective but less commonly used due to specialized equipment requirements
  • Recurrence rates below 15% 2

Important Considerations

• Recurrence Prevention: Recurrence is the most common complication after pterygium surgery, with rates varying by technique 1
• Risk Factors: Chronic UV radiation exposure, dry/dusty environments, and ocular surface inflammation increase risk 1
• Complications: Potential complications include diplopia due to scarring or injury to the medial rectus, corneal scarring, and infection 1
• Postoperative Care: Typically includes topical antibiotics, corticosteroids, and regular follow-up to monitor for recurrence

Special Situations

• Recurrent Pterygium: More aggressive with higher recurrence rates

  • Consider combination approaches (conjunctival autograft + MMC)
  • More extensive surgical planning required

• Large Pterygium: May require more extensive grafting

  • Consider amniotic membrane if conjunctival tissue is limited

The choice of surgical technique and adjunctive therapy should be based on pterygium size, location, and risk factors for recurrence. Conjunctival autografting remains the gold standard with the lowest recurrence rates and best cosmetic outcomes 1, 3.