Treatment of Pterygium
Surgery is the definitive treatment for pterygium when it causes visual impairment, significant astigmatism, threatens the optical axis, or causes persistent ocular surface discomfort. 1, 2, 3
Indications for Surgical Intervention
Surgical removal is indicated when pterygium causes: 3, 4
- Loss of visual acuity from encroachment on the visual axis
- Increasing corneal astigmatism affecting vision quality
- Impending invasion of the optical axis (even before visual symptoms)
- Persistent ocular surface discomfort unresponsive to conservative measures
Optimal Surgical Technique
The bare sclera excision technique alone is no longer acceptable due to unacceptably high recurrence rates. 1, 5 Modern pterygium surgery must combine excision with adjunctive measures to prevent recurrence.
Recommended Surgical Approaches:
Conjunctival autografting is the most commonly used and effective method for preventing recurrences. 1, 2 The surgical options in order of preference include:
- Limbal conjunctival autograft - preferred technique 2
- Free conjunctival autograft - highly effective alternative 2, 4
- Amniotic membrane transplantation - when autograft unavailable 2, 3
- Rotational conjunctival flap - alternative coverage method 2
- Peripheral lamellar keratoplasty - reserved for cases with significant corneal ingrowth 3
Adjunctive Anti-Recurrence Therapy
Mitomycin C at 0.02% concentration (0.2 mg/ml) applied for brief periods (e.g., 15 seconds) during surgery effectively prevents recurrence. 6 However, use it judiciously due to potential sight-threatening complications with long-term exposure. 1
Additional adjunctive options include: 2, 3
- 5-fluorouracil - alternative antimetabolite
- Beta-radiation - use with extreme caution due to long-term complication risks 1
- Topical interferons - emerging option
- Anti-VEGF agents (Avastin) - novel anti-angiogenic approach 2, 4
Critical Caveat on Antimetabolites:
Both mitomycin C and beta-irradiation carry risks of serious long-term sight-threatening complications and should be used judiciously. 1 The decision to use these agents must weigh recurrence risk against complication potential.
Anesthetic Considerations
Use topical anesthesia rather than retrobulbar anesthesia to reduce the risk of postoperative diplopia. 6 Retrobulbar blocks increase diplopia risk compared to topical techniques. 7
Postoperative Management
Following pterygium surgery, implement this regimen: 8, 4
- Topical steroid-antibiotic combination (e.g., Tobradex) for 1-2 weeks to prevent infection and control inflammation 8
- Preservative-free lubricants for long-term ocular surface comfort 4
- Monitor intraocular pressure if using steroids, especially in glaucoma patients 8
- Limit steroid duration to minimize complications including elevated IOP, cataract formation, and delayed wound healing 8
Important Warning:
Prolonged topical antibiotic use promotes resistant organism growth; limit duration appropriately. 8
Potential Surgical Complications
Be aware of these specific complications: 7, 6
- Diplopia from medial rectus muscle damage or scarring - most common motility complication
- Exotropia from direct medial rectus damage during excision
- Esotropic restrictive strabismus from excessive scarring
- Ocular motility problems from florid scarring with recurrence
Careful surgical technique minimizing medial rectus manipulation is essential to prevent these complications. 6
Long-Term Prevention Strategy
After successful surgery, patients require: 4
- Long-term UV protection with wraparound sunglasses - addresses primary etiology
- Regular follow-up to detect early recurrence
- Continued preservative-free lubrication for ocular surface health
Conservative Management (Non-Surgical)
For early, asymptomatic pterygium not meeting surgical criteria: 3
- Observation with UV protection
- Preservative-free artificial tears for dry eye symptoms (burning, itching, tearing)
- Topical lubricants for ocular surface discomfort
However, once visual symptoms or significant growth occurs, delaying surgery risks more aggressive recurrence requiring repeated interventions. 3