What is the recommended treatment approach for a patient with pterygium?

Pterygium Treatment

Surgery is the definitive treatment for pterygium, with excision plus conjunctival autograft being the gold standard technique to minimize recurrence. 1, 2

Indications for Surgical Intervention

Surgical removal is indicated when pterygium causes:

• Visual impairment from extension onto the optical zone 1, 3
• Significant corneal astigmatism 1, 3
• Persistent ocular irritation despite conservative measures 3
• Cosmetic concerns affecting quality of life 1

Optimal Surgical Technique

The preferred surgical approach is pterygium excision with conjunctival autograft (CAU), which provides superior outcomes compared to other techniques. 2, 4

Technical Considerations:

• CAU is superior to amniotic membrane transplantation for both primary and recurrent pterygium 2, 4
• Rotational conjunctival flap offers shorter surgical time and prevents graft displacement due to its vascular pedicle 4
• Ensure adequate conjunctival graft size to prevent postoperative retraction 2
• Use thin conjunctival grafts with minimal Tenon tissue 2
• Fibrin glue reduces recurrence rates compared to sutures 2
• Amniotic membrane should be reserved for cases with large conjunctival defects or insufficient conjunctiva 4

Adjunctive Therapy to Prevent Recurrence

Mitomycin C (MMC) at 0.02% concentration applied for 15 seconds during surgery is the recommended adjuvant to prevent recurrence. 5, 2

Alternative Adjuvants:

• Topical cyclosporine combined with conjunctival autograft shows the best evidence for reducing recurrence 6
• Subconjunctival 5-fluorouracil (5-FU) injections are safe and effective for halting progression 2
• Anti-VEGF agents (bevacizumab) show temporary benefit but effects are not sustained 2
• Beta-irradiation can be used but carries risk of adverse effects 6, 3

Anesthesia Selection

Use topical anesthesia rather than retrobulbar anesthesia to reduce the risk of postoperative diplopia. 5

Critical Surgical Complications to Avoid

Ocular Motility Complications:

• Diplopia from medial rectus muscle damage or scarring 7, 5
• Exotropia from medial rectus damage 7, 5
• Esotropic restrictive strabismus from scarring 7, 5
• Ocular motility problems from florid scarring in recurrent cases 7, 5

Prevention Strategies:

• Meticulous surgical technique to avoid medial rectus injury 5
• Minimize excessive suturing 2
• Ensure adequate graft coverage without tension 2

Management of Recurrent Pterygium

For recurrent pterygium, perform excision with conjunctival autograft plus MMC as adjuvant therapy. 2

Non-Surgical Options for Early Recurrence:

• Multiple weekly subconjunctival 5-FU injections to halt progression 2
• Repeated anti-VEGF injections for impending recurrence (temporary effect) 2

Risk Factors for Recurrence

Patient-related factors:

• Dry eye disease 2
• Black race 2
• Young age 2
• Fleshy appearance of pterygium (controversial) 2

Surgical factors to avoid:

• Excessive suturing 2
• Insufficient conjunctival graft size 2
• Thick conjunctival graft with retained Tenon tissue 2
• Postoperative graft retraction 2

Timing of Recurrence

Most recurrences occur within the first 3-6 months postoperatively, though late recurrence can occur years later. 2