Treatment Options for Pterygium
Surgery is the definitive treatment for pterygium when it causes visual impairment, significant astigmatism, threatens the optical axis, or produces persistent ocular surface discomfort. 1, 2, 3
Indications for Surgical Intervention
Proceed with surgical excision when any of the following are present:
- Loss of visual acuity from corneal invasion 3
- Progressive or significant astigmatism affecting vision 1, 3
- Impending invasion of the optical axis (approaching or crossing the pupillary margin) 3
- Persistent ocular surface discomfort unresponsive to conservative measures 3
- Cosmetic concerns in conjunction with other symptoms 1
Optimal Surgical Technique
The preferred surgical approach combines pterygium excision with conjunctival autografting, as bare sclera excision alone carries unacceptably high recurrence rates. 4
Primary Surgical Options (in order of preference):
- Conjunctival autograft transplantation - Most commonly recommended technique with lower recurrence rates 1, 4
- Limbal conjunctival autograft - Particularly effective for preventing recurrence 1
- Amniotic membrane transplantation - Alternative when autograft tissue is limited 1, 2
- Free conjunctival autograft - Reduces recurrence risk 1
Avoid:
- Bare sclera technique alone - Associated with high recurrence rates and should not be used as monotherapy 4
Adjunctive Anti-Recurrence Therapies
Intraoperative mitomycin C (0.02% concentration for 15 seconds) is the most established adjunctive therapy to prevent recurrence. 5
Evidence-based adjunctive options:
- Mitomycin C (0.02%) applied intraoperatively for brief duration (e.g., 15 seconds) 5, 1, 2, 4
- 5-fluorouracil - Alternative antimetabolite 2, 4
- Beta-radiation - Use judiciously due to potential long-term complications 1, 4
- Anti-VEGF agents (bevacizumab/Avastin) - Emerging anti-angiogenic approach 1, 3
- Topical interferons - May reduce recurrence 1
Critical Safety Consideration:
Use mitomycin C and beta-radiation judiciously because of potential sight-threatening long-term complications. 4 The brief exposure time (15 seconds) minimizes toxicity while maintaining efficacy 5.
Anesthetic Choice to Minimize Complications
Use topical anesthesia rather than retrobulbar anesthesia to reduce the risk of postoperative diplopia. 6, 5
Retrobulbar or peribulbar anesthesia increases risk of:
- Anesthetic myotoxicity affecting extraocular muscles 7
- Postoperative diplopia from muscle damage 6, 5
Postoperative Management
Immediate postoperative period (1-2 weeks):
- Topical antibiotic-steroid combination (e.g., tobramycin/dexamethasone) for limited duration 8
- Limit steroid use to 1-2 weeks to minimize complications including elevated intraocular pressure and delayed wound healing 8
- Monitor intraocular pressure closely in patients with glaucoma risk 8
Long-term management:
- Preservative-free lubricants for ocular surface comfort 3
- UV protection (sunglasses, hats) to prevent recurrence - critical long-term measure 3
- Regular follow-up to detect early recurrence or complications 5
Potential Surgical Complications to Counsel Patients About
Diplopia from medial rectus damage or scarring is a recognized complication of pterygium surgery. 6, 5
Key complications include:
- Diplopia from medial rectus injury or scarring 6, 5
- Exotropia from medial rectus damage 6, 5
- Esotropic restrictive strabismus from scarring 6, 5
- Ocular motility problems from florid scarring with recurrence 6, 5
- Recurrence - the most common complication, reduced by proper technique and adjuvants 1, 2, 4
Conservative Management (Non-Surgical)
For asymptomatic or minimally symptomatic pterygium not meeting surgical criteria:
- Observation with regular monitoring 1, 2
- Preservative-free lubricants for dry eye symptoms 3
- UV protection to slow progression 2, 3
- Anti-inflammatory measures may prevent progression 9
Common Pitfall to Avoid:
Do not delay surgery once visual axis is threatened or significant astigmatism develops, as recurrent pterygium after multiple surgeries becomes more aggressive and difficult to manage 2.