Pterygium Management
For pterygium, begin with conservative management using ocular lubricants and UV protection; reserve surgical excision with conjunctival autograft for lesions causing visual impairment, significant astigmatism, or progressive growth toward the visual axis.
Conservative Management
Initial treatment focuses on symptom control and preventing progression:
Ocular lubrication is the cornerstone of conservative therapy, using artificial tears (carboxymethylcellulose 0.5-1%, carmellose sodium, or hyaluronic acid) applied as frequently as needed to address dry eye symptoms including burning, itching, and tearing 1, 2
UV protection is critical since ultraviolet radiation is the most important trigger for pterygium development; patients should wear wraparound sunglasses and avoid excessive sun exposure 2
Anti-inflammatory measures may help prevent progression from early conjunctival changes to established pterygium, though specific agents are not standardized 3
Topical corticosteroids can be considered for acute inflammation, though their role in long-term management is limited 1
Indications for Surgical Intervention
Surgery is indicated when conservative measures fail and specific criteria are met:
Visual compromise from the lesion approaching or encroaching on the optical zone 2, 4
Significant irregular astigmatism affecting visual quality 2
Progressive growth toward the visual axis despite conservative management 2
Persistent symptoms (foreign body sensation, redness, irritation) unresponsive to medical therapy 2
Cosmetic concerns in select cases, though this is a secondary consideration 4
Surgical Technique
Conjunctival autograft is the preferred surgical approach:
Pterygium excision with conjunctival autograft is the gold standard technique, offering superior recurrence rates compared to bare sclera excision 4
Bare sclera excision alone should be avoided due to recurrence rates of 30-89% 4, 5
Modified techniques include transposition of conjunctival flap, amniotic membrane transplantation, or peripheral lamellar keratoplasty for extensive corneal involvement 2
Surgical plane identification is facilitated by passing instruments under the neck of the pterygium, though not at the apex where tissue is more adherent 3
Adjunctive Anti-Recurrence Therapy
Additional measures to prevent recurrence should be used judiciously:
Mitomycin C application is one of the most commonly used adjunctive therapies but carries risk of sight-threatening complications including scleral thinning, ulceration, and infections; use with extreme caution 4, 5
Beta-irradiation using strontium-90 applicators at 30 Gy in three fractions over 2-3 weeks starting within 24 hours post-surgery achieves recurrence rates below 15%, though long-term complications including radiation-induced cataract are possible 5
Anti-VEGF agents (bevacizumab, ranibizumab) show promise for treating the neovascular component but remain investigational 6
5-fluorouracil is another option but shares similar safety concerns with mitomycin C 2
Critical Pitfalls to Avoid
Common errors that compromise outcomes:
Overly aggressive resection away from the cornea removes relatively normal conjunctiva unnecessarily, as the pathological tissue is primarily at the head of the pterygium 3
Premature surgery for asymptomatic lesions not threatening vision leads to unnecessary risk of recurrence and complications 2, 4
Indiscriminate use of mitomycin C or beta-irradiation without considering long-term safety risks can result in devastating complications including scleral perforation 4, 5
Failure to address underlying dry eye and UV exposure post-operatively increases recurrence risk 2, 3
Post-Operative Management
Careful follow-up is essential:
Topical antibiotics and corticosteroids should be used post-operatively with close monitoring for complications 7
Continued UV protection and ocular lubrication are mandatory to prevent recurrence 2
Long-term surveillance for recurrence, which typically occurs at the surgical site within the first year 4, 5