What are the indications for observation versus surgical excision of pterygium, and what are the preferred surgical techniques and postoperative management?

Pterygium Management: Indications and Surgical Approach

Indications for Surgery vs Observation

Surgical excision should be performed when pterygium causes reduced visual acuity, progressive astigmatism, impending invasion of the optical axis, or significant ocular surface complaints. 1

Observe if:

• Asymptomatic and not progressing 2
• No visual axis involvement 1
• Minimal cosmetic concern 2
• No significant corneal astigmatism 1

Operate if:

• Visual acuity is compromised 1
• Progressive astigmatism develops 1
• Growth threatens or involves the optical zone 2, 1
• Significant ocular surface symptoms (burning, itching, tearing, irritation) 2, 3
• Cosmetic concerns are substantial 3

Preferred Surgical Technique

Pterygium excision combined with free conjunctival autograft is the preferred surgical technique to minimize recurrence. 1, 4

Technical Approach:

• Avoid bare sclera excision alone due to high recurrence rates 5, 3
• Conjunctival autografting is the most commonly used and effective method for preventing recurrence 5, 4
• Modified bare sclera techniques with conjunctival flap transposition are acceptable alternatives 2
• Amniotic membrane transplantation can be considered 2, 3
• Peripheral lamellar keratoplasty for cases with significant corneal ingrowth 2

Anesthetic Considerations:

• Use topical anesthesia rather than retrobulbar anesthesia to reduce the risk of postoperative diplopia 6

Adjunctive Therapies

Mitomycin-C (MMC) at 0.02% concentration for 15 seconds is the standard adjunctive therapy when indicated, though it should be used judiciously. 7, 6

When to Consider Adjunctive Therapy:

• Recurrent pterygium 5
• High-risk cases 5
• Primary pterygium with aggressive features 2

Available Options:

• Mitomycin-C 0.02% (0.2 mg/ml) for 15 seconds is most commonly used 7, 6
• Topical cyclosporine with conjunctival autograft shows excellent results in reducing recurrence 4
• 5-fluorouracil (5-FU) 2, 3, 4
• Beta-irradiation (use with extreme caution due to sight-threatening complications) 5, 3
• VEGF inhibitors (Avastin) 3
• Topical interferons 3

Critical Caveat:

MMC and beta-irradiation carry potential long-term risk of sight-threatening complications and should be used judiciously. 5 The concentration and duration must be precisely controlled to avoid endothelial cell damage 7

Postoperative Management

Immediate Postoperative Care:

• Preservative-free artificial tears consistently 1
• Topical corticosteroids 1
• Topical antibiotics (surgeon discretion) 7
• NSAIDs may be considered 7

Long-term Management:

• Long-term UV protection is essential to prevent recurrence 1
• Regular follow-up to monitor for recurrence 6
• Early detection of recurrence allows for prompt intervention 2

Surgical Complications to Avoid

Motility Complications:

• Diplopia from medial rectus damage or scarring 8, 6
• Exotropia from medial rectus damage 8, 6
• Esotropic restrictive strabismus from scarring 8, 6
• Florid scarring with recurrence causing ocular motility problems 8, 6

Prevention Strategies:

• Careful surgical technique to avoid medial rectus injury 6
• Prefer topical over retrobulbar anesthesia 6
• Minimize aggressive tissue manipulation 2
• Prevent aggressive recurrence through optimal primary surgery 8

Key Clinical Pitfalls

• Do not perform bare sclera excision alone - this has unacceptably high recurrence rates 5, 3
• Do not use excessive MMC concentration or duration - risk of endothelial damage and other complications 7, 5
• Do not neglect postoperative UV protection counseling - UV exposure is the primary pathogenic factor 1
• Do not use retrobulbar anesthesia routinely - increases diplopia risk 6