From the EDITOR   As we all know, pterygia are especially common in sunny, dry climates and can range from a mild nuisance to a significant source of ocular irritation and visual distortion. In this issue, my colleague Matthew Wojcik reviews their clinical impact, current surgical techniques, and what to expect during the post-operative course. He also highlights how pterygium removal can optimize corneal measurements prior to cataract surgery.

By Matthew Wojcik, OD   |  PCLI—Yakima, wa

A pterygium is a common fibrovascular growth of the bulbar conjunctiva that extends over the limbus and onto the corneal surface. Globally, it affects an estimated 12% of the population, although prevalence varies significantly by geography. UV exposure is considered the primary risk factor, so pterygia are seen more frequently in sunny climates and areas closer to the equator.

Regional Prevalence

The PCLI site where I practice is located in the Yakima Valley of central Washington, in the rain shadow of the Cascade Mountains. We enjoy abundant year-round sunshine, and many of our patients work in agriculture and spend long hours outdoors. As a result, clinically significant pterygia are a routine part of our practice.

Symptoms and Clinical Impact

Pterygia can produce a wide range of symptoms, and treatment depends largely on severity. Most patients experience mild to moderate discomfort, redness, foreign body sensation, or dryness and can be managed successfully with lubricating drops and anti-inflammatory agents.

Others develop more significant discomfort that interferes with daily activities and ultimately leads to surgical referral. In some cases, pterygia can grow large enough to affect vision by inducing significant irregular astigmatism and hyperopia. In these cases, pterygium removal is recommended to improve the patient’s acuity and, hopefully, prevent permanent reduction in visual quality from corneal scarring or irregular astigmatism.

Pterygia can also complicate cataract surgery planning. Patients with corneal distortion often have unreliable keratometry and topography measurements. In patients considering premium IOLs, I frequently recommend pterygium removal before cataract surgery so the cornea can stabilize and provide more accurate measurements.

Surgical Techniques

Numerous surgical techniques are used today, all designed to remove the pterygium while minimizing recurrence. Recurrence rates in the literature vary widely due to surgical technique, surgeon experience, UV exposure, and the severity of the lesion.

The bare sclera technique is an older method that is not frequently used because it is associated with higher recurrence rates. Standard techniques generally involve covering the exposed scleral bed with tissue after excision.

The most common approach is a conjunctival autograft, in which the patient’s own conjunctival tissue is used to cover the exposed scleral bed following pterygium removal. However, in cases involving larger pterygia, insufficient conjunctival tissue, or other surgical considerations, an amniotic membrane graft may be used as an alternative. At our Yakima facility, conjunctival autografting is used in the majority of cases.

Autograft Technique

Pterygium excision with conjunctival autografting is a fairly straightforward stepwise procedure.

• First, the pterygium is excised. Then the autograft is prepared, obtained, and placed over the exposed scleral bed. Most surgeons harvest the graft from the superior conjunctiva because it generally provides excellent cosmesis and favorable healing characteristics.
• The autograft is secured to the scleral bed with tissue glue or suturing, depending on the surgeon’s preference.
• In select patients, mitomycin C is applied to the scleral bed before graft placement, particularly in eyes with aggressive or recurrent disease.
• A corneal epithelial defect is present after surgery, corresponding to the size of the pterygium that was removed.

Post-op Expectations

The post-op course for uncomplicated pterygium surgery is usually routine. Most patients are seen at 1 day, 1 week, and 1 month, and remain on topical steroid therapy for approximately 6 weeks.

Day 1 — I evaluate the position of the graft and ensure the edges of the epithelial defect are smooth and healing appropriately. Although the ocular surface appearance can look dramatic at this stage, most patients report less discomfort than they anticipated. Bandage contact lenses are not routinely used but may be considered in select circumstances, and OTC analgesics can be used. If patients do experience significant discomfort, I reassure them that this is typically temporary and improves as the ocular surface heals. Topical antibiotics and steroids are initiated four times daily and continued until the next follow-up visit.

Week 1 — The corneal epithelium should be intact, with symptoms and discomfort substantially improved. At this stage, I check for corneal dellen formation and epithelial defects. If either is present, I place a bandage contact lens to promote healing. If the epithelium is closed, topical antibiotics are discontinued.

If the graft looks thin, is well-positioned, and the harvest site is healing, I prescribe FML for use once prednisolone acetate is finished. If there is graft edema, I typically prescribe a prednisolone refill instead. It is rare that patients develop persistent epithelial defects, dellen, or scleral melt that require more frequent follow-up.

Month 1 — For most patients, this is the final visit before returning to their referring provider. I look for early signs of recurrence and confirm that they are satisfied with comfort and the cosmetic outcome. Patients generally continue topical steroids for another two weeks before discontinuing them entirely.

If elevated IOP needs to be managed or there is evidence of an early recurrence, I schedule an additional follow-up visit. With recurrence, a longer course of steroid therapy can be trialed, but some cases ultimately require repeat surgery.

Conclusion

Pterygium surgery can significantly improve ocular comfort, reduce chronic inflammation, and improve visual quality in patients with advanced disease. The procedure is available at all PCLI locations. Conjunctival autografting provides excellent cosmetic outcomes and relatively low recurrence rates. For most patients, post-op management is straightforward, complications are uncommon, and recovery is very manageable.

Questions If you have questions, feel free to contact any of our optometric physicians. We’re always happy to help.