Pterygium

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Symptoms

  • May be asymptomatic or only cosmetically disturbing
  • Redness, foreign body sensation, change in refraction, visual impairment

Findings

  • Typically nasal (also temporal) fibrovascular tissue extending from conjunctiva to cornea
  • Punctate lesions of conjunctiva/cornea, adjacent corneal indentation, iron line (Stocker line)
  • Refraction: increased astigmatism

Differential Diagnoses

  • Carcinoma in situ (CIN): papillomatous, gelatinous, whitish tissue growth
  • Other conjunctival tumors
  • Pingueculum: limited to the conjunctiva, cornea not affected
  • Pannus

Work-up

  • Visual acuity and refraction: Astigmatism?
  • Slit lamp examination (how many mm from the limbus?), photodocumentation
    • Signs of malignancy? (Leukoplakia, gelatinous mass, papillomatous, prominent feeder vessels)
  • Is motility restricted?

Medical Treatment

  • UV protection, protection against wind and dust
  • Intensive lubrication with drops and ointments, especially if punctate epithelial keratoconjunctivitis or dellen is present
  • Red eye: FML Liquifilm gtt 4x/day for 2 weeks (no long-term therapy), alternatively Acular gtt (Ketorolac) 3-4x/day, in case of itching consider Zaditen SDU 2x daily

Surgery

  • Main indications:
    • Visual axis affected or endangered
    • Visual impairment due to pronounced astigmatism
    • Restricted motility
    • Suspected dysplasia/malignancy
    • Documented growth
  • Other indications:
    • Growth described by the patient
    • Severe complaints without improvement with drops
    • Cosmetically disturbing
    • Consider before cataract surgery
  • Operation: Pterygium excision with free conjunctival graft (+/- Mitomycin C / 5-FU)
  • Postoperative contact lens to reduce discomfort

Postoperative Management

  • Contact lens in place for 10-14 days
  • Tobrex gtt or Floxal UD 4x/day (at least as long as the contact lens)
  • Dexafree UD initially every 1-2 hours, then taper slowly
    • Treat for a minimum of 2-3 months, reduces recurrence rate!
  • Initial fixed pain medication (e.g., with paracetamol/ibuprofen)
  • Follow-ups after 1 day, (2 weeks), 1 month, 3 months, 1 year
    • Is the contact lens in place? Is the graft in place? Infections? Recurrences? Corneal ulcer? Intraocular pressure?

Sources

  • Hall AB. Understanding and managing pterygium. Community Eye Health. 2016;29(95):54-56.
  • EyeWiki Pterygium
  • The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
  • Kanski‚Äôs Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Edition (2015)