Dr. NIKITA JAISWAL

PTERYGIUM & IT’S MANAGEMENT

INTRODUCTION

ANATOMY

PATHOGENESIS

CLASSIFICATION

MANAGEMENT

GLOSSARY

Pronounced as (tur-IJ-ee-um)Also known as: surfer’s eye or farmer’s eye

Derived from geek word ‘pteryx’ meaning little wing

Pterygium is a wing shaped or triangular shaped growth of conjunctiva & fibrovascular tissue on the superficial cornea.

INTRODUCTION

UV radiations--- exposure to these rays results into induction of mediators for growth of pterygium.

`Point mutations of proto-oncogenes K-ras

Alterations in the expression of tumor suppresor genes as p53/p63

HPVDNA associationsOverexpression of various proteins as defensins & phospholipases

D.

IT’s A PROLIFERATIVE LESION RATHER THAN DEGENERATIVE CONDITION.

PATHOGENESIS

Degenerating collagen results in hyalinization of

the subepithelial C.T

It comprises of abnormal elastic fibres.

They take up stain but do not degrade with elastase &

thus it is called elastotic.

HISTOPATHOLOGY

SMALL ARE ASYMPTOMATICIRRITATION

FOREIGN BODY SENSATIONCONGESTIONLACRIMATION

DRYNESSASTIGMATISM

CLINICAL FEATURES

Sunlight exposure

Hot & dry climate

Age related degeneration

hereditary

RISK FACTORS

Exposure to nasal side because of temporal

side obstruction due to nasal bridge.

Presence of longer lashes on the

temporal eyelid which is 2/3 rd times longer

than medial.

Tears travel to medial side from lateral side carrying dust particle

& irritating the conjuctiva .

SITE

CAP

HEAD

BODY

PARTS OF PTERYGIUM

Thick,fleshy

Prominent vascularity

Gradually increases in size

Progresses to central cornea

Presence of stockers line

Thin

Less vascularity

Regresses or becomes stationary

But it never disappears.

PROGRESSIVE ATROPHIC

TYPES

CLINICAL GRADING

TAN’s CLASSIFICATION

GRADING OF PTERYGIUM

GRADE 1: EXTENDS 2mm on the cornea

Grade 2: involves upto 4 mm of the cornea it can be primary or secondary.

TYPE 3: Encroaches more than 4mm of the cornea & it

can hamper visual axis.

T1 GRADE: Clearly visible episcleral vessels under the

pterygium

TAN’S CLASSIFICATION

T2 GRADE: partially visibility of the episcleral

vessels under the pterygium.

T3 GRADE: total obscured view of the episcleral

vessels under the pterygium.

CHARACTERS PTERYGIUM PSEUDOPTERYGIUM

AGE More common in older age groups

May be seen in any group

SITE 3’o clock to 9’o clock meridians

May appear anywhere on the cornea

LATERALITY bilateral Mostly unilateral

STAGES Progressive,reggresive or stationary

Always stationary

ETIOLOGY Degenerative processMay occur due to exposure to sunlight & dust

Inflammatory process2’ to chemical burns,trauma.

LIMBAL RELATIONS

Adhered to limbus Not adhered to limbus

ASSOCIATIONS pinguecula ------

MANAGEMENT

CONSERVATIVE MANAGEMENT

Asymptomatic, small pterygium can be left alone

Lubricating eyedrops

Sunglasses to prevent UV light exposure

Mild steroids if inflammation is there.

HAMPERING VISUAL FIELD

ASTIGMATISM

COSMETIC CONCERN

RECURRENCE

INDICATIONS FOR SURGERY

The primary aim is to:

EXCISION.

PREVENT ITS RECURRENCE.

SURGICAL MANAGEMENT

surgical

Excision

evulsionSuperficia

l keratecto

my

Closure methods

Bare scleral

Simple conjunctiv

al

Conjunctival

autografts

Lamellar corneal

transplants

BARE SCLERA

No sutures or fine, absorbable sutures used to appose conjunctiva to superficial sclera in front of

rectus tendon insertion

Leaves area of “bare sclera”Relatively high recurrence

rate

SIMPLE CLOSURE

Free edges of conjunctiva

opposed togetherindicated only if defect is very

small

ROTATIONAL FLAP CLOSURE

A U-shaped incision is made adjacent to the

wound to form tongue of conjunctiva that is rotated into place.

Grafted tissue should be approximately 0.5 – 1 mm larger than the

areaMost importantly

conjunctival tissue with only minimal or no

Tenon’s. conjunctival autograft can be attached with sutures, fibrin glue,

elctrocautery or autologous blood

CONJUNCTIVAL GRAFT CLOSURE

10- nylon or 8-0 vicryl interrupted sutures are used to anchor the graft

FIBRIN GLUE

LIMBAL CONJUNCTIVAL AUTOGRAFTS

It has been suggested that including the limbal stem cells in the conjunctival

autograft may act as a barrier to conjunctival cells migrating onto the corneal

surface and help prevent recurrence.

The limbal- conjuntival graft includes approximately 0.5mm of the limbus and the

peripheral cornea.This method is more demanding and time

consuming to perform

AMNIOTIC MEMBRANES

Useful for very large conjunctival defects as in primary double-headed pterygium

Amniotic membrane posseses antiscarring, antiangiogenic and anti-inflammatory properties, which may be useful for treating pterygium

This method minimizes the risk of iatrogenic injury to the rest of the conjunctiva surface

It requires costly donor tissue

Intraoperative mitomycin application(0.2mg/ml for 3 minutes)

Postoperative mitomycin(0.4 or 0.2mg/ml four times daily for 4-14 days)

Post operative Thiotepa drops(1:2000 3 hourly for 6 weeks)

Post operative beta irradiation (15 Gy in either single or divided doses)

ADJUNCT -THERAPY

Corneal/scleral following extensive dissection

Medial rectus muscle injury

Bleeding

Globe perforation

Damage to canalicular system

RecurrenceNecrosis

EndophthalmitisScleritisKeratitis

Pyogenic granulomaDellen

Persistent epithelial defect

INTRA-OPERATIVE POST-OPERATIVE

COMPLICATIONS

PINGUECULA

DIFFERENTIAL DIAGNOSIS

LIMBAL DERMOID

OSNN

NODULAR EPISCLERITIS

THANK YOU