Date post: | 12-Apr-2017 |
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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