WHAT IS A PTERYGIUM?
Pterygium refers to any wing-like triangular membrane occurring in the neck, eyes, knees, elbows, ankles or digits. The term comes from the Greek word pterygion meaning “little wing”. From this was derived the Latin “pteryx” which means “winged one”. First recorded use was 1562.
Pterygium (pronounced tur-IJ-ee-um) is a growth on the cornea (the clear front window of the eye) and the conjunctiva – the thin, filmy membrane that covers the white part of your eye (sclera). These growths are caused by dry eye, exposure to wind and dust, smoke, heat (industrial workers who work in furnaces, or welders) and UV (ultra-violet) exposure. For this reason, a pterygium is often called “a surfer’s eye.”
A pterigium usually grows on the nasal side of the eye, but can also grow on the lateral side and, in some patients, tends to be so extensive as to seem like it is growing from all directions! The reason why it is most often seen on the nasal aspect is thought to be because light reflects from the nose onto this surface and also because light from the lateral aspect passes through the cornea and is focused onto this area! In other words, this area gets more sun damage (and wind damage) than the lateral side.
A pingueculum is the early stage of damage to the conjunctiva when the growth is confined to the conjunctiva. Once it affects or crosses the limbus (the edge of the cornea), it is called a pterygium.
Pterygia are more common in men than ladies, and are seen more often the closer one is to the equator or to sunny and windy climates.
WHAT SYMPTOMS DOES A PTERYGIUM CAUSE?
In the early stages, pterygia may not cause any problems other than being visible as a red, elevated growth, oftenon the inner aspect of the white part of the eye. As they progress, patients may develop, increased redness, dryness, irritation and blurry or fluctuating vision. Patients who wear contact lenses may have difficulty comfortably wearing the lens.
(ADVANCED) INFORMATION ON PTERYGIA FOR RESIDENTS/FELLOWS/SURGEONS/INTERESTED PATIENTS!
Pterygium in the conjunctiva is characterized by elastotic degeneration of collagen (actinic elastosis) and fibrovascular proliferation. It has an advancing portion called the head of the pterygium, which is connected to the main body of the pterygium by the neck. Sometimes a line of iron deposition can be seen adjacent to the head of the pterygium called Stocker’s line. The location of the line can give an indication of the pattern of growth.
The predominance of pterygia on the nasal side is possibly a result of the sun’s rays passing laterally through the cornea, where it undergoes refraction and becomes focused on the limbic area. Sunlight passes unobstructed from the lateral side of the eye, focusing on the medial limbus after passing through the cornea. On the contralateral (medial) side, however, the shadow of the nose medially reduces the intensity of sunlight focused on the lateral/temporal limbus.
Some research also suggests a genetic predisposition due to an expression of vimentin, which indicates cellular migration by the keratoblasts embryological development, which are the cells that give rise to the layers of the cornea. Supporting this fact is the congenital pterygium, in which pterygium is seen in infants. These cells also exhibit an increased P53 expression likely due to a deficit in the tumor suppressor gene. These indications give the impression of a migrating limbus because the cellular origin of the pterygium is actually initiated by the limbal epithelium.
The pterygium is composed of several segments:
- Fuchs’ Patches (minute gray blemishes that disperse near the pterygium head)
- Stocker’s Line (a brownish line composed of iron deposits)
- Hood (fibrous nonvascular portion of the pterygium)
- Head (apex of the pterygium, typically raised and highly vascular)
- Body (fleshy elevated portion congested with tortuous vessels)
- Superior Edge (upper edge of the triangular or wing-shaped portion of the pterygium)
- Inferior Edge (lower edge of the triangular or wing-shaped portion of the pterygium).
“Well, the last time I had a picture taken I could hardly see my eyes because of the weight of heavy eyelid. Then I paid attention to how I was actually using my eyes and I really noticed when I was looking at anything especially the computer I was straining my forehead to see better. Since I have had it done I no longer have to lift the forehead and tilt my head to see. It is amazing! I love…” D. Rock 63 Yrs Old with Fat Droopy Eyes – Salt Lake City, UT
WHAT CAN I DO TO IMPROVE MY SYMPTOMS?
- Protection from ultraviolet light, direct wind and heat helps to delay the growth of a pterygium and also improves symptoms. Surfers and other water-sport athletes should wear eye protection that blocks 100% of the UV rays from the water, as is often used by snow-sport athletes.
- Use of artificial drops and ointment (see our list of preservative-free and preserved drops and ointments here) help reduce irritation, provide lubrication to the surface of the pterygium and generally make the eyes feel better.
- Use of vasoconstrictors like visine drops will reduce the redness temporarily but will give you an increase rebound redness if you use the drops chronically.
- If you are outdoors, hiking, biking, etc, it helps to wear the ultraviolet protecting sunglasses which also protect you from the wind with side protection.
WHAT SURGICAL APPROACH IS USED TO REMOVE AND REPAIR A PTERYGIUM?
- A Cochrane review found conjunctival autograft surgery was less likely to have reoccurrence of the pterygium at 6 months compared to amniotic membrane transplant.(1) This is the technique we have perfected and we use this approach for primary and re-do procedures with excellent success. The additional use of mitomycin C is of unclear effect. Radiotherapy has also be used in an attempt to reduce the risk of recurrence. However, it is very rarely used now. We haven’t ever needed to use radiotherapy on our patients.
- Auto-grafting: conjunctival auto-grafting is a surgical technique that is an effective and safe procedure for pterygium removal. When the pterygium is removed, the tissue that covers the sclera known as the Tenons layer is also removed. Auto-grafting covers the bare sclera with conjunctival tissue that is surgically removed from an area of healthy conjunctiva. That “self-tissue” is then transplanted to the bare sclera and is fixated using tissue adhesive.
- Amniotic membrane transplantation: amniotic membrane transplantation is an effective and safe procedure for pterygium removal when used appropriately. Amniotic membrane transplantation offers practical alternative to conjunctival auto graft transplantation for extensive pterygium removal. Amniotic membrane transplantation is tissue that is acquired from the innermost layer of the human placenta and has been used to replace and heal damaged mucosal surfaces including successful reconstruction of the ocular surface. It has been used as a surgical material since the 1940s, and has been shown to have a strong anti-adhesive effect. Using an amniotic graft facilitates epithelialization, and has anti-inflammatory as well as surface rejuvenation properties.
- The postoperative care after a pterygium removal is just as important as the surgery. We will give detailed instructions to you after your surgery.
"HOW DO YOU PERFORM PTERYGIUM RESECTION AND REPAIR?"
- We use a careful microscopic resection of the abnormal tissues with preservation of the healthy stem cells at the corneal limbus and with resection of the “root” of the pterygium and any other peripheral sources of scarring and vascularization.
- The specimen is sent for histopathology if there is any suspicion that there might be changes other than a pterygium: sometimes, chronic sun damage will lead to a condition called carcinoma-in-situ or even a frank carcinoma.
- The bed is prepared with careful removal of any residual abnormal cells and the cornea is polished. A free conjunctival graft is obtained and glued into position without sutures.
USE OF AMNIOTIC MEMBRANE
Under certain circumstances, especially when we are referred patients with several prior surgeries, scarring, or lack of adequate availability of “clean” conjunctiva, we will use an amniotic membrane graft. The principles are similar to performing a primary pterygium resection but great care is needed to remove scar tissue, fibrous tissue and traction bands, together with fibrovascular connections to the caruncle or plica semilunaris which lead to recurrence.
The amniotic membrane is glued into position with care and protected with a contact lens.
Postoperative care is similar to that after a primary pterygium but there may be other specific instructions we may give you.
Some patients need eyelid or fornix surgery if there is double vision or traction on the eyelids which is sometimes seen in these more complicated cases.
“I had to have pterygium surgery three times on my right eye and each time I had it grow back and left me with scarring and double vision. Dr. I am glad my doctor finally called Dr. Patel and discussed my case with him. Dr. Patel agreed to see me and he fixed me in one go! It was a long operation but worth every minute of it. I have no double vision and my eye actually looks white finally.“ T. Rodriguez. Highly recommended for pterygium surgery – Salt Lake City & Saint George, UT
- You will have a patch on your eye overnight: please remove the patch the morning after surgery.
- Do not rub your eyelids vigorously for the first two weeks.
- We will provide you with a shield which you will wear every night for the first two weeks: this will avoid you rubbing your eye in your sleep: the conjunctival graft is very delicate.
- You will have some blurry vision: this is normal and settles.
- No swimming in a swimming pool for two weeks please.
- No vigorous exercise for one week (tennis, skiing, etc).
- Most patients can drive/walk/etc the day after surgery. Sometimes, swelling can make driving difficult for a couple of days.
- You should not wear a contact lens for the first ten days please.
- You will be prescribed steroid drops which are usually put into the operated eye four times a day for four weeks and twice a day for two weeks. In some patients the treatment may be continued longer.
- You will also be prescribed an ointment which we will ask you to apply to the inner corner of your operated eye once at night for six weeks.
- We will arrange to see you in clinic.
- Please do not get a refraction of spectacles for two months after surgery as the curvature of your cornea will change (for the better) and this will avoid you needing repeated changes of glasses.
- Even with excellent surgery, the redness of the eye that is there from long-standing sun and wind damage will leave some redness. This is normal.
FACTS YOU SHOULD KNOW
Aspirin, aspirin-containing drugs, ibuprofen and other blood-thinners should be stopped 7 days before surgery. This includes herbs, all vitamins, and certain other drugs: we will give you a list which covers most such thinners. If you are on prescription blood-thinners like Coumadin or Plavix, we will advise you & your physician about possible changes in that medication prior to & after surgery.
It is normal for the conjunctival graft to look pink and sometimes swollen for the first few weeks. At times, blood can collect under the graft and the graft can look red: this is completely normal. To protect your conjunctival graft during sleep for the first week or two, we often ask patients to wear a shield on the operated eye at night.
The reason why most people get pterygia is because of injury to the lining of the eye caused by ultraviolet light, heat, wind and dryness. When we remove the pterygium, the growth and irregularity are both handled, but the surrounding tissues will still have some degree of damage from prior injury. Therefore, some degree of dryness will still be there and you will need to use artificial tears as needed. There is a list of preservative-free drops and preserved drops and gels and ointments here.
Most patients can have surgery with mild intravenous sedation. Although many people are squemish about things close to their eyes, almost everyone does very well with the appropriate level of sedation from my expert anesthesia team. Children will need a general anesthetic. Sometimes, when we are dealing with patients who are referred to us with complex recurrences of pterygia with extensive scarring, we will request a general anesthetic to be administered to make your surgery as comfortable as possible. My anesthesia team and I will discuss this with you and chose the best level of anesthesia for you so as to keep you comfortable.
All operations have success and failure rates. Fortunately, with the modern techniques we use, recurrence of a pterygium is now rare. However, if one does not protect the eye from ultraviolet light, heat and dust and if artificial tears are not used as needed, there is a higher risk of recurrence of the pterygium. Some degree of redness of the graft and surrounding tissues will remain but this is not a recurrence.
If your work involves heavy lifting or a lot of computer time, you would be wise to get a week off work.
Depending upon your specific requirements, we will be happy to give you a note for work.
Often, patients will have a pterygium on one side which we will operate upon and either a small pterygium or a pingueculum on the other eye. All of these do not need surgery. If you begin to protect your eye from ultraviolet light and reduce dryness and direct heat injury to the eye (work, play, etc), you can slow down the growth of these pingueculae. If you do not have any symptoms and the growth is not distorting the cornea, there is no need to undergo surgery.
Only if the pterygium causes irritation, dryness, or problems with vision
We will review your history and examine you: this will allow us to guide you as to whether the surgery may or may not be necessary.
Most insurances cover the surgical operation when it is performed for the appropriate reasons. If your insurance requires the submission of your history, findings and photographs to get pre-approval, we will ensure we do this.
There will be blurry vision during the healing phase: this may last from a few weeks to, sometimes, more than two months. Most patients can function
perfectly well but the refraction may change.
Some patients need a refraction for new spectacles
about two months(or more) after surgery as the corneal curvature will change (for the better) after surgery.
We almost never use sutures with pterygium surgery as we use medical tissue glue: this makes your healing more comfortable and faster. It also means you need steroid drops and ointment for a shorter period of time.
for the surgeon to take longer (or shorter) on
some cases, depending upon findings: therefore,
surgery times are ESTIMATES ONLY.
Although the graft and the conjunctiva are usually red for the first week, there will only be minimal bruising of the eyelids from the local anesthetic that is administered to you. You can use ice packs on the eye gently, although, with conjunctival grafts, we prefer you not to use ice as this can apply undue pressure on the conjunctival graft.
Surprisingly, most patients find they get very little discomfort after this surgery. You may need the prescription pain medication for one or two days; thereafter, simple over-the-counter pain medication like Tylenol suffices.
Preauthorization may take four to six weeks from the time of submission of your information to the insurance company: we don’t have control over this, unfortunately.
USE OF FLAPS
In some cases, using our experience with reconstruction of the face with small and large flaps, we design the reconstruction after removal of the pterygium using similar flaps. These are accurately designed to cover the defect without tension and proper attention is paid to the conjunctiva, the Tenon’s tissue and the corneal limbus.
HOW WE USED TO REMOVE AND REPAIR PTERYGIA WITH SUTURES: OF HISTORICAL INTEREST......
WHAT KIND OF RESULTS CAN I EXPECT?
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Dr. BCK Patel MD, FRCS
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Saint George, UT 84790, USA