E-ISSN 0976-2892

Major Review

Current Concepts in
Management of Pterygium
Delhi J Ophthalmol 2014; 25 (2): 78-84
DOI: http://dx.doi.org/10.7869/djo.83

Anuj Bahuva, Srinivas K Rao* The pterygium is a common ocular disorder. Medical therapy is ineffective and the goals of surgery are
complete removal of the lesion and the prevention of recurrence. Although a wide variety of treatment
Darshan Eye Care & Surgical Centre,
modalities are currently available, there is no consensus on the ideal option. Pterygium excision is often
Chennai, Tamil Nadu, India
combined with conjunctival autograft, mitomycin C, beta-irradiation or other adjunctive therapies to
reduce recurrence rates. Although studies report the success rates with these approaches, variable
*Address for correspondence inclusion criteria, differences in follow-up and definition of recurrence make comparison of outcomes
difficult. This article reviews the current options available for the management of Pterygium, reviews the
outcomes and suggests guidelines for various categories of the lesion encountered in clinical practice.

Keywords : pterygium • conjunctival graft • PERFECT • bare sclera • recurrence

Pterygium was first described in 1000 just a degenerative lesion, but could be a
Srinivas K Rao DO, DNB, FRCSEd BC by Sushruta. The prevalence rates result of uncontrolled cell proliferation.
Darshan Eye Care & Surgical Centre vary in different parts of the world, and is Matrix metalloproteinases (MMPs) and
T 80, Fifth Main Road, Anna Nagar, highest in the “Pterygium belt” described tissue inhibitors of MMPs (TIMPs) at
Chennai 600040, Tamil Nadu, India by Cameron between the latitudes 370 the advancing pterygium edge may be
Email: srinikrao@gmail.com north and south of the equator.1 The responsible for the inflammation, tissue
prevalence in India ranges from 9.52 to remodeling, destruction of Bowman’s
13%3 and is more common in rural parts layer and pterygium invasion into the
of the country. The earliest described cornea.8 It has also been speculated that
surgical approach for pterygium was a pterygium may represent an area of
simple excision leaving the scleral bed localized limbal stem cell deficiency,
bare. Although this can be performed with result invasion of the adjacent
as an office procedure, the recurrence cornea by the conjunctiva.9 Surgical
rates range from 30 to 80% and the techniques that fail to address these
postoperative cosmesis is poor, resulting pathophysiologic causative factors, such
in this procedure being abandoned.4 as the bare sclera technique, appear to
Since then, various modifications in be associated with the highest rates of
technique have been reported and with recurrence. Since a recurrence is more
current approaches, the recurrence aggressive than the primary lesion in
rates after surgery can be as low as 0%.5 speed and extent of corneal invasion,
The rationale of these approaches and it is important to choose the primary
choosing the appropriate strategy in a procedure that has the highest rate of
patient is detailed in this article. success.

Pathophysiology Medical Management of Pterygium

Among the several risk factors The lesion starts as a small
reported, exposure to UV rays is perhaps elevation at the limbus, often in the
the most accepted risk factor for the interpalpebral region. At this stage, the
occurrence of pterygium.6 UV radiation lesion is termed a ‘roundlet’, and can
can cause mutations in genes such as the be asymptomatic, or prone to recurrent
p53 tumor suppressor gene, resulting in episodes of inflammation with redness
abnormal pterygial epithelium. Recent and irritation. Since exposure to wind,
studies have suggested that human dust, and ultraviolet radiation are
papilloma virus may also be implicated believed to be involved in the causation,
in pterygium pathogenesis.7 These treatment at this stage includes the
findings suggest that pterygium is not use of ultraviolet filters in glasses and

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lubricant tear drops. The use of steroid eye drops to manage the pterygium head away from the cornea and repositioning
the inflammation is also described.10 While these measures the head of the pterygium.13 While these modifications did
are expected to slow the rate of progression of the lesion, improve the results, recurrences were still common, and the
there is little data available on the efficacy of this approach. technical complexity of these procedures limited their use.
Most patients present with corneal involvement and in
these patients, surgery is recommended for various reasons Conjunctival Flap
- a documented history of progression, astigmatism causing Sliding conjunctival flaps harvested from the inferior
poor vision, proximity to the visual axis, poor cosmesis, or superior bulbar conjunctiva were used to close the
recurrent inflammation and concern about malignant scleral defect. Although the recurrence rate reported by this
change11 (Figure 1a and 1b). technique is 1-5%, the surgery is technically complicated
with suboptimal cosmesis.14

Conjunctival Autograft
The first real advance in Pterygium management was the
description of the technique of conjunctival-limbal autograft
transplantation after Pterygium excision, by Kenyon in
1985.15 In their landmark paper, the authors used a free
conjunctival-limbal graft with the same dimensions as the
scleral bed, harvested from the superior bulbar conjunctiva,
and sutured this in the scleral bed. The graft is preferably
taken from the superior temporal bulbar conjunctiva,
because of the technical difficulty in harvesting a graft
from the inferior bulbar conjunctiva. The inferior limbus
and inferior bulbar conjunctivae are more exposed to the
deleterious effects of ultraviolet radiation, compared to the
superior limbus and superior temporal bulbar conjunctiva
Figure 1 (a): Pterygium invading visual axis which are shielded by the upper lid.16 Conjunctival-limbal
autografts are associated with recurrence rates ranging
from 0 to 15%.17 In a series from India, Rao et al reported
the outcomes of this procedure in 53 eyes with 36 primary
and 17 recurrent pterygia, with a mean follow-up of 18.9
+ 12.1 months. The recurrence rate was 3.8%.18 The steps
of the technique followed in the report are described in
brief below. A wire speculum is used to separate the lids. A
superior rectus bridle suture is inserted. The suture is used
to abduct the eye maximally (assume nasal pterygium) by
clipping it to the drapes adjacent to the lateral canthus. A
small incision is made in the conjunctiva just medial to the
head of the pterygium. Beginning here, the conjunctiva is
progressively dissected from the body of the pterygium
towards the caruncle. The head of the pterygium is left
attached to the cornea, enabling easier dissection of the
conjunctiva. The corneal epithelium 2 mm ahead of the
head of the pterygium is scraped off with a hockey-stick
Figure 1(b): Pterygium crossing visual axis
knife. Once the plane is defined, the pterygium head is
Evolution of Approaches to Management of easily avulsed using a combination of blunt dissection and
traction. Residual fibrous tissue on the cornea is removed
Pterygium
by sharp dissection with a No. 15 Bard-Parker blade. The
Bare Sclera Technique body of the pterygium with the involved Tenon’s capsule
This technique involves surgical excision of the and cicatrix is then excised, taking care to ensure the safety
pterygium with the exposed sclera left bare. It has been of the underlying medial rectus muscle and the overlying
described as a quick and easy procedure, often performed conjunctiva. The size of the conjunctival graft required to
in the office with topical or subconjunctival anesthesia. resurface the exposed scleral surface is determined using
This has a high recurrence rate ranging from 30-80 %, Castroviejo calipers. The measured dimensions are marked
and is hence, seldom used today. Other variations of this onto the superotemporal conjunctiva. Using a Pierse-Hoskins
approach were tried to mitigate the high recurrence rate, forceps and Westcott scissors, the graft is excised starting at
and these named procedures include - primary closure of the forniceal end. Care is taken to obtain as thin a graft as
the defect12, splitting the head of the pterygium, rotation of possible without button-holing. Once the limbus is reached,

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the graft is flipped over onto the cornea and the Tenon’s
attachments at the limbus were meticulously dissected. The
flap is then excised using a Vannas scissors, taking care to
include the limbal tissue. After excision, the conjunctival-
limbal graft is slid onto the cornea. Without lifting the tissue
off the cornea, it is rotated and moved onto its scleral bed
with fine non-toothed forceps. A limbus-limbus orientation
is maintained. This helps avoid inadvertent scrolling of the
graft with resultant inversion of the surfaces. The graft is
smoothened out in its bed taking care to avoid any folding
of the edges. The graft is secured using interrupted 10-0
nylon sutures. The four corners of the graft are anchored
with episcleral bites to maintain position. The medial
edge of the graft is sutured with 2-4 additional sutures,
preferably including episclera. The donor area is covered by
pulling the forniceal conjunctiva forward and anchoring it
to the limbal episcleral tissue with 2 interrupted 10-0 nylon Figure 2(c): Close up post opereative picture of the same eye
sutures. 0.5cc dexamethasone is injected subconjunctivally
at the conclusion of the procedure and the eye is patched P.E.R.F.E.C.T Surgery
firmly with antibiotic eye ointment. Postoperatively, topical Dr Hirst from Australia reports a recurrence rate of
betamethasone eye drops are used every 2 hours for the first 0.5% with a technique he calls P.E.R.F.E.C.T. which stands
operative week and then tapered over the next 5-6 weeks. for ‘Pterygium Extended Removal Followed by Extended
Antibiotic ointment is used 3 times daily for the first 2 weeks. Conjunctival Transplant’. In this approach, he does an
Any retained sutures are removed at 6 weeks (Figure 2 - 4). extensive conjunctival autografting of about 15mm by 12
mm.19 The advantages of this approach are less recurrence
and a better cosmetic outcome as graft edge and the surgical
scars are hidden in the fornices and caruncle. The main
limitation is that this is time consuming and technically
challenging procedure.

Free Conjunctival Autograft

It has been suggested that including limbal stem cells
in the conjunctival autograft (limbal–conjunctival graft)
may act as a barrier to conjunctival cells migrating onto
the corneal surface and help prevent recurrence. The
limbal–conjunctival graft includes approximately 0.5mm
of the limbus and peripheral cornea. The recurrence rates
after limbal–conjunctival autograft surgery range from 0 to
15%.20 In some situations, where there has been previous
Figure 2(a): Pterygium before surgery surgery, or limbal damage due to other causes, surgical
manipulations when removing a limbal graft may promote
further damage to stem cells. In this situation, Tan et al
have suggested that the use of free conjunctival grafts may
have equivalent outcomes. This technique may also be
advantageous when surgery is performed in a patient with
a subsequent risk of glaucoma and the need to preserve
the superior bulbar conjunctiva. However, it is possible
that limbal–conjunctival autografts are more effective
than conjunctival autografts for recurrent pterygium.21 In
some patients with an existing superior conjunctival bleb,
other superior conjunctival pathology, or in anticipation of
the need to perform glaucoma surgery superiorly, it may
be feasible to perform the surgery, using tissue from the
inferior bulbar conjunctiva. The results of this approach
were reported by Rao et al R, with an acceptable recurrence
rate of 18.2 %.22
Figure 2(b): After pterygium excision with conjunctival autograft

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graft now facing the fornix and vice versa. This is a useful
technique for cases in which it is not possible or desirable to
use the superior conjunctiva as a donor source, such as with
excision of extensive pterygium, which leaves insufficient
conjunctival tissue for the autograft, double pterygium,
glaucoma surgery etc. Recurrence rate with this technique
has been described as 4%.24

Figure 3(a): Recurrent pterygium

Figure 4(b): Pseudo pterygium after excision of the neoplasia

Figure 3(b): After conjunctival autograft

Figure 4(c): After excision of pseudo pterygium with conjunctival autograft

Amniotic Membrane Transplantation

Amniotic membrane transplantation has recently been
proposed as a treatment option to prevent recurrences.
Amniotic membrane possesses anti-scarring, anti-
angiogenic and anti-inflammatory properties, which
may be useful for treating pterygium. An additional
advantage is that it removes the need for harvesting large
autografts, thereby minimizing iatrogenic injury to the rest
Figure 4(a): Ocular surface squamous neoplasia of the conjunctival surface. Besides the conventional de-
Conjunctival Rotation Autograft Surgery epithelialized cryopreserved human amniotic membrane,
Conjunctival rotation autografting was first described the efficacy of freeze dried or lyophilized membranes
by Tan et al23, and requires the removal of conjunctiva over have also been studied. Recurrence rate of pterygium
the body of the pterygium. This tissue is stored in saline, with amniotic membrane use ranges from 12 to 40 %.25-27
while the rest of the surgery is performed to remove the Delayed vascularization of amniotic membrane is thought
Pterygium. Subsequently, the tissue is replaced and sutured to be responsible for the delayed recurrence after pterygium
in place in the bare scleral bed, with the limbal aspect of the surgery. Although, this appears to be a safe and easy

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solution, avoiding the need for harvesting conjunctival, have also been used as adjuvants to prevent recurrences and
autografts, neither the cosmesis nor the recurrence rates have shown promising results in some studies.
compare favorably with conjunctival auto grafting for
Pterygium surgery. Other Advances for Ease of Surgery
Fibrin Glue
Cultivated Conjunctival Transplantation Fibrin glue has been used as an alternative to sutures
A novel method of closing the surgical defect involves
for securing conjunctival grafts. The use of fibrin glue
the use of an ex-vivo expanded conjunctival epithelial sheet
shortens operating times significantly, is associated with
on an amniotic membrane substrate. Initially used by Tan
less postoperative discomfort with success rates that are
et al, to reconstruct the bulbar conjunctival surface after
comparable to sutured grafts.42 Most cases performed
excision of an extensive nevus, the operated eye achieved
with fibrin adhesive heal with minimal inflammation.
early reepithelialization of the ocular surface, with minimal
The immediate adherence of the graft and the lack of
postoperative inflammation and quick ocular rehabilitation.
postoperative inflammation have been proposed as
Subsequently, the efficacy of this approach was studied in the
advantages with this approach. The major concerns that
management of Pterygium surgery, comparing it to standard
need to be addressed include the cost and the potential risk
amniotic membrane transplantation, and a recurrence rate
of transmitted infection like HIV, hepatitis B or C or prion-
of 23 % was noted.28 Further studies are needed to evaluate
mediated disease but there are no such reported infections.
the success of this approach in pterygium surgery.
Autologous Serum
Adjunctive Methods for Prevention of Recurrence Patients own blood is used as a bio adhesive in
Radiation pterygium surgery and the recurrence rate was found to be
Radiation of the bare sclera with Strontium 90 is largely similar to fibrin glue. It is more cost effective with no risk of
given up due to patients developing scleral necrosis at the transmission of infections. The drawback of this technique
site. It has been replaced by other safer adjuvants.29 is that the complications regarding graft displacement and
graft retraction are more common in patients with grafting
Mitomycin C (MMC) with autologous blood than with the glue.43
The adjunctive use of Mitomycin C during pterygium
surgery has been shown to decrease the recurrence rate. Complicated Cases and Approach to their
MMC is used in two forms, intra-operative application to Management
the bare scleral bed and post operative drops. Since there is
a potential for abuse of the drops used postoperatively and Lamellar Keratoplasty
their complications, this has largely been given up today.30 Lamellar keratoplasty has been used to replace
The reported recurrence rates associated with intraoperative the thinning and corneal scarring seen after pterygium
mitomycin C use range from 10.5.31 to 38%.32 Increasing excision. It does not appear to offer any special advantage
the duration of intra operative exposure to MMC reduces in preventing pterygium recurrence. This has mostly
recurrences.33 Although mitomycin C has been shown to been used to treat recurrent pterygium to restore corneal
be an effective treatment for pterygium, its use has been thickness in thinned, scarred corneas or associated corneal
associated with serious sight-threatening complications such opacity in the visual axis. The main limitations are the
as infectious scleritis, severe secondary glaucoma, corneal need for donor corneal tissue with the attendant risks of
edema, corneal perforation, corectopia, iritis, sudden onset graft rejection and transmission of infection, as well as the
mature cataract, scleral calcification and incapacitating increased complexity of the procedure.44
photophobia and pain.34-36 These complications have been
reported both with intra operative use of MMC and post Split Graft for Double Pterygia
operative mitomycin eye drops. A split graft can be used to cover large conjunctival
defects created in double-head pterygium (Figure 5). In this
Corticosteroids procedure the conjunctival graft including the limbal tissue
As inflammation is considered to be one of the risk factors is transplanted nasally, as the nasal limbus is reported to
for primary and recurrent pterygium, corticosteroids have a be more exposed to the UV radiation by internal reflection
definite role to play. The postoperative use of subconjunctival from the temporal limbus.45
triamcinolone seems to benefit patients having risk factors
like conjunctival inflammation, hemorrhage, granuloma Combination of Approaches
and fibrovascular proliferation by preventing recurrences.37 Conjunctival autografting with amniotic membrane
Post-operative topical corticosteroid eye drops also decrease grafting has been used in recurrent pterygium with
the incidence of recurrences by reducing the inflammation.38 restriction of movements. In these cases, amniotic membrane
is used to cover the muscle to prevent fibrosis and restriction
Others of movements while the conjunctival autograft is used to
Daunorubicin39, doxorubicin40 and 5 fluorouracil (5FU)41 close the defect from the pterygium surgery.46

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Limbal deficiency at donor site

Corneal or scleral infection
Graft infection
Scleral necrosis (Figure 6)
Dellen
Ocular perforation and retinal detachment
Endophthalmitis
Episcleral pyogenic granuloma

Future Prospects
Bevacizumab
Studies are underway to try Bevacizumab as an adjuvant in
pterygium surgery to prevent recurrence.47

Financial & competing interest disclosure

The authors do not have any competing interests in any product/
Figure 5: A double headed pterygium procedure mentioned in this study. The authors do not have any financial
interests in any product / procedure mentioned in this study.

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