Chapter (Sanusi Kabiarat)

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CHAPTER TWO

2.0 CASE REVIEW

NASAL CONJUCTIVA GROWTH (Pterygium)

According to Detels R, Dhir SP, Pterygium: a geographical study. Arch Ophthalmol. 1967;78:
485–491, Pterygium is a degenerative disorder of the conjunctiva. It is usually seen as a triangular
fleshy fibrovascular proliferation from the bulbar conjunctiva onto the cornea, located mostly on
the nasal side. Though it occurs worldwide, its prevalence is high in the “pterygium belt” between
30 degrees north and 30 degrees south of the equator.

2.1 ANATOMY OF THE AFFECTED PART (Cornea)

DEFINITION
The cornea is the outermost, clear layer of the eye, immediately anterior to the anterior chamber,
iris, and pupil. The cornea borders the sclera at the corneal limbus and is involved in the refraction
of light entering the human eye.
Five distinct layers make up the cornea, including the
➢ Epithelium
➢ Bowman's membrane
➢ Stroma
➢ Descemet's membrane, and the
➢ Endothelium.

Note: The abundant soluble protein in the human cornea is the Albumin. (Laibson PR. Cornea and
sclera. Arch Ophthalmol. 1972 Nov;88(5):553-74.)

2.2 STRUCTURE AND FUNCTION OF THE CORNEA


Aside protecting the eye from outside infiltrates and ultraviolet radiation, the cornea is responsible
for approximately 65% to 75% of the refraction of light as it passes through the eye. The cornea
performs the initial refraction onto the lens, which further focuses the light onto the retina. Tears
spread across the surface of the eye laterally in the blinking process. With their lipid, aqueous, and
mucin components, tears are important to the maintenance of corneal health as they keep the cornea
moist and clean.The epithelium includes epithelial cells and a basement membrane. The primary
functions of the corneal epithelium are twofold: to prevent the entrance of foreign objects or
substances, and to accommodate the absorption of nutrients such as oxygen from the tears that
pass over its surface.

➢ Bowman's membrane is comprised of a thin, transparent layer of collagen. Trauma or injury


can disrupt this collagenous film, which may cause scarring that impairs vision, depending
on its location and extent.

➢ The stroma is the thickest layer of the cornea. The stroma is made up primarily of water
and collagen and is vital to the maintenance of the spherical shape of the cornea, which is
critical to the proper passage and refraction of light into the eye.

➢ Descemet's membrane is another thin layer that has relative strength due to the collagen
fibers which comprise it. The corneal endothelial cells produce this collagen. Descemet's
membrane is capable of repairing itself with relative ease following injury. It is crucial to
protecting the internal structures of the eye from infection and trauma.
➢ The innermost layer of the cornea is the endothelium. This thin layer plays a vital role in
maintaining the clarity of the cornea as the endothelial cells pump excess fluid from the
stroma. Endothelial cells do not appear to regenerate appreciably, and their destruction can
cause lasting dysfunction.

Laibson PR. Cornea and sclera. Arch Ophthalmol. 1972 Nov;88(5):553-74.

Randleman JB, Khandelwal SS, Hafezi F. Corneal cross-linking. Surv Ophthalmol. 2015 Nov-
Dec;60(6):509-23.

Ricard-Blum S, Ville G. Collagen cross-linking. Int J Biochem. 1989;21(11):1185-9.

2.3 CAUSES OF PTERYGIUM

Some people refer to a pterygium as “surfer’s eye,” because the condition often affects people who
spend a lot of time in the sun.

However, pterygia can also develop as a result of eye irritation from wind, dust, or dirt.

It was suggested by Int J Ophthalmol. 2014; 7(3): 563–573. that genetics also play a role in the
development of pterygia.

Although UV exposure does play a role, even people who have low UV exposure can develop
pterygia. Likewise, some people who have high UV exposure may never develop the condition.

According to the National Eye Institute, pterygia are most common in people aged 20–40.

2.4 SIGNS AND SYMPTOMS OF PTERYGIUM


In the early stage of pterygium, it might not be noticeable. But if it begins to grow, it may become
visible. The growth will typically appear fleshy and triangular. It may be red, pink or yellow.

➢ Part of what a person can also experience is :


➢ Redness of the conjunctiva
➢ Itching, dryness and burning in one or both eyes
➢ A sensation sand in the eye

Medical New today 2022

(https://www.medicalnewstoday.com/articles/pterygium#complications)

2.5 DIAGNOSIS
When a person begins to experience the highlighted symptoms, the person should see an eye doctor
(Ophthalmologist). The doctor will take family history of pterygium or other eye condition and
then examine the eye using a slit lamp to diagnose pterygium. This process is called slit lamp
examination.

2.6 TREATMENT

If the pterygium is small and is not causing issues, a person may choose to manage it with home
remedies and over-the-counter (OTC) treatments such as artificial tears to keep the eye lubricated
and relieve minor discomfort, using an eye ointment when artificial tears are not sufficient.

If the pterygium becomes larger or causes bothersome symptoms, however, a person may require
surgery operation.

However, pterygia often grow back after surgery. For this reason, the doctor may only recommend
surgery if a person’s symptoms are severe.

According to Int J Ophthalmol. 2016; 9(3): 465–468, using the treatment mitomycin C (MMC)
before, during, or after surgery may help prevent the pterygium from growing back. MMC works
by preventing certain cells from growing on the conjunctiva. A surgeon can inject this treatment
into the eye or apply it to the pterygium in the form of eye drops.

Also, Cochrane Database Syst Rev. 2016 Feb; 2016(2): CD011349. found that using a graft of
conjunctival tissue with surgery may help prevent recurrence of a pterygium. In this case, the
surgeon will remove a small part of a person’s healthy conjunctiva and attach it to the area of
pterygium removal.

2.7 PREVENTION

The best way to prevent a pterygium is to protect the eyes from irritants such as:

• sun

• wind

• dryness

• dust and grit

To protect the eyes, a person can:

• Wear sunglasses

• Wear a wide-brimmed hat

• Wear suitable eye protection

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