OPHTHALMOLOGY PTERYGIUM & ITS MANAGEMENT.

1. Dr. NIKITA JAISWAL
PTERYGIUM & IT’S
MANAGEMENT

2. INTRODUCTION
ANATOMY
PATHOGENESIS
CLASSIFICATION
MANAGEMENT
GLOSSARY

3. 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

4. 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 associations
Overexpression of various proteins as defensins & phospholipases D.
IT’s A PROLIFERATIVE LESION RATHER THAN DEGENERATIVE
CONDITION.
PATHOGENESIS

5. 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

6. SMALL ARE ASYMPTOMATIC
IRRITATION
FOREIGN BODY SENSATION
CONGESTION
LACRIMATION
DRYNESS
ASTIGMATISM
CLINICAL FEATURES

7. Sunlight exposure
Hot & dry climate
Age related degeneration
hereditary
RISK FACTORS

8. 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

9. CAP
HEAD
BODY
PARTS OF PTERYGIUM

11. 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

12. CLINICAL GRADING
TAN’s CLASSIFICATION
GRADING OF PTERYGIUM

13. GRADE 1: EXTENDS 2mm on the
cornea

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

15. TYPE 3: Encroaches more than
4mm of the cornea & it can hamper
visual axis.

16. T1 GRADE: Clearly visible episcleral
vessels under the pterygium
TAN’S CLASSIFICATION

17. T2 GRADE: partially visibility of the
episcleral vessels under the
pterygium.

18. T3 GRADE: total obscured view of
the episcleral vessels under the
pterygium.

19. 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 process
May occur due to exposure
to sunlight & dust
Inflammatory process
2’ to chemical burns,trauma.
LIMBAL
RELATIONS
Adhered to limbus Not adhered to limbus
ASSOCIATIONS pinguecula ------

22. MANAGEMENT

23. CONSERVATIVE MANAGEMENT
Asymptomatic, small pterygium can be left alone
Lubricating eyedrops
Sunglasses to prevent UV light exposure
Mild steroids if inflammation is there.

24. HAMPERING VISUAL FIELD
ASTIGMATISM
COSMETIC CONCERN
RECURRENCE
INDICATIONS FOR SURGERY

25. The primary aim is to:
EXCISION.
PREVENT ITS RECURRENCE.
SURGICAL MANAGEMENT

26. surgical
Excision
evulsion
Superficial
keratectomy
Closure
methods
Bare scleral
Simple
conjunctival
Conjunctival
autografts
Lamellar
corneal
transplants

28. 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

29. SIMPLE CLOSURE
Free edges of conjunctiva
opposed together
indicated only if defect is
very small

30. ROTATIONAL FLAP CLOSURE
A U-shaped incision is made
adjacent to the wound to form
tongue of conjunctiva that is
rotated into place.

31. Grafted tissue should be
approximately 0.5 – 1 mm
larger than the area
Most 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

32. FIBRIN GLUE

34. 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

35. 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

36. 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

37. Corneal/scleral following extensive
dissection
Medial rectus muscle injury
Bleeding
Globe perforation
Damage to canalicular system
Recurrence
Necrosis
Endophthalmitis
Scleritis
Keratitis
Pyogenic granuloma
Dellen
Persistent epithelial defect
INTRA-OPERATIVE POST-OPERATIVE
COMPLICATIONS

38. PINGUECULA
DIFFERENTIAL DIAGNOSIS

39. LIMBAL DERMOID

40. OSNN

41. NODULAR EPISCLERITIS

42. THANK YOU