CHAPTER I

INTRODUCTION

Pterygium is a disease of the eye surface which appear as triangular shape

growth made up of epithelial conjunctival bulbi and subconjunctival connective
tissue hypertrophy, can occur on the lateral and medial sides and growth is leading
to kornea.1

Pterygium commonly found in tropical and sub-tropical regions that located

near the ekuator.1 In Indonesia pterygium incidence rate in the population over 21
years of age reached 10%.1 Some known risk factors are genetical predisposition,
immune mechanisms and chronic irritation of the environment including
ultraviolet light, wind and dust, although the exact etiology remains known
unclear.2

Pterygium has been associated with the occurrence of astigmatism and

sharply lowered penglihatan.1 Advanced pterygium will also lead to corneal
opacities that leads to impaired vision can even cause blindness.

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 CHAPTER II
LITERATURE REVIEW

2.1 Conjunctiva
The conjunctiva is the thin, transparent mucous membrane that covers the
posterior surface of the lids (the palpebral conjunctiva) and the anterior surface of
the sclera (the bulbar conjunctiva). It is continuous with the skin at the lid margin
(a mucocutaneous junction) and with the corneal epithelium at the limbus.3
The bulbar conjunctiva is loosely attached to the orbital septum in the fornices
and is folded many times. This allows the eye to move and enlarges the secretory
conjunctival surface. (The ducts of the lacrimal gland open into the superior
temporal fornix.) Except at the limbus (where Tenon's capsule and the conjunctiva
are fused for about 3 mm), the bulbar conjunctiva is loosely attached to Tenon's
capsule and the underlying sclera. 3
A soft, movable, thickened fold of bulbar conjunctiva (the semilunar fold) is
located at the inner canthus and corresponds to the nictitating membrane of some
lower animals. A small, fleshy, epidermoid structure (the caruncle) is attached
superficially to the inner portion of the semilunar fold and is a transition zone
containing both cutaneous and mucous membrane elements. 3
The epithelium is non-keratinizing and around five cell layers deep. Basal
cuboidal cells evolve into flattened polyhedral cells, subsequently being shed
from the surface. Mucus-secreting goblet cells are located within the epithelium,
being most dense inferonasally and in the fornices. 4
The stroma (substantia propria) consists of richly vascularized loose
connective tissue. The accessory lacrimal glands of Krause and Wolfring are
located deep within the stroma. Secretions from the accessory lacrimal glands are
essential components of the tear film. 4
Conjunctiva-associated lymphoid tissue (CALT) is critical in the initiation and
regulation of ocular surface immune responses. It consists of lymphocytes within
the epithelial layers, lymphatics and associated blood vessels, with a stromal
component of lymphocytes and plasma cells, including follicular aggregates.4

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2.2 Cornea
The cornea is a transparent tissue comparable in size and structure to the
crystal of a small wristwatch. It is inserted into the sclera at the limbus, the
circumferential depression at this junction being known as the scleral sulcus. The
average adult cornea is 550 m thick in the center, although there are racial
variations, and about 11.75 mm in diameter horizontally and 10.6 mm vertically.3
From anterior to posterior, it has five distinct layers: the epithelium (which is
continuous with the epithelium of the bulbar conjunctiva), Bowman's layer, the
stroma, Descemet's membrane, and the endothelium. The epithelium has five or
six layers of cells. Bowman's layer is a clear acellular layer, a modified portion of
the stroma. The corneal stroma accounts for about 90% of the corneal thickness. It
is composed of intertwining lamellae of collagen fibrils that run almost the full
diameter of the cornea. They run parallel to the surface of the cornea and by virtue
of their size and proximity are optically clear. The lamellae lie within a ground
substance of hydrated proteoglycans in association with the keratocytes that
produce the collagen and ground substance. Descemet's membrane, constituting
the basal lamina of the corneal endothelium, has a hom ogeneous appearance on
light microscopy but a laminated appearance on electron microscopy due to
structural differences between its prenasal and postnatal portions. 3
The endothelium has only one layer of cells, but this is responsible for
maintaining the essential deturgescence of the corneal stroma. The endothelium is
quite susceptible to injury as well as undergoing loss of cells with age. Endothelial
repair is limited to enlargement and sliding of existing cells, with little capacity
for cell division. Failure of endothelial function leads to corneal edema. 3

2.3 Pterygium
2.3.1 Definition
A pterygium is an elevated, superficial, external ocular mass that usually
forms over the perilimbal conjunctiva and extends onto the corneal surface.
Pterygia can vary from small, atrophic quiescent lesions to large, aggressive,

3
rapidly growing fibrovascular lesions that can disort the corneal topography, and,
in advanced cases, they can obscure the optical center of the cornea.5,6

2.3.2 Epidemiology
Pterygium spread throughout the world, but more in the hot, dry climates.
Prevalence is also high in the dusty and dry. Factors that often affect is the area
near the equator, which is the area which is located approximately 370 North and
South latitude from the equator. The high prevalence of up to 22% in the regions
near the equator and less than 2% in the area located above 400 latitude. The
incidence of pterygium is quite high in Indonesia, located in the equatorial region,
which is 13.1% .7
Patients under 15 years old are rare pterygium. Pterygium Prevalence
increases with age, especially the 2nd and 3rd decade of life. High incidence
between the ages of 20 and 49. The incidence of recurrency more often at young
age than old age. Men 4 times more risky than women and is associated with
smoking, low education, history of exposure to the outside environment.7,8

2.3.3 Pathogenesis
The etiology of pterygium is unclear. But the disease is more common in
people who live in hot climate areas. Therefore an overview of the most accepted
of it is a response to environmental factors such as exposure to the sun
(ultraviolet), dry area, inflammation, areas of high winds and dust or other
irritants factors. Local drying of the cornea and conjunctiva caused by tear film
abnormalities cause the growth of new fibroplastic is one of the theories. The high
incidence of pterygium in cold area with dry climate supports the theory.9
Ultraviolet is a mutagen to p53 tumor suppressor gene in the basal limbal
stem cell. Without apoptosis, transforming growth factor-beta is produced in
excessive amounts and cause increased collagenase process. The cells migrate and
angiogenesis. The result is degeneration of collagen and visible changes in
subepithelial tissue fibrovascular. Subconjunctival tissue elastoic degeneration ,
proliferation of vascular tissue below the epithelium and then penetrate the

4
corneal. Damage to the cornea appears in the bowman membrane layer by
fibrovascular tissue growth, often accompanied by mild inflammation. The
epithelium may be normal, thick or thin, and sometimes occurs dysplasia.1,9,10
Limbal stem cells are the source of the regeneration of the corneal
epithelium. In the state of limbal stem cell deficiency, there will be formation of
conjunctival tissue on the surface of the cornea. Symptoms of deficiency are
limbal conjunctival growth into the cornea, vascularization, chronic inflammation,
damage to the basement membrane and the growth of fibrotic tissue. They are also
found in pterygium and therefore many studies suggest that pterygium is a
manifestation of a deficiency or dysfunction of limbal stem cell. The possibility of
interpalpebra limbal stem cell damage caused by ultraviolet light.7

2.3.4 Clinical Features and Classification

Patients who present with a history of recent enlargement are more likely to
require early excision for subsequent aggressive growth. Aggressive growth or an
atypical appearance should prompt excision biopsy. These are the symptoms of
pterygium:4
a. Most small lesions are asymptomatic
b. Irritation and grittiness are caused by a dellen localized drying effect
at the advancing edge due to interference with the precorneal tear film
(more likely if the head of the pterygium is especially elevated).
c. Patients who wear contact lenses may develop symptoms of irritation at
an earlier stage due to edge lift.
d. Lesions may interfere with vision by obscuring the visual axis or
inducing astigmatism.
e. There may be intermittent inflammation similar to pingueculitis.
f. Cosmesis may be a significant problem.
g. Extensive lesions, particularly if recurrent, may be associated with
subconjunctival fibrosis extending to the fornices that may cause
restricted ocular excursion.

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h. If pseudopterygium is suspected, there may be a history of a causative
episode.
These are the signs of pterygium:4
a. A pterygium is made up of three parts: a cap (an avascular halo-like
zone at the advancing edge), a head and a body
b. Linear epithelial iron deposition (Stocker line) may be seen in the
corneal epithelium anterior to the head of the pterygium
c. Fuchs islets are small discrete whitish flecks consisting of clusters of
pterygial epithelial cells often present at the advancing edge
d. A pseudopterygium is classically distinguished by both location away
from the horizontal (though this may also be seen with true pterygia) and
firm attachment to the cornea only at its apex (head).
Pterygium can be classified into:11
a. Type I: extends approximately 2 mm of the cornea. Stoker's line or iron
deposits can be found in the corneal epithelium and the head of
pterygium. The lesions are often asymptomatic although often only
slight inflammation. Patients with contact lens wear may have
complaints more quickly.
b. Type II: cover up to 4 mm of the cornea, refractive primary or recurrent
after surgery, affect the tear film and cause astigmatism.
c. Type III: 4 mm of the cornea and interfere with the visual axis.
Extensive lesions, especially recurrent subconjunctival fibrosis can be
associated with that extends to fornik and usually cause eyeball
movement disorders.
Pterygium can also be divided into four degrees, which are:12
a. Grade 1: if the pterygium is confined to the corneal limbus.
b. Grade 2: if it passes the corneal limbus but not more than 2 mm pass
through the cornea.
c. Grade 3: already exceed grade 2 but does not exceed the outskirts of
pupils in normal light conditions (pupil in normal circumstances about 3-
4 mm).

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 d. Grade 4: pterygium growth through the pupil so could disturbing the
visual.

2.3.5 Differential Diagnosis

A pterygium can be clinically distinguished from two similar conditions,
pinguecula and pseudopterygium. The former is a small, elevated, yellowish mass
confined to the limbus and bulbar conjunctiva in the intrapalpebral fissure and
may occasionally become inflamed. Surgical excision is rarely indicated, but if
done, the lesion tends not to recur.13 Both its prevalence and incidence increase
with age.14 Pingueculae are common in both temperate and tropical climates and
occur with similar frequency in both sexes.14 Exposure to ultraviolet light does not
increase the risk of developing a pinguecula.15,16

Pterygium-like growths presenting at an oblique angle should suggest an

alternate diagnosis, such as pseudopterygium or Terrien's marginal degeneration.17
Pseudopterygium may mimic the appearance of pterygia, since it is a
fibrovascular scar arising in the bulbar conjunctiva that extends onto the
cornea.18 In contradistinction to pterygium, pseudopterygia are the result of
previous ocular surface inflammation from such varied causes as trauma, chemical
burns, cicatrizing conjunctivitis, surgery, or peripheral corneal ulceration. The
identifying feature of pseudopterygia is their lack of adhesion to the corneal
limbus. A probe or muscle hook can easily pass underneath pseudopterygia at the
limbus, whereas usually it cannot with true pterygia.17 The lack of organization of
pseudopterygia into recognizable parts (cap, head, and body) and their tendency to
occur outside the interpalpebral space further distinguish them from true pterygia.

Ninety percent of pterygia are located nasally.17 Nasal and temporal pterygia
can occur in the same eye, but isolated temporal pterygia are extremely rare. 8Both
eyes are frequently involved, but often asymmetrically. It is unusual for the apex
to extend across the midline.19

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2.3.6 Management
Patient with pterygium can be observed unless the lesions exhibit growth
toward the center of the cornea or the patient exhibits symptoms of significant
redness, discomfort, or alterations in visual function. Pterygia can be removed for
cosmetic reasons, as well as for functional abnormalities of vision or discomfort.20
Surgery for excision of pterygia is usually performed in an outpatient setting
under local or topical anesthesia eith sedation, if necessary. Multiple different
procedures have been advocated in the treatment of pterygia. These procedures
range from simple excision to sliding flaps of conjunctiva with and without
adjunctive external beta radiation therapy and/or use of topical chemotherapeutic
agents, such as mitomycin C (MMC).21,22
Using free grafts of conjunctiva (with or without limbal tissue) at the same
time as primary excision of the lesion has been widely advocated as the preferred
treatment modality for aggressive pterygia. For moderate-to-severe pterygia, some
corneal surgeons use amniotic membrane transplants. Both the conjunctival
autografts and the amniotic membrane transplants may be sutured onto adjacent
conjunctiva and subjacent cornea. Some corneal surgeons seal the graft tissue onto
the underlying sclera with the aid of fibrin tissue glue rather than with
sutures.23,24,25,26,27,28
A study by Kheirkhah et al found that conjunctival inflammation was much
more common with amniotic membrane transplantation than with conjunctival
autograft after pterygium surgery. However with control of such inflammation
and intraoperative application of mitomycin C, both techniques brought similar
final outcomes.29

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 CHAPTER III
CASE PRESENTATION

1. Patient identity
Name : Fatimah
Sex : Female
Age : 45 years old
Address : Mempawah
Ethnic : Melayu
Occupation : Housewife
Religion : Moslem
Date of consult : February 1st 2017

2. Anamnesis
a. Chief complaint :
Redness membrane appeared on the right eye.

b. History of disease :
Patient come to the Klinik Mata dan THT Ayani, complaining about the
reddish white membrane appeared on her right eye since ten years ago.
The membrane form a triangle. At first, patient realized this membrane as
a small membrane on the right eye near the nose (didnt involved the black
part of the eye) since 10 years ago. Then, the membrane were growing
increasingly creeping closer to the black part of the patient's eye. Patient
also getting the foreign body sensation on her right eye. The complains
especially appears when in hot weather, and also windy weather. Patient is
not using any drugs to cope her complain. There is no itchy eyes and eye
discharge. Disturbances in vision also denied. A history of trauma to the
eye denied. History of chemical exposure to the eye were also denied. The
use of glasses or contact lenses denied. Another ocular disease history was
denied.

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 c. Past clinical history :
Patient said she never experienced a history of trauma to her eyes. Didnt
use any glasses or lense before. No history of diabetic mellitus,
hypertension and allergy.

d. Family history
There are no one of her family have the same complaint. Diabetes mellitus
and hypertension history in family was denied by patient.

3. General Physical assessment

General condition : Good, with no pain
Awareness : Compos mentis
Vital sign :
a. Blood Pressure : 120/80 mmHg
b. HR : 84 x/minute
c. RR : 18 x/minute
d. Temperature : 36,6C

4. Ophthalmological status
Visual acuity :
a. OD : 5/30 ph no improvement
b. OS : 5/5

Right eye Left eye

Orthophoria Eye ball Orthophoria
position

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 Eye
Movement

ptosis (-), lagoftalmos (-), Palpebra ptosis (-), lagoftalmos (-),

exoftalmos (-), edema (-) exoftalmos (-), edema (-),
tenderness (-), trichiasis (-), tenderness (-), trichiasis (-),
sikatriks (-) sikatriks (-)
Tarsal : hiperemi (-), Conjunctiva Tarsal : hiperemi (-),
membrane (-) membrane (-)
Bulbi : Redness (-), Bulbi : Redness (-), discharge
discharge (-), triangle-shaped (-), injection conjungtiva (-),
reddish membrane with base cililary injection (-)
on nasal side conjunctiva
and peak on the cornea
triangle-shaped reddish Cornea edema (-), defect (-), infiltrate (-)
membrane with base on nasal ulcer (-)
side conjunctiva and peak on the
cornea, in front of the pupil
clear, deep COA clear, deep
Iris colour : brown Iris and Iris colour : brown
Pupil: circular, 3mm, isokor, pupil Pupil: circular, 3 mm, isokor,
Direct light pupillary reflex (+), Direct light pupillary reflex (+),
consensual reflex (+) consensual reflex (+)
Clear Lens Clear
Clear, no hermorrhage Vitreous Clear, no hemorrhage
Optic disk : firm margin, Fundus Optic disk : firm margin,

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 yellowish, rounded, C/D ratio yellowish, rounded, C/D ratio 1:3
1:3 Blood vessel : AV ratio (arteri 2:3
Blood vessel : AV ratio (arteri vena)
2:3 vena)

Shadow test :
OD : Negative
OS : Negative
Tonometry
OD : 15 mmHg
OS : 16 mmHg
Visual field test
OD : Normal
OS : Normal
Ishihara test
OD : Not performed
OS : Not performed
Fluorescein test
OD : Not performed
OS : Not performed

5. Resume
Patient come to an Ophtalmologist complaining about the reddish white
membrane appeared on her right eye since ten years ago. The membrane form a
triangle. At first, patient realized this membrane as a small membrane on the right
eye near the nose (didnt involved the black part of the eye) since 10 years ago.
Then, the membrane were growing increasingly creeping closer to the black part
of the patient's eye. Patient also getting the foreign body sensation on her right
eye. The complains especially appears when in hot weather, and also windy
weather. Patient is not using any drugs to cope her complain. There is no itchy

12
eyes and eye discharge. Disturbances in vision also denied. A history of trauma to
the eye denied. History of chemical exposure to the eye were also denied.
From the ophtalmology examination, visual activity on the right eye 5/30 and
in the left eye 5/5. Conjunctiva of the right eye has fibrovascular growth from
nasal side and growing onto the cornea and reaching in front of the pupil.

6. Diagnose
Working Diagnose:
OD : Pterygium grade IV
OS :-

7. Treatment
Non medicamentous :
a. Educate the patient to use a protective glasses or wear hat when the
patient go outside
Surgery
a. Conjunctival autograft with MMC intraoperative

8. Prognosis
a. Ad vitam : bonam
b. Ad functionam : dubia ad bonam
c. Ad sanactionam : dubia ad bonam

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 CHAPTER IV
DISCUSSION

From anamnesis, a 45 years old female was found to have typical

symptoms of pterygium which is the appearance of membranes on the nasal side
conjunctiva, triangular-shaped with the peak is on the cornea in front of the pupil,
as well as the foreign body sensation. The patient had no impaired vision
complains, discharge, itching, swelling and pain. It can distinguish this case from
red eye with decreasing visus diagnostic.

From physical examination on the oculi dextra found a triangular-shaped

fibrovascular membrane from the nasal side conjunctiva that passes through the
corneal and lasts in front of the pupil. Based on the clinical criteria degree, this
condition included on grade IV pterygium oculi dextra. Distinguishing the
diagnosis of pterygium with other differential diagnosis, in pseudopterygium, the
membrane appeared is not only started from the nasal or temporal side, but could
be from anywhere. In addition, from the anamnesis can be found the history of
ocular trauma before. Pterygium can also be distinguished by pinguecula from the
location. In Pinguecula, there is membrane like bump that only can appear on the
conjunctiva and limbus. Pinguecula never arrive on thr cornea. While in this case
from the examination found that the triangular-shaped membrane is achieving the
cornea.

For the treatment, it is recommended to reduce the outdoor activities and

wear a hat and sunglasses when they're outdoor. It is intended to minimize
exposure of the UV rays so that the likelihood progression of the disease would
decrease and minimize dust that can irritate the eyes.

Surgical treatment is recommended to this patient due to the condition of

the pterygium itself is growing onto the cornea and is threatening the visual axis.
Even the patient doesnt complaining about the visual disturbance for her daily
activity, but the visual acuity is decreasing. The surgical treatment that can be

14
done is conjunctival autograft technique. Conjunctival autograft technique is
chosen because of the recurrence rates are low (reported as low as 2 percent and
as high as 40 percent). Besides the complications are infrequent. A study by
Lawrence H. Hirst reported and recommends a large incision for pterygium
excision and a large graft and has reported a very low recurrence rate with this
technique.

Mytomycin C intraoperative usage considered in this case to reduce

recurrence of pterygium because of its ability to inhibit fibroblasts. There are two
forms of MMC that are currently used: the intraoperative application of MMC
directly to the scleral bed after pterygium excision, and the postoperative use of
topical MMC eyedrops. Several study now advocate the use of only intraoperative
MMC to reduce toxicity.

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 CHAPTER V
CONCLUSION

Mrs F 45 years old complaint a membrane appeared on her right eyes

since 10 years ago. She complains about the foreign body sensation on her right
eyes, but there is no visual disturbance. The complains especially appear in hot
and windy weather. In ophtalmology examination, visual activity on the right eye
is 5/30. Conjunctiva of the right eye has fibrovascular growt from nasal side and
infiltrate to cornea until in front of pupil. The diagnose for the right eye is
Pterygium grade IV. The therapy include non-medicamentous (wearing
eyeglasses or hat when patient having outdoor activity) and the surgical treatment
to remove the pterygium with conjunctival autograft technique with intraoperative
MMC.

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