PTERYGIUM

Understanding and
managing pterygium
Anthony Bennett Hall to see if the symptoms have improved
Consultant Ophthalmologist: Hunter with conservative treatment and to check
Eye Surgeons, Newcastle Eye Hospital,
if the pterygium has grown.
Newcastle, Australia.
Use an information leaflet to help you
A pterygium is a wing-shaped fibrovas- to counsel patients. We use a leaflet
cular proliferation of the conjunctiva that which has a picture of a pterygium, a

Anthony Bennett Hall

grows across the cornea.1 Pterygium list of indications, a description of the
occurs more frequently in people who live procedure, what to expect in the post-
in areas with high ultraviolet radiation. operative period, possible complications,
Dusty, hot, dry, windy, and smoky and the likelihood of recurrence. The
environments also play a part.2 Most picture is useful in helping you to explain
occur on the nasal side. Pterygium examined using a slit lamp the diagnosis, the indications for surgery
and the pterygium operation. Warn
be valuable in detecting irregular astig-
Diagnosis matism and distortion caused or induced
patients that the eye may be quite painful
Step 1. Taking a detailed history for a day or two.
by pterygium.
How long has the growth been present?
Typically, this would be for many months When to treat
Complications
or years. This helps to differentiate it Patients need to be fully informed
The most important indications for
from ocular surface squamous neoplasia about possible complications before
treatment are:
(OSSN), which tends to have a shorter you start.
history (see pages 52–53). • Involvement of, or threat to, the visual Complications can occur during the
Ask the patient if it has been getting axis operation or may present later.
bigger. Some pterygia are inactive and • Loss of vision from astigmatism Intraoperative complications include:
have not grown for decades. • Restriction of eye movement
• Perforation of the globe
What symptoms is the patient • Atypical appearance suggesting
• Thinning of sclera or cornea from
complaining of? There may be redness, dysplasia
dissection
irritation, blurring of vision, double • Increasing size (documented by an
• Intraoperative bleeding
vision, itching, and a concern about the ophthalmologist)
• Excessive cautery
cosmetic appearance.3 Less important indications are: • Muscle damage
• Increasing size (reported by the patient) • Reversing the conjunctival autograft
Step 2: Examination
• Symptoms of irritation and complaints (placing it epithelial surface down)
Check the visual acuity. You should
always do a complete eye examination of redness, etc. Early postoperative complications
and look for other causes of discomfort or • Cosmetic issues include:
vision loss.
Counselling patients • Persistent epithelial defects
Measure the size of the pterygium from
• Dellen formation (an area of corneal
the limbus to the apex of the pterygium Patients benefit from counselling before
thinning adjacent to limbal swelling
on the cornea. Record this on a diagram and after the operation.
that prevents normal wetting of the
in the clinical record so that, the next time Not every pterygium needs to be
corneal surface)
you see the patient, you can tell if the operated on. Some patients may expect
• Haematoma beneath the graft
pterygium has grown. to have their pterygium removed when
• Loss of the graft
Look for any atypical simple conservative
features that might ‘You should always treatments such as
• Pyogenic granuloma
make you worry about lubricating drops or Late complications include:
dysplasia (early-stage do a complete eye steroids may be all
• Recurrence
cancer), such as leuco-
plakia (an elevated,
examination and that is needed. It is
important to explain
• Corneo-scleral necrosis
• Scleritis
white, dry-looking patch), look for other to patients that there
• Endophthalmitis
a raised gelatinous mass, is a chance of recur-
or a large, prominent causes of rence, so the pterygium Recurrence is a major late complication.
feeder blood vessel. Be may come back even The highest rate of recurrence occurs in
especially alert if you discomfort or if it has been surgi- the bare sclera technique.1,5 The section
live in Africa where there
is a high prevalence of
vision loss.’ cally removed. However,
surgery with a conjunc-
opposite describes a technique of
excision with conjunctival autografting,
OSSN.4 tival graft (as described which reduces the recurrence rate.1 You
Examine the eye movements to look opposite) substantially reduces the risk may wish to consider using adjuvants
for any evidence of restricted movement of recurrence. such as 5-fluorouracil or mitomycin C,
caused by the pterygium. Compile a list of indications to suit but be aware that mitomycin C is
Retinoscopy will reveal any with-the- your setting. Use the list to counsel associated with a higher rate of visually
rule astigmatism that may be caused by patients about their suitability for an threatening complications. Adjuvants can
the pterygium. Corneal topography can operation. Review them in a few months be reserved for recurrent cases.1

54 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016

Pterygium surgery: the conjunctival autografting technique
Before the operation
Consider using steroids for a few days
preoperatively to reduce inflammation.
Before you begin giving the anaes-
thetic, check the notes to make sure
you are proceeding on the correct eye.
Mark the eye, as you would for any eye
procedure, to avoid possible confusion.
Give the patient topical anaesthetic
drops before they come into the theatre.
Dilating drops will help reduce the pain
from postoperative ciliary spasm.5
Anaesthesia
If you have a cooperative
patient, you can infiltrate
local anaesthetic under the
conjunctiva using a fine-gauge
needle. Use a long-acting
anaesthetic such as bupiv-
acaine as this can give some
hours of pain relief after the
operation. Adrenaline will aid
haemostasis.
Anthony Bennett Hall
conjunctival sac with 5% (aqueous)
povidone iodine solution, and drape
the patient. A scrub nurse should assist
you. A surgical pack containing an eyelid
speculum, two pairs of Moorfield’s
forceps, fine-toothed forceps, Wescott
scissors, needle holder, crescent blade or
No. 15 blade, bipolar or ball cautery, fine
absorbable suture (7-0 or 9-0) or 10-0
nylon and swabs.
Even if you have given a sub-Tenon’s
block, injecting anaesthetic with adren-
aline under the conjunctiva will help to
Figure 1. Dissecting pterygium off the limbus
elevate the pterygium off the sclera and
separate the conjunctival epithelium
from the underlying Tenon’s capsule.
The vasoconstrictive effect will also
limit bleeding. A traction suture may be
needed to move the eye if the patient has
had a block. This may be inserted through
the superior peri-limbal conjunctival
tissues or be a corneal traction suture.
Excising the pterygium
To get a good view, ask the patient to look
in the direction away from the pterygium.
Start the excision of the
pterygium by grasping it with
Moorfields forceps and making
radial incisions with Wescott
scissors along the edges. Find
the plane under the pterygium
and Tenon’s capsule anterior
to the medial rectus muscle.
Take care to stay away from
the medial rectus muscle so
that it is not cut or damaged

inadvertently. Cut along the

Infiltrate the anaesthetic base of the pterygium (parallel
under the pterygium and under to the limbus). Make sure you
the conjunctival epithelium stay anterior to the plica. The
supero-temporally. The pterygium should lift easily
advantage of local infiltration off the sclera. It becomes
is that the patient retains the Figure 2. Dissecting thin graft off Tenon’s capsule adherent at the limbus and
ability to move the eye and can you will need to use a crescent
be asked to look left, right or blade or No. 15 blade to
down to expose the part of the carefully dissect it off the
eye that is being operated on. cornea (Figure 1). The sclera
Give a sub-Tenon’s anaes- must be clean of any Tenon’s
thetic if the patient is likely capsule.
to be uncooperative or if you Ask your assistant to keep
anticipate a lengthy procedure. the field free of blood so that
You will need to reassure the you have a clear view of the
Anthony Bennett Hall

patient and explain each step depth of your dissection.

as you proceed with the anaes- Most bleeding will stop of
thesia and the excision. its own accord. Only use
cautery if the bleeding is so
Pterygium profuse that it is likely to form
excision and a large haematoma and lift
Figure 3. Suturing limbal corner of graft to sclera the conjunctival graft off the
autoconjunctival sclera. A little blood will act as
graft autologous fibrin glue.
Pterygium surgery should not
be delegated to the most junior Taking the
trainee surgeon. Supervision of
trainees should be continued conjunctival
until they are competent at all autograft
the steps required. This will Ask the patient to look down.
reduce recurrence rates.3 Marking the epithelium with
Anthony Bennett Hall

Prepare the patient as a sterile skin marker will help

you would for intraocular you to identify the surface
surgery. Wear a sterile gown of the graft. Make two radial
and gloves, disinfect the incisions in the superior
skin around the eye and the Continues overleaf ➤

COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 55

PTERYGIUM Continued

bulbar conjunctiva. The incisions should Figure 4. Graft one week after surgery antibiotic drops 4 times a day for a week.
outline an area that is about the same The topical steroid should continue for at
in size as the nasal conjunctival defect. least a month.
Carefully dissect the conjunctiva off the Examine the patient the next day to
underlying Tenon’s capsule (Figure 2). make sure that the graft is in place.
Once you are in the correct plane you The next visit is at 1 week (Figure 4).
should incise the conjunctival graft along Review the patient at 1 month and
its posterior edge. Lift the posterior edge 3 months to make sure there are no

Anthony Bennett Hall

and carefully dissect off any adherent complications. Signs and symptoms of
Tenon’s capsule. Your assistant may recurrence usually occur 4–6 weeks after
hold one corner of the graft for you. The surgery.5
graft may be placed epithelium up on a Encourage the patient to return in a
paper template (suture cover) before it year so that you can check for any recur-
is cut off from the limbus. This improves sclera to avoid posterior migration of the rence of the pterygium.
the handling and orientation of the thin graft (Figure 3). Suture the remaining
conjunctival tissue.2 corners of the graft to the nasal
References
1 Kaufman SC, Jacobs DS, Lee WB, Deng SX, Rosenblatt
conjunctiva. If you are using nylon, use a MI, Shtein RM. Options and adjuvants in surgery
Placing and suturing the mattress suture to bury the knots. Place for pterygium: a report by the American Academy of
Ophthalmology. Ophthalmol 2013;120(1):201-8.
graft additional sutures as required to close Epub 2012/10/16.
Orientate the graft with the limbal donor any gaps between the graft and the 2 Koranyi G, Seregard S, Kopp ED. Cut and paste: a no
suture, small incision approach to pterygium surgery. Br
edge closest to the nasal limbus. nasal conjunctiva. J Ophthalmol. 2004;88(7):911-4. Epub 2004/06/19.
Fibrin glue can speed up pterygium Apply chloramphenicol ointment to the 3 Hirst LW. The treatment of pterygium. Surv Ophthalmol.
2003;48(2):145-80. Epub 2003/04/11.
surgery and may reduce postoperative conjunctiva and firmly pad the eye. 4 Gichuhi S, Sagoo MS, Weiss HA, Burton MJ.
pain.2 However, the cost of fibrin glue is Epidemiology of ocular surface squamous neoplasia in
prohibitive, even in some high-resource Postoperative care Africa. Trop Med Int Health. 2013;18(12):1424-43.
Epub 2013/11/19.
settings. A good alternative is 9-0 or 10-0 The patient will need good pain relief after 5 Sheppard JD, Mansur A, Comstock TL, Hovanesian
nylon: it is widely available, cheap, and surgery. We prescribe a combination of JA. An update on the surgical management of
pterygium and the role of loteprednol etabonate
causes no tissue reaction.5 paracetamol and codeine for a day or two. ointment. Clin Ophthalmol. 2014;8:1105-18. Epub
Anchor the two limbal corners to the Ask the patient to instil steroid and 2014/06/27.

© The author/s and Community Eye Health Journal 2016. This is an Open Access article distributed under the Creative Commons Attribution Non-Commercial License.

CLINICAL SKILLS FOR OPHTHALMOLOGY

Heiko Philippin
How to irrigate the eye
Sue Stevens • For severe acid or alkali burns,
Former Nurse Advisor, Community Eye emergency irrigation should continue
Health Journal, International Centre for
Eye Health, London School of Hygiene
for at least 15 minutes; 30 minutes
and Tropical Medicine, London, UK. is better. It is advisable to continue to
irrigate acid/alkali burn injuries for a
Remember to wash your hands before further 12–24 hours by setting up a
and after performing all procedures. saline drip to continue to gently irrigate
Indications the eye.
• To remove single or multiple foreign You will need:
bodies from the eye • A large syringe or a small receptacle Irrigating
• To wash the eye thoroughly following with a pouring spout, such as a feeding the eye
any chemical injury to the eye cup
• Irrigating fluid (normal saline or clean
Note: Irrigation of the conjunctival sac • Ask the patient to fix his/her gaze ahead.
water at room temperature)
is an emergency treatment if there has • Open the eyelids. If necessary, gently
• Local anaesthetic eye drops
been chemical injury to the eye. use eyelid retractors.
• Towel or gauze swabs
Alkali (e.g. lime) and acid (e.g. car battery) • Pour or syringe the fluid slowly and steadily,
• Lid retractors if available
solutions in the eye may cause serious from no more than 5 centimetres away,
• A bowl or kidney dish
damage to the cornea and conjunctiva, onto the front surface of the eye, inside
resulting in long-term loss of vision. Method the lower eyelid and under the upper
The sooner the chemical can be • Instil local anaesthetic eye drops. eyelid.
diluted and removed, the less likely there • With the patient lying down, protect the • If possible, evert the upper eyelid to
is to be damage to the ocular surface. neck and shoulders with a towel or sheet. access all of the upper conjunctival fornix.
Immediate, copious irrigation may • Place the bowl or kidney dish against • Ask the patient to move the eye in all
save the eye after chemical injury. the cheek, on the affected side, with the directions while the irrigation is maintained.
head tilted sideways towards it. • Check and record the visual acuity when
• For foreign body removal, a minute or • Fill the feeding cup or syringe with the the procedure is finished.
so of irrigation should be sufficient to irrigating fluid and test the temperature • In alkali and acid burns, refer the patient
remove any foreign bodies. on your hand. to an ophthalmologist for assessment.

56 COMMUNITY EYE HEALTH JOURNAL | VOLUME 29 ISSUE 95 | 2016 © The author/s and Community Eye Health Journal 2016. This is an Open Access
article distributed under the Creative Commons Attribution Non-Commercial License.