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 Berasal dari Bahasa Yunani ‘pterygio’ yg

berarti wing/sayap
 Jaringan fibrovaskular berbetuk sayap non
malignan dengan proliferasi yang lambat
 Berasal dari jaringan subkonjungtiva
 Dapat melebar ke kornea dan menggangu
visus
 World wide distribution.
 Distribusi hampir seluruh dunia
 Lebih sering pada iklim hangat dan kering
 Prevalensi : 22% daerah ekuator
<2% pada lintang antara
28-38degree.
 Berhubungan langsung dengan jumlah paparan sinar UV
 Jenis kelamin: laki-laki: perempuan = 2: 1
 Umur:> 40 tahun prevalensi tinggi
 20-40 tahun insiden tinggi.
 Di India prevalensi adalah 9,5%.
 Morbiditas: menyebabkan perubahan
signifikan dalam fungsi visual pada kasus-
kasus lanjut.
 Hubungan yang kuat antara paparan sinar UV
dan pembentukan pterygium.

 Lebih umum pada pasien yang bekerja di luar


ruangan.
 Dalam tukang las dari pekerja pabrik lainnya.
FAKTOR ANGIOGENESIS:
 Paparan UV yang lama menyebabkan
perubahan biologis pada membran bowman.
 Protein yang berubah sehingga terbentuk
dapat bertindak sebagai faktor angiogenik /
pterygiogenic
 Paparan UV: Dapat menginduksi hiperplasia
di sel limbal. Sel-sel yang berubah ini
menyerang kornea dan limbus yang bergerak
secara sentripental dengan mereka. Ini
menjelaskan bentuk sayap pterygium.

 Radiasi UV menyebabkan penipisan sel


langerhan di limbus. (Stocker's line).
 Paparan UVB + perubahan tear film

 kerusakan

 Kehilangan kolagen dan dehidrasi

 Akumulasi ekstraselluar matrix

 Antigenic,type1 HS Pinguecula
 Fibroblastic reaction
Inflammation
 PTERYGIUM PTERYGIUM
 Light entering the temporal limbus at
90degree is concentrated at medial limbus.

 Related to corneal curvature.

 This explains the predominance of medial


pterygium.
Lingkungan yang kering dan berdebu.

Pengeringan film air mata oleh angin


melemahkan jaringan spertiga medial dari
aperture palpebral.

Ini memungkinkan radiasi aktinik untuk


merusak konjungtiva, epitel kornea dan
membran bowman.
 MICROTRAUMA: iritasi mekanis oleh partikel
debu, diperkuat oleh aliran air mata dari
lateral ke medial.

 IMUNOLOGI: Kompleks iritasi IgE-sel yang


terikat memulai pelepasan mediator inflamasi
dari sel mast.
◦ Pelepasan faktor stimulasi.
◦ Pengembangan pterygium
 Ekspresi vimentin.
 Mutasi p53 menyebabkan penurunan
apoptosis dan peningkatan TGF-b yang
mengarah ke peningkatan pertumbuhan
jaringan.

 PTICEGIUM-RESUREN : Sel induk lebih


tersebar dan pola ekspresi lebih padat.
 HYPOXIA: peningkatan area non perfusi dan
pembuluh yang dilemahkan pada limbus
nasal selama tahap awal pterygium
menyebabkan perekrutan sel progenitor.

 Virus Marker : infeksi HPV dan virus herpes


dianggap sebagai faktor risiko (jarang).
 Degenerasi kolagen elastotik. (Bukan jaringan
elastis yang sebenarnya)
 Fibrovaskuler proliferasi dengan penutup asel
epitel. Dicirikan dengan
◦ proliferasi Seluler.
◦ Renovasi jaringan.
◦ Neovaskularisasi.

 Jaringan subepitel menunjukkan degenerasi


basofilik.
 Penghancuran selaput bowman di kornea.
 Jadi ada bekas luka /sikatrik kornea residual
ketika pertumbuhan ini dihilangkan.

 Epitel menunjukkan perubahan sekunder


seperti orthokeratosis, acanthosis,
dyskeratosis.

 Peningktan jumlah sel mast


Normal conjunctiva Pterygium
CLINICAL STAGING PATHOLOGICAL
STAGING
Stage I Exposure Size and number of Altered tear film
conjunctivitis Conjunctival vessels Mild vascular
Mild – moderate congestion response
S/S of dryness
No formed lesions
Stage II Pinguecula Distinct raised lesion on Cell injury
Grade I and pterygium bulbar conjunctiva Inflammatory
With or w/o abnormal response
vascularization and
inflammation
Stage III Limbal pterygium Head is on or across Lesion
Grade II the limbus with or w/o organization
an iron line at the
conjunctival corneal Mixed
interface proliferation
and
Vascularization and degeneration
fibrous proliferation
Symptoms more
pronounced

Stage IV Corneal Lesion 2mm or more Lesion b/w


Grade III pterygium into cornea epithelium and
Invasion of granulation bowman
tissue
Zone of dellen Mixed
Stocker’s line proliferative
Infiltration of corneal and
nerves- pain degeneration
Stage V Compound Induced astigmatism Lesion extended
pterygium Symptoms more into stroma
frequent and severe
Mixed
proliferative and
degeneration

Proliferation- Small lymphocytes and plasma cells


Degeneration- Swirls of type I collagen
 Fuch’s patches.
 Stocker’s line.
 Hood.
 Head.
 Body.
 Base.
 Superior edge.
 Inferior edge.
 Progressive: thick
fleshy
marked vascularity.
It has opaque infitrative spot known as cap.
Stocker’s line.

 Atrophic/stationary: thin
attenuated
poor vascularity
no cap.
Progressive pterygium Atrophic pterygium
 Primary double pterygium.
 Recurrent pterygium.
 Pseudopterygium.
 Malignant pterygium(rare):recurrent
pterygium with restriction of ocular
movements.
 Tanpa gejala
 Sensasi benda asing
 Tidak nyaman
 kongesti (kemerahan)
 Iritasi dan grittiness-gangguan dengan film
air mata precorneal.
 Gangguan penglihatan
◦ Menutup visual axis
◦ induksi astigmatisme
 Kosmetik.
Pterigium 4 grade:
Grade 1: puncak pterigium mencapai tepi limbus

Grade 2: melewati limbus kornea tapi tak lebih dari 2


mm

Grade 3: pterygium sudah melebihi grade 2 tapi tidak


melewati pinggiran pupil dalam keadaan cahaya
normal

Grade 4: pertumbuhan sudah melewati pupil sehingga


mengganggu penglihatan
Condition Signs and symptoms Tests

Pseudopterygiu Most often hx of -Slit-lamp examination:


m previous infective, reveals lesion to be
chemical, thermal, or adhesion of a fold of
traumatic injury to the conjunctiva, which has
cornea. occurred as a response to
May occur at multiple a previous peripheral
locations and is not corneal
restricted to the 3 and 9 ulcer/inflammation.
o'clock (interpalpebral) -Lesion typically only fixed
positions. at its apex to the cornea
so that a probe may be
passed underneath its
body at the limbus, while a
true pterygium adheres to
the underlying cornea
throughout its length.
Thinning of the underlying
cornea may be seen at its
head.
Pinguecula Does not encroach on Slit-lamp examination:
the cornea. reveals exact extent and
nature of lesion. A
pingueculum is limited to
limbus and conjunctiva
and does not encroach
onto the cornea.

Marginal keratitis Associated with Corneal swab/scraping:


blepharitis. Infiltrate on microscopy and culture
corneal surface is positive for infecting
separated by a clear organism, but infecting
zone from the limbus. organisms are often not
Occur at 2, 4, 8, and detected, as many cases
10 o'clock position. are due to an
Does not have typical inflammatory reaction to
pterygium shape. Often staphylococcal proteins
superior and inferior.
Corneal micropannus Hx of trachoma or lack Slit-lamp examination:
of corneal oxygenation reveals encroachment
due to excessive of fine blood vessels
contact lens wear. onto corneal surface.

Conjunctival Rare. Does not have Slit-lamp examination:


carcinoma in situ/ typical pterygium gelatinous-appearing
bowens epithlioma. shape. Not restricted mass.
to the 3 and 9 o'clock Biopsy: cytological
(interpalpebral) features of a
positions and can squamous cell
occur at any position carcinoma, but the
on the cornea. basal membrane of
the epithelium
remains intact.
Squamous cell Rare. Does not have typical Slit-lamp examination:
carcinoma pterygium shape. Not surface may appear
restricted to the 3 and 9 keratinised and
o'clock (interpalpebral) friable.
positions and can occur at Biopsy: well-
any position on the cornea. differentiated
May arise from a pterygium, squamous cell
carcinoma in situ, or de carcinoma with
novo. invasion of the basal
membrane.

Limbal dermoid Benign choriostomatous Histology contains


tissue. MC site:inferior abberant tissue like
temporal quadrant. epidermal
appendages,connectiv
e tissue,skin,fatmuscle
teeth.
Pinguekula

 Pseudopterygium
Keratitis marginal
 Tes Sonde
 Symptomatic patients- Tear substitutes / Air
mata buatan
 Inflammation- Topical steroids

 Kacamata hitam- mengurangi paparan sinar


UV dan menurunkan pertumbuhan
1. Extension to the visual axis and induced
astigmatism.

2. Recurrent irritation.

3. Cosmetic- patient should be explained


there is fairly high risk of recurrence, which
may be more unsightly.
 Free conjunctival autograft for primary and
recurrent pterygium.
 Pre op evaluation:
1. Evaluation of pterygium.
2. Evaluation of superior bulbar conjunctiva.
3. Pre op preparation.
4. Anaesthesia and sedation.
 Mechanism of action: it acts forming a fibrin
clot between graft and host tissue.
 Advantages : decreases the post op pain.
reduces the surgical time as well
as recurrence rate.
Disadvantage : not FDA approved.
graft dehiscence.
infection, discomfort.
Recurrence rate: less as compared to suture.
 Avoid exposure to sunlight.

 Use of dark sun glasses.

 Topical steroid antibiotic drops, topical


NSAIDS, artificial tears.

 POD3/5 graft acquires redness.


 Complete healing expected between 6-
8weeks.

 Topical medications should be tapered.


Lubricants should remain for 3months.

 Instruction to patient: avoid exposure to


sunlight.
 Graft failure.
 Granuloma formation.
 Conjunctival infection.
 Suture detachment.
 Delayed healing.
 Recurrence.
Bare sclera technique:
-recurrence:
5-68%
(primary)
35-82%
(recurrent)
 Subconjunctival scarring limitation of
movements diplopia.

 Disinsertion of medial rectus muscle.

 Scleral perforation.

 Corneal irregularity due to deep stromal


excision.
 Growth of fibrovascular tissue across the limbus
onto cornea after initial removal.

 Excludes persistence of deeper corneal vessels


and scarring which may remain even after
adequate removal.

 Bunching of conjunctiva and formation of


parallel loops of vessels, which aim almost like
an arrowhead at the limbus, usually denotes a
conjunctival recurrence.
 Grade 1 – normal appearing
operative site.
 Grade 2 – fine episcleral
vessels in the site extending
to the limbus.
 Grade 3 – additional fibrous
tissues in site.
 Grade 4 – actual corneal
recurrence.
 The area of bare scleral was covered with
amniotic membrane, which was oriented with
the basement membrane side up.

 The amniotic membrane was sutured


through the episcleral tissue to the edge of
the conjunctiva along the bare sclera border
with 7-8 interrupted 8-0 Vicryl sutures.

 The eye was patched.


 Useful in:

 very large conjunctival defects.


 To preserve superior conjunctiva for future
glaucoma surgery.

 Advantages: faster healing rate


less discomfort.
lower recurrence rate(2% in
1year follow up)