A pterygium is a triangular, vascular sheet of tissue that begins in the conjunctiva covering the white of the eye and advances onto the clear cornea. It is benign and it is not a cancer, but because it tends to progress rather than stay put, it needs monitoring.
It usually appears on the nasal side of the eye. Light entering from the side is refracted at the corneal edge and concentrates on the nasal limbus, which explains both the typical location and why one eye is often more affected than the other.
Pterygium is frequently confused with pinguecula. A pinguecula is also a yellowish raised patch of conjunctiva near the corneal edge, but it does not advance onto the cornea. It is usually monitored and rarely needs surgery.
The diagnosis is made at the slit lamp. I measure how many millimetres the lesion has advanced onto the cornea, how densely vascularised it is and how close it lies to the visual axis. Thick, richly vascularised pterygia through which the underlying tissue cannot be seen are considered more active and progress faster. Visual acuity and astigmatism readings show whether the tissue is distorting the cornea. Photographic documentation is the most practical way of following progression objectively.
Not every pterygium needs surgery. Small, quiet and symptom-free lesions are managed with sun protection and artificial tears. I recommend surgery when the lesion advances towards the visual axis, when astigmatism is affecting vision, when blur cannot be corrected with glasses or lenses, when irritation and redness persist despite drops, when it prevents contact lens wear, or when the appearance genuinely troubles the patient.
Surgery is carried out under drops and local anaesthesia, general anaesthesia is not required, and it usually takes 20 to 30 minutes. Patients go home the same day.
The pterygium is carefully separated from the corneal surface and the underlying sclera. The corneal surface is then smoothed, and the care taken at this step has a direct effect on the quality of vision afterwards.
How the bare area is covered after removal is the decisive step of the operation. I take a thin patch of healthy conjunctiva from the upper part of the patient's own eye and lay it over the bare area; this is called a conjunctival autograft. The donor site heals on its own and leaves no scar. The graft can be secured with fine sutures or with tissue adhesive, and adhesive tends to leave less stinging afterwards.
The importance of the autograft is this: in the older technique, where the bare area was left uncovered, pterygium recurred at a high rate. Covering it with healthy conjunctiva brings the risk of recurrence down to a very low level. The widespread belief that this operation always comes back belongs to that older uncovered technique. Where a graft cannot be harvested or would be insufficient for a very broad lesion, amniotic membrane can be used instead.
Recurrence is what patients ask about most. With current autograft surgery the risk is low, and when recurrence does happen it is usually within the first 6 to 12 months, which is why follow-up during the first year matters. Factors that raise the risk are younger age, thick and actively vascularised lesions, lack of sun protection after surgery, and a previously recurrent pterygium.
Other possible issues are temporary swelling of the graft site, stinging from sutures, transient double vision and, rarely, persistent corneal haze. Most of these can be dealt with once they are picked up at follow-up.
The only effective prevention is reducing ultraviolet exposure. Whether or not surgery is planned, I advise ultraviolet-filtering sunglasses that also shield from the side, a wide-brimmed hat, eye protection in dusty and windy conditions, and artificial tears to keep the surface moist. Treating any accompanying dry eye disease reduces symptoms and leaves the surface less irritated. Not every growth on the conjunctiva is a pterygium; when the shape, colour or growth rate is unusual, conjunctival tumours enter the differential and the excised tissue is sent for pathology.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist, Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
That widespread belief belongs to the older technique in which the bare area was left uncovered. In current surgery a thin conjunctival patch, an autograft, is taken from the upper part of the patient's own eye and laid over the excised area, which brings recurrence down to a very low level. Recurrence, when it happens, is usually within the first 6 to 12 months, so I place real weight on follow-up during the first year.
No. Small, quiet and symptom-free lesions are managed with sun protection and artificial tears. I recommend surgery when the lesion advances towards the centre of the cornea, when astigmatism starts to affect vision, when irritation and redness persist despite drops, when it prevents contact lens wear, or when the appearance troubles the patient.
The operation is done under drops and local anaesthesia, so it is not painful, and it usually takes 20 to 30 minutes. General anaesthesia is not needed and patients go home the same day. Stinging, watering and light sensitivity are expected for the first two to three days, and simple pain relief can be used. When the graft is secured with tissue adhesive rather than sutures, there tends to be less stinging.
Marked redness lasts through the first week and largely subsides within two to four weeks. A fully normal appearance can take one to three months. Visual acuity settles gradually as the corneal surface recovers, so a new spectacle prescription is not given before that period is over. Swimming is usually postponed for the first month.
Small pterygia do not affect vision. As the tissue advances it pulls and flattens the cornea and produces astigmatism, at which point vision blurs and may not be fully correctable with glasses. Once it reaches the centre of the cornea it obscures vision directly. For that reason I advise assessment rather than waiting when there are signs of progression.
Both appear on the white of the eye near the corneal edge and both are linked to sun exposure. The difference is whether they advance onto the cornea: a pinguecula stays within the conjunctiva and does not cross onto the cornea, whereas a pterygium grows over it. Pinguecula is usually just monitored; pterygium comes to surgery when it progresses.
The only effective measure is reducing ultraviolet exposure. Use ultraviolet-filtering sunglasses that shield from the side and a wide-brimmed hat; for outdoor workers this is a necessity rather than a preference. Protect the eyes in dusty and windy conditions and keep the surface moist with artificial tears. These measures should continue after surgery as well, because they lower the risk of recurrence.
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