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EASY GUIDE TO
PTERYGIUM
CHARLES S. ZWERLING, MD FACSFormer Associate Clinical Professor
Of Ophthalmology
University of North Carolina
Goldsboro Eye Clinic2709 Medical Office PlaceGoldsboro, NC 27534phone: 919-736-3937fax: 919-735-3701Www.goldsboroeyeclinic.come mail: zwerling@micropigmentation.org
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
Published by
Page 8
Table of Contents
Signs & Symptoms
Patho-Physiology
Management
Clinical Pearls
Future Prospects
EASY GUIDE TO
PTERYGIUM
CHARLES S. ZWERLING, MD FACSFormer Associate Clinical Professor
Of Ophthalmology
University of North Carolina
Goldsboro Eye Clinic2709 Medical Office PlaceGoldsboro, NC 27534phone: 919-736-3937fax: 919-735-3701Www.goldsboroeyeclinic.come mail: zwerling@micropigmentation.org
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
Published by
Page 8
Table of Contents
Signs & Symptoms
Patho-Physiology
Management
Clinical Pearls
Future Prospects
EASY GUIDE TO
PTERYGIUM
CHARLES S. ZWERLING, MD FACSFormer Associate Clinical Professor
Of Ophthalmology
University of North Carolina
Goldsboro Eye Clinic2709 Medical Office PlaceGoldsboro, NC 27534phone: 919-736-3937fax: 919-735-3701Www.goldsboroeyeclinic.come mail: zwerling@micropigmentation.org
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
Published by
Page 8
Table of Contents
Signs & Symptoms
Patho-Physiology
Management
Clinical Pearls
Future Prospects
EASY GUIDE TO
PTERYGIUM
CHARLES S. ZWERLING, MD FACSFormer Associate Clinical Professor
Of Ophthalmology
University of North Carolina
Goldsboro Eye Clinic2709 Medical Office PlaceGoldsboro, NC 27534phone: 919-736-3937fax: 919-735-3701Www.goldsboroeyeclinic.come mail: zwerling@micropigmentation.org
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
Published by
Page 8
Table of Contents
Signs & Symptoms
Patho-Physiology
Management
Clinical Pearls
Future Prospects
EASY GUIDE TO
PTERYGIUM
CHARLES S. ZWERLING, MD FACSFormer Associate Clinical Professor
Of Ophthalmology
University of North Carolina
Goldsboro Eye Clinic2709 Medical Office PlaceGoldsboro, NC 27534phone: 919-736-3937fax: 919-735-3701Www.goldsboroeyeclinic.come mail: zwerling@micropigmentation.org
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
GOLDSBORO EYE CLINICCHARLES S. ZWERLING, MD, FACSWWW.GOLDSBOROEYECLINIC.COM
Published by
Page 8
Table of Contents
Signs & Symptoms
Patho-Physiology
Management
Clinical Pearls
Future Prospects
Page 2 Page 7
creating a symptomatic dry eye syndrome.
Rarely, the pterygium may induce irregular corneal warpage, or
even obscure the visual axis of the eye,
resulting in diminished acuity.
Clinical inspection of pterygium reveals a
raised, whitish, triangular wedge of fibrovascular tissue,
whose base lies within the inter-palpebral
conjunctiva and whose apex encroaches the cornea. The leading
edge of this tissue often displays a fine, reddish-brown iron deposition line (Stocker's line). The vast majority of pterygia (about 90
percent) are located nasally. These lesions are more commonly
encountered in warm, dry climates, or in patients who are
creating a symptomatic dry eye syndrome.
Rarely, the pterygium may induce irregular corneal warpage, or
even obscure the visual axis of the eye,
resulting in diminished acuity.
Clinical inspection of pterygium reveals a
raised, whitish, triangular wedge of fibrovascular tissue,
whose base lies within the inter-palpebral
conjunctiva and whose apex encroaches the cornea. The leading
edge of this tissue often displays a fine, reddish-brown iron deposition line (Stocker's line). The vast majority of pterygia (about 90
percent) are located nasally. These lesions are more commonly
encountered in warm, dry climates, or in patients who are
SIGNS AND SYMPTOMS
In most cases, routine ocular evaluation
reveals pterygium in asymptomatic
individuals or in patients who present with
cosmetic concern about a tissue "growing over
the eye." In some instances, the
vascularized pterygium may become red and
inflamed, motivating the patient to seek
immediate care. In other cases, the
irregular ocular surface can interfere with the
stability of the precorneal tear film,
SIGNS AND SYMPTOMS
In most cases, routine ocular evaluation
reveals pterygium in asymptomatic
individuals or in patients who present with
cosmetic concern about a tissue "growing over
the eye." In some instances, the
vascularized pterygium may become red and
inflamed, motivating the patient to seek
immediate care. In other cases, the
irregular ocular surface can interfere with the
stability of the precorneal tear film,
ophthalmologist may recommend some
steroid eye drops for several weeks to
decrease the inflammation and
prevent regrowth of the pterygium.
FUTURE PROSPECTS
The first report of a surgical treatment of a pterygium is more than
3000 years old. The management of
pterygia and recurrent pterygia is improving yet many questions
remained unanswered. Future studies may
elucidate the cause of the pterygium as well as
the cause of complications related to the adjunctive therapy after pterygium surgery and prevent recurrence.
ophthalmologist may recommend some
steroid eye drops for several weeks to
decrease the inflammation and
prevent regrowth of the pterygium.
FUTURE PROSPECTS
The first report of a surgical treatment of a pterygium is more than
3000 years old. The management of
pterygia and recurrent pterygia is improving yet many questions
remained unanswered. Future studies may
elucidate the cause of the pterygium as well as
the cause of complications related to the adjunctive therapy after pterygium surgery and prevent recurrence.
If I have a pterygium, where can I be
evaluated?If you live in the
Goldsboro area, an appointment can be
made with the ophthalmologist,
Charles S. Zwerling, MD of Goldsboro Eye Clinic. For an appointment call
919-736-3937
If I have a pterygium, where can I be
evaluated?If you live in the
Goldsboro area, an appointment can be
made with the ophthalmologist,
Charles S. Zwerling, MD of Goldsboro Eye Clinic. For an appointment call
919-736-3937
Page 3Page 6
What is involved in the surgical removal of a
pterygium?
The removal may take place in a procedure
room or operating room setting. The pterygium is carefully dissected
away. In order to prevent regrowth of the
pterygium, your ophthalmologist may remove some of the surface tissue of the
same eye (conjunctiva) and suture it into the bed of the excised
pterygium. Alternatively, an antimetabolite such as mitomycin may be
applied to the site. Postoperatively, your
What is involved in the surgical removal of a
pterygium?
The removal may take place in a procedure
room or operating room setting. The pterygium is carefully dissected
away. In order to prevent regrowth of the
pterygium, your ophthalmologist may remove some of the surface tissue of the
same eye (conjunctiva) and suture it into the bed of the excised
pterygium. Alternatively, an antimetabolite such as mitomycin may be
applied to the site. Postoperatively, your
pterygium be surgically removed?
This will depend largely on the judgment of your physician. Removal will likely be advised if the
pterygium is growing far enough onto the cornea to threaten your line of vision. Pterygia may
also be removed if they cause a persistent
foreign body sensation in the eye, or if they are constantly inflammed
and irritating. In addition, some pterygia grow onto the cornea in
such a way that they can pull on the surface
of the cornea and change the refractive properties of the eye, causing astigmatism.
Removing the pterygium may decrease the astigmatism.
pterygium be surgically removed?
This will depend largely on the judgment of your physician. Removal will likely be advised if the
pterygium is growing far enough onto the cornea to threaten your line of vision. Pterygia may
also be removed if they cause a persistent
foreign body sensation in the eye, or if they are constantly inflammed
and irritating. In addition, some pterygia grow onto the cornea in
such a way that they can pull on the surface
of the cornea and change the refractive properties of the eye, causing astigmatism.
Removing the pterygium may decrease the astigmatism.
persons who spend a great deal of time
outdoors. Other agents that may contribute to
the formation of pterygia include
allergens, noxious chemicals and irritants
(e.g., wind, dirt, dust, air pollution). Heredity may
also be a factor. Whatever the etiology, pterygia represent a degeneration of the
conjunctival stroma with replacement by
thickened, tortuous elastotic fibers.
Activated fibroblasts in the leading edge of the pterygium invade and fragment Bowman's
layer as well as a variable amount of the
superficial corneal stroma. Histologically,
pterygium development resembles actinic
degeneration of the skin.
Pterygia often persist
persons who spend a great deal of time
outdoors. Other agents that may contribute to
the formation of pterygia include
allergens, noxious chemicals and irritants
(e.g., wind, dirt, dust, air pollution). Heredity may
also be a factor. Whatever the etiology, pterygia represent a degeneration of the
conjunctival stroma with replacement by
thickened, tortuous elastotic fibers.
Activated fibroblasts in the leading edge of the pterygium invade and fragment Bowman's
layer as well as a variable amount of the
superficial corneal stroma. Histologically,
pterygium development resembles actinic
degeneration of the skin.
Pterygia often persist
chronically exposed to outdoor elements or
smoky/dusty environments.
Pterygia must be distinguished from
pingueculae, which are more yellow in color
and lie within the interpalpebral space but
generally do not encroach beyond the limbus. Pingueculae also lack the wing-
shaped appearance of pterygia, the former being more oval or
ameboid in appearance.
PATHOPHYSIOLOGY Ultraviolet light
exposure (both UV-A and UV-B) appears to be the most significant
factor in the development of
pterygia. This may explain why the
incidence is vastly greater in populations
near the equator and in
chronically exposed to outdoor elements or
smoky/dusty environments.
Pterygia must be distinguished from
pingueculae, which are more yellow in color
and lie within the interpalpebral space but
generally do not encroach beyond the limbus. Pingueculae also lack the wing-
shaped appearance of pterygia, the former being more oval or
ameboid in appearance.
PATHOPHYSIOLOGY Ultraviolet light
exposure (both UV-A and UV-B) appears to be the most significant
factor in the development of
pterygia. This may explain why the
incidence is vastly greater in populations
near the equator and in
Page 4 Page 5
(e.g., Naphcon-A) and/or mild topical
corticosteroids (e.g., FML, Vexol) four times
daily in the affected eye.
Surgical excision of pterygia is indicated
only for unacceptable cosmesis and/or
significant encroachment of the
visual axis. The treatment of choice
involves dissection and removal of the fibrous
tissue down to the level of Tenon's capsule.
Free conjunctival flaps are then grafted over
the bare sclera. Postoperative adjuvant therapy with b-radiation,
topical thiotepa, mitomycin-C and other antimetabolic agents
may diminish the chance of recurrence. In cases that involve significant corneal
scarring, lamellar or
(e.g., Naphcon-A) and/or mild topical
corticosteroids (e.g., FML, Vexol) four times
daily in the affected eye.
Surgical excision of pterygia is indicated
only for unacceptable cosmesis and/or
significant encroachment of the
visual axis. The treatment of choice
involves dissection and removal of the fibrous
tissue down to the level of Tenon's capsule.
Free conjunctival flaps are then grafted over
the bare sclera. Postoperative adjuvant therapy with b-radiation,
topical thiotepa, mitomycin-C and other antimetabolic agents
may diminish the chance of recurrence. In cases that involve significant corneal
scarring, lamellar or
and an ameboid shape. CIN is an invasive
ocular cancer that can inflict significant
morbidity. Obtain a biopsy if CIN is
suspected. Pterygia can affect vision if left
unchecked. The corneal degradation may extend
beyond the leading edge of the lesion. This
means that the pterygium need not
cover the visual axis to inflict significant visual compromise. Surgery must be performed
before vision is affected. Follow up on medium- to large-sized pterygia at least once or twice yearly, and include a manifest refraction,
corneal topography, slit lamp evaluation with measurement of the
pterygium, and photodocumentation if
possible.When should a
and an ameboid shape. CIN is an invasive
ocular cancer that can inflict significant
morbidity. Obtain a biopsy if CIN is
suspected. Pterygia can affect vision if left
unchecked. The corneal degradation may extend
beyond the leading edge of the lesion. This
means that the pterygium need not
cover the visual axis to inflict significant visual compromise. Surgery must be performed
before vision is affected. Follow up on medium- to large-sized pterygia at least once or twice yearly, and include a manifest refraction,
corneal topography, slit lamp evaluation with measurement of the
pterygium, and photodocumentation if
possible.When should a
penetrating keratoplasty may be indicated.
CLINICAL PEARLS
A pterygium is a benign clinical entity in most cases. Distinguish
between the potentially progressive pterygium
and the less threatening pinguecula-large
pingueculae may be difficult to differentiate
from pterygia. Conjunctival
intraepithelial neoplasia (CIN), a precursor of
conjunctival squamous cell carcinoma, is
another clinical entity that must be ruled out in
the diagnosis of pterygia. This lesion is
generally unilateral, elevated and
gelatinous, with deep irregular vascularization
penetrating keratoplasty may be indicated.
CLINICAL PEARLS
A pterygium is a benign clinical entity in most cases. Distinguish
between the potentially progressive pterygium
and the less threatening pinguecula-large
pingueculae may be difficult to differentiate
from pterygia. Conjunctival
intraepithelial neoplasia (CIN), a precursor of
conjunctival squamous cell carcinoma, is
another clinical entity that must be ruled out in
the diagnosis of pterygia. This lesion is
generally unilateral, elevated and
gelatinous, with deep irregular vascularization
after surgical removal; these lesions appear as
a fibrovascular scar arising from the
excision site. These "recurrent pterygia" probably have no
relationship to ultraviolet radiation, but rather may be likened to keloid development in
the skin.
MANAGEMENT
Because pterygia appear to be linked to
environmental exposure, manage
asymptomatic or mildly irritative cases with UV-blocking spectacles and
liberal ocular lubrication. Advise
patients to avoid smoky or dusty areas as much as possible. Treat more
inflamed or irritated pterygia with topical
decongestant/antihistamine combinations
after surgical removal; these lesions appear as
a fibrovascular scar arising from the
excision site. These "recurrent pterygia" probably have no
relationship to ultraviolet radiation, but rather may be likened to keloid development in
the skin.
MANAGEMENT
Because pterygia appear to be linked to
environmental exposure, manage
asymptomatic or mildly irritative cases with UV-blocking spectacles and
liberal ocular lubrication. Advise
patients to avoid smoky or dusty areas as much as possible. Treat more
inflamed or irritated pterygia with topical
decongestant/antihistamine combinations
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