Pterygium excision is a commonly-performed anterior segment surgical procedure that, while often perceived as relatively straightforward, can be associated with a significant risk of recurrence and various post-operative complications.
For ophthalmologists, achieving optimal surgical outcomes requires not only meticulous technical execution but also rigorous patient education, thoughtful intra-operative planning, and tailored post-operative management strategies.
This article outlines key surgical approaches, addresses intra-operative and post-operative complexities, and provides evidence-based recommendations aimed at minimizing recurrence rates and maximizing patient satisfaction.
Overview of pterygium
A pterygium is a wing-shaped fibrovascular proliferation of conjunctival tissue that invades the corneal surface, most frequently arising from the nasal limbus.1 It is considered a degenerative and proliferative disorder of the ocular surface, and its etiopathogenesis is multifactorial.2
Figure 1: Graded according to the Johnston, Williams, and Sheppard classification system, Grade III (A) and Grade IV (B) pterygium.3
Figure 1: Pterygium. ©Sara I Van Acker, et al. Used under CC BY-NC-ND 4.0.
Risk factors for pterygium
Chronic ultraviolet (UV) radiation exposure, alcohol use, and older age are some of the most strongly implicated risk factors, promoting limbal stem cell dysfunction and fibroblast activation.3
Clinically, pterygia are often asymptomatic in their early stages; however, progression can lead to ocular discomfort, chronic hyperemia, induced astigmatism, and eventual invasion of the visual axis, thereby compromising visual acuity.4
Surgical planning: Tailoring the technique to the patient
Pterygium removal is typically indicated for chronic irritation and inflammation, or visual impairment due to corneal encroachment.5 Despite the routine nature of the procedure, several operative and post-operative challenges persist.
Firstly, pterygia can have recurrence rates that are quite high, especially when using the traditional bare sclera technique, which can range from 38% to over 80% in some series.6,7 In contrast, techniques utilizing conjunctival autograft possibly with adjuvant therapies such as Mitomycin C (MMC) remain the gold standard of care, having the lowest recurrence rates of all available treatment techniques, at about 6 to 9% without MMC, and 3 to 4% with MMC. 8,9,10
Amniotic membrane transplantation (AMT)
However, when specific unique surgical considerations must be considered for high-risk patients, the amniotic membrane transplantation (AMT) technique has nearly comparable outcomes with the corneal autograft technique.11,12
The benefit of using this technique instead of the conjunctival autograft technique is that it preserves the patient’s native conjunctiva in anticipation of future procedures.
AMT in glaucoma and cataract patients
In particular, high-risk glaucoma patients who require acute intervention for pterygium may benefit from having an intact superior or inferonasal conjunctiva, in anticipation of the potential need for insertion of glaucoma drainage devices.13,14
Therefore, performing a conjunctival autograft in these areas can reduce the available surface for future glaucoma surgeries and increase the risk of implant failure or scarring. In such cases, using an amniotic membrane transplant instead may offer a strategic advantage, with the amniotic membrane becoming a scaffold for healing and inflammation control while sparing the patient’s native conjunctiva for future surgical access.
Furthermore, in patients with coexisting cataracts, the timing of pterygium excision can directly impact refractive outcomes.15 Large or nasally extending pterygia, especially those encroaching on the visual axis or pupillary zone, can induce irregular astigmatism and distort keratometry readings.
If cataract surgery is performed without addressing the pterygium first, intraocular lens (IOL) power calculations may be inaccurate, leading to unexpected post-operative refractive errors.16 To ensure precise biometry measurements, it is often advisable to remove the pterygium first and wait 2 to 3 months for the corneal curvature to stabilize before repeating pre-cataract measurements.
This approach not only improves visual quality post-operatively but also enhances patient satisfaction by reducing the risk of residual refractive error.17
Using Mitomycin C to mitigate recurrence
Additionally, intra-operative use of MMC, at concentrations of 0.02 to 0.04% for limited durations, further reduces recurrence in aggressive or recurrent pterygia, but carries risks of sight-threatening complications, such as scleral melt and delayed healing.18,19 Thus, it should be reserved for select cases, and the site of MMC application should be irrigated thoroughly following its use.
Figure 2: Scleral melt (5 x 3mm) involving almost the full thickness of the sclera (A) following pterygium excision with the bare sclera technique and application of MMC. An amniotic membrane graft was placed over the entire area of pterygium excision (B), and topical and systemic steroids, along with topical antibiotics and lubricants, were prescribed. The scleral graft was healthy at the 1-month follow-up (C), and the scleral surface was completely healed by 6 months (D).
Figure 2: Scleral melt©Akhil Bevara et al. Used under CC BY-NC-ND 4.0.
Recently, innovations such as the PERFECT technique (extended pterygium excision with a large autograft) have been reported to have near-zero recurrence in expert hands, though operative time and required expertise often limit widespread adoption.20,21
Special considerations in planning pterygium surgery
Surgeons must plan accordingly to anticipate procedures or complications that may arise from their patients’ respective comorbidities.
Patients who require special consideration include individuals with:
- Ocular surface disease (OSD)
- Systemic autoimmune or inflammatory conditions
- Previous ocular surgeries
- Pediatric classification
OSD
In patients with ocular surface disease, such as severe dry eye, meibomian gland dysfunction, or ocular rosacea, these underlying diseases should be addressed pre-operatively and post-operatively to help reduce recurrence and optimize surgical healing.
In this group of patients, some have advocated for AMT for its anti-inflammatory properties and promotion of epithelial regeneration.22
Systemic diseases
Moreover, in those with systemic autoimmune or inflammatory conditions, coordination with rheumatology, aggressive pre-operative disease control, and avoidance of bare sclera excision are essential to limit post-operative inflammation and scarring, as it has been implicated previously in the literature, both mechanistically and in post-operative infection resulting in flare-ups of chronic autoimmune disease.23,24,25
Prior ocular surgery
Patients with previous ocular surgery may limit available conjunctiva for grafting, necessitating alternative strategies such as rotation flaps, nasal autografts, or AMT, while careful imaging or mapping of the conjunctival surface can optimize surgical planning.26,27
In cases of double-headed pterygium—arising from both nasal and temporal sides—a conjunctival autograft from the surgical eye may be combined with AMT or contralateral conjunctival autograft to ensure adequate coverage.
This author favors completing the nasal pterygium first with a conjunctival autograft and waiting 1 year to allow for a re-harvest of the superior conjunctiva for the future temporal pterygium removal.
Figure 2: Double-headed pterygia with hair-like extension growth.
Figure 2: Bilateral pterygia©Tarek Roshdy Elhamaky et al. Used under CC BY 4.0.
Pediatric and elderly patients
In pediatric or young adult patients who have particularly aggressive forms of the disease, conjunctival autograft, often with MMC, balances a low recurrence rate and safety when combined with strict UV avoidance post-operatively.28,29
For frail elderly or medically complex individuals, shorter surgical times and low-manipulation techniques, such as fibrin glue-assisted graft fixation (as opposed to suture fixation), can minimize peri-operative morbidity while maintaining good outcomes.30
Post-operative care
Post-operatively, topical steroids, such as prednisolone acetate 1%, are often used to manage inflammation, and practice patterns on duration vary widely. It is important to not taper steroids too early (i.e., 1 week), but maintain them for at least 4 weeks and sometimes even as long as 3 months to help reduce the chance of early recurrence.31
Of course, this also requires careful monitoring and balancing of the patient’s other ocular conditions (cataracts, intraocular pressure, etc.). Finally, patient education on strict sun protection, particularly in those with high occupational UV exposure, is crucial in conjunction with appropriate surgical management to reduce recurrence and optimize long-term results.
Key takeaways
Key takeaways from contemporary pterygium management emphasize the importance of tailoring surgical technique to optimize outcomes.
- Conjunctival autografting remains the gold standard, offering the best combination of safety, efficacy, and the lowest recurrence rates.
- The use of fibrin glue has been shown to improve the patient experience by decreasing post-operative discomfort and ocular surface inflammation.
- In cases where conjunctival tissue is insufficient, such as in eyes with prior surgeries or advanced scarring, amniotic membrane transplantation serves as a suitable alternative due to its anti-inflammatory and healing properties.
- Mitomycin C, while effective in reducing recurrence, must be employed selectively with close post-operative monitoring to avoid serious complications such as scleral thinning or delayed healing.
- Finally, educating patients on diligent UV protection and ocular surface management following surgery is critical to reducing recurrence rates and promoting long-term ocular surface stability.
In conclusion
Pterygium surgery continues to evolve. Being one of the most widely performed ocular surface procedures, it offers a range of techniques that can be tailored to individual patients based on their respective risk factor profiles.
While the bare sclera technique is now largely considered historic due to high peri-operative risks, and risks of pterygium recurrence, approaches such as conjunctival autografting and amniotic membrane transplantation (with consideration of Mitomycin C) remain the most widely utilized.
Each technique carries distinct advantages and limitations, and careful planning, including attention to patient comorbidities, ocular surface health, and future surgical needs, is necessary to optimize long-term outcomes.
Ultimately, the success of pterygium surgery rests on meticulous surgical technique, thoughtful patient education, shared decision-making, and proactive post-operative care. By integrating these principles, ophthalmologists can reduce pterygium recurrence, improve cosmetic outcomes, and provide patients with durable, vision-preserving results.
