An overview of potential patient presentations includes the following:
Pterygium as a presenting problem that is primary, isolated, and the sole problem with respect to potential upcoming surgery.
Pterygium is the presenting and primary problem, but the patient has other nonsurgical ocular concerns that are best addressed in the perioperative period to ensure successful recovery and long-term outcome.
Pterygium is the presenting and primary problem, but the patient has other nonsurgical non-ocular concerns that are best addressed in the perioperative period to ensure successful recovery and long-term outcome.
Pterygium as a presenting surgical problem is primary, but the patient has other ophthalmic surgical concerns that are imminent, concentric, or in need of simultaneous surgery in the same session.
Pterygium is present as an incidental finding on a patient presenting for elective corneal, cataract, refractive, or glaucoma surgery.
Pterygium is present as an incidental finding on a patient presenting for nonelective surgery that may involve trauma, endophthalmitis, retinal detachment, chemical injury, or some other emergency.
Let us look at each of these scenarios individually as we prioritize proper management of the pterygium, which is integral to optimizing the ocular surface essential for preserving ocular health, maintaining quality vision, and achieving success in most aspects of modern ophthalmic and particularly anterior segment surgery.
Our “mental checklist” for each of these scenarios prior to any intervention or surgical procedure will ask how this might impact the patient in the following ways:
Structural integrity of the eye.
Transmission of light/optical pathway.
Refracting or focusing of light.
Patient comfort.
Patient appearance.
Patient perception.
Furthermore, it is important to have an understanding of the factors that brought about the development of the pterygium, such as genetic and environmental factors, previous surgery, or trauma. David Paton, MD, is credited with relating that a pterygium on the eye can be thought of similar to the callus on the hand of the farmer. A pterygium is more likely to recur if the ocular surface is re-exposed to the ongoing insult that brought it about in the first place.
12.2 Pterygium: Primary, Isolated, Sole Problem
For the patient presenting with a pterygium as a surgical problem that is primary, isolated, and is the sole problem with respect to potential upcoming surgery, this is relatively straightforward (▶ Fig. 12.1 and ▶ Fig. 12.2). Meticulous resection includes leaving as smooth as possible the corneal surface. The Algerbrush diamond pterygium burr is a technique that the author seldom advocates, as a meticulous dissection is usually superior. The author never uses an antimetabolite on a primary surgical pterygium procedure. Conjunctival flaps, amniotic membrane, and conjunctival grafts all tend to do well in milder cases compliant with respect to reducing and avoiding future ultraviolet (UV) exposure. Conjunctival grafts appear to be superior in the more aggressive and recurrent cases.
Fig. 12.1 Pterygium encroaching on pupillary margin.
Fig. 12.2 Visually significant chronic pterygium.
12.3 Primary Pterygium Complicated by Additional Ocular Concerns
These patients are very common and require additional attention to ensure proper healing. Local problems may include dry eye or ocular rosacea. Delayed healing and disease recurrence is more likely to occur in these patients. Addressing dryness, meibomian gland dysfunction (MGD), and exposure prior to surgery will pay dividends when it comes to healing after the surgery and long-term success.
With respect to the ocular form of rosacea, a few additional comments are worth mentioning. Ocular involvement of rosacea is not uncommon but, on occasion, can be easily missed when the ocular involvement is much greater than the cutaneous component. Ocular involvement may appear as bilateral, commonly asymmetric, and on occasion, unilateral. Active keratitis is frequently misdiagnosed as herpes simplex keratitis. Corneal neovascularization can be quite aggressive, and all of this can complicate pterygium before and after surgery. Proactively addressing this not only helps in the perioperative period but also reduces complications such as lipid keratopathy in the long run. A nickel allergy is a marker for patients prone to ocular rosacea. Patients, particularly female patients, may have a history of problems wearing jewelry made with 10 ct gold. For example, 10 ct earrings are made with a nickel alloy that many rosacea patients are unfortunately allergic to; it turns their ear lobes green.
Early ocular cicatricial pemphigoid (OCP) and other forms of cicatrizing conjunctivitis may be aggravated by pterygium surgery and may impact the decision to undergo surgery. Surgery in these patients may require a prolonged course of corticosteroids postoperatively.
Glaucoma patients bring special consideration as topical glaucoma medications are somewhat toxic and irritating to the ocular surface, which may impact healing and pterygium recurrence. Additionally, previous or future glaucoma surgery may be impacted by the extent of conjunctival resection that accompanies pterygium surgery. Furthermore, these patients need IOP monitoring more closely, taking into consideration the postoperative use of topical corticosteroids after pterygium surgery.
12.4 Primary Pterygium Complicated by Additional Nonocular Concerns
Another concern that can contribute to complex pterygium management is the patient who presents with a history of peripheral noninfectious keratitis—found in patients who develop ocular involvement of an underlying autoimmune disease. There are many conditions (rheumatoid arthritis, scleroderma, polyarteritis nodosa, Wegener’s granulomatosis, and Mooren’s ulceration) where inflammation and tissue loss may result in a pterygium in the healing response (▶ Fig. 12.3). There may be minimal tissue support underneath the pterygium, and these patients should be approached cautiously realizing the autoimmune process could recur. Furthermore, in some of these more severe cases, the pterygium may be part of a healing process that is lending tissue support. Avoiding surgery may be the best approach in these complex patients as a surgical approach will likely require a corneal patch graft. In these cases, the eye is diseased, and pterygium growth is a response to inflammation and healing. It is important to make sure that the patient has been fully evaluated and is under optimal systemic management before tackling the ocular surface surgically. A very important consideration here is the patient who has recurrent pterygium who may also have undergone a procedure that used an antimetabolite or even radiation in the distant past that can further complicate these eyes with perforation or poor healing.
Fig. 12.3 Marginal degeneration with pterygium and pigmentary changes.
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