Understanding Recurrent pterygium: Causes, Symptoms, and Treatment Options
- Phornrak Sriphon
- Jun 22, 2023
- 7 min read
Updated: Nov 29, 2024
By Phornrak Sriphon,MD Glaucoma specialist
Pterygium is a commonly encountered eye disease in Thailand due to its geographical location, which exposes the population to high levels of sunlight. It is considered a significant risk factor for the development of pterygium.
Pterygium refers to an abnormal growth of conjunctival tissue that extends onto the cornea. It often appears as a triangular-shaped growth, commonly found at the inner or outer edge of the eye. However, pterygium is not malignant or cancerous. Therefore, it can be effectively treated and cured.
Pterygium recurrence refers to the regrowth of abnormal tissue after it has been surgically removed. It commonly occurs within 3-12 months following the removal procedure.
The grading of pterygium is based on the size of the tissue growth that extends onto the cornea. It can be categorized into four grades as follows:
Grade 1: The pterygium extends onto the cornea by approximately 1 mm.
Grade 2: The pterygium extends onto the cornea by approximately 2-3 mm.
Grade 3: The pterygium extends onto the cornea by approximately 3-4 mm.
Grade 4: The pterygium extends onto the cornea by more than 4 mm, reaching the pupil.
Risk Factors for Pterygium
Risk Factors for Primary Pterygium
Prolonged exposure to UV radiation for more than 5 hours per day
Increasing age
Male gender being more susceptible than females
Genetic factors
Exposure to dust or wind
Chronic dry or inflamed eyes
Risk Factors for Recurrent Pterygium:
Younger age: Patients younger than 40 years old have a higher risk of pterygium recurrence.
Surgical technique: The choice of surgical technique and the skill of the surgeon can affect the recurrence rate. Certain surgical methods may have a higher risk of recurrence compared to others.
Thick and vascular pterygium: Pterygium with a thick and vascular appearance, characterized by redness and increased tissue thickness, may have a higher likelihood of recurrence.
Dark-skinned individuals: People with darker skin, such as individuals of African, Hispanic, or Asian descent, may have an increased risk of pterygium recurrence compared to those with lighter skin.
Symptoms of Pterygium
Presence of a visible red fleshy growth on the conjunctiva, either at the inner or outer edge of the eye.
Easy occurrence of redness in the eyes.
Irritation, itching, and stinging sensation in the eyes.
Blurred vision, especially when looking from the side or when the pterygium obstructs the line of sight.
Obstruction of vision by the pterygium reaching the eyelid margin.
Treatment of Pterygium:
-Non-surgical treatment:
Eye drop medication according to symptoms
Wearing sunglasses to protect from sunlight and wind
Cleaning the eyelid
Preventing dry eyes by adjusting behavior and using artificial tears
-Surgical treatment or excision of the pterygium:
Currently, there are two main techniques for the excision of pterygium: 1. Excising without graft placement is not widely popular because it may result in a higher risk of recurrence.
2. Excising with graft placement
Conjunctival autograft: In this technique, a piece of healthy conjunctival tissue is taken from another part of the patient's eye and used to replace the excised pterygium.
Amniotic membrane graft: In this technique, an amniotic membrane, which is obtained from donated placenta, is used to cover the area where the pterygium was removed. This helps promote healing and reduces the risk of recurrence.
Techniques to enhance prevention of recurrence.
Injecting MMC (Mitomycin C) during surgery.
Injecting 5-FU (5-Fluorouracil) after surgery.
Injecting Anti-VEGF (Vascular Endothelial Growth Factor) after surgery.
Using biological glue.
The surgical procedure for pterygium typically involves the following steps:
-Anesthesia: The patient is given local anesthesia to numb the area around the eye. In some cases, general anesthesia may be used.
- Pterygium removal: The surgeon carefully dissects and removes the pterygium tissue from the cornea and underlying sclera. Techniques such as scraping or excision may be used.
- Application MMC (Mitomycin C) if need.
- Conjunctival autograft or Amniotic membrane graft.
- Suture graft or use biological glue for attachment the graft.
- Last check excision+ Pressure patch.
For surgical indications:
Visual obstruction: The pterygium causes significant visual impairment, such as blocking or obstructing the line of sight.
Astigmatism: The pterygium-induced astigmatism is severe, resulting in distorted or blurred vision.
Chronic inflammation: The pterygium is chronically inflamed and does not respond well to medical treatment, causing recurrent episodes of redness, irritation, and discomfort.
Cosmetic concerns: The pterygium's appearance affects the person's confidence and quality of life, leading to self-consciousness or psychological distress.
Here are some recommendations for pterygium surgery:
Pre-operative guidelines before pterygium surgery include:
Practice sleeping with a cloth covering your face for 30 minutes before bed.
Practice eye movements, including moving your eyes left-right and up-down, and hold for a few seconds.
The surgery will involve the use of local anesthesia through eye drops and injections. There is no inhalation anesthesia involved.
The actual pterygium removal procedure may take approximately 15 to 40 minutes, depending on the type of surgery.
Discontinue blood-thinning medications at least 7 days before the surgery (consult with your physician each time).
Take a shower and wash your face and hair on the morning of the surgery.
Wear comfortable clothing and a button-up shirt on the day of the surgery.
Consume easily digestible food before coming in for the surgery.
Clean the eyelid with ocusoft products before the surgery and use artificial tears before the procedure.
Post-operative guidelines after pterygium surgery
Keep your eyes tightly closed for 2 days, then you can open them at home.
If you wear contact lenses, the doctor will schedule an appointment to remove them 2 days after the surgery.
You can start using eye drops after opening your eyes, except if you wear contact lenses. In that case, you can start using the eye drops right away.
It is normal to experience significant eye pain during the first 2 days. Take the prescribed pain medication as instructed by your doctor.
If you underwent grafting and suturing, the doctor will schedule a follow-up appointment for suture removal 10-14 days after the surgery.
Avoid water getting into your eyes for 1 week or until the sutures are removed.
Do not wear contact lenses until the sutures are removed.
Post-operative redness in the eyes will gradually subside, and there may be slight irritation if sutures were used.
Wear sunglasses with UV protection to prevent recurrence.
Clean the eyelids daily and use preservative-free artificial tears regularly.
Resume normal daily activities and work as tolerated.
Keep all follow-up appointments within the first 6 months as the doctor may consider administering medication to prevent recurrence.
These recommendations are provided by doctor Phornrak Sriphon, in accordance with standard treatment guidelines and her experience. However, the specific details may vary among individual doctors.
Research studies on the recurrence of pterygium have been conducted in the field of ophthalmology and eye diseases.
There are 4 contentious issues and key conclusions regarding the recurrence of pterygium:
Risk factors for recurrence after removal:
Timing of recurrence:
Prevention of recurrence:
Treatment of recurrent pterygium:
Issue 1. Risk factors for recurrence after removal:
The risk factors for recurrence of pterygium after removal can be divided into two categories: based on cellular level and clinical risk factors.
Cellular Level Risk Factors: At the cellular or gene level, it has been concluded that the genes found during recurrent pterygium may differ from those present during the initial occurrence. There is also mention of various viruses, such as HSV (Herpes Simplex Virus), EBV (Epstein-Barr Virus), CMV (Cytomegalovirus), and HPV (Human Papillomavirus), which may contribute to the recurrence.
Clinical Risk Factors:
Gender does not have an impact on the recurrence of pterygium.
Individuals under the age of 40 have been found to have a recurrence rate up to 3.5 times higher. This can be explained by the fact that younger individuals tend to have a faster healing process, leading to the development of angiogenesis and collagen formation, ultimately resulting in inflammation and recurrence.
Pre-existing conditions such as severe ocular inflammation, particularly dry eye and Meibomian gland dysfunction (MGD), contribute to increased chances of recurrence.
The size of the pterygium and surgical techniques are factors that may influence recurrence, although conclusive evidence regarding the impact of larger size on recurrence is still lacking. Some studies suggest that larger size may contribute to recurrence.
The initial surgical technique is crucial, including careful grafting, minimal tissue excision, and the use of certain types of sutures. Using autologous tissue from the patient's own conjunctiva before surgery has been found to minimize recurrence.
Issue 2.When does recurrence occur?
Research studies have generally observed recurrences within the range of 3 to 12 months. Therefore, it is crucial to ensure patient follow-up and adherence to treatment within the first 12 months after surgery.
Issue 3: Methods to prevent recurrence
For individuals who have recently undergone surgery, it is important to adhere strictly to certain practices to minimize the risk of encountering factors that may promote lesion regrowth and prevent eye inflammation. The recommended practices are as follows:
To prevent sun exposure and dust, it is recommended to wear UV 100 protective glasses and a hat or use wind-blocking glasses when necessary in unsuitable environments.
Cleaning the eyelids to manage Demodex mites and addressing dry eye and MGD (Meibomian Gland Dysfunction) are also important.
Regular use of preservative-free artificial tears to prevent dryness and adjusting behaviors can be helpful.
Additional supportive techniques to prevent recurrence, as found in research, include the application of mitomycin C (MMC) and the use of biological glue. However, these specific techniques should be part of the surgical recommendations provided by the operating physician.
The post-operative period, particularly 4-6 weeks, is crucial, and controlling inflammation by using steroid eye drops is important. Regular check-ups with the physician are necessary to monitor eye pressure.
Issue 4: Treatment of Recurrent Pterygium
Non-Surgical Treatment of Recurrent Pterygium : options can be considered for the management of recurrent pterygium. These options may include Injection of Anti-vascular Endothelial Growth Factor (Anti-VEGF): Anti-VEGF agents, such as be
Surgical excision of recurrent pterygium commonly involves the use of autologous conjunctival graft. It has been found that using one's own conjunctival tissue as a graft results in the lowest recurrence rate.
Summary:
For individuals with pterygium, consider the following four points:
For individuals under the age of 40 without indications, it is advised not to undergo pterygium excision.
Assess your own risk and choose the appropriate technique if necessary.
Postoperative care is crucial, including sun and dust protection, regular eyelid hygiene, and consistent use of non-preservative artificial tears.
It is recommended to follow up at least once a year.
Examples of before and after pterygium excision.
Reference
Article : https://www.ncbi.nlm.nih.gov/pmc/arti…
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