Pterygium Excision with Conjunctival Autograft

This paper will discuss the different approaches to the surgical management of pterygium, emphasizing the conjunctival autograft technique and the use of antimetabolites. HISTORICAL PERSPECTIVE Clinically, a pterygium is a wing-shaped fibrovascular growth arising from the bulbar conjunctiva onto the superficial cornea.1 It is composed of a body, which overlies the sclera, and a head, which conforms the leading edge. Stocker’s line, an epithelial iron deposition at the advancing edge of the pterygium, is a common clinical feature. Pterygia are most often located in the interpalpebral fissure. A nasal presentation is more frequent, but temporal and even bilateral (kissing) pterygia have been described. Histopathologically, there is elastotic degeneration of the subconjunctival collagen.2 Exposure to wind, dust, and a dry climate has been implicated in the development of pterygia. A recent publication suggests a fiberoptic type of transmission of ultraviolet light from the temporal side of the cornea, through the stroma and onto the nasal aspect of the eye, perhaps partially explaining why these lesions are more commonly found nasally.3 Nonsurgical management of pterygium includes the liberal use of topical lubricating solutions, the occasional use of vasoconstrictors or mild anti-inflammatory agents for flare-ups, and protection from ultraviolet light with sunglasses. Numerous surgical techniques have been described since the early 1960s,4 including the bare sclera technique, simple closure with absorbable sutures, sliding flap, rotational conjunctival flap, conjunctival autoplasty, mucous membrane graft, and conjunctival autograft. In addition, adjuvant therapy to some of these techniques may include the use of beta-therapy with strontium-90 and antimetabolite therapy with mitomycin C or fluorouracil.5 The indications for the surgical excision of a pterygium include continuous or recurrent irritation, decreased visual acuity, and an unsightly appearance. Decreased vision may occur due to an actual invasion of the visual axis, or even a peripheral distortion that induces with-the-rule astigmatism that is hemimeridional on the side of the pterygium.6 The routine use of videokeratography in the preoperative evaluation of pterygium is beneficial in establishing the degree of visual compromise and in determining an improvement postoperatively.