Pterygium & ITS MANAGEMENT

OPHTHALMOLOGY PTERYGIUM & ITS MANAGEMENT.

1. Dr. NIKITA JAISWAL PTERYGIUM & IT’s MANAGEMENT

2. INTRODUCTION ANATOMY PATHOGENESIS CLASSIFICATION MANAGEMENT glossary

3. Pronounced as ( tur -IJ- ee -um) Also known as: surfer’s eye or farmer’s eye Derived from geek word ‘ pteryx ’ meaning little wing Pterygium is a wing shaped or triangular shaped growth of conjunctiva & fibrovascular tissue on the superficial cornea. INTRODUCTION

4. UV radiations--- exposure to these rays results into induction of mediators for growth of pterygium . ` Point mutations of proto-oncogenes K- ras Alterations in the expression of tumor suppresor genes as p53/p63 HPVDNA associations Overexpression of various proteins as defensins & phospholipases D. IT’s A PROLIFERATIVE LESION RATHER THAN DEGENERATIVE CONDITION. PATHOGENESIS

5. Degenerating collagen results in hyalinization of the subepithelial C.T It comprises of abnormal elastic fibres. They take up stain but do not degrade with elastase & thus it is called elastotic . HISTOPATHOLOGY

6. SMALL ARE ASYMPTOMATIC IRRITATION FOREIGN BODY SENSATION CONGESTION LACRIMATION DRYNESS ASTIGMATISM CLINICAL FEATURES

7. Sunlight exposure Hot & dry climate Age related degeneration hereditary Risk factors

8. Exposure to nasal side because of temporal side obstruction due to nasal bridge. Presence of longer lashes on the temporal eyelid which is 2/3 rd times longer than medial. Tears travel to medial side from lateral side carrying dust particle & irritating the conjuctiva . site

9. CAP HEAD BODY PARTS OF PTERYGIUM

10. Thick,fleshy Prominent vascularity Gradually increases in size Progresses to central cornea Presence of stockers line Thin Less vascularity Regresses or becomes stationary But it never disappears. PROGRESSIVE ATROPHIC TYPES

11. CLINICAL GRADING TAN’s CLASSIFICATION GRADING OF PTERYGIUM

12. GRADE 1: EXTENDS 2mm on the cornea

13. Grade 2: involves upto 4 mm of the cornea it can be primary or secondary.

14. TYPE 3: Encroaches more than 4mm of the cornea & it can hamper visual axis.

15. T1 GRADE: Clearly visible episcleral vessels under the pterygium tan’s classification

16. T2 GRADE: partially visibility of the episcleral vessels under the pterygium .

17. T3 GRADE: total obscured view of the episcleral vessels under the pterygium .

18. CHARACTERS PTERYGIUM PSEUDOPTERYGIUM AGE More common in older age groups May be seen in any group SITE 3’o clock to 9’o clock meridians May appear anywhere on the cornea LATERALITY bilateral Mostly unilateral STAGES Progressive,reggresive or stationary Always stationary ETIOLOGY Degenerative process May occur due to exposure to sunlight & dust Inflammatory process 2’ to chemical burns,trauma . LIMBAL RELATIONS Adhered to limbus Not adhered to limbus ASSOCIATIONS pinguecula ------

19. MANAGEMENT

20. Conservative management Asymptomatic, small pterygium can be left alone Lubricating eyedrops Sunglasses to prevent UV light exposure Mild steroids if inflammation is there.

21. HAMPERING VISUAL FIELD ASTIGMATISM COSMETIC CONCERN RECURRENCE INDICATIONS FOR SURGERY

22. The primary aim is to: EXCISION . PREVENT ITS RECURRENCE . SURGICAL MANAGEMENT

23. Bare sclera No sutures or fine, absorbable sutures used to appose conjunctiva to superficial sclera in front of rectus tendon insertion Leaves area of “bare sclera” Relatively high recurrence rate

24. Simple Closure Free edges of conjunctiva opposed together indicated only if defect is very small

25. Rotational Flap Closure A U-shaped incision is made adjacent to the wound to form tongue of conjunctiva that is rotated into place.

26. Grafted tissue should be approximately 0.5 – 1 mm larger than the area Most importantly conjunctival tissue with only minimal or no Tenon’s . conjunctival autograft can be attached with sutures, fibrin glue, elctrocautery or autologous blood CONJUNCTIVAL GRAFT CLOSURE 10- nylon or 8-0 vicryl interrupted sutures are used to anchor the graft

27. FIBRIN GLUE

28. Limbal Conjunctival Autografts It has been suggested that including the limbal stem cells in the conjunctival autograft may act as a barrier to conjunctival cells migrating onto the corneal surface and help prevent recurrence. The limbal - conjuntival graft includes approximately 0.5mm of the limbus and the peripheral cornea. This method is more demanding and time consuming to perform

29. AMNIOTIC MEMBRANES Useful for very large conjunctival defects as in primary double-headed pterygium Amniotic membrane posseses antiscarring , antiangiogenic and anti-inflammatory properties, which may be useful for treating pterygium This method minimizes the risk of iatrogenic injury to the rest of the conjunctiva surface It requires costly donor tissue

30. Intraoperative mitomycin application(0.2mg/ml for 3 minutes) Postoperative mitomycin (0.4 or 0.2mg/ml four times daily for 4-14 days) Post operative T hiotepa drops(1:2000 3 hourly for 6 weeks) Post operative beta irradiation (15 Gy in either single or divided doses) Adjunct -therapy

31. Corneal/scleral following extensive dissection Medial rectus muscle injury Bleeding Globe perforation Damage to canalicular system Recurrence Necrosis Endophthalmitis Scleritis Keratitis Pyogenic granuloma Dellen Persistent epithelial defect INTRA-OPERATIVE POST-OPERATIVE COMPLICATIONS

32. PINGUECULA DIFFERENTIAL DIAGNOSIS

33. LIMBAL DERMOID

34. OSNN

35. NODULAR EPISCLERITIS

36. THANK YOU