Pterygium

Pterygium or "Phrygium": Causes, Symptoms, and Treatment

Pterygium (colloquially known as "phrygium") is an abnormal growth of fibrovascular conjunctival tissue on the cornea, usually in the nasal or temporal area of ​​the eye. It is a benign condition but can affect vision if it progresses.

Main Causes

Chronic UV exposure (sun rays): Main risk factor.

Dry eyes and chronic irritation (dust, wind, pollution).

Genetic factors: Higher prevalence in tropical areas and in people with fair skin.

Symptoms

Triangular or "winged" appearance that invades the cornea (usually from the nasal side).

Eye redness (hyperemia).

Sensation of a foreign body or grittiness.

Blurred vision (if it grows toward the center of the cornea).

Irritation and tearing.

Diagnosis

Slit-lamp examination by an ophthalmologist.

Corneal topography: To assess whether it distorts the corneal curvature.

Differentiation from pinguecula (similar, but does not invade the cornea).

Treatment

1. Conservative Treatment (if small and asymptomatic)

Lubricants (artificial tears).

Anti-inflammatories (topical steroids if there is inflammation).

UV protection (UV 400 sunglasses).

2. Surgery (if it affects vision or is cosmetically bothersome)

Surgical excision:

The abnormal tissue is removed, and the area is covered with an autologous conjunctival graft (from the same patient) or amniotic membrane to reduce recurrence.

Advanced techniques:

Use of mitomycin C (antimetabolite) to prevent recurrence.

Tissue glue (fibrin) instead of sutures.

Complications if left untreated:

Irregular astigmatism (due to corneal traction).

Corneal opacity (if it invades the visual axis).

Postoperative recurrence (up to 30–40% without grafting).

Prevention

Wear sunglasses with 100% UV protection.

Avoid dry or dusty environments.

Lubricate your eyes if there is prolonged exposure to the sun or screens.

Content Warning

Sensitive Content

Not Recommended for Children

Surgical Technique for Pterygium Excision

Pterygium surgery aims to remove abnormal tissue and prevent recurrence. The most effective method currently is excision with a conjunctival autograft, which reduces the recurrence rate to less than 5-10% (vs. 30-50% with older techniques).

Surgical Steps

1. Preoperative Preparation

Complete ophthalmologic evaluation: Corneal topography, visual acuity.

Topical antibiotic (e.g., moxifloxacin) administered 24 hours before surgery.

Anesthesia:

Topical (proparacaine drops) + Subconjunctival (2% lidocaine).

Optional sedation.

2. Pterygium Excision

Marking the area: The tissue to be removed is delineated.

Pterygium Detachment:

The head of the pterygium is lifted from the cornea with a diamond knife or trephine blade.

The body of the pterygium is dissected from the underlying sclera.

Scleral Bed Cleaning:

All residual fibrovascular tissue is removed to prevent recurrence.

3. Ocular Surface Reconstruction

Option 1: Conjunctival Autograft (Gold Standard)

A graft of healthy conjunctiva is taken (usually from the same eye, superior area).

It is secured to the scleral bed with:

Absorbable sutures (8-0 Vicryl) or

Fibrin glue (less postoperative inflammation).

Option 2: Amniotic Membrane (Alternative if there is insufficient healthy conjunctiva)

Cryopreserved amniotic membrane is placed as a biological cover.

4. Application of Mitomycin C (Optional)

Use 0.02% mitomycin C (sponge) for 2-3 minutes on the scleral bed to reduce fibroblastic proliferation (only in aggressive or recurrent cases).

Additional Techniques to Minimize Recurrence

"SLIT" Technique (Sutureless and Glue-free Limbal Conjunctival Autograft):

Conjunctival graft without sutures or glue, using natural pressure.

Use of argon laser: To coagulate abnormal blood vessels.

Postoperative

Topical antibiotic + corticosteroid (4 weeks).

Lubricants (preservative-free artificial tears).

Follow-up at 24 hours, 1 week, and 1 month.

Why is the Autograft the Gold Standard?

Protects the surgical area and restores the anatomical barrier.

Contains limbal cells that inhibit fibrovascular regrowth.

Less inflammation vs. older techniques (such as simple resection).

Postoperative Follow-up for Pterygium and Risk of Recurrence

Pterygium has a natural tendency to recur, especially if proper surgical technique is not performed or if the patient remains exposed to risk factors. Structured follow-up is key to detecting and managing early recurrences.

Risk Factors for Recurrence

Inadequate surgical technique:

Simple resection (without autograft) → 30-50% recurrence rate.

Use of mitomycin C or conjunctival grafting reduces the risk to <10%.

Continuous UV/sun exposure without protection.

Uncontrolled dry eye.

Poorly managed postoperative inflammation.

Genetic factors (higher incidence in younger patients and men).

Postoperative Follow-up Protocol

1. First Week (Early Follow-up)

24-48 hour visit:

Assess for pain, redness, or epithelial defects.

Verify that the autograft is adherent (in cases with sutures/glues).

Week 1:

Remove sutures, if used (in conjunctival grafts).

Control inflammation (use topical steroids if necessary).

2. First Month (Initial Recovery)

Visit at 2-4 weeks:

Evaluate corneal reepithelialization.

Rule out graft infection or necrosis.

Start lubricants if postoperative dry eye is present.

3. At 3-6 Months (Maximum Risk of Recurrence)

Visit at 3 months:

Look for abnormal blood vessels (first sign of recurrence).

Perform corneal topography if induced astigmatism is suspected.

Visit at 6 months:

Confirm stability.

If there is no recurrence, the subsequent risk is low.

4. Long-Term Follow-Up (1 Year +)

Annual:

Review UV exposure and dry eye symptoms.

Educate the patient on prevention (sunglasses, lubrication).

Signs of Recurrence

Localized redness (especially in the original area).

Appearance of fibrovascular tissue toward the cornea.

Recurrent foreign body sensation.

Progressive astigmatism (on topography).

Management of Recurrence

Initial medical treatment:

Topical steroids (e.g., fluorometholone) to reduce inflammation.

Intensive lubricants.

If there is active growth toward the cornea:

Resurgery with autograft + mitomycin C (0.02% for 2 min).

In complex cases: amniotic membrane + antifibrotics.

Recurrence Prevention

Mandatory use of UV400 sunglasses (even on cloudy days).

Control dry eye with artificial tears.

Avoid dusty or irritating environments.

Ensure eye follow-up every 6 months or more.

Can all patients with pterygium ("flesh") undergo surgery?

Pterygium surgery is common, but not all cases require or can be operated on immediately. The decision depends on factors such as size, symptoms, risk of recurrence, and the patient's ocular health.

Indications for Pterygium Surgery

Growth toward the cornea (threatens the visual axis).

Chronic inflammation (redness, pain).

Induced astigmatism (blurred vision).

Cosmetic discomfort or ongoing irritation.

Conditions That May Delay or Avoid Surgery

1. Small, asymptomatic pterygium

If it does not affect vision or cause discomfort, it can be monitored.

2. Severe, uncontrolled dry eye

Surgery can worsen dryness. It should be treated first.

3. Infections or active inflammation

Conjunctivitis, blepharitis, or keratitis: These must be resolved before surgery.

4. Previous corneal diseases

Keratoconus or corneal scarring: Increased risk of complications.

5. Continuous sun exposure without protection

If the patient does not wear UV glasses postoperatively, the pterygium may recur.

6. Patients at high risk of recurrence

History of recurrent pterygium.

Outdoor workers (fishermen, farmers).

Surgical Techniques and Risk of Recurrence

Simple excision (without graft): 50–80% recurrence rate (not recommended).

Conjunctival autograft: 5–10% recurrence rate (standard technique).

Amniotic membrane: Used in complex cases (e.g., multiple recurrences).

90% of pterygia recur if they are only excised without grafting. The proper technique makes all the difference!

What to do if you are not a candidate for surgery?

Medical Treatment:

Lubricants (artificial tears).

Anti-inflammatories (topical steroids if irritation occurs).

UV Protection:

UV400 sunglasses are mandatory.

Factors That Influence the Final Cost of Pterygium Surgery

The price of pterygium surgery can vary significantly depending on several factors, from the type of surgical technique to the patient's comfort level during the procedure. Below, we detail the main elements that determine the cost:

1. Type of Surgical Technique

The method used directly influences the price:

Technique/Relative Cost/Advantages/Disadvantages

Simple excision without graft

Cost: Low (higher risk of recurrence)

Advantage: Fast and inexpensive

Disadvantage: High recurrence rate (30-50%)

Conjunctival autotransplantation (standard technique with sutures)

Cost: Medium

Advantages: Reduces recurrence (<5%)

Disadvantages: Sutures can cause discomfort

Autotransplantation with tissue adhesive (Tissucol®, fibrin)

Cost: High

Advantages: Suture-free, more comfortable

Disadvantages: Higher material cost

Use of amniotic membrane

Cost: High

Advantage: Ideal for cases Complex/Recurrent

Disadvantage: Expensive Material

2. Type of Anesthesia

Topical/Local Anesthesia (drops only + infiltration) → Lower cost (simple outpatient procedure).

Conscious Sedation (plus anesthesiologist) → Higher cost, but greater patient comfort (recommended for anxious patients or for long surgeries).

3. Surgical Center (Clinic or Hospital)

Specialized Ophthalmology Clinics → Variable cost depending on technology and facilities.

Private Hospitals → Higher prices due to operating room fees and additional medical equipment.

4. Surgeon Experience

General Ophthalmologists → Can offer lower prices, but less specialization in advanced techniques.

Ocular Surface/Corneal Specialists → Higher cost, but better complication management and lower recurrence rate.

5. Medications and Postoperative Care

Postoperative drops (antibiotics, anti-inflammatories, lubricants).

Postoperative checkups (follow-up at 1 week, 1 month, etc.).

Use of therapeutic lenses or patches.

How to Choose the Best Option?

✔ Prioritize techniques with a low recurrence rate (autologous transplant + tissue adhesive).

✔ Evaluate whether sedation is necessary for comfort.

✔ Verify the surgeon's experience (avoid suspiciously cheap "deals").