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Pterygium / Pingueculum

Dear Patient,

This information pamphlet has been provided so that you may understand these conditions more fully and better decide if surgical treatment is what you want.

A pterygium is a wedge shaped tissue that grows over the surface of the eye. It may occasionally extend over the cornea enough to affect clarity of vision. It varies in colour from pale pink to crimson red.



A pingueculum is an irregular shaped growth over the white of the eye. It differs from a pterygium as it does not grow over the cornea and thus incapable of affecting vision. It is usually yellow centered with variable amounts of surrounding redness.



It is common for a pterygium and pingueculum to be present in the same person.

A pterygium usually occurs on the inner side of the eye.

CAUSE

It is clear that sun exposure and dry environment are major risks for the development of both these lesions.

Personal susceptibility also plays a big role and probably determines why one person will develop a pingueculum another a pterygium and some will develop neither.

SYMPTOMS

1.Redness and swelling:  These are the most common symptoms of all. Occasionally noted more by family and friends than the patient, especially if there are no other symptoms.

2.Irritation: The sensation of a “foreign body” in the eye is common and variable in intensity. Both redness and irritation are worse in the hot and dry seasons.

3.Reduced vision: Vision can only be reduced by the pterygium and only after it has extended beyond 3mm onto the cornea. This is a concerning symptom to both patient and doctor and should be addressed by removal of the pterygium as soon as practical. If the pterygium is allowed to extend to overlie the pupil zone vision may be permanently reduced even after removal of the lesion.

4.Scleritis: This causes intense redness around the pingueculum and pain. Often steroid drops or strong anti-inflammatory tablets are required to settle this uncommon complication of these lesions. When experienced this will prompt the patient to have the lesion removed such is the discomfort it causes.

TREATMENT

1.Sun avoidance: The human eye unfortunately cannot tan and it is unsafe to apply sun block lotion to it. Thus protection from the sun with quality, wrap around sunglasses, with or without a broad rimmed hat is required by all of us from a young age. The damage to the surface of the eye, which causes these two lesions, is cumulative, thus protection is helpful to reduce further damage even after they have started to grow.
2.Lubricant eye drops: These offer soothing relief, but the benefit is unfortunately short lived. It is best to use non-preserved drops such as Cellufresh, Thera tears or Refresh.
3.Decongestant eye drops: The better of these are Albalon and Naphcon. These are designed to reduce redness. They are safe to use provided the bottle has not been open for more than 28 days and used no more than once or twice a day. Long-term use may cause allergy or reduced effectiveness.
4.Laser: Laser plays no role in effective management of these lesions.

SURGICAL MANAGAMENT

History and research has shown that simply cutting off these lesions is met with a 70% chance of early and aggressive recurrence.

Starting about 30 years ago early success was seen with the application of radiotherapy and chemotherapy after the lesion was removed. However experience shows severe long-term side effects from this form of treatment.

The “state of the art” approach has been shown to be the complete removal of the lesion and the insertion into the excision site, a graft of healthy tissue harvested at the time of surgery from the same person, usually same eye.

This graft, known as an “autoconjunctival graft” is taken from behind the upper eyelid and usually sewn or glued with “tissue glue”. Even though a little more uncomfortable, the cosmetic result is better with a sutured graft than one glued.

If managing a large pterygium or one that has re-grown after previous removal, a special approach is required. This involves, usually days or a few weeks prior to planned surgery, the injection into the pterygium a medicine (5FU) that controls the speed of healing. The subsequent operation is the now standard of complete removal and autoconjunctival grafting.

The operation is performed with regional anaesthesia, using a small painless injection.

AFTER SURGERY

Once the operation is over a pad is applied after instillation of two drops designed to help healing.

On the following day the pad is removed and the operation site examined. All being well drops and pad are reapplied. The patient will look after the eye from this point on with instructions provided by the treating doctor. One or two more examinations are required over the next 6 weeks.

Improved outcomes are achieved by correct use of eye drops and avoiding extreme movement of the eyes for the first week after surgery (ie avoiding looking hard right or left).  Drops are used for up to 8 weeks after surgery.

The timing of return to work is variable, but usually not before 5 days post operation. Particularly dusty or dirty work conditions should be avoided for up to 3 weeks.

The patient will experience significant discomfort for two days after surgery. This pain is lessened by suitable analgesia, such as panadeine, and by rest including keeping the other eye closed as much as practical.

For the next 2 weeks the eye is irritable and red with swelling. Usually at 3-4 weeks post operation the eye is becoming comfortable and beginning to look “quiet”.

Healing is generally complete at 6-8 weeks.

RISK OF RECURRENCE

The accepted rate of recurrence, at 18 months following surgery, with the approach of excision and autoconjunctival grafting is <5%.

THE RISKS OF SURGERY

There have not been shown to be any significant long term risks from excision with autoconjunctival grafting.

Common short-lived side effects of surgery are;
1.Discomfort as described above.
2.Bruise to the tissue around and under the graft.
3.Swelling and droop of upper lid.
4.Double vision, rarely this may persist. Most at risk are those having removal of a recurrent pterygium.

WHAT TO EXPECT

1.Improved appearance and comfort
2.Under close scrutiny a “wound” line will be seen at the point of operation, which under normal circumstances is not evident to patient or others.

If you require further information please don’t hesitate to ask.

Dr Mark Chehade
Eye Specialist and Surgeon

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