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Pterygium (Surfer's Eye) and Pinquecula


     A pterygium is a non-cancerous fleshy growth which starts on the conjunctiva (the outer covering of the white part of the eye) and grows over the cornea (the clear front of the eye).  If it remains on the white part of the eye it is a pinquecula.  They are almost certainly related to sun exposure and probably exacerbated by anything which injures or irritates the surface of the eye such as salt water or blowing dust.  Pterygia (pural) usually grow from the nose side of the eye toward the center of the eye, and are not uncommonly bilateral (in both eyes) although one side is usually worse.  Dr. Stingl has surgically removed hundreds of pterygia, many from farm workers in Florida.  It was this extensive experience that led Dr. Stingl to his current philosophy about treating advancing pteryia.  Like many other eye problems,  the lifelong use of sunglasses and a broad rimmed hat can greatly reduce the chances of developing a pterygium.  Artificial tears may also be helpful.  Dr. Stingl has noted that younger adults (20-40yo) tend to have the most agressive pterygia.  He has also seen many older adults (70-90yo) can have rather large pterygia that are stable.


      Once a pterygium grows across the limbus (the circle which separates the conjunctiva from the cornea) surgical excision is usually the only way to completely remove it.  This limbus or limbal area is very special as we now know this is where the stem cells reside which are the source of cells which constantly replace the corneal epithelium, or outer cells that cover the clear front of the eye.  One of the jobs of the limbus is to prevent the growth of blood vessels onto the cornea, so some may consider a pterygium to be a failure of the limbus 


     Not all pterygia need to be removed.  If the patient is comfortable, does not mind the cosmetic appearance and serial examinations demonstrate that there is no advancement it is very reasonable to continue to watch it.  However, if the pterygium is growing and threatening the visual axis (growing across the pupil which is the hole in the colored iris that we see through) it should be removed before it gets near the center of the eye.  The central cornea is precious and after we remove a pterygium from the cornea it may look clear, but it is never quite as perfect as it was before the pterygium grew over it.  In general, the smaller the pterygium, the less traumatic the surgery and the lower the chances of recurrence.   If a pterygium has grown back after surgical removal it is a recurrent pterygium, which are, in general, more difficult to remove because of the scar tissue and  more likely to recur again.

     Every case and every patient is different.  Of course, it is the primary goal to be sure that the visual axis is clear for good vision.  Both the growth of a pterygium and the surgical removal can alter the 'roundness' of the cornea making it 'football' shaped which is astigmatism.  This can be corrected with spectacles, contact lenses or refractive procedures.  Some patients are bothered by the irritation of a pterygium which may feel like a constant foreign body sensation, so this can be an important goal.  Other patients, particularly some patients with pinqueculae, may be very bothered by the cosmetic appearance, even if they have no irritation at all.  Dr. Stingl relies on good communication and understanding with the patient to be sure he is doing what is in the patient's best interest.   If Dr. Stingl believes your pterygium has a very high chance for recurrence, he may recommend using Mitomycin-C, a chemotherapuetic agent widely used in ophthalmology, at the time of surgery.  Dr. Stingl has not used Beta radiation for a long time because he has not found it necessary.   An amniotic membrane may also be useful, but in general, Dr. Stingl has found that the extra expense and additional surgery are unnecessary.   Dr. Stingl prefers to stretch a conjunctival flap carefully moving the cells from the normal limbus (hopefully taking a portion of the stem cells) to cover the area over the sclera (the white part of the eye) where the pterygium was removed so that the transplanted limbal cells are facing the cornea.  Dr. Stingl has found this technique to have the lowest chance of recurrence.

The recurrence rate for pterygia is high; in some studies more than half of the pterygia grew back.  That is why if you decide to have surgical removal of a pterygium at the Stingl Eye Clinic it is VERY important to take your drops as directed, wear your sunglasses when outside or exposed to ultraviolet light and continue to come back for follow up.  Usually steroid eye drops are used after pterygium surgery to lessen inflamation.  A small percentage of the population are 'steroid responders' meaning the pressure inside the eye will rise without symptoms when steroids are applied which is one more reason to be sure to come back for the follow up appointments.  If the patient's occupation or avocation is contributing to the ocular inflamation, steps must be taken to eliminate or mitigate the exposure.  Even three or four months after the surgery the patient may think since the eye is quiet and white with no discomfort that the drops may be discontinued and the follow up visits are unimportant, but sadly the pterygium regrows insidiously.  Dr. Stingl watches the limbal area where the pterygium was removed for at least 6 months, but preferably a year to look for microscopic vessels starting to cross toward the cornea.   If the regrowth starts, Dr. Stingl believes it is best to take action immediately, using a variety of techniques including argon laser and other medications including Avastin (anti-Vascular Endothelial Growth Factor).  Every pterygium surgeon has regrowths, but with prompt action Dr. Stingl has greatly reduced the need for an additional surgical excision.

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