Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

asymptomatic

1st line – ultraviolet (UV) light protection

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ACUTE
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asymptomatic
1st line – 

ultraviolet (UV) light protection

Small asymptomatic pterygia require no active treatment. Patients should be advised to protect their eyes from UV light with good-quality wrap-around sunglasses and hats with peaked brims.

ocular irritation, burning, or itching: without visual impairment, rapid growth, or cosmesis concerns

1st line – artificial tears

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ACUTE
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ocular irritation, burning, or itching: without visual impairment, rapid growth, or cosmesis concerns
1st line – 

artificial tears

These symptoms may be alleviated with topical artificial tear preparations. These agents are available over the counter.

Consider – topical corticosteroid

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ACUTE
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ocular irritation, burning, or itching: without visual impairment, rapid growth, or cosmesis concerns
Consider – 

topical corticosteroid

Additional treatment recommended for SOME patients in selected patient group

If there is associated inflammation of the pterygium, topical corticosteroids such as fluorometholone or loteprednol may be prescribed under ophthalmological supervision. All patients on topical corticosteroids should have their intraocular pressure regularly monitored, initially at 2-3 weeks, because of the risk of topical corticosteroid-induced ocular hypertension/glaucoma.[15]​​

Primary options

fluorometholone ophthalmic: (0.1%) 1-2 drops into the affected eye(s) two to four times daily

OR

loteprednol ophthalmic: (0.5%) 1-2 drops into the affected eye(s) four times daily

2nd line – surgery

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ACUTE
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ocular irritation, burning, or itching: without visual impairment, rapid growth, or cosmesis concerns
2nd line – 

surgery

If there is continuing and significant ocular irritation despite optimal medical therapy, then surgical intervention is indicated. Typically such procedures are performed under local anaesthesia.

Simple excision is the most straightforward technique, but recurrence rates >33% have been reported.[16]​​

Conjunctival autografting and flaps is the most commonly used surgical technique and involves covering the bare scleral area created following pterygium excision with either rotational conjunctival flaps above and/or below or with a free conjunctival graft taken from the superior bulbar conjunctiva. [Figure caption and citation for the preceding image starts]: Eye following pterygium excision and conjunctival autografting 1 day after surgeryFrom personal collection of David O'Brart; used with permission [Citation ends].com.bmj.content.model.Caption@16b456ec Recurrence rates after conjunctival autografting techniques are encouraging.[17][18]​​[48] [ Cochrane Clinical Answers logo ]

With an extensive pterygium or in glaucoma patients, amniotic membrane transplantation may be used to cover the bare scleral area.[24]​​[27]​​

Lamellar keratoplasty (partial thickness corneal transplantation) may be required if corneal thinning is significant, or with extremely aggressive or recurrent cases.

Excimer laser phototherapeutic keratectomy (PTK) may be a useful adjunctive treatment in aggressive cases involving the visual axis.

Redirection of the head of the pterygium has been abandoned due to high recurrence rates.

Consider – topical agent or beta-radiation

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ACUTE
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ocular irritation, burning, or itching: without visual impairment, rapid growth, or cosmesis concerns
Consider – 

topical agent or beta-radiation

Additional treatment recommended for SOME patients in selected patient group

Various agents have been used in an effort to reduce recurrence after primary surgery and especially to treat recurrent disease if it occurs.

Such agents include postoperative eye-drop regimens of thiotepa and mitomycin eye-drops, perioperative mitomycin and daunorubicin application, fluorouracil, and beta-radiotherapy using strontium-90 plaques.[29]​​[30]​​[31]​​[32]​​[33]​​[34]​​[35][36]​ Availability of these agents may differ between countries.

While such adjunctive agents may reduce rates of recurrence following simple excision, their use can be associated with significant sight-threatening complications such as corneal endothelial cell loss, scleral ulceration, melting, and even perforation.[36]​[37]​​[38]​​[39]​​​​​

More recently the use of topical monoclonal antibodies against vascular endothelial growth factors (anti-VEGF) has been advocated as an adjunctive therapy postoperatively, either in drop form or as sub-conjunctival injections.[41] In a meta-analysis, topical bevacizumab was relatively safe, associated only with an increased risk of sub-conjunctival haemorrhage, but it had no significant effect on preventing pterygium recurrence.[42]​ In another meta-analysis, conjunctival autograft combined with ciclosporin eye drops was the best adjunctive treatment to prevent recurrence following primary pterygium surgery.[43] The role of such agents as a primary therapy without adjunctive surgery is equivocal.[42]​​[44]​​[45]​​

Consult specialist for guidance on use of eye-drop regimens and doses.

visual impairment or rapid enlargement or poor cosmesis

1st line – surgery

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ACUTE
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visual impairment or rapid enlargement or poor cosmesis
1st line – 

surgery

There are several surgical techniques, depending on the characteristics of the pterygium. Typically such procedures are performed under local anaesthesia.

Simple excision is the most straightforward technique, but recurrence rates >33% have been reported.[16]​​[48]

Conjunctival autografting and flaps is the most commonly used surgical technique and involves covering the bare scleral area created following pterygium excision with either rotational conjunctival flaps above and/or below or with a free conjunctival graft taken from the superior bulbar conjunctiva. [Figure caption and citation for the preceding image starts]: Eye following pterygium excision and conjunctival autografting 1 day after surgeryFrom personal collection of David O'Brart; used with permission [Citation ends].com.bmj.content.model.Caption@455d782c Recurrence rates after conjunctival autografting techniques are encouraging.[17][18]​​ [ Cochrane Clinical Answers logo ]

With an extensive pterygium or in glaucoma patients, amniotic membrane transplantation may be used to cover the bare scleral area.[24]​​[27]​​

Lamellar keratoplasty (partial thickness corneal transplantation) may be required if corneal thinning is significant, or with extremely aggressive or recurrent cases.

Excimer laser phototherapeutic keratectomy (PTK) may be a useful adjunctive treatment in aggressive cases involving the visual axis.

Redirection of the head of the pterygium has been abandoned due to high recurrence rates.

Consider – topical agent or beta-radiation

Back
ACUTE
|
visual impairment or rapid enlargement or poor cosmesis
Consider – 

topical agent or beta-radiation

Additional treatment recommended for SOME patients in selected patient group

Various agents have been used in an effort to reduce recurrence after primary surgery and especially to treat recurrent disease if it occurs.

Such agents include postoperative regimens of thiotepa and mitomycin eye-drops, perioperative mitomycin and daunorubicin application, fluorouracil, and beta-radiotherapy using strontium-90 plaques.[29]​​[30]​​[31]​​[32]​​​[33]​​[34]​​[35][36]​ Availability of these agents may, however, differ between countries.

While such adjunctive agents may reduce rates of recurrence following simple excision, their use can be associated with significant sight-threatening complications such as corneal endothelial cell loss, scleral ulceration, melting, and even perforation.[36]​[37]​​[38]​​[39]​​​

More recently the use of topical monoclonal antibodies against vascular endothelial growth factors (anti-VEGF) has been advocated as an adjunctive therapy postoperatively, either in drop form or as sub-conjunctival injections.[41] In meta-analysis, topical bevacizumab was relatively safe, associated only with an increased risk of sub-conjunctival haemorrhage, but it had no significant effect on preventing pterygium recurrence.[42]​ In another meta-analysis, conjunctival autograft combined with ciclosporin eye drops was the best adjunctive treatment to prevent recurrence following primary pterygium surgery.[43] The role of such agents as a primary therapy without adjunctive surgery is equivocal.[42]​​[44]​​[45]​​

Consult specialist for guidance on use of eye-drop regimens and doses.

ONGOING

recurrent pterygia

1st line – surgery

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ONGOING
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recurrent pterygia
1st line – 

surgery

Treatment of recurrent pterygia can be problematic. Dissection of recurrent lesions from the cornea can be difficult. Such lesions do not usually shear off the surface mechanically but adhere firmly to the underlying corneal stroma and require sharp dissection. Underlying thinning of the cornea may be present, and occasionally lamellar corneal transplantation may be required to restore the normal surface contour.

Recurrent pterygia have a higher rate of recurrence after excision than primary lesions. Many surgeons advocate using adjunctive therapies such as topical mitomycin when treating such lesions, although their use can be associated with significant sight-threatening complications such as scleral melting.[37]​ It is the author's preference not to use such agents but to perform a repeat conjunctival autografting technique with the inclusion of limbal tissue with the graft.[18]​​

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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