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Pterygium (ReelDx + Lecture)

VIDEO-CASE-PRESENTATION-REEL-DX

pterygium50-year-old with a growth extending over the cornea

Patient will present as → a 65-year-old male Hispanic farmworker who is brought to you by his concerned wife. She reports he has had this "thing" on his left eye for years and refuses to seek care. He denies pain or discharge from the affected eye. Physical exam reveals an elevated, superficial, fleshy, triangular-shaped fibrovascular mass in the inner corner/nasal side of the left eye.

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A pterygium is a triangular wedge of fibrovascular conjunctival tissue over the medial or lateral aspect of the cornea approaching the pupil

  • Pterygium is associated with increased sun (UV) exposure and climates where there is wind, sand, and dust
  • The most common symptoms caused by pterygium are redness and irritation. Visual impairment is less common
  • Pterygium oscillates between active and inactive
    • Pterygium, when active (marked clinically by redness and localized thickening), can grow over a period of several months to years
    • When inactive (white and flat), pterygium may remain static for decades with no measurable increase in size or clinical significance.
  • Differentiate from pinguecula, which is a yellow, elevated nodule on the nasal side of the eye (fat and protein) that does not grow
Pterygium (conjunctiva)

Superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in the inner corner/nasal side of the eye)

The diagnosis of pterygium is clinical and made by the classic appearance of a wedge-shaped growth extending onto the cornea

  • Look for an elevated, superficial, fleshy, triangular-shaped “growing” fibrovascular mass
  • Pterygium is also more likely to be bilateral than unilateral

Patients with a small pterygium can be treated symptomatically for redness and irritation with artificial tears or other ocular lubricants

  • Only surgically remove when vision or eye movement is affected
  • Exposure to ultraviolet (UV) light is an important risk for recurrence - Lubrication and protection with a hat and/or UV-blocking spectacles that fit closely, wrap-around, or have side shields can prevent recurrence

Surgery for pterygium is indicated in the following situations:

  • Induced astigmatism that causes visual impairment
  • Opacity in the visual axis
  • Documented growth that is threatening to affect the visual axis via astigmatism or opacity
  • Restriction of eye movement
  • Significant cosmetic impact or intractable irritation

Question 1
A 50-year-old man, who has worked as a lifeguard for over 30 years, presents with a complaint of a slowly progressive growth on his left eye that has begun to affect his vision. On examination, there is a fleshy, triangular-shaped growth of conjunctiva encroaching onto the nasal side of the cornea. Which of the following is the most significant risk factor for the development of this condition?
A
Chronic use of contact lenses
Hint:
Not a significant risk factor for pterygium.
B
Frequent use of ocular steroids
Hint:
More associated with cataract and glaucoma.
C
History of recurrent corneal infections
Hint:
Not directly linked to pterygium development.
D
Genetic predisposition
Hint:
While there may be a genetic component, UV light exposure is a more significant risk factor.
E
Long-term exposure to ultraviolet (UV) light
Question 1 Explanation: 
Long-term exposure to ultraviolet (UV) light is a significant risk factor for the development of pterygium. This is particularly common in individuals with outdoor occupations, like this patient who has worked as a lifeguard.
Question 2
A 45-year-old man presents to the clinic with a complaint of a slowly progressive growth on his left eye that has become increasingly bothersome over the past year. He works as a construction worker and spends most of his time outdoors. On examination, a fleshy, triangular-shaped growth of conjunctiva is observed encroaching onto the nasal side of the cornea. The patient reports occasional irritation and redness but no significant vision changes. Which of the following is the most appropriate management for this patient's condition?
A
Observation and artificial tears
B
Topical antiviral therapy
Hint:
This is used for viral infections of the eye, such as herpes simplex keratitis, and is not indicated for a pterygium.
C
Surgical excision
Hint:
Surgery is considered when the pterygium is actively growing and threatening vision, or causing significant discomfort or astigmatism, not for stable, asymptomatic cases.
D
Topical corticosteroid therapy
Hint:
While steroids can reduce inflammation, they are not typically used for pterygium management due to potential side effects and are not indicated unless there is significant inflammation.
E
Systemic antibiotic treatment
Hint:
This is not indicated for pterygium as it is not an infectious condition.
Question 2 Explanation: 
The patient's presentation is consistent with a pterygium, a benign growth of the conjunctiva that can extend onto the cornea, often associated with prolonged UV light exposure. In cases where the pterygium is asymptomatic or causes only mild irritation and does not threaten vision, the recommended management is observation and symptomatic relief with lubricating eye drops, such as artificial tears. Surgical removal is reserved for cases where the pterygium significantly interferes with vision, induces astigmatism, or becomes cosmetically unacceptable.
Question 3
A 38-year-old construction worker presents with a pterygium in his right eye that has grown to the extent that it is encroaching on the visual axis. He reports discomfort and decreased vision. What is the most appropriate treatment for this patient?
A
Observation and artificial tears
Hint:
Appropriate for asymptomatic or mildly symptomatic cases.
B
Topical corticosteroids
Hint:
May be used to reduce inflammation but do not address the growth.
C
Surgical excision
D
Radiation therapy
Hint:
Not a standard treatment for pterygium.
E
Topical antihistamines
Hint:
Used for allergic conjunctivitis, not pterygium.
Question 3 Explanation: 
Surgical excision is indicated for a pterygium that is encroaching on the visual axis and causing symptoms like discomfort and decreased vision, as in this patient. The procedure involves removing the growth and often includes a conjunctival autograft to reduce recurrence.
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References: Merck Manual · UpToDate

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