PANCE Blueprint EENT (7%)

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 oscillate 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) does not grow

superficial, fleshy, triangular-shaped “growing” fibrovascular mass (most common in inner corner/nasal side of they 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
The best course of action for a patient with a bothersome inflamed pinguecula (pingueculitis) is
A
antibiotic drops
Hint:
Antibiotic drops have no benefit with pingueculitis.
B
excision
Hint:
Excision is indicated for a pterygium that is threatening vision.
C
Visine drops
Hint:
Visine drops will not do anything, but artificial tears may be beneficial.
D
no treatment
Question 1 Explanation: 
Pinguecula are hyaline, elastic nodules that appear yellow and affect both sides of the cornea but usually more on the nasal side. Pterygium is a fleshy, triangular growth of a pinguecula that involves the cornea. With pingueculitis, no treatment is necessary; a short course of NSAID drops or steroids may help.
Question 2
Pterygium is associated with
A
An increased risk of glaucoma
Hint:
See B for explanation
B
Involvement of the pupillary area, which may require surgical excision if affected
C
Improvement with the use of topical anesthetics
Hint:
In most cases, treatment is supportive with topical vasoconstrictors, saline drops, and protection from sunlight. Surgery is reserved for more severe cases in which vision is compromised.
D
Trauma to the retina
Hint:
See B for explanation
E
Macular degeneration
Hint:
See B for explanation
Question 2 Explanation: 
Pterygium is a fleshy, triangular growth of a pinguecula that involves the cornea. In some cases, it may involve the pupillary area and requires surgical removal. The causes include irritation from UV sunlight, allergens, and excessive drying, sandy, or windy conditions that cause chronic irritation. In most cases, treatment is supportive with topical vasoconstrictors, saline drops, and protection from sunlight. Surgery is reserved for more severe cases in which vision is compromised.
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