An update on the surgical management of pterygium and the role of loteprednol etabonate ointment

Abstract

Pterygium, a sun-related eye disease, presents as wing-shaped ocular surface lesions that extend from the bulbar conjunctiva onto the cornea, most commonly on the nasal side. Pterygia show characteristic histological features that suggest that inflammation plays a prominent role in their initial pathogenesis and recurrence. Appropriate surgery is the key to successful treatment of pterygia, but there is also a rationale for the use of anti-inflammatory agents to reduce the rate of recurrence following surgery. Multiple surgical techniques have been developed over the last two millennia, but these initially had little success, due to high rates of recurrence. Current management strategies, associated with lower recurrence rates, include bare sclera excision and various types of grafts using tissue glues. Adjunctive therapies include mitomycin C and 5-fluorouracil, as well as the topical ocular steroid loteprednol etabonate, which has been shown to have a lower risk of elevated intraocular pressure than have the other topical ocular steroids. Here, the surgical management of pterygium is presented from a historical perspective, and current management techniques, including the appropriate use of various adjunctive therapies, are reviewed, along with an illustrative case presentation and a discussion of the conjunctival forceps designed to facilitate surgical management. Despite thousands of years of experience with this condition, there remains a need for a more thorough understanding of pterygium and interventions to reduce both its incidence and postsurgical recurrence. Until that time, the immediate goal is to optimize surgical practices to ensure the best possible outcomes. Loteprednol etabonate, especially the ointment formulation, appears to be a safe and effective component of the perioperative regimen for this complex ocular condition, although confirmatory prospective studies are needed.

Pterygium;

“…Recurrence is the major complication of pterygium excision. Different strategies [1][2][3][4][5] adopted to minimize this complication include per operative use of mitomycin-C, Beta radiation, excimer lasers, amniotic membrane graft to the bare sclera, conjunctival rotational flaps and conjunctival graft with or without stem cells. Now a days conjunctival graft with limbal stem cells is considered as gold standard.…”

Extracellular matrix and fibroblast injection produces pterygium-like lesion in rabbits

“…Pterygium is a benign fibrovascular growth of the ocular surface commonly associated to discomfort and red eye, and as disease progresses is often related to decreased vision (topographic astigmatism) and ocular motility restriction in severe cases [1]. A wide variety of pro-inflammatory cytokines induced by fibrogenic growth factors, oxidative stress and DNA methylation have been implicated in the pathogenesis of pterygium.…”

The excision-generated effect of pterygium on the related corneal astigmatism

“…There could be intermittent inflammation similar to pingueculitis, so cosmesis may be a significant problem. Extensive lesions, particularly if recurrent, may be associated with sub-conjunctival fibrosis extending to the fornices that may cause restricted ocular excursion (Sheppard et al, 2014). A pterygium is made up of three parts: a 'cap' (an avascular halo-like zone at the advancing edge), a head, and a body (Kawano et al, 2011).…”