Pterygium for Residents: Grading, Surgery and Preventing Recurrence
Last updated: November 2026
Pterygium is a wing-shaped fibrovascular growth of conjunctiva onto the cornea, linked to ultraviolet light and very common in India. The surgery is simple; preventing recurrence is the real skill.
Features
- Usually nasal, in the interpalpebral zone; risk factors are UV exposure, outdoor work, dry and dusty climates.
- Parts: cap (avascular leading edge, sometimes with a Stocker iron line), head, neck and body.
- Effects: cosmetic, irritation, induced with-the-rule astigmatism, and loss of vision if it reaches the visual axis.
Indications for surgery
- Encroachment towards the visual axis, or progression on serial photographs.
- Significant induced astigmatism or irregular topography.
- Restricted eye movements or diplopia (recurrent pterygium).
- Persistent irritation, cosmesis; suspicion of ocular surface squamous neoplasia (send for histology).
Surgical options and recurrence
| Technique | Typical recurrence |
|---|---|
| Bare sclera excision | High: often 30–80%; no longer recommended alone |
| Bare sclera with intraoperative mitomycin C | Lower, but risk of scleral melt |
| Conjunctival autograft (from superior bulbar conjunctiva) with fibrin glue or sutures | Lowest: commonly under 10%; the standard of care |
| Amniotic membrane graft | Higher than autograft; useful when conjunctiva must be spared (glaucoma surgery planned) or for large or double-headed lesions |
Tips
- Keep the graft oriented limbus to limbus, and remove Tenon tissue thoroughly from the bed and graft.
- Smooth the corneal bed (diamond burr) to reduce recurrence and astigmatism.
- Fibrin glue shortens surgery and reduces discomfort compared with sutures.
- Advise sunglasses afterwards; topical steroids for several weeks reduce early recurrence.
- Delay biometry and refractive planning for cataract until the cornea has stabilised after pterygium surgery.
Where residents slip
- Doing bare sclera excision alone.
- Turning the autograft upside down.
- Doing biometry before removing a large pterygium.
Test yourself: flip cards
Related: Cornea, Topography and Keratoconus Screening Card: Cut-offs and Staging, Biometry Check Before Cataract Surgery: When to Recheck and Which Formula.
Key sources
- Kaufman SC, et al. Options and adjuvants in surgery for pterygium: a report by the American Academy of Ophthalmology. Ophthalmology. 2013;120:201-208
- Clearfield E, et al. Conjunctival autograft for pterygium. Cochrane Database Syst Rev. 2016
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