Pterygium Surgery, Sydney
Assessment and Management of 'Surfer's Eye'
Pterygium Overview
A pterygium is a raised, fleshy growth on the white part of the eye that can extend onto the cornea. It is sometimes called 'surfer’s eye' because it is associated with long-term exposure to ultraviolet light, wind, dust and outdoor conditions and is commonly seen in surfers and beach goers.
Pterygium is common in Australia, particularly in people who spend time outdoors, at the beach, on the water or in high-glare environments. In Sydney, many patients notice a pterygium after years of sun exposure, surfing, sailing, outdoor work or driving.
Some pterygia are mild and can be monitored. Others become red, irritated, cosmetically noticeable or large enough to affect vision. When a pterygium grows towards the centre of the cornea, changes the shape of the eye or causes persistent symptoms, pterygium surgery may be recommended.
At Eye and Retina Specialists, our doctors assess pterygium and provide advice about monitoring, medical treatment and surgical options.
What is a pterygium?
A pterygium is a benign growth of conjunctival tissue from the white part of the eye onto the cornea. The cornea is the clear front window of the eye, and tissue growing across it can affect comfort, appearance or vision.
Most pterygia grow from the inner corner of the eye, on the side closest to the nose. This is called a nasal pterygium. Less commonly, a pterygium can occur on the outer side of the eye.
A pterygium is not cancer. However, it can gradually enlarge over time. It is important to assess and manage a pterygium before it approaches or grows across the visual axis, as this can cause corneal scarring and more permanently affect vision. Occasionally, other potentially serious ocular surface conditions can resemble a pterygium, so ophthalmic assessment is important.
A nasal pterygium extending to involve the visual axis
Pinguecula vs pterygium
A pinguecula and a pterygium are both common sun-related changes on the surface of the eye, but they are not the same.
A pinguecula is a small yellow-white raised area on the conjunctiva. It sits on the white part of the eye near the cornea but does not grow onto the cornea. Pingueculae are common in people with long-term ultraviolet light, wind and dry environmental exposure. They can become red or inflamed, but they usually do not affect vision.
A pterygium is different because it grows onto and invades the cornea. This is why a pterygium can sometimes blur vision, induce astigmatism or risk visually significant corneal scarring if it grows too far towards the centre of the cornea.
In simple terms, a pinguecula stays on the white part of the eye. A pterygium crosses onto the cornea.
Comparison of pterygium and pinguecula: a pterygium grows onto the cornea, whereas a pinguecula does not
What causes pterygium?
Pterygium is strongly linked to environmental exposure. The main risk factors include ultraviolet light, wind, dust, dry eye, chronic irritation and long-term outdoor activity. Light entering from the side can be focused by the cornea onto the nasal limbus at high intensity, explaining the preponderance of nasally located pterygia.
Pterygium is commonly seen in people who surf, sail, cycle, run, play outdoor sport, drive frequently or work outdoors. Builders, tradespeople, gardeners, lifeguards and people who spend many years in bright coastal environments are also at higher risk.
Sunlight reflected from water, sand, concrete and roads can increase UV exposure to the eyes. Wearing wraparound sunglasses and a broad-brimmed hat can reduce the risk of a pterygium developing and may also reduce progression or recurrence after surgery.
The Coroneo Effect describes peripheral light focusing by the anterior eye onto the nasal limbus, the area where pterygium most commonly develops
Adapted from Coroneo, Müller-Stolzenburg and Ho, 1991
Symptoms of pterygium
A pterygium may cause no symptom, especially in the early stages. Many people may notice a small raised area, yellow-white patch or red triangular growth on the white of the eye. Others might have it pointed out by friends or relatives, or by their optometrist when attending for glasses or a routine eye check.
As a pterygium becomes larger, it may become intermittently inflamed. Symptoms can include redness, grittiness, irritation and a gritty foreign body sensation. Some people report their eyes are chronically red from pterygium. Others find the symptoms fluctuate. A pterygium may look or feel worse after prolonged sun exposure, windy environments or swimming. Larger pterygia can induce corneal astigmatism, and people may find their vision becoming blurry and needing their glasses prescription changed.
How we assess pterygium
At Eye and Retina Specialists, assessment usually includes vision testing and slit lamp examination of the ocular surface. Our ophthalmologists assess the size, thickness, vascularity and position of the pterygium, including how far it extends onto the cornea.
Depending on the case, further testing may include refraction, corneal topography, ocular surface photography and dry eye assessment. Corneal topography can be useful when the pterygium is causing astigmatism or when cataract surgery is being considered.
Assessment also looks for features that are not typical of pterygium. If a lesion has unusual pigmentation, thickening, irregular vessels, recurrent bleeding or atypical growth, further investigation may be needed.
Corneal topography demonstrates irregular astigmatism induced by a right nasal pterygium
When is surgery recommended for a pterygium?
Small, non-inflamed pterygia can often be monitored, especially if they are not growing and are not causing significant symptoms.
Surgical excision may be necessary due to the following reasons:
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The pterygium grows across the cornea and is at risk of covering the pupil, thereby blocking the visual axis.
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The pterygium distorts the corneal surface, causing significant astigmatism and blurred or distorted vision.
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The pterygium becomes red, inflamed and irritable, and does so on a recurrent basis.
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You are concerned about the unsightly appearance of the pterygium and wish for it to be removed.
Pterygium Excision Surgery
Pterygium surgery involves removing the abnormal tissue from the eye surface and reconstructing the area to reduce the risk of recurrence.
The surgery is performed as a day procedure. The eye is numbed with local anaesthetic under sedation. A full general anaesthetic is usually not required.
The most commonly recommended technique is pterygium excision with conjunctival autograft. After the pterygium is removed, a thin layer of healthy conjunctiva is taken from another part of the same eye and placed over the area where the pterygium was removed. The graft helps the surface heal and significantly reduces the chance of the pterygium growing back.
Illustration of pterygium surgery showing excision of a pterygium
Conjunctival Autograft
Pterygium excision alone has high rates of recurrence, where the pterygium grows back. Conjunctival autograft surgery is recommended because it significantly reduces the risk of recurrence.
The graft acts as a healthy tissue barrier over the exposed sclera. In many cases, the graft can be secured with medical tissue glue rather than sutures. Tissue glue may reduce early irritation compared with sutures. In selected complex cases, amniotic membrane or other techniques may be considered, particularly when there is extensive conjunctival scarring or recurrent disease.
Illustration of conjunctival autograft surgery showing the graft being transferred and then positioned over the tissue defect from the pterygium excision
Risks of pterygium surgery
Pterygium surgery is a common eye operation and most patients recover well with a good surgical outcomes. However all medical procedures have potential risks. Your ophthalmologist will discuss the risks with you before surgery and take the time to answer your questions.
Possible risks of pterygium surgery include infection, bleeding, delayed healing, scarring, persistent redness, irritation, dry eye symptoms, light sensitivity, blurred vision, graft swelling, graft displacement, change in astigmatism, double vision, recurrence of the pterygium, and the need for further treatment or surgery. Serious complications are uncommon.
Recovery after pterygium surgery
After pterygium surgery, the eye may be gritty and red for the first few days . There may be some watering and light sensitivity during the early healing. The eye gradually settles in the first few weeks after surgery. Antibiotic and steroidal anti-inflammatory drops are usually prescribed after surgery. Your surgeon will provide you specific details of the drops and duration for your particular case.
It is normal for the conjunctival graft to look pink, swollen or red in the first few weeks after surgery. Patients are advised not to rub the eye for the first few weeks after surgery. A shield may be used at night to protect the graft during sleep. Follow-up visits are used to check graft position, inflammation and healing. Although rare, increasing pain, worsening discharge, marked loss of vision or rapidly increasing redness should be promptly reported.
Recovery time depends on the eye, the type of work and the level of irritation. Many patients return to light duties within a few days, but some patients take about a week off work. More time may be needed if work involves heavy lifting, dust exposure, outdoor conditions, long driving hours or heavy computer use. Swimming and vigorous exercise should be avoided during the early healing period. Driving depends on vision, comfort and whether the other eye sees well.
Frequently Asked Questions (FAQs)
1. I have a pterygium and cataract in the same eye. Which one should be operated on first?
A significant pterygium can affect corneal astigmatism and the measurements used for cataract surgery planning. This can adversely affect the intraocular lens choice, especially if the pterygium continues to grow following cataract surgery. A significant pterygium can alter corneal astigmatism and reduce the accuracy of the measurements used to calculate the intraocular lens power for cataract surgery.
For patients with large or growing pterygium, pterygium surgery is usually recommended before cataract surgery. The eye is then allowed to heal and stabilise before intraocular lens measurements are conducted and cataract surgery performed. Small stable pterygia that do not distort the cornea may not need surgery before cataract surgery. Our doctors will evaluate your clinical examination findings and investigation test results before providing their recommendation for each individual patient.
2. Can the pterygium come back after surgery?
Yes, pterygium can recur after surgery. Recurrence risk depends on several factors, including age, ultraviolet exposure, inflammation, pterygium size, previous surgery and surgical technique.The risk can be reduced by conjunctival autograft, good control of post-operative inflammation, using prescribed drops as directed, avoiding eye rubbing and protecting the eye from ultraviolet light, wind and dust.
Long-term sun protection remains important even after successful surgery. Wraparound UV-protective sunglasses and a broad-brimmed hat are sensible, especially for people who surf, sail, work outdoors or spend long periods in high-glare environments.
3. Can children develop UV-related changes on the eye?
Yes. Sun-related changes on the surface of the eye can sometimes be seen in children, especially those who spend a lot of time outdoors or around reflected light from water, sand, concrete or sport fields.
A pterygium is uncommon in young children, but ultraviolet-related changes can occur such as pinguecula, ocular surface irritation and early limbal changes can occur. In the early stages these changes may not cause symptoms, so children may not complain even when their eyes are being exposed to significant UV light.
The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) Position Statement on UV Eye Protection warns that UV damage to children’s eyes is common by adolescence. Children should wear UV-protective wrap-around sunglasses and a broad-brimmed hat when outdoors, particularly at the beach, on the water, during sport and in high-glare conditions. Australian research, including work co-authored by Dr Neil Sharma published in the American Journal of Ophthalmology, has shown that early ultraviolet-relate changes on the eye surface can be detected in Sydney school-aged children as young as 9 years old .
Protecting children’s eyes with UV-blocking wrap-around sunglasses is recommended from an early age
4. What sunglasses are available for children?
A variety of sunglasses brands and styles are available for children, even from a young age. Children should be encouraged to wear close-fitting sunglasses that provide UV protection, especially during outdoor playtime activities, at the beach, during sport and in other high-glare environments. Children are more likely to wear sunglasses consistently if the frames are comfortable, lightweight and secure. Wraparound or close-fitting designs are important because they reduce peripheral UV exposure. One Australian option is Beamers (https://www.beamers.com.au), a children’s sunglasses brand developed by RANZCO ophthalmologists to help protect children’s eyes from UV exposure.
5. Where are you located?
Eye and Retina Specialists is located in Waterloo in the Green Square precinct. Our doctors provide pterygium assessment and treatment advice. Our practice frequently treats patients from Zetland, Alexandria, Beaconsfield, Rosebery, Redfern, Kensington, Eveleigh, Surry Hills, Eastlakes, Mascot, Erskineville, Newtown, Chippendale, Ultimo, Daceyville, Kingsford, Randwick, St Peters and Centennial Park, as well as the Inner West, Eastern Suburbs and greater Sydney.
Email or phone our reception team to organise a consultation to help determine whether your pterygium is suitable for monitoring, medical treatment or surgery.