EXTERNAL DISEASE OPHTHALMIC PEARLS

Pterygium in Young Children

terygium is a benign, wedge- condition is rarely seen in children and shaped, progressive fibrovascular more commonly in persons over the 1 Povergrowth of the degenerated age of 40 years.3 However, the risk fac- bulbar , seen most com- tors noted above can particularly affect monly on the nasal limbus (Fig. 1). children who play outdoors. The condition is often asymptomatic, especially early in its development. As a Pathophysiology gradually encroaches toward Numerous studies suggest a genetic the visual axis, it can cause astigma- predisposition to the development tism, which may be the main visual of pterygium. During embryological complaint.1 In addition, the lesion may development, there may be cellular become inflamed, leading to ocular migration of keratoblasts prompted surface irritation. by vimentin, a type III intermediate CLINICAL APPEARANCE. Pterygium in Although pterygium is rare in young filament protein. a young child seen at our clinic. children, we have treated several of Another theory suggests that these patients at our medical college. increased P53 expression, along with bral fissure, originating in the nasal a paucity of tumor suppressor gene, aspect of the conjunctiva. Typically, Epidemiology facilitates the abnormal proliferation of the growth progresses gradually and Among the general population, the limbal epithelium. Type 1 hypersensi- horizontally toward the limbus, , prevalence of pterygium varies widely, tivity is also known to play a role in the and visual axis. The condition is usually with estimates ranging from 0.3% to pathogenesis of pterygium. bilateral. 29% worldwide. A meta-analysis of The affected eye may be red, with no pooled data from 20 studies, encom- Histology discharge. There may be an irritated, passing more than 900,000 cases in 12 Histopathologic examination demon- gritty sensation, leading to constant eye countries, found an overall prevalence strates conjunctival mucosa lined by rubbing. of 10.2%, with a slightly higher rate stratified squamous nonkeratinized ep- Refractive effects. A small pterygi- among men than women.2 ithelium with interspersed goblet cells. um has few symptoms and no harmful Pterygium occurs most frequently Compared with adults, children have effects. However, as it grows, the child among people who live in tropical areas an increased number of mast cells. The may complain of blurred vision due to near the equator. Ultraviolet light ex- underlying stroma shows fibrocollage- development of refractive , posure is thought to be the most likely nous tissue, with areas of hyalinization generally of the with-the-rule type. cause, and dust, dryness, and wind are and superficial congested vessels. Frequent headaches may occur as a also risk factors. consequence of the astigmatism. The peak incidence of primary Clinical Presentation pterygium lies between the ages of 20 The classic presentation of pterygium Differential Diagnosis and 40 years; outside of that range, the is a fibrovascular lesion in the palpe- . This condition appears as a yellow-white mound or aggregation of smaller mounds on the bulbar conjunc- BY SUSAN DSOUZA, MBBS, DOMS, AND M. GURUDUTT KAMATH, MBBS, tiva adjacent to the limbus, remaining DOMS, MS. EDITED BY SHARON FEKRAT, MD, AND INGRID U. SCOTT, MD, localized to the conjunctiva without

Susan Dsouza, MBBS, DOMS MPH. involving the cornea. The histology is

EYENET MAGAZINE • 35 very similar to pterygium, and pinguec- We also instruct the patient not to ulae often precede the development of 2 rub the eye and not to move the eyes pterygium. excessively. Pseudopterygium. This term de- scribes a band of conjunctiva adhering Follow-up to an area of compromised cornea at its In our experience, recurrence is more apex as a result of chemical or thermal aggressive and occurs earlier—at 4 to burns, trauma, or marginal corneal dis- 6 months—in children than in adults. ease. The lesion is not confined to the Children who have had pterygium exci- palpebral fissure. As an important point sion should be examined every month of distinction, a probe can be passed for 6 months and, subsequently, once beneath a pseudopterygium near the every 6 months. Long-term follow-up limbus, while this is impossible in true AFTER TREATMENT. Rotational may yield better understanding of pterygium. conjunctival autograft was used after childhood pterygium and its outcome. excision of pterygium. Workup 1 Liu L et al. BMJ Open. 2013;3:e003787. doi:10. The clinical diagnosis of pterygium is • Astigmatism leading to visual impair- 1136/bmjopen-2013-003787. based on history, anterior segment slit- ment 2 Noor RA. Malays J Med Sci. 2003;10(2):91-92. lamp examination, and refraction to • Cosmetic concerns www.ncbi.nlm.nih.gov/pmc/articles/PMC assess for astigmatism. Primary pterygium. In children 3561894/. Accessed Aug. 24, 2017. Staging. Pterygium is graded with a primary pterygium, conjunctival 3 Monga S et al. Am J Ophthalmol. 2012;154(5): according to the extent of corneal autograft is the treatment of choice.5 859-864. involvement. Conjunctival rotational autograft (Fig. 4 Ibechukwu BI. East Afr Med J. 1992;69(9):490- Grade I: at the limbus 2) can be considered, with the caveat 493. Grade II: between the limbus and that in some active children, constant 5 Yadav AR et al. Indian J Ophthalmol. 2015; the eye movement may displace the graft. 63(6):491-495. Grade III: extending to the pupillary Recurrent pterygium. In cases of margin recurrence, a conjunctival autograft Dr. Dsouza is a senior resident and Dr. Kamath Grade IV: crossing the pupillary technique may be attempted again. As is a professor; both are in the Department of margin an alternative, we have had good results , Kasturba Medical College, with the older technique of conven- Mangalore, Karnataka, India. Relevant financial Treatment tional bare pterygium excision. disclosures: None. Management of pterygium in children It is important to note that this surgery is generally the same as in adults. De- must be performed with use of adjunc- finitive resolution may be more difficult tive therapies, such as mitomycin C, to Write an Ophthalmic to achieve than it is in adults, however, reduce the otherwise unacceptable risk Pearls Article because pterygium recurs more aggres- of recurrence. However, antifibrotic Pearls articles typically offer sively and at a reportedly higher rate of agents are associated with complica- step-by-step summaries of eti­ 36.1% in children.4 tions, including corneal melting, cor- ology, diagnosis, treatment, and Conservative management. Medical neal perforation, prolonged punctate follow-up. treatment for symptomatic children keratopathy, scleral necrosis, secondary To get started, you need only with small pterygia includes use of , and . a few things: artificial tears and weak topical steroids Another option is amniotic mem- • a great topic to reduce inflammation and improve brane transplantation, but it is costly, • a faculty advisor to review comfort. requires preservation, and is not widely your manuscript and add his/her The child may be advised to wear available. pearls from clinical experience sunglasses while outdoors; reducing Postsurgical care. In our clinic, we • a copy of the Writers Guide­ ultraviolet light exposure may decrease advise the following postsurgical regi- lines and the Pearls Checklist to the growth stimulus. men: tobramycin sulfate 0.3% drops 6 ensure that all key requirements Surgery. Surgical therapy may be times per day for 15 days; 1% prednis- have been met. Find them at aao. appropriate for larger pterygia en- olone acetate drops 4 times per day for org/eyenet/write-for-us. croaching on the limbus and progress- a week, then tapered over 3 weeks; and Are you a resident? A resident ing toward the visual axis. 0.5% carboxymethylcellulose sodium article published in the Ophthal­ Indications for surgery include the drops 6 times a day for a month. mic Pearls section will satisfy the following: For pain, oral nonsteroidal anti- RRC requirements for resident • Intractable irritation inflammatory drugs are given in pedi- scholarly activity.

• Opacity in the visual axis atric doses according to body weight. Susan Dsouza, MBBS, DOMS

36 • DECEMBER 2017