Chapter 20
Management of Pterygium with
Coexisting Cataract
INTRODUCTION
Pterygium is one of the most common ocular surface diseases in
the elderly. Its prevalence has been noted to be higher in certain
populations such as outdoor workers who have significant sun
exposure, but its exact pathogenesis and underlying causes are
not completely understood.
Pterygium is characterized by a triangular or wing-shaped
fibrovascular connective tissue overgrowth of bulbar
conjunctiva that grows onto the corneal surface. While most
pterygia are asymptomatic and cause no more than cosmetic
concerns, some may lead to refractive changes and serious
visual disturbances. This will be discussed later in this chapter.
The coexistence of pterygium and cataract (Fig. 20.1),
particularly in older adults, is an important challenge for
clinicians, because of the ongoing debate regarding the “ideal”
timing and technique of pterygium surgery. With recent
technological advances both in surgical techniques
Fig. 20.1 Anterior segment photograph shows the coexistence of
cataract with pterygium in a 65-year-old patient. A large inflamed
pterygium that is beginning to obstruct the pupil should be treated
first with an appropriate anti-inflammatory agent prior to excision. In
such cases with a larger pterygium, cataract surgery should be
performed at least one month after the pterygium surgery
Koray Gumus, Cynthia I Tung, Zaina Al-Mohtaseb
and in intraocular lenses, cataract surgery has become more
sophisticated in that it approaches the precision of refractive
surgery. In addition, patient expectations have risen as they
expect a perfect refractive result after cataract surgery. This is
the reason that the timing and the refractive outcomes of
pterygium surgery have attracted more attention in the last few
years.
THE IMPACT OF PTERYGIUM
ON VISUAL PARAMETERS
Pterygia do not only lead to visual impairment by invading the
visual axis or distorting the central topography, but they also
induce focal corneal flattening, severe astigmatism, and
deterioration of corneal aberrations.
While surgical excision can improve pterygium-induced
refractive errors and topographical changes, corneal distortion
may be more difficult to reverse completely, particularly in
cases of large pterygia. One of our studies has recently proven
that corneal aberrations continue to change beyond the early
postoperative period, even up to one year. Therefore, any
refractive procedures may be postponed until at least one year
after the pterygium surgery. Thus, this finding is clinically
important in the timing of pterygium excision and subsequent
cataract surgery, in eyes with coexisting cataract.
In the management of comorbid pterygium and cataract,
detailed slit-lamp examination, corneal topography, and
repeated IOL power calculations are necessary to determine the
proper course of treatment. The size of the pterygium, its
location, its contribution to distortions in keratometry (K)
readings, and worsening in corneal aberrations are primary
factors for determining the course of treatment (Figs 20.2A and
B). For small pterygia, simultaneous surgery may not affect
refractive outcome, so small lesions may not need to be
considered in preoperative work up. Kim et al. showed that the
mean corneal power did not change significantly after surgery in
patients with pterygia smaller than 2 mm. Thus, in these eyes,
cataract surgery can be performed first and pterygium excision
can be planned later for symptomatic improvement or cosmetic
purposes. However, if the pterygium is large and
 Chapter 20: Management of Pterygium with Coexisting Cataract
A wherein thirty patients with pterygium and cataract were treated
B type of IOL selected are important factors that require careful
Figs 20.2A and B Anterior segment photographs show different
sizes of pterygia with corresponding root mean square (RMS)
values of corneal aberrations. It is certainly clear that the larger
pterygium is associated with significantly increased corneal
aberrations compared to the small pterygium
induces clinically significant astigmatism or causes distortion in
K readings, it may be best to perform pterygium excision first to
avoid an undesired refractive outcome after cataract surgery. In
other words, pterygia that interfere with K readings should be
excised as a separate procedure before proceeding with cataract
surgery.
SIMULTANEoUS PTERYGIUM
AND CATARACT SURGERY
In clinical practice, while some clinicians prefer simultaneous
pterygium excision and cataract extraction, others prefer to
perform these two surgeries separately. There are some pros and
cons of simultaneous surgery. Performing these two procedures
at once can save time and energy for the surgeon and is cost-
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effective for the patient, particularly in the Indian subcontinent
where the incidences of pterygium and senile cataract are higher
than elsewhere. One recent study investigated the predictability
of intraocular lens (IOL) power calculation after simultaneous
pterygium excision and phacoemulsification with IOL
implantation. The authors concluded that simultaneous
pterygium and cataract surgery was safe and effective, and the
accuracy was moderately predictable. However, they also
warned readers about a significant myopic shift that might occur
postoperatively, possibly resulting from the steepening of the
cornea after pterygium removal, especially when the size of the
pterygium was large.
Although the possibility of adverse effects on corneal
wound healing and increase in postoperative complications may
be low, it definitely should still be considered. In one study
with simultaneous pterygium excision and cataract extraction,
the authors concluded that the combined procedure did not
interfere with the healing of the cataract incision. In that study,
the patients underwent pterygium excision first and were treated
intraoperatively with 500 rads of beta radiation over the
pterygium site, immediately followed by cataract extraction.
The necessity of immediate use of topical steroid on
postoperative day 1 to prevent intraocular inflammation might
lead to a delay of corneal wound healing, particularly if it is
near the site of pterygium excision. Delay in wound healing can
be addressed by use of bandage contact lenses and/or new
therapeutic agents that promote corneal wound healing, such as
topical regenerating agents (RGTA), coenzyme Q eye drops,
and new generation artificial tears.
The severity of pterygium-induced astigmatism and also the
attention during simultaneous surgery for pterygium and
cataract. Since it is impossible to tell how much astigmatism is
pre-existing versus induced by the pterygium, clinicians should
avoid any intraoperative astigmatic correction such as corneal-
relaxing incisions or implantation of toric IOLs. In these cases,
standard monofocal IOLs are preferred.
Some considerations in surgical technique should be
addressed carefully. The incisions should be water-tight to avoid
any possible wound leak. There should be a low threshold to
place a suture, particularly in cases where antimetabolites such
as mitomycin C(MMC) are used. In recurrent pterygia, deciding
the locations of side ports can be challenging because the
corneal stroma may be thin at the site of pterygium excision. In
these cases, using a temporal clear cornea approach for cataract
surgery may be a preferred approach.
TIMING OF the CATARACT
SURGERY: BEFORE OR AFTER
THE PTERYGIUM EXCISION