Recurrent pterygium

After surgical excision of pterygium its recurrence is frequent, up to 64% for some authors, which indicates the difficulty of its treatment and the importance of the recurring or recurring pterygium.

In this article we make a review of the most relevant for its identification as well as the therapeutic guidelines to achieve its resolution.

Recurrent pterygium

After surgical excision of pterygium its recurrence is frequent, up to 64% for some authors, which indicates the difficulty of its treatment and the importance of the recurring or recurring pterygium.

In this article we make a review of the most relevant for its identification as well as the therapeutic guidelines to achieve its resolution.

What is recurrent or recurring pterygium?

El Recurrent or recurrent pterygium is the reactivation of the inflammatory process in the area previously treated by a primary pterygium either with drugs or surgery.

This definition is important because it is not necessary to wait for the recurrent pterygium to invade the cornea, the simple fact of visualize changes in the conjunctiva, vascular congestion and thickening, will be enough to put us on notice of the start of a new recurrence. Another issue is the interval from the first surgery and the recurrence. In most publications (1-4) it is mentioned that 90% of recurrences occur between the first and third month although cases with more than 1 year since initial treatment have been described (4).

We have the problem when it comes to proposing the therapeutic regimen, there is no clear consensus regarding what we have to do and that would explain the variability in the recurrence data that we find in the literature, from 3% in the Salomon series (5) up to 63% in the Essex series (6). 

Causes of recurrent pterygium

In general they are two groups of factors those related to recurrences, some due to surgery and others due the patient himself and environmental situations.

In the first case, we usually have a incomplete primary surgery due to:

  • It was not removed all the tenon affects.
  • Remains left of fibrotic tissue in the cornea and in the limbus.
  • Area corneo-scleral irregular.
  • Suture of the conjunctival edges subjected to tension.
  • was the exposed corneal-scleral limbus, without covering with the conjunctiva or the anmiotic membrane implant (IMA) or conjunctiva that we would have used.
  • Dehiscence of the conjunctival margins.
  • Not enough control inflammatory scar reaction.

Regarding the personal and environmental factors we have:

  • Patients males and with age less than 40 years.
  • Patients of origin Asian, African American e Hispanics.
  • Presence of the VEGF-460 gene, related to vascular proliferation and the appearance of pterygium
  • Being exposed to a dry and dusty environment.
  • presence of the syndrome Dry Eye.

How is recurrence generated?

El mechanism that explains recurrence is the reactivation of the inflammatory process present in the primary form. He surgical trauma act as a inflammatory response enhancer.

Si limbal stem cells persist after surgery activated and fibroblast tissue active, it is produced un increase in proliferative cytokines and vascular growth factors (VEGF) that induce fibrovascular proliferation, while increase the synthesis of metalloproteinases that destroy Bowman's membrane and stromal collagen, facilitating the advancement of the pterygium (7,8) 

recurrent pterygium

Recurrent pterygium showing the advance of the blood vessels over the corneal scar of the first surgery (asterisk).

Characteristics of recurrent pterygium

In most cases it presents greater aggressivenessa more violent inflammatory reactionwith proliferation fibroblast, thickening e irregularity of the affected tissues. Sometimes the scarring process can reach produce symblepharon and limitations in ocular motility. So DT performed a morphological classification in 1997 that is still used today and helps us to identify the type of recurrence (9).

In cases in which a conjunctival or IMA graft was performed, retraction of the implanted tissue is usually observed.

One of the ways we have identify the activity of a relapsed pterygium is ultraviolet fluorescence photography, which shows the points of maximum activity and their progression to the cornea (10).

Treatment of relapsed pterygium

There is no full consensus on how to address the treatment of recurrent pterygiumTherefore, we want to give some guidelines that are very personal, the result of what we have found published in the specialized literature and also, the result of a long experience in the treatment of these cases.

Once we are facing a recurrence, even after correct surgery and adequate postoperative treatment, with anti-inflammatories and lubricants of the ocular surface, The first step will be the preparation of these patients against a new surgery.

Until then or if the patient decides not to undergo a new intervention of the pterygium We will propose the following therapeutic guidelines based on the state of the pterygium.

relapsed pterygium

Recurrent pterygium (A) with conjunctival fibrosis seen in greater detail (B) and appearance after surgery with conjunctiva autograft (C).


In the majority of cases in which signs of inflammatory reactivation In the first months of the postoperative period, we started a more intense topical anti-inflammatory treatment, with corticosteroids and if necessary we add immunomodulators such as cyclosporine A.

La Mitomycin C in drops has not shown significant improvement and is accompanied by multiple side effects, especially eye irritation and toxic keratitis (11), in the same way, the 5-Fluouracil has not shown fully satisfactory results (12), therefore we do not recommend its use.


Treatment with topical anti-VEGF drugs, such as Bevacizumab, since studies on the pathophysiology of relapses show an increase in VEGF (13,14). The results obtained are quite encouraging, concluding that in most cases a significant reduction in recurrenceEven in some cases it was not necessary to perform the pterygium surgery again and in the cases where yes surgery was necessary for complete healing, the surgical trauma was always lower and risk of subsequent recurrence was also reduced (15,16). We do not have personal experience with the use of topical Bevacizumab and therefore we cannot yet comment on its efficacy.

Mitomycin C

Perhaps one of the guidelines that is giving us very positive results is the subconjunctival infiltration of the pterygium with Mitomycin C. Injection of 0.015% Mitomycin C, 1 month before surgery, allows reduce patient recovery time, postoperative inflammatory response, and recurrence rate, as proposed by Mandour (17) and side effects are not appreciated they did appear when administered topically.

At this time we have started the use of subconjunctival Bevacizumav, 3 weeks before surgery, as proposed by Bahar (18) and Razeghinejad (19) but there is still time to verify its possible efficacy.

After this preparation of the patient we are in a position to propose surgery, following some recommendations that we expose in the following section.

Recurrent pterygium operation

All the Surgical keys to avoid a new recurrence We can group them into the following points:

  • Cleavage ampread of the affected area.
  • Corneal zone resection (head of the Pterygium), from the limbus towards the center of the cornea.
  • Careful cleaning of the corneoscleral limbus.
  • Regularization of the treated surface.
  • Mitomycin C Application to avoid fibroblastic proliferation (intraoperative injection of Bevacizumab has not shown satisfactory results in the incidence of recurrences (19).
  • Conjunctive autograft or anmiotic membrane graft It covers the entire denuded area, without areas of tension and taking care that it is well placed on the limbus, on the edge of the cornea.
  • Graft fixation with bioadhesives, to avoid the inflammatory reaction that sutures usually induce.

The success of the surgery goes through a correct postoperative treatment, with anti-inflammatories and lubricants.

Video of the complete pterigion operation and all the steps defined HD

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Postoperative period of recurrent pterygium

At postoperative immediately a breakdown of the tear film, due to the irregularity of the tissues, are raised and the BUT is usually less than 10 secondsthat's why it's it is essential to avoid that no desiccation areas appear (Dellen), that could induce more inflammation.

The lubricants are essential to avoid mechanical friction, trauma to the eyelid on the treated area, especially if we have made a graft and fixed it with bioadhesives (20,21).


La correct application of these recommendations can explain the recurrence differences in the publications on the matter, which as we have pointed out go from 3% in the case of Solomon (5), to 64% in the case of Essex (6).

What does seem to have more consensus is in the fact that The conjunctiva autograft is the technique that offers the best results, even above the anmotic membrane grafts (22,23), the problem is that we do not always have a conjunctive of the contralateral eye, especially in complicated cases, advanced double pterygium, syblepharon presence o limbo insufficiencyIn these cases, there is no other choice but to resort to the amniotic membrane.


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Recurrent pterygium
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Recurrent pterygium
We speak of recurrent or primary pterygium when in the treatment of a pterygium there is a reactivation of inflammation. Get information here!
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Área Oftalmológica Avanzada
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