CHAPTER IINTRODUCTION

A pterygium is a fleshy triangular band of fibrovascular tissue with a broad base on the nasal or temporal epibulbar area, a blunt apex or head on the cornea, and a gray zone, or cap, which just precedes the apex. It is most common in the 20 to 30 year age group, in males, in tropical climates, and in people exposed to the elements and ultraviolet light.1 It is thought to be an irritative phenomenon because of ultraviolet light, drying, and windy environments, since it is common in persons who spend much of their lives out of doors in sunny, dusty, or sandy, windblown surroundings. The pathologic findings in the conjunctiva are the same as those of pinguecula. In the cornea, there is replacement of Bowman's layer by hyaline and elastic tissue.2

CHAPTER IILITERATURE REVIEW

2.1 Conjunctiva

The conjunctiva is the mucous membrane lining the eyelids and reflecting onto the sclera of the anterior surface of the eye.3A transparent mucous membrane, known as the conjunctiva, lines the inner surface of the eyelids (palpebral conjunctiva) and covers the sclera of the anterior portion of the eye (bulbar conjunctiva). The conjunctiva is composed of a stratified columnar epithelium that contains goblet cells overlying a basal lamina and a lamina propria composed of loose connective tissue. Secretions of the goblet cells become a part of the tear film, which aids in lubricating and protecting the epithelium of the anterior aspect of the eye. At the corneoscleral junction, where the cornea begins, the conjunctiva continues as the stratified squamous corneal epithelium and is devoid of goblet cells. 3 2.2CorneaThe cornea is the transparent, avascular, and highly innervated anterior portion of the fibrous tunic that bulges out anteriorly from the orb. It is slightly thicker than the sclera and is composed of five histologically distinct layers 3: 1) Corneal epithelium2) Bowman's membrane3) Stroma4) Descemet's membrane5) Corneal endothelium The corneal epithelium, the continuation of the conjunctiva (a mucous membrane covering the anterior sclera and lining the internal surface of the eyelids), is a stratified, squamous, nonkeratinized epithelium, composed of five to seven layers of cells, that covers the anterior surface of the cornea. The larger superficial cells have microvilli and exhibit zonulae occludentes. The remaining cells constituting the corneal epithelium interdigitate with and form desmosomal contacts with one another. Their cytoplasm contains the usual array of organelles along with intermediate filaments. The corneal epithelium is highly innervated by numerous free nerve endings. Mitotic figures are observed mostly near the periphery of the cornea, with a turnover rate of approximately 7 days. Damage to the cornea is repaired rapidly as cells migrate to the defect to cover the injured region. Subsequently, mitotic activity replaces the cells that migrated to the wound. The corneal epithelium also functions in transferring water and ions from the stroma into the conjunctival sac.3Bowman's membrane lies immediately deep to the corneal epithelium. Electron micrographs reveal it to be a fibrillar lamina, 6 to 30 m thick, composed of type I collagen fibers arranged in an apparently random fashion. It is believed that Bowman's membrane is synthesized by both the corneal epithelium and cells of the underlying stroma. Sensory nerve fibers pass through this structure to enter and terminate in the epithelium.3 The transparent stroma is the thickest layer of the cornea, constituting about 90% of its thickness. It is composed of collagenous connective tissue, consisting mostly of type I collagen fibers that are arranged in 200 to 250 lamellae, each about 2 m in thickness. The collagen fibers within each lamella are arranged parallel to one another, but fiber orientation shifts in adjacent lamellae. The collagen fibers are interspersed with thin elastic fibers, embedded in ground substance containing mostly chondroitin sulfate and keratan sulfate. Long, slender fibroblasts are also present among the collagen fiber bundles. During inflammation, lymphocytes and neutrophils are also present in the stroma. At the limbus (sclerocorneal junction) is a scleral sulcus whose inner aspect at the stroma is depressed and houses endothelium-lined spaces, known as the trabecular meshwork, that lead to the canal of Schlemm. The canal of Schlemm is the site of outflow of the aqueous humor from the anterior chamber of the eye into the venous system.3 Descemet's membrane is a thick basement membrane interposed between the stroma and the underlying endothelium. Although this membrane is thin (5 m at birth) and homogeneous in younger persons, electron microscopy has demonstrated that it becomes thicker (17 m) and has cross-striations and hexagonal fiber patterns in older adults.3 The corneal endothelium, which lines the internal (posterior) surface of the cornea, is a simple squamous epithelium. It is responsible for synthesis of proteins that are necessary for secreting and maintaining Descemet's membrane. These cells exhibit numerous pinocytotic vesicles, and their membranes have sodium pumps that transport sodium ions (Na+) into the anterior chamber; these ions are passively followed by chloride ions (Cl-) and water. Thus, excess fluid within the stroma is resorbed by the endothelium, keeping the stroma relatively dehydrated, a factor that contributes to maintaining the refractive quality of the cornea.32.3 PterygiumPterygium (L. Pterygion = a wing) is a wing-shaped fold of conjunctiva encroaching upon the cornea from either side within the interpalpebral fissure.42.3.1 EpidemiologyThe prevalence rates of pterygium obtained for a number of populations vary widely, from 1.2% in urban, temperate white people5 to 23.4% in the black population of tropical Barbados.5 These study populations differ in race, latitude, and sun exposure, but generally prevalence rates in the tropics are higher than at temperate latitudes. Research in Indonesia in Riau showed 17.0% prevalence of pterygium.62.3.2 EtiologyEtiology of pterygium is not definitely known. But the disease is more common in people living in hot climates. Therefore, the most accepted view is that it is a response to prolonged effect of environmental factors such as exposure to sun (ultraviolet rays), dry heat, high wind and abundance of dust.2.3.3 Risk FactorsRisk factors that influence the occurrence of pterygium is:a. AgeIt is uncommon for patients to present with pterygium prior to age 20 years. Patients older than 40 years have the highest prevalence of pterygia.7b. Ultraviolet light exposureThere is close relationship between pterygium and ultraviolet rays in ophthalmology. The incidence of pterygium is much higher in outdoor workers who are working for long hours in the sun-belt area. Ultraviolet light which plays a role in pterygium is ultraviolet B. UV-B rays can cause chronic inflammatory reactions that formed fibrovaskular tissue.8c. GeographicSeveral surveys have shown that the countries nearer the equator have higher rate of pterygium than the other regions, the possible reason is due to stronger exposure to ultraviolet rays.7d. GenderPterygium are reported to occur in males twice as frequently as in females.7e. HereditaryIn black african, there was a positive family history of pterygium in 36% of cases. In Australia 38% of patients admitted for pterygium surgery compared with 8 - 12% of controls admitted for other conditions had a family history of the growth. In South Africa 30 - 35% of urban predominantly white individuals who had attended an ophthalmic practice because of pterygium had a positive family history.9f. MicrotraumaMikrotrauma because of certain particles such as cigarette smoke, dust and sand is one of the risk factors for pterygium. Mikrotrauma a trigger of chronic inflammation that causes the occurrence of pterygium.72.3.4 Pathogenesis and PathophysiologyA central process in pterygium pathogenesis is thought to be matrix metalloproteinase (MMP) activation by ultraviolet light (UV) and subsequent MMP activity against interstitial tissue. A number of MMPs are involved but MMP1 is abundantly expressed in pterygium.10The pathophysiology of pterygia is characterized by elastotic degeneration of collagen and fibrovascular proliferation, with an overlying covering of epithelium. Histopathology of the abnormal collagen in the area of elastotic degeneration shows basophilia with hematoxylin and eosin stain. This tissue also stains with elastic tissue stains, but it is not true elastic tissue, in that it is not digested by elastase.72.3.5 Clinical FeaturePterygium is more common in elderly males doing outdoor work. It may be unilateral or bilateral. It presents as a triangular fold of conjunctiva encroaching the cornea in the area of palpebral aperture, usually on the nasal side, but may also occur on the temporal side. Pterygium is an asymptomatic condition in the early stages, except for cosmetic intolerance. Visual disturbances occur when it encroaches the pupillary area or due to corneal astigmatism induced due to fibrosis in the regressive stage. Occasionally diplopia may occur due to limitation of ocular movements.6

2.3.6 StagingBased on the degree of growth, the pterygium can be classified into 4 stage12:a. Stage 1Fibrovaskular tissue growth confined to the limbus.

Stage 1 Pterygiumb. Stage 2Fibrovaskular tissue growth has been through limbus but not greater than 2 mm across the cornea.

Stage 2 Pterygiumc. Stage 3Fibrovaskular tissue growth beyond 2 mm of the cornea, but does not exceed the edge of the pupil of the eye.

Stage 3 Pterygium

d. Stage 4Fibrovaskular tissue growth has been over the edge pupils.

Stage 4 PterygiumBased on its location, pterygium generally classified into unilateral and bilateral pterygium. Unilateral pterygium pterygium is that only occurs in one eye, whereas bilateral pterygium was found in both eyes. In addition, pterygium pterygium also can be classified into the nasal, temporal, or nasal and temporal part in one eye is commonly called kissing pterygium.Almost 97% pterygium in nasal. Only about 3% which is in the temporal. In some cases, can be found kissing pterygium.The predominance of pterygia on the nasal side is possibly a result of the sun's rays passing laterally through the cornea, where it undergoes refraction and becomes focused on the limbic area. Sunlight passes unobstructed from the lateral side of the eye, focusing on the medial limbus after passing through the cornea. On the contralateral (medial) side, however, the shadow of the nose medially reduces the intensity of sunlight focused on the lateral/temporal limbus.102.3.7 DiagnosisPatients with pterygia present with a variety of complaints, ranging from no symptoms to significant redness, swelling, itching, irritation, and blurring of vision associated with elevated lesions of the conjunctiva and contiguous cornea in one or both eyes.11The clinical presentation can be divided into 2 general categories, as follows7:a. One group of patients with pterygium can present with minimal proliferation and a relatively atrophic appearance. The pterygia in this group tend to be flatter and slow growing and have a relatively lower incidence of recurrence following excision. b. The second group presents with a history of rapid growth and a significant elevated fibrovascular component. The pterygia in this group have a more aggressive clinical course and a higher rate of recurrence following excision.2.3.8 Differential DiagnosisPterygium must be differentiated from pseudopterygium and pinguecula. Pseudopterygium is a fold of bulbar conjunctiva attached to the cornea. It is formed due to adhesions of chemosed bulbar conjunctiva to the marginal corneal ulcer. It usually occurs following chemical burns of the eye.Tabel 1. Differences between pterygium and pseudopterygiumPterygiumPseudopterygium

EtiologyDegenerative processInflammatory process

AgeUsually occur in elderly personCan occur at any age

SiteAlways situated in the palpebral apertureCan occur at any site

StagesEither progressive, regressive, or stationaryAlways stationary

Probe TestProbe cannot be passed underneathProbe can be passed underneath

Pingueculae are extremely common in adults. They appear as yellow nodules on both sides of the cornea (more commonly on the nasal side) in the area of the palpebral aperture. The nodules, consisting of hyaline and yellow elastic tissue, rarely increase in size, but inflammation is common.2.3.9 Differential DiagnosisComplications of pterygium include visual impairment, impaired eye movement, and dry eye. Visual impairment occurred primarily in pterygium stage 3 and 4. Visual impairment in pterygium mainly caused by the pull of the cornea, causing astigmatism. Pterygium block the entry of light into the retina, especially in pterygium who had passed the edge of the pupil of the eye.7Eyeball movement disorders can occur due to pterygium causing adhesions and restrictions on movement of the eyeball. Pterygium will cause the conjunctiva and sclera that loosely binds become sticky so that movement of the eye becoming more difficult. In addition, the existence of pterygium growth will cause the area to the movement of the eyeball becomes smaller.7Dry eye often occur in pterygium. This is caused by defects of the tear film. Conjunctiva is one of the forming of the tear film. Goblet cells in the conjunctiva will not produce a layer of tears if the surface is covered by the pterygium. This is what causes dry eye in the pterygium.72.3.10 TreatmentPatients with pterygia can be observed unless the lesions exhibit growth toward the center of the cornea or the patient exhibits symptoms of significant redness, discomfort, or alterations in visual function. Pterygia can be removed for cosmetic reasons, as well as for functional abnormalities of vision or discomfort.14)a. Medical CareMedical therapy of pterygia consists of artificial tears/topical lubricating drops as well as occasional short-term use of topical corticosteroid anti-inflammatory drops when symptoms are more intense.Artificial tears provide topical ocular surface lubrication and fill defects in the tear film, in patients with irregular corneal surfaces and irregular tear films. These conditions are very common in the setting of pterygium.Topical corticosteroid is used to reduce inflammation on the ocular surface and other ocular tissues. Corticosteroids can be helpful in the management of inflamed pterygia by reducing the swelling of the inflamed tissues of the ocular surface adjacent to the lesions. 12b. Surgical CareSurgical care is indicated for stage 3 and stage 4 pterygium. Removal of the pterygium involves surgical excision of the head, neck and body of the pterygium. The body and base of the pterygium are dissected with conjunctival scissors, while the head and neck of the pterygium that has invaded the cornea is often removed with a surgical blade. An attempt is made to identify the plane of dissection, which facilitates removal of the pterygium while keeping the underlying corneal surface smooth. Remnant stromal attachments may be smoothed out with the blade.The surgical options available include the use of conjunctival autograft, amniotic membrane transplant, and use of fibrin glue.12

2.3.11 PreventionMinimizing exposure to ultraviolet radiation should reduce the risk of development of pterygia in susceptible individuals. Patients are advised to use a hat or a cap with a brim, in addition to ultraviolet-blocking coatings on the lenses of glasses/sunglasses to be used in areas of sun exposure. This precaution is even more important for those patients living in tropical or subtropical areas or for those patients who are engaged in outdoor activities with a high risk of ultraviolet exposure.72.3.12 PrognosisThe visual and cosmetic prognosis following excision of pterygia is good. The procedures are well tolerated by patients, and, aside from some discomfort in the first few postoperative days, most patients are able to resume full activity within 48 hours of their surgery.12

CHAPTER IIICASE1. Patient identityName: Mr. AGSex : MaleAge: 46 years oldAddress: jalan meranti PontianakJob : ContractorReligion : Moslem Patient was examined on May 22st, 2015

2. Anamnesis a. Chief complaint: flesh growing in the right eyeb. History of disease : Patient complained there is something like a meat growing in his right eye and he complain his right eyes become redness and sometimes itchy, watery and pain when exposed to wind. This complains have percieved since a year ago. Patient had no complaint about eyes discharge. he claimed, there were no history of eye trauma and did not consume any drugs before. he formerly worked as a contractor. He worked under the hot sun. c. Past clinical history: Patient claims that there is no history of the same symptoms before. He said that he never have hypertension and diabetes mellitus. He also disclaim about another eyes disease, systemic disease and another disease because he never did a medical check up.d. Family history : There are no one of his family have the same complaint.

3. General Physical AssessmentGeneral condition : goodAwareness: compos mentisVital Signs:Heart Rate: 80x/minuteRespiration freq.: 20x/minuteBlood Pressure: 130/80 mmHgTemperature: 36,5oC

4. Ophthalmological StatusVisual acuity:a. OD : 5/5 b. OS: 5/5 c. Add +1.50

OD OS

Right eyeLeft eye

OrthotropiaEye ball positionOrthotropia

ptosis (-), lagoftalmos (-), edema (-)Palpebra ptosis (-), lagoftalmos (-), edema(-)

Redness(+),Triangular flesh (+)Conjungtiva Normal, Redness (-)

Clear, edema (-)Cornea Clear, edema (-)

clear, deepCOAclear, deep

Iris colour : brownPupil: circular, 3mm, isokor, reactive to lightIris and pupilIris colour : brownPupil: circular, 3mm, isokor, reactive to light

Clear Lens Clear

Negative (-)Shadow TestNegative (-)

Eye ball movement ++++++++++++++++ODOS

Visual field test (confrontation) : normal

5. ResumePatient complained there is something like a meat growing in his right eye and he complain his right eyes become redness and sometimes itchy, watery and pain when exposed to wind, this complains have percieved since a year ago. Patient had no complaint about eyes discharge from both of eyes and he claimed, there were no history of eye trauma and did not consume any drugs before. Patient claims that there is no history of the same symptoms before. He said that he never have hypertension and diabetes mellitus. He also disclaim about another eyes disease, systemic disease and another disease because he never did a medical check up. There are no one of his family have the same complaint.Vital signs of this patient are in normal range. Visual acuity of OD is 5/5. Visual acuity of OS is 5/5. Conjunctiva of OD, redness (+), wing-like growth from nasal confined to the limbus. Conjunctiva of OS, redness (-).a. Working Diagnose: OD: Pterygium grade II OS: -

b. Differential Diagnosisi. Pseudopterygiumii. Pinguecula6. Plan for examination Slit lamp Glucose blood examination

7. Treatment:Non medicamentous: using of protective glasses, wear hat.Medicamentous: artificial tear 1-2 gtt prn, naphazoline eyedrop 0,1% 2-4 x 1gtt.

8. PrognosisODAd vitam: bonamAd functionam: dubia ad bonamAd sanactionam: dubia ad bonam

CHAPTER IVDISCUSSION

Patient complained there is something like a meat growing in his right eye and he complain his right eyes become redness and sometimes itchy, watery and pain when exposed to wind, this complains have percieved since a year ago. Patient had no complaint about eyes discharge from both of eyes and he claimed, there were no history of eye trauma and did not consume any drugs before. Patient claims that there is no history of the same symptoms before. He said that he never have hypertension and diabetes mellitus. He also disclaim about another eyes disease, systemic disease and another disease because he never did a medical check up. There are no one of his family have the same complaint.Visual acuity is for 5/5 for OD and 5/5 for OS. From clinical assestment, There is triangular flesh in the right eye and redness in conjungtiva OD.From resume above, the diagnosis for the right eye of patient was pterygium grade II based on the apparance of the growth in conjunctiva and grade II because Fibrovaskular tissue growth has been through limbus but not greater than 2 mm across the cornea. The main complain from patient is a flesh growing in his right eye and redness. The flesh growing its because a matrix metalloproteinase (MMP) activation by ultraviolet light (UV) and subsequent MMP activity against interstitial tissue and the redness of the right eye its because the inflamation reaction from the pyteregium. Recomended therapy for this patient includes nonmedicamentous such as wearing protective glasses and hat to protect from ultraviolet light and dust. Medicamentous therapy for this patient is with artificial tear to lubricate the ocular surface and to fill in defects in the tear film and topical vasoconstrictor to reduce eye redness. Surgery is not indicated for OD since the pterygium is grade II.

CHAPTER VCONCLUSIONThe diagnosis of this patient is pterygium grade II in his right eye. The therapy for the pterygium include wearing protective glasses and hat, artificial tear, topical vasoconstrictor and surgery but in this patient surgery is not indicated for OD since the pterygium is grade II.

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