Beware of Conjunctival Granulomas After Pterygium Surgery

With lower recurrence rates in patients receiving conjunctival autograft, there has been an increased recognition and reporting of conjunctival granulomas as a complication of pterygium surgery. As far as these researchers from Dartmouth determined, theirs is the first study from North America reporting such findings. Photo: Stephanie Jian, OD. Click image to enlarge. Historically, surgical treatment of pterygia consisted of simple excision, which was associated with high recurrence rates. In recent years, several other surgical techniques for pterygium removal have been developed and employed—including amniotic membrane grafting, conjunctival transpositional flap, conjunctival autograft and use of antifibrotic drugs (mitomycin C or 5-FU). Conjunctival autografting using fibrin glue has become most common of late, given its efficacy and low recurrence rates. Researchers from the Dartmouth Hitchcock Medical Center evaluated the postoperative complications of pterygium surgery with conjunctival autograft and fibrin glue from 2011 to 2022 and the associated pathology, with particular attention to rates of granuloma formation and recurrence. They found a higher rate of granuloma formation (2.4%) than recurrence (1.2%). These rates of conjunctival granuloma development and recurrence were surprising given that recurrence is often considered the primary endpoint of pterygium surgery.Of 86 cases that were identified through a chart review, 84 were performed with autograft and fibrin glue, one was performed with just amniotic membrane transplant with fibrin glue and one was performed with both conjunctival autograft and amniotic membrane transplant plus fibrin glue. No intraoperative mitomycin C or 5-FU was used.The study identified three patients with postoperative complications, including two cases of postoperative conjunctival granulomas and one case of recurrent pterygium. Both conjunctival granulomas were treated with surgical excision without recurrence and sent to pathology for analysis. The recurrent pterygium was treated with 5-FU injections, after which there were minimal symptoms and no progression at the last follow-up. The study authors noted in their paper on the study for Eye & Contact Lens that conjunctival granulomas following pterygium surgery are believed to arise as part of a prolonged inflammatory response resulting in an epithelial mesenchymal transition.“In light of our evolving perspective on these entities, there is discussion as to whether conjunctival granulomas previously reported as pyogenic granulomas are instead robust granulation tissue reactions or foreign body granulomatous reactions,” the researchers wrote in their paper. “Our findings seem to substantiate the latter impression.”They concluded that eyecare practitioners managing such patients with pterygia should be aware of this potential complication and be prepared to manage or comanage it.Click here for the journal source. Fearon KH, Gu D, LeBlanc RE, et al. Conjunctival granulomas more common than recurrence in an 11-year series of pterygium surgery. Eye Contact Lens. May 21, 2025. [Epub ahead of print].