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1341

WORLD VIEW

Pterygium in Indonesia: prevalence, severity and risk

factors
G Gazzard, S-M Saw, M Farook, D Koh, D Widjaja, S-E Chia, C-Y Hong, D T H Tan
.............................................................................................................................

Br J Ophthalmol 2002;86:1341–1346

Series editors: W V Good Aim: To determine prevalence rates, severity, and risk factors for pterygium in adults in provincial
and S Ruit Indonesia and to validate a clinical grading scheme in a population based setting.
Methods: A population based prevalence survey of 1210 adults aged 21 years and above was con-
ducted in five rural villages and one provincial town in Riau province, Sumatra, Indonesia, an area
near to the equator. A one stage household cluster sampling procedure was employed: 100
households were randomly selected from each village or town. Pterygia were graded for severity (T1
to T3, by visibility of episcleral vessels) and the basal and apical extent measured by an ophthalmolo-
gist (GG) with a hand held slit lamp. Refraction was measured by hand held autorefractor (Retinomax).
Face to face household interviews assessed outdoor activity, occupation, and smoking. The participa-
tion rate was 96.7%.
Results: The mean age was 36.6 years (SD 13.1), 612 were male. The age adjusted prevalence rate
of any pterygium was 10.0% (95% confidence intervals (CI) 8.2 to 11.7) and of bilateral pterygia was
4.1% (95% CI 2.9 to 5.3). There was a significant dose-response relation with age (2.9% (95% CI 0.4
to 5.8) for 21–29 years versus 17.3% (95% CI 10.4 to 24.2) 50 years and above; p for trend <0.001)
and occupations with more time outdoors (p for trend = 0.02). This was true for both sexes, all grades
See end of article for of lesion (T1 to T3), and bilateral disease. A multivariate logistic regression model showed pterygium
authors’ affiliations was independently related to increasing age and outdoor activity 10 years earlier. The mean basal
....................... diameter = 3.3 mm (SD 1.51, range 0.1–9.5) and extent from limbus = 1.4 mm (SD 1.18, range 0.1–
Correspondence to: 8.0). Higher grade pterygia were larger for basal and apical extent (p for trend <0.001). The presence
Mr Gus Gazzard, of pterygium was associated with astigmatism (defined as cylinder at least −0.5 dioptres (D); p
Department of Wound <0.001). This association increased with increasing grade of lesion (p for trend <0.001). Median cyl-
Healing, Institute of
Ophthalmology, Bath
inder for those with pterygium (−0.50 D) was greater than for those without (−0.25D), (p <0.001), and
Street, London EC1V 9EL, increased with higher grade of lesion (p for trend <0.001). For eyes with pterygia, magnitude of astig-
UK; gusgazzard@ matism was associated with greatest extent from the limbus, (p = 0.03), but not basal width (p = 0.99).
[Link] Conclusions: There is a high prevalence rate of pterygia in provincial Sumatra. The independent
Accepted for publication increase with age and past outdoor activity (a surrogate for sun exposure) is consistent with previous
16 July 2002 findings. Clinical grading of pterygium morphology by the opacity of the lesion was a useful additional
....................... marker of severity.

P
terygium is a disfiguring and potentially blinding disease grading scheme to this population based sample. Ours is the
that in the advanced stages can require complex surgery first study, to our knowledge, to examine the Malay/
for full visual rehabilitation.1 Insights into risk factors, Indonesian racial group.
causes, and the distribution of the disease may be useful in
guiding appropriate strategies for preventive measures.2 The
prevalence rates of pterygium obtained for a number of popu-
lations vary widely,3–7 from 1.2% in urban, temperate white METHODS
people8 to 23.4% in the black population of tropical A population based prevalence survey in five rural villages and
Barbados.2 These study populations differ in race, latitude, and one provincial town of Riau province, Sumatra, Indonesia, was
sun exposure, but generally prevalence rates in the tropics are conducted from April to June 2001 as part of a large general
higher than at temperate latitudes. Theories of the pathogen- village health survey. The region is tropical with secondary
esis of pterygium have implicated ultraviolet light exposure as forests, near the Kampar River, one degree north of the equa-
a major causative factor. Evidence for sunlight exposure as one tor, and the nearest large city is the capital of the Riau
of the prime aetiological agents derives both from case-control province, Pekan Baru. A random sample of all household
studies9 and prevalence surveys.4 8 10–13 members living in five villages (Kuala Terusan Baru,
As with theories of pathogenesis, techniques of treatment Pelalawan, Delik, SP7, and Segati) and the nearby provincial
for pterygia have advanced in recent years. Alongside recogni- town, Kerinci was assessed. Villages were variously situated in
tion of mechanisms of disordered cell growth14–19 has been the forest (Segati), near logging roads (Kuala Terusan Baru,
development of techniques for conjunctival20 21 and amniotic Delik), alongside the Kampar River (Pelalawan), and close to
membrane1 transplantation to reduce recurrence after sur- a paper and pulp mill (SP7). All houses in each village were
gery. It has been further shown, in a randomised control trial individually mapped and assigned a number by an enumera-
comparing bare sclera excision with conjunctival autograft- tion team. A one stage cluster sampling procedure was
ing, that simple clinical grading of pterygium morphology can conducted whereby 100 households were randomly selected
usefully predict the likelihood of recurrence.20 from a sampling frame of the total number of households in
We report the findings of a prevalence study from equatorial each village (as there were only 60 households in Delik all 60
Indonesia and the application of this same morphological were assessed). Membership of a household was defined as

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1342 Gazzard, S-M Saw, M Farook, et al

Table 1 Age-sex specific prevalence rates of pterygia in provincial south Sumatra, Indonesia
Prevalence rate, any pterygium (95% CI)

Total (n=1210) Men (n=612) Women (n=598)

All ages (n)

Crude rate 1210 9.3 (7.3, 11.2) 612 10.0 (7.4, 12.5) 598 8.5 (5.5, 11.6)
Age adjusted rate* 10.0 (8.2, 11.7) 10.4 (7.9, 12.9) 9.5 (7.0, 12.0)

Age (years)
21–29 414 2.9 (0.4, 5.8) 185 3.8 (0.0, 7.8) 229 2.2 (0.02, 4.3)
30–39 393 8.1 (3.0, 13.3) 212 8.5 (3.0, 14.0) 181 7.7 (16.8, 13.8)
40–49 201 16.4 (9.5, 23.3) 104 14.4 (3.5, 25.4) 97 18.6 (13.6, 23.5)
50–and above 202 17.3 (10.4, 24.2) 111 18.9 (10.6, 27.2) 91 15.4 (9.5, 21.2)
p (trend) <0.001 <0.001 <0.001

Income (rupiah† per month)

<500 000 584 10.1 (7.0, 13.3) 294 11.2 (7.9, 14.6) 290 9.0 (5.4, 12.5)
500 000–1 000 000 430 9.8 (4.6, 14.9) 217 10.1 (6.7, 16.5) 213 9.4 (3.4, 15.4)
1 000 000 or more 196 5.6 (2.4, 8.9) 101 5.9 (1.5, 11.7) 95 5.3 (1.6, 10.4)
p (trend) 0.1 0.16 0.38

Smoking
Never smoked 625 9.4 (6.8, 12.1) 105 12.4 (8.6, 16.1) 520 8.8 (5.4, 12.3)
Ever smoked 585 9.1 (5.9, 12.2) 507 9.5 (6.0, 12.9) 78 6.4 (2.1, 10.7)
p value 0.82 0.37 0.48

Occupation‡
Level 0 594 7.5 (3.7, 11.4) 149 8.7 (3.3, 14.1) 445 7.2 (3.4, 11.0)
Level 1 110 9.1 (2.2, 16.0) 66 12.2 (2.1, 22.2) 44 4.5 (1.0, 8.1)
Level 2 74 9.4 (0.0, 21.6) 28 10.7 (0.0, 26.3) 46 8.7 (0.0, 21.8)
Level 3 63 6.3 (0.3, 12.4) 54 5.6 (0.0, 12.6) 9 11.1 (2.6, 19.6)
Level 4 369 12.4 (6.9, 18.0) 315 10.8 (5.4, 16.1) 54 22.2 (12.5, 32.0)
p (trend) 0.02 0.7 0.001

Outdoor activity
5 years ago
>5 hours/day 568 11.1 (8.3, 13.9) 208 11.2 (7.7, 14.6) 434 11.0 (5.8, 16.2)
<5 hours/day 642 7.6 (5.4, 9.9) 404 7.7 (4.0, 11.4) 164 7.6 (4.8, 10.4)
p value 0.2 0.18 0.19

10 years ago
>5 hours/day 575 12.3 (9.0, 15.6) 228 13.0 (9.7, 16.7) 407 11.0 (4.4, 17.6)
<5 hours/day 635 6.5 (3.6, 9.4) 384 4.8 (0.6, 9.0) 191 7.4 (4.5, 10.2)
p value 0.001 0.002 0.14

*Standardised to Indonesia 1990 population census.

†10000 rupiah = 1US$.
‡See text for more detailed description of categories (0 = indoor, 1–4 = outdoor, increasing time spent in outdoors, 0–4).

the habitual occupation of that dwelling with a presence in the proper. Before the examinations, meetings were held with the
house for at least 2 of the preceding 4 weeks. village leaders to explain the purpose of the study and obtain
Among the randomly selected 1251 adult villagers 21 years cooperation from the community. Informed verbal consent
and above, examinations were performed on 1210, an initial was obtained from the subjects and all subjects were treated in
participation rate of 96.7%. There were 216 subjects recruited accordance with the tenets of the Declaration of Helsinki.
from Kerinci, 231 subjects from Kuala Terusan Baru, 229 from Approval for the study was obtained from the ethics
Pelalawan, 120 from Delik, 233 from SP7 and 181 from Segati. committee, Singapore Eye Research Institute.
Of these, 297 were described as possible positives in the initial
screening survey and 248 were re-examined (a secondary par- Eye examinations
ticipation rate of 83.5%). The unexamined subjects were con- A trained interviewer visited each identified house and exam-
sidered as negative cases for the purpose of this analysis. Non- ined both eyes of all household members. Training of
participants included non-contactables and refusals. Non- interviewers in the recognition of pterygium was conducted
contactables were defined as individuals who were not by a single qualified ophthalmologist from Singapore (GG)
contactable on three separate occasions and refusals defined using a standard set of photographs. Examination was
as individuals who declined to participate in the study. The performed with an oblique torchlight from the inferotemporal
median age of the participants (33.0 years, n =1210) and approach. For the purposes of the initial detection survey
non-participants (31.0 years, n = 41) was not different (p = positive cases were defined as those with any lesion extending
0.64, rank sum test). up to or crossing the nasal or temporal limbus. Each interviewer
was issued with a reference set of standard photographs. To
Sample size estimation ensure the detection of subtle lesions, avoid false negatives
A sample size of 1030 was needed for a two sided hypothesis and to minimise diagnostic errors, all interviewers were
to estimate the prevalence of pterygium of 10% and an allow- instructed to label as “positive” all pingueculae and any lesion
able difference of 3%, if the power was 0.9 and type I error, α about which they were at all uncertain. Ophthalmologists,
was 0.05. A non-participation rate of 10% was factored in the public health doctors, and an optometrist made quality checks
estimation. of each interviewer’s competence in the detection of pterygia
Training of team members and a pilot study of 16 subjects in during the pilot study and again on several occasions during
SP7 were conducted in April 2001, 2 weeks before the survey the study.

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Pterygium in Indonesia 1343

Table 2 Age and sex specific prevalence rates of the different grades of pterygia (n = 1210)
Prevalence rates (95% CI)

Grade I pterygia Grade II pterygia Grade III pterygia

(Transparent) (Intermediate) (Opaque) Bilateral pterygia

All ages No
Crude rate 1210 4.5 (2.9, 6.0) 2.8 (1.3, 4.4) 2.0 (0.8, 3.2) 3.7 (2.0, 5.4)
Age adjusted rate* 4.6 (3.4, 5.8) 3.1 (2.0, 4.1) 2.3 (1.4, 3.2) 4.1 (2.9, 5.3)

Age (years)
21–30 414 1.2 (0.0, 2.7) 0.1 (0.0, 2.2) 1.0 (0.0, 2.2) 1.2 (0.0, 3.0)
31–40 393 4.3 (0.4, 8.3) 2.8 (2.0, 3.6) 1.0 (0.0, 2.7) 2.5 (1.4, 3.6)
41–50 201 10.0 (3.4, 16.4) 3.9 (0.4, 7.6) 2.5 (0.0, 6.1) 7.5 (2.2, 12.7)
51 and above 202 5.9 (0.0, 12.4) 5.9 (2.2, 9.7) 5.4 (2.2, 8.7) 7.4 (3.0, 11.9)
p (trend) <0.001 <0.001 0.001 <0.001

Sex
Male 612 4.7 (2.5, 7.0) 3.1 (2.0, 4.2) 2.0 (0.9, 3.3) 3.6 (2.0, 5.2)
Female 598 4.1 (2.2, 6.2) 2.5 (0.0, 5.2) 1.8 (0.5, 3.2) 3.8 (1.4, 6.3)
p value 0.64 0.54 0.72 0.82

Outdoors activity 10 years ago

(>5 hours/day) 575 5.9 (3.5, 8.4) 4.2 (2.4, 6.0) 2.3 (0.0, 3.8) 4.9 (2.6, 7.2)
(<5 hours/day) 635 3.1 (1.8, 4.5) 1.6 (0.0, 3.3) 1.7 (0.0, 3.6) 2.7 (0.8, 4.6)
p value 0.02 0.009 0.51 0.047

*Standardised to Indonesia 1990 population census.

Corrected and uncorrected distance visual acuity was tion worker, labourer, plantation worker (0 is indoors, 1–4 are
measured in good lighting conditions (outside the village hut) outdoors, with increasing time spent outdoors, 0 through 4).
using tumbling “E” logMAR charts for each eye separately
following a standard protocol (Ferris). Autorefraction meas- Definitions and data analysis
urements in the right and left eye were performed using one A subject was defined as “positive” for pterygium if at least
of two hand held autorefractors, the Retinomax K-plus one pterygium lesion was confirmed in either eye by the
(Nikon, Tokyo, Japan) and the average of eight refractive error examining ophthalmologist. The prevalence rates and 95% CI
readings were taken without cycloplegia.22 23 of pterygia for subjects with different characteristics were cal-
culated, allowing for clustering by household and village. Age
Pterygia grading adjusted rates were derived using 1990 Indonesian national
Follow up examination for corroboration of the diagnosis and census data. The crude and multivariate odds ratios with 95%
grading was conducted by a single trained ophthalmologist CI denoting the associations between the various lifestyle
(GG) using a portable slit lamp (Kowa Co Ltd, Japan) in the variables and pterygia were calculated. Adjusted odds ratios
villages on all subjects identified. Pterygia were defined as a were obtained using multiple logistic regression models, with
radially oriented fibrovascular lesion crossing the nasal or adjustment for clustering. All statistical analyses were
temporal limbus. Grading was based on the visibility of the performed using the commercially available software STATA
underlying episcleral blood vessels. This has been previously version 7.0 (STATAcorp).
described and validated as a marker of severity.20 T1
(“atrophic”) is defined as episcleral vessels clearly visible, T2 RESULTS
(“intermediate”) as vessels partially visible, and T3 (“fleshy, The mean age was 36.6 years (SD 13.1). There were 612 males
opaque”) as vessels wholly obscured. Size was measured with and 598 females. The proportion of villagers who owned a
calipers as the chord length of the corneal limbus involved and radio was 56.6%, 59.4% owned a television set, and electricity
the greatest distance from the limbus to the apex of the lesion. was available in 82.3% of the dwellings. Eighty six per cent
were married, 8.4% single, and 5.6% were widowed or
Demographic and lifestyle data divorced.
Data on demographic and lifestyle factors were collected by The overall age adjusted prevalence rate of any pterygia in
means of in-person household interviews by trained inter- adults over 21 was 10.0% (95% CI 8.2 to 11.7). The age-sex
viewers using a standard questionnaire. This was translated specific prevalence rates of pterygia are shown in Table 1. The
into Bahasa Indonesia and back translated into English to rates for all adults over 40 years were 16.8% (95% CI 10.8 to
ensure the accuracy of translation. The questionnaire was pilot 22.8) overall, 16.1% (95% CI 8.3 to 24.0) for males and 17.6%
tested in 29 adults in two of the villages (SP7 and Kerinci). (95% CI 12.8 to 2.4) for females.
Individual questions were revised and rephrased. Interviewers The rates in subjects over 51 years were six times that of the
were Indonesian nurses and volunteers all fluent in Bahasa 21–30 year olds (17.3% v 2.9%). The dose-response relation
Indonesia. The villagers were asked about the total family with age was similar for males and females. The prevalence in
income, the number of hours spent outdoors in the sun per the greatest income group was half that of the lowest (5.65%
day, currently and 5 and 10 years ago, and smoking status. A v 10.1%) though this was not significant (p = 0.095). There
detailed occupational history was taken. Occupations were was no significant difference in the rates of pterygia by side
grouped into five levels by an occupational health physician (right 6.4% (95% CI 5.1 to 7.8); left 6.6% (95% CI: 4.5 to 8.8),
with experience of rural Indonesia, based on the average day- p = 0.8) or sex (males 10.0% (95% CI 7.4 to 12.5); females
time sun exposure experienced: level 0 = factory worker, stu- 8.5% (95% CI: 5.5 to 11.6), p = 0.37). A history of smoking was
dent, homemaker, unemployed government officer, teacher, not significantly related to pterygium in the univariate analy-
nurse; level 1 = entrepreneur, private employer, level 2 = ani- sis (no smoking history 9.4% (95% CI 6.8 to 12.2); any smok-
mal breeder, daily worker, rubber tapper, goods seller; level 3 = ing history 9.1 (95% CI: 5.8 to 12.2), p = 0.82). There was no
driver, level 4 = fisherman, farmer, wood collector, construc- difference in the location (nasal v temporal), grade, extent or

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1344 Gazzard, S-M Saw, M Farook, et al

Table 3 Characteristics of all pterygia lesions (n = 163)

Grade III
Grade I pterygia Grade II pterygia pterygia
All pterygia (transparent) (intermediate) (opaque)
(n = 163) (n = 89) (n = 42) (n = 32) p Value

Width of base (mm)

Mean (SD) 3.3 (1.51) 2.6 (1.29) 3.7 (1.8) 4.5 (1.5) <0.001
(range) (0.1–9.5) (0.1–6.0) (1.0–6.0) (1.5–9.5) (for trend)
Extent from limbus (mm)
Mean (SD) 1.4 (1.18) 1.0 (0.71) 1.6 (0.9) 2.3 (1.9) <0.001)
(range) (0.1–8.0) (0.1–3.0) (0.5–4.0) (0.5–8.0) (for trend)

No (%)
Location
Nasal 152 (93) 80 (90) 42 (100) 30 (94) 0.1
Temporal 11 (7) 9 (10) 0 (0) 2 (6)
Affected eye
Right 82 (50) 47 (53) 19 (45) 16 (50) 0.72
Left 81 (50) 42 (47) 23 (55) 16 (50)

width of pterygia between right and left eyes. As expected prevalence of lesions was seen for all three grades (Table 3).
nasal pterygia (9.3%, CI: 7.2 to 11.3) were far more common The basal width and the extent from the limbus all increased
than temporal (0.91%, CI: 0.6 to 1.2). with increasing grade, but there was no variation by
A history of more than 5 hours per day of outdoor activity nasal/temporal location or side. Five individuals had three
10 years earlier was associated with almost twice the rate of pterygia, two subjects had four lesions, and 45 had bilateral
those without such a history (12.3% v 6.5%, Table 1), whereas disease.
a history of more than 5 hours per day of outdoor activity 5 The presence of pterygium (by individual) was significantly
years earlier was not significantly related (7.7% v 11.1%, associated with the presence of astigmatism (cylinder > −0.5
p=0.2). The mean time spent outdoors per day 10 years earlier dioptre (D), p <0.001). This association increased with
was higher for those with pterygia than those without (6.0 v increasing grade of lesion (p for trend <0.001). The median
5.4 hours/day, p=0.017), but not significantly different for cylinder for those individuals with pterygium was greater
current exposure or that 5 years before (4.6 v 4.2, p=0.59, and than for those without (−0.50D v −0.25D, p <0.001), and
5.8 v 5.4, p=0.14, respectively). An occupation involving any increased with higher grades of lesion (p for trend <0.001).
outdoor activity was associated with more pterygia than an For eyes with pterygia, the distance a lesion extended from the
occupation with none (7.6%, 95% CI 3.7 to 11.4) for indoor limbus was greater in those with astigmatism than those
occupations v 10.9% (95% CI 6.9 to 14.8) for outdoor, p = without (median 1.25 mm v 1.0 mm, p = 0.03). The basal
0.049; OR = 1.5 (95% CI 1.5 to 2.2). The associations of width was greater but not significantly so (median 3.6 mm v
increasing time spent outside and higher prevalence rates 3.4 mm, p = 0.99). The effects of wearing spectacles could not
were significant for grades 1 and 2 and the occurrence of be assessed as only 11 individuals habitually wore distance
bilateral disease, but not for grade 3 pterygia for which the correction; none of these had pterygia. Similarly, very few
numbers were smaller (Table 2). Habitually wearing a hat out- individuals ever wore sunglasses.
doors (16.9% of individuals), conferred no significant protec- The visual acuity (VA) of eyes with pterygia was worse than
tion (8.8%, 95% CI 6.8 to 10.7) for rare or occasional wearers v for eyes without pterygia, (median logMAR acuity 0.1 v 0.2,
11.7% (95% CI 6.7 to 16.8) for those who always wore a hat, p p<0.001: in the 45 cases of bilateral lesions the eye with the
= 0.19). higher grade lesion was considered). The relation between
The age and sex specific prevalence rates of the different grade of lesion and VA was not significant (median VA for
grades of pterygia are shown in Table 2. A similar increase in grade 1 lesions = 0.2, with grade 2 = 0.2 and grade 3 = 0.3, p

Table 4 A multiple logistic regression model with multivariate adjusted odds ratios
of pterygium for various risk factors
Multivariate adjusted OR*
Crude OR (95% CI) p Value (95% CI) p Value

Sex 0.84 (0.52 to 1.37) 0.37 0.65 (0.41 to 1.04) 0.08

Age (years)
21–30 1.00 1.00
31–40 2.97 (1.20 to 7.34) 0.002 2.79 (1.17 to 6.89) 0.003
41–50 6.58 (1.95 to 22.10) <0.001 6.36 (1.89 to 21.39) <0.001
51–and above 7.02 (2.14 to 23.02) <0.001 7.31 (2.36 to 22.70) <0.001

Outdoor activity 10 years ago

<5 hours/day 1.00 1.00
>5 hours/day 2.04 (1.23 to 3.40) 0.001 1.64 (0.96 to 2.80) 0.02

Smoking
Never smoked 1.00 1.00
Ever smoked 0.96 (0.57 to 1.60) 0.82 0.46 (0.24 to 0.90) 0.004

*From a multiple logistic regression model that simultaneously includes all factors present.

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Pterygium in Indonesia 1345

= 0.12). Pterygia were significantly larger in eyes with VA findings, as ours is a rural population located close to the
worse than 0.3 (mean extent = 1.8 mm) compared to those equator with extensive time spent outdoors. Daytime sun
with VA 0.3 or better (mean extent =1.2 mm) (p = 0.03). exposure (mean 4.6 hours/day) was greater than both cases
However, the difference in basal width was of borderline (with pterygia, 2.1 hours) and controls (without pterygia, 1.6
significance (p=0.07); 3.8 mm for those with VA worse than hours) in the Singapore case-control study.27 Sumatran
0.3 v 3.2 mm for VA 0.3 or better). Pterygium was responsible subjects thus receive high levels of sunlight exposure and
for a reduced visual acuity of 1.0 (6/60 Snellen) or worse in hence ultraviolet irradiation. The link is further borne out in
three eyes, of three individuals, and no cases of bilateral our study by the positive relations of pterygia with both past
blindness. outdoor activity and occupation as graded by sun exposure.
A multivariate logistic regression model showed that there This alone may go some way to explaining the high rates in
was a significant increased risk of pterygia with age and out- our population. Although we have used a comparatively crude
door activity 10 years previously but not with sex, controlling measure of sunlight exposure (self reported time spent
for the other factors (Table 4). Smoking was associated with a outdoors and occupation) as surrogates for ultraviolet
significantly lower risk in the multivariate model (OR 0.46), exposure there was a definite positive relation after controlling
although the smoking-pterygia association was not signifi- for age, sex, and smoking on multivariate analysis. Racial dif-
cant in the univariate analysis. The risk of having any ferences in susceptibility cannot be ruled out, however, and
pterygium at age 50 years or over was seven times that of a have been described in previous studies.2 11 The low rates of
21–29 year old, whereas extensive time spent outdoors a dec- sunglasses wearing, which has been shown to be highly
ade previously conferred a 1.6 times increased risk. protective against pterygia elsewhere (OR 0.18; 95% CI, 0.06 to
0.59),2 suggests there is potential for a simple preventative
DISCUSSION intervention in this population. Health education campaigns
We found a high prevalence rate of pterygium in a provincial, advocating sunglasses and reductions in sun exposure, which
targeted at-risk groups such as outdoor workers would be
Asian, equatorial population: one in 10 adults over 21 years
beneficial.
were affected. Rates increased with age and greater outdoor
The multivariate modelling of risk factors showed an inde-
activity in the past, but there was no significant sex difference.
pendent increase in risk with age and outdoor activity but
Thicker, opaque (“grade 3”) pterygia were larger; both in the
conversely a protective effect of smoking (OR 0.46; 95% CI 0.27
extent of encroachment onto the cornea and in basal (limbal)
to 0.78). This apparent significant effect is puzzling, and per-
diameter. Pterygium was positively associated with the
sisted despite an extensive exploration of the data for a
presence of astigmatism (> 0.5D cylinder) and the cylinder confounder (such as occupation) that might have accounted
was greater for larger, higher grade lesions. This is the first for it. A similar finding has also recently been described in the
study to assess the Indonesian/Malay racial group, who com- Barbados Eye Survey (OR 0.59; 95% CI, 0.39 to 0.90), with no
prise the majority of the inhabitants of Indonesia, the world’s suggested explanation, and was seen on univariate but not
fourth most populous country. It is also the first population multivariate analysis of the Melbourne Visual Impairment
based study to assess the association between astigmatism, Project. We are not aware of any putative protective
grade of pterygia, and the extent of the lesion.20 mechanism.
Previously reported prevalence rates of pterygia vary widely It has been shown in clinic based studies that “fleshier,”
with race, age, sex, and geography.3–5 7 8 11 24–26 higher grade lesions are more likely to recur after surgery. Our
This may reflect the action of racial (genetic) and/or survey found that these higher grade pterygia were associated
environmental factors. Black subjects (aged 40–84 years) in with a greater extension from the limbus, basal width, and
Barbados, which lies in the tropics 13° north of the equator, astigmatism. This further validates, in a population based sur-
had very high rates (23.4%)2 whereas rates in urban white vey, the use of this simple clinical grading system as a predic-
people (40–101 years) in temperate Melbourne, Australia, tor of clinical pterygium severity. Clinic studies have shown
were much lower (1.2%).8 Pterygium rates of white people that pterygia induce a flattening of the corneal curvature and
over 40 in temperate rural Australia (6.7%),8 and urban that this may be partially reversed after surgery.28 In our sur-
Chinese Singaporeans over 40 (6.9%)5 (at the same latitude as vey pterygia were indeed associated with astigmatism and
our study, one degree north of the equator), were intermediate astigmatism was greater for higher grade lesions.
between these extremes. Our overall rates were lower as the Late surgical treatment of pterygium is associated with
sampling frame included all adults over 21. However, when a more frequent permanent corneal scarring and more complex
comparable age group is considered—that is, the over 40 year surgery. Our study suggests that grade (“transparency”) is a
old adults, rates in Sumatra (16.8%) were higher than all other good indicator of several measures of severity (extent,
races previously studied, except the black population of likelihood of recurrence, induced astigmatism). This would
Barbados. thus support the earlier treatment of higher grade lesions: the
In common with other studies of pterygium, the prevalence inference from these cross sectional data being that fleshier
of pterygium in Sumatra increased with age.3 4 7–12 25 In lesions may progress more rapidly, which agrees with clinical
contrast with some studies in which pterygia were found to be impression.
more common in males,3 8 11 12 but in keeping with some Strengths of this study include the fact that all pterygia
others,2 6 there was no sex difference in our study. This may were graded and the size assessed by a single trained ophthal-
reflect variations between study populations in the extent to mologist and that the population studied is at high risk, being
which there are differences in outdoor activity and sun expo- equatorial and with outdoor work common, making the
sure between the sexes, although direct comparisons of preva- detection of risk factors easier. Although one of the limitations
lence rates between studies must be made with caution of the study is that nurses performed the initial screen rather
because of potential differences in the definitions, varying age than ophthalmologists, we conducted careful training and
compositions of the study population, measurement tech- quality control of the screeners, who were instructed to refer
niques, and study methodology. any and all abnormal anterior segment lesions for assessment:
The pathogenesis of pterygium is associated with p53 onco- over-referral rather than under-referral was encouraged.
gene expression,14 18 fibroblast transformation,15 and altera- However, since not all subjects were available for grading by
tions in cytokines16 (for example, TGF-β) and matrix metallo- the ophthalmologist, and these were considered as negative
proteinase activity.17 19 Ultraviolet light exposure has been for the analysis, the true rates may be even higher than we
implicated in p53 mutagenesis18 and epidemiologically with have described. (Of those 248 examined by the ophthalmolo-
the aetiology of pterygium.4 8 10–13 This agrees with our gist, 112 had the diagnosis of pterygium confirmed, a rate of

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1346 Gazzard, S-M Saw, M Farook, et al

45%. If extrapolated to the 49 villagers not rescreened, then an 3 Panchapakesan J, Hourihan F, Mitchell P. Prevalence of pterygium and
additional 22 individuals who might have had pterygia were pinguecula: the Blue Mountains Eye Study. Aust NZ J Ophthalmol
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overall (not age adjusted) rate of 11.1% rather than the crude Ophthalmic Epidemiol 1999;6:219–28.
rate of 9.3% that we report. Further limitations are that this is 5 Wong TY, Foster PJ, Johnson GJ, et al. The prevalence and risk factors
for pterygium in an adult Chinese population in Singapore: the Tanjong
also a cross sectional study in which both ocular prevalence Pagar survey. Am J Ophthalmol 2001;131:176–83.
data and risk factor information were derived concurrently, 6 Forsius H, Maertens K, Fellman J. Changes of the eye caused by the
rather than a case-control or cohort study, and that ultraviolet climate in Rwanda, Africa. Ophthalmic Epidemiol 1995;2:107–13.
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Our study in provincial, equatorial Indonesia found one of Australia. Br J Ophthalmol 2000;84:289–92.
the highest rates of pterygia in the world and determined a 9 Saw SM, Banerjee K, Tan D. Risk factors for the development of
potentially modifiable risk factor: outdoor activity. This is the pterygium in Singapore: a hospital-based case-control study. Acta
Ophthalmol Scand 2000;78:216–20.
first population based study to demonstrate the validity of the 10 Hill JC, Maske R. Pathogenesis of pterygium. Eye 1989;3:218–26.
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Grant support: Singapore Eye Research Institute for National Medical 14 Tan DT, Lim AS, Goh HS, et al. Abnormal expression of the p53 tumor
Research Council (NMRC), SERI/MG/97-04/0005, Singapore and suppressor gene in the conjunctiva of patients with pterygium. Am J
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Pterygium in Indonesia: prevalence, severity

and risk factors
G Gazzard, S-M Saw, M Farook, D Koh, D Widjaja, S-E Chia, C-Y Hong and
D T H Tan

Br J Ophthalmol 2002 86: 1341-1346

doi: 10.1136/bjo.86.12.1341

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