358 ARTIGO ORIGINAL

Characteristics and prevalence of pterygium in

small communities along the Solimões and Japurá
rivers of the Brazilian Amazon Rainforest
Características e prevalência do pterígio em
comunidades ribeirinhas dos Rios Solimões
e Japurá localizados na Amazônia Brasileira

Lívia Adnet Martins Ribeiro1, Luiz Felipe Guaraná Martins Ribeiro2, Paulo Roberto de Azevedo Castro3,
Fílicio Doné Lima da Silva4, Verônika Maria Weyll Adnet Martins Ribeiro5, Arlindo José Freire Portes6,
Abelardo de Souza Couto Junior7

ABSTRACT
Purpose: To evaluate the prevalence and characteristics of pterygium in small communities along the Solimões
and Japurá rivers, State of Amazonas, Brazil. Design: cross-sectional study. Methods: This study was carried out on
populations of the Brazilian Amazon rainforest. Data were collected by two separate ophthalmologists in three
expeditions, covering 55 local communities. A total number of 1295 patients were examined, of which 659 were over
18 years old. The patients diagnosed with pterygium answered a questionnaire addressing gender, age and outdoor
activity. Pterygium lesion sizes were graded as grade 1 (lesion covers until limbus), grade 2 (lesion covers cornea by
2 mm), grade 3 (lesion surrounds the pupil) and grade 4 (lesion crosses the pupil). Results: Pterygium prevalence
was 21.2% for the overall population and 41.1% in those over 18 years old. Patients between 40-50 years old were
most affected by pterygium. Pterygium data distribution by gender showed that 57.8% were men. The majority of the
patients diagnosed with pterygium was active outdoors (89.5%). Subjects affected in both eyes were 75.6%. Of the
total population positive to pterygium the majority was grade 1 (44%) and 2 (48.7%). Most of the patients (85%)
developed nasal pterygium. Conclusion: This study shows one of the highest prevalences of pterygium in the world,
covering a Brazilian region never studied before.
Keywords: Pterygium/epidemiology; Prevalence; Brazil; Amazon

1
MD,Resident,Instituto Benjamin Constant - Rio de Janeiro (RJ), Brasil;
2
MD,Hospital Adventista de Manaus - Manaus (AM), Brasil;
3
PhD,Universidade Federal do Rio de Janeiro (UFRJ) - Rio de Janeiro (RJ), Brasil;
4
MD,Fellow, Hospital do Olho - Rio de Janeiro (RJ), Brasil.
5
MD,ONG Enxerga Brasil - Brasil;
6
PhD,Universidade Estácio de Sá (UNESA) - Rio de Janeiro (RJ), Brasil;
7
PhD,Instituto Benjamin Constant - Rio de Janeiro (RJ), Brasil and Faculdade de Medicina de Valença – Valença (RJ), Brasil.

From the Instituto Benjamin Constant - Rio de Janeiro (RJ), Brasil

Interest conflitct - None

Recebido para publicação em 9/5/2011 - Aceito para publicação em 26/9/2011

Rev Bras Oftalmol. 2011; 70 (6): 358-62

Characteristics and prevalence of pterygium in small communities along the Solimões and Japurá rivers of the... 359

RESUMO
Objetivo: Avaliar a prevalência e as características do pterígio em comunidades ribeirinhas dos rios Solimões
e Japurá, estado do Amazonas, Brasil. Métodos: Foi realizado um estudo observacional, em comunidades ribeirinhas
dos rios Solimões e Japurá. Os dados foram coletados por dois avaliadores em três expedições médico oftalmológicas,
num período de 9 meses, que abrangeram 55 comunidades ribeirinhas, totalizando 1295 pacientes examinados,
sendo 659 maiores de 18 anos. Os portadores de pterígio foram analisados através de um questionário abrangendo
sexo, idade e atividade laborativa ao sol ou não. O tamanho da lesão foi quantificado em graus. Resultados: A
prevalência do pterígio na população geral foi de 21.2%. A prevalência entre os maiores de 18 anos foi de 41.1%.
A faixa etária mais acometida foi a de 41 a 50 anos. Dos portadores, 42.2% eram do sexo feminino e 57.8% do sexo
masculino. 89.5% dos pacientes acometidos pela lesão trabalhavam ao ar livre. Dos portadores, 75.6% apresenta-
vam acometimento de ambos os olhos. Dos pacientes acometidos, 48.7% possuíam pterígio grau 2, 44.0% apresen-
tavam a lesão de grau 1, 5.4% de grau 3 e 1.8% de grau 4. Dos olhos acometidos, 85.0% apresentavam somente
pterígio nasal, 2.9% apresentavam somente pterígio temporal e 14.5% apresentavam pterígio temporal e nasal.
Conclusão: Nosso estudo, nos rios Solimões e Japurá, revelou a existência de uma das maiores taxas de pterígio do
mundo, em uma região que nunca havia sido avaliada.
Descritores: Pterígio/epidemiologia; Prevalência; Brasil; Amazônia

INTRODUCTION in creating and developing pterygium lesions (8).

The communities evaluated in this study are
located in the Amazon rain forest, in an isolated region

P
terygium is defined as a growth onto the cornea,
usually nasally, of a fibrovascular tissue, often of difficult access, near the equator. The population found
triangular in shape, that is continuous with the in these communities is composed of Indian and white-
conjunctiva. This lesion may be clinically aggressive and indians descent. Their activities are fishing, hunting and
occasionally threaten vision(1,2). Recent studies suggest agriculture. Almost all the subjects examined have never
that pterygium is a proliferative condition instead of had contact with an ophthalmologist before. To the
degenerative, highly associated with UV exposure(3-5). present day, there has been no data about prevalence of
The condition is common in the so-called ‘pterygium pterygium in these communities.
zone’, which is defined by a geographical latitude of 40º In Brazil, there is no data about prevalence of
north and south of the equator(6). In countries within this pterygium in the whole country and even for specific
area prevalence of up to 22% in the general population regions there are few studies that cover this subject. A
has been reported(7). previous study of pterygium in Hospitals of Salvador and
The pathogenesis of pterygium is very complex and Manaus showed a similar frequency of the lesion in both
the subject’s genetic background is reported to be relevant genders(9). Another study reported a high incidence of

Figure 1: Location of
the studied region,
Solimões and Japurá
rivers, state of Amazo-
nas, Brazil

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360 Ribeiro LAM, Ribeiro LFGM, Castro PRA, Silva FDL, RibeiroVMWAM, Portes AJF, Couto Júnior AS

(lesion surrounds the pupil) and grade 4 (lesion crosses

the pupil). This graduation was used in the study of
pterygium in the the Botucatu region(13). When a indivi-
dual had more than one lesion, the most severe one was
analyzed, as shown in Figure 2. The type of presentation
of the lesion was classified as nasal, temporal or both
nasal and temporal lesion.This study was approved by
the Ethics Committee of the Medical School of Valença.
(protocol number 005.0.334.000-10)

RESULTS
Pterygium was found in 21.2% (275/1295) of all
subjects examined. Pterygium prevalence rate between
Figure 2: A - Nasal lesion grade 1; B- Temporal and nasal lesion
grade 2; C - Temporal and nasal lesion grade 3; D- Temporal and subjects that were above 18 years old was 41.1% (271/
nasal lesion grade 4 659). Four patients under 18 years old (15-17 years old)
were found with pterygium lesion.
pterygium in an institute of ophthalmology in Manaus (10). About 26.9% of the patients that had pterygium
Recently pterygium prevalence has been were between 41-50 years old. From total subjects
reported among indians at the Negro river region, Ama- diagnosed with pterygium, 57.8 % (159/275) were male
zonas state. According to the reports, a pterygium and 42.2% (116/275) were female.
prevalence of 12.8 % from total Indian population (11) Outdoor activity was referred by 89.4% (246/275)
and 18.4 % among elderly and adults was described. of the patients with the lesion.
Furthermore, pterygium lesions were found mainly in Of total subjects diagnosed with pterygium, 75.6%
Indian groups with higher UV exposure(12). (208/275) had it in both eyes.
The objective of this study is to evaluate pterygium Out of 483 affected eyes evaluated, 85.1% (411/
prevalence and characteristcs in small communities of 483) showed only nasal lesion, 2.5% (12/483) only tem-
the Amazon rainforest located along the Solimões and poral lesion, and 12.4% (60/483) both temporal and na-
Japurá rivers, state of Amazonas, Brazil (Figure 1). sal pterygium. Severity assessment in 275 patients
demonstrated 44%, 48.7%, 5.4% and 1.8% classified as
METHODS grade 1, grade 2, grade 3, and grade 4, respectively
(Tables 1 and 2).
A cross-sectional study was developed in small
communities along the Solimões and Japurá rivers, DISCUSSION
located in the countries of Tefé, Alvarães, Maraã and
Fonte Boa, state of Amazonas, Brazil. Data were collected The pterygium prevalence along the Solimões
by two different evaluators in three medical expeditions. and Japurá rivers, of 41.1 % in individuals over 18 years
The study covered 55 local communities and 1295 old reported here, is higher than others regions previously
patients. A total of 659 patients were above 18 years old reported, such as India, where the prevalence of
and 636 were under 18 years old. These communities pterygium in individuals above 50 years of age was 5.2%
were selected because none of them had never been (14)
. In Singapore a prevalence of 9.7% in those who were
evaluated by an ophthalomologist before. During each over 40 years old has been recorded(15) and in Indonesia
visit, the examiners tried to assess the entire community. a prevalence of 10.0% in adults over 21 years old(16). In
Eyeglasses were donated to patients who needed Nigeria there is a prevalence of 8.2% in individuals from
them. Patients having pterygium lesion answered a 18 to 49 years old(17).
questionnaire covering gender, age, and outdoor activity, In this study we showed a higher rate of pterygium
such as fishing, hunting and agriculture. than the ones previously described by others in the Amazon
The pterygium lesions sizes were graded clinically rainforest like in the Negro river region where a
by slit-lamp biomicroscopy as grade 1 (lesion cover until prevalence of 12.8% in the population in general (11) and
limbus), grade 2 (lesion covers cornea by 2 mm), grade 3 of 18.4% in adults and elderly had been described (12).

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Characteristics and prevalence of pterygium in small communities along the Solimões and Japurá rivers of the... 361

Table 1

Distribution of commited subjects according age and lesion grade

Age Grade Total (%)

G1 G2 G3 G4

11-20 5 3 0 0 8 (2.9)
21-30 27 18 1 0 46 (16.7)
31-40 26 27 2 0 55 (20.0)
41-50 29 38 5 2 74 (26.9)
51-60 12 26 3 1 42 (15.2)
> 61 22 22 4 2 50 (18.1)
11-20 5 3 0 0 8 (2.9)
Total (%) 121 (44.0) 134 (48.7) 15 (5.4) 5 (1.8) 275 (100)

Table 2

Distribution of commited subjects with

pterygium according to gender and lesion
grade. F - female; M - male

Grade F M Total (%)

G1 55 66 121 (44.0)
G2 54 80 134 (48.7)
G3 6 9 15 (5.4)
G4 1 4 5 (1.8)
Total 116 (42.2) 159 (57.8) 275 (100)

The severity of the lesion is important in this study. conclusion, this work described one of the highest
The pterygium observed was classified mainly as grade pterygium rates in the world, in an Amazon region that
2 and grade 1, but lesions in grade 4, that causes a severe had never had been studied before, showing the
visual acuity disability, were found in 5 subjects, importance of further studies of the riverside population
suggesting that it may still exist blindness caused by in the Amazon rainforest.
pterygium in that region. Furthermore, we showed that
four patients under 18 years old and 48 patients with Acknowledgments
ages between 19 e 30 years old developed pterygium. NGO Enxerga Brasil, Brazilian Army, Mamirauá
From total subjects diagnosed with pterygium, 39.6% Institute
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