Cameron believed the overall tendency of the prevalence of pterygium increased with older age, and reached the peak at 7080[24].
Gender Reports on whether gender is related to pterygium have been debated. The ZES found a statistical significance in pterygia between men and women, and women had a higher risk level than men (OR, 1.5; 95%CI: 1.22.0) [19]. Women were at higher risk than men, which is consistent with reports from the two studies conducted in China[15, 16]. Tibetan people have a unique lifestyle which often involves much rural and outdoor work. Tibet has always been a matriarchal society and women are still heavily engaged in outdoor work and they do not traditionally wear glasses. The Authors believe that these elements contribute to the higher prevalence of pterygium in women (16.6%) compared to men (12.8%)[19].
The Blue Mountains Eye study [9] and the Tanjong Pagar survey [14] found that men were at higher risk than women. The same results were found by McCarty et al[7] and Moran and Hollows[4]. In HES, the statistical significance was found in pterygia between men and women, similar to other reports[11, 20, 3842].
Education Level and Socioeconomic Status The level of education is correlated with economic status; a lower level of education is possibly the result of a lower socioeconomic status. For the Chesapeake Bay watermen, more than 8 years of education was found to be beneficial in protecting them from pterygium (OR, 0.42; 95% CI: 0.280.62)[10]. In the Barbados Eye Study, logistic regression analyses indicated a positive association between pterygium and fewer years of education (≤12 years) (OR, 1.43; 95% CI: 1.012.03)[12]. In ZES, it was found that fewer years of education (<3 years) had a positive effect on pterygium (OR, 1.6; 95%CI: 1.12.4) as did a low socioeconomic status (OR, 1.9; 95%CI: 1.52.4) [19]. The HES found that fewer years of education (<3 years) had a positive effect on pterygium (OR, 2.1; 95%CI: 1.43.2) as did a low economic family status (OR, 1.3; 95%CI: 1.01.6)[20].
Dry Eye Symptoms and Signs ZES found a positive association between dry eye symptoms and pterygium (OR, 1.3; 95%CI: 1.01.7) but failed to identify dry eye as a cause or effect in this group of people[19]. This finding is consistent with a populationbased study by Lee et al[40] in Indonesia (OR, 1.8; 95%CI: 1.42.5). Mathur et al[33] and Ishioka et al[41] found an association between pterygium and a shortened tear breakup time and Schirmers test in the casecontrol studies. Khoo et al[42] found the environmental factors associated with dry eye, such as ultraviolet light quantities and a dusty polluted environment, which have been implicated in pterygium formation[42]. The HES found pterygium was independently associated with Schirmers test (≤5mm) (OR, 2.4; 95% CI:1.93.1), tear breakup time (≤10s) (OR, 2.3; 95% CI:1.82.9), and a positive association between dry eye symptoms and pterygium (OR, 1.9; 95%CI:1.52.5) [19] . This finding is consistent with a populationbased study in Indonesia (OR, 1.8; 95%CI: 1.42.5) [40].
OTHERS
Recent studies [4347] have suggested that P53 and human papillomavirus may also be implicated in pterygium pathogenesis. UV radiation can cause mutations in genes such as the P 53 tumor suppressor gene, resulting in its abnormal expression in pterygial epithelium. These findings suggest that pterygium is not just a degenerative lesion, but could be a result of uncontrolled cell proliferation[4547]. Matrix metalloproteinases (MMPs) and tissue inhibitors of MMPs (TIMMPs) at the advancing pterygium edge may be responsible for the inflammation, tissue remodeling, and angiogenesis that characterize pterygia, as well as the destruction of Bowmans layer and pterygium invasion into the cornea[4347]. Tseng et al[48] have also speculated that pterygium may represent an area of localized limbal stem cell deficiency. Corneal limbal autograft or amniotic transplantation was adopted for pterygium treatment[49,50].
In conclusion, pterygium is a significant ocular problem around the world, primarily due to ocular sun exposure and the effect of the unique climate, representing an important health problem. The risk factors are related to geographic setting, sun light and ultraviolet exposure, age, gender, economic situation, dry eye syndrome and others. The key point of the prevention of pterygium should focus on its relevant risk factors. People should be strongly encouraged to wear a widebrimmed hat and/or sunglasses whenever they are outside.
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