Pterygium is a common ophthalmic disease characterized by proliferative tissue extending from the bulbar conjunctiva to the cornea, which may gradually affect vision. Contemporary reconstructive surgery—particularly conjunctival limbal autograft (CLAU), which restores the limbal stem cell niche—has achieved excellent outcomes, with recurrence rates below 2% in specialized practice. Nevertheless, surgical excision remains inherently invasive, requires substantial operator expertise and autologous grafting, and cannot reverse the underlying ultraviolet-induced limbal progenitor cell damage or prevent de novo lesion formation. These limitations have driven growing interest in pharmacological strategies that intervene before irreversible structural damage occurs. This article reviews the pathogenesis of pterygium and current therapeutic practice. We critically analyze the benefits and limitations of surgical intervention, examine the mechanistic rationale for pharmacological targets, and evaluate drug repurposing and drug delivery systems as complementary avenues. Pharmacotherapy may offer advantages beyond surgery, including non-invasive early intervention before pterygium reaches surgical threshold, reduced dependence on operator expertise and facility resources, adjuvant suppression of residual disease activity after excision, and a safe therapeutic alternative for patients who are unsuitable for or decline invasive surgery. We believe these efforts will pave the way for safer, more effective, and precision-based treatment options for pterygium.