|Year : 2021 | Volume
| Issue : 2 | Page : 260-263
A comparative study of suture-less and glue-free versus sutured conjunctival autograft for the management of primary pterygium
Sachit Mahajan, Satish Kumar Gupta
Department of Ophthalmology, Government Medical College, Jammu, Jammu and Kashmir, India
|Date of Submission||02-May-2021|
|Date of Decision||19-May-2021|
|Date of Acceptance||21-May-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Sachit Mahajan
Lane No. 2 (Down), Greater Kailash, Jammu - 180 011, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background and Aim: Various modalities are currently available for the management of pterygium, of which free limbal conjunctival autograft is now the most preferred method to prevent recurrence. The most common method for the fixation of autograft, at the required site, is by suturing, but it is associated with various complications. Suture-less and glue-free conjunctival autograft is a new, easy, and cheaper technique for the management of pterygium. This study was conceptualized to compare the two most commonly used techniques for conjunctival autograft fixation in pterygium surgery, either sutureless, glue-free fixation, or sutured graft. Materials and Methods: This prospective, longitudinal study included 100 eyes of 100 patients who were divided into two groups A and B, who underwent pterygium surgery with sutureless conjunctival autografting and sutured conjunctival autografting with 10'0 nylon sutures, respectively, under local anesthesia. Both the groups were compared with respect to mean operating time and postoperative complications. Data were analyzed with OpenEpi online software version 3 using t-test. Results: Mean operating time was significantly less (24.35 ± 1.22 min) in Group A as compared to Group B (28.62 ± 1.78 min) (P = 0.009). Postoperative symptoms were more in sutured conjunctival autograft group (80%) as compared to the sutureless conjunctival autograft group (10%). Two patients had graft displacement in group A. Recurrence was noted in one patient in Group A and in two patients in Group B. Conclusion: Sutureless and glue-free conjunctival autografting is less time-consuming and is associated with lesser postoperative complications as compared to sutured conjunctival autografting.
Keywords: Autograft, fibrin, pterygium, sutures
|How to cite this article:|
Mahajan S, Gupta SK. A comparative study of suture-less and glue-free versus sutured conjunctival autograft for the management of primary pterygium. Arch Med Health Sci 2021;9:260-3
|How to cite this URL:|
Mahajan S, Gupta SK. A comparative study of suture-less and glue-free versus sutured conjunctival autograft for the management of primary pterygium. Arch Med Health Sci [serial online] 2021 [cited 2022 Oct 2];9:260-3. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/260/334029
| Introduction|| |
Pterygium is derived from the Greek word pterygos, meaning “wing” It is a triangular, wing–shaped, degenerative, fibrovascular hyperplastic proliferative tissue consisting of conjunctival epithelium and hypertrophied subconjunctival connective tissue, encroaching from the conjunctival limbal area onto the cornea. It is a common ocular surface disorder in tropical and sub-tropical countries., It occurs more commonly in people who are exposed to ultraviolet-B radiation. Localized limbal stem cell deficiency is also thought to be as a causative factor for pterygium formation. Other factors which are also involved in the causation of pterygium include dusty, hot, dry, windy, and smoky environments.
It more commonly affects elderly persons and is rare before 20 years of age. Initially, a small pterygium causes only slight irritation or heaviness of the eyes, cosmetic blemish, and redness, but advanced pterygium causes impairment of vision due to involvement of pupillary axis and induced astigmatism. The definite management involves pterygium excision. Various modalities are currently available for the management of pterygium, which includes bare sclera resection, bare sclera resection with the application of mitomycin-C in different concentrations, and pterygium excision plus conjunctival autografting or amniotic membrane grafting.,,,
Free limbal conjunctival autograft is now the most preferred method to prevent recurrence as it is both anatomically and physiologically similar to the tissue required. The most common method for the fixation of autograft, at the required site, is by suturing, but it is associated with various complications like increased operating time, postoperative discomfort, inflammation, buttonholing, necrosis, giant papillary conjunctivitis, scarring, and granuloma formation. Fibrin glue is also widely used for fixation of conjunctival autograft and has many advantages like easy fixation of the graft, shorter operation time, reduction in complications and postoperative discomfort but it also has some disadvantages also like high cost, the risk of transmission of infections, and inactivation by iodine preparations.,,
Suture-less and glue-free conjunctival autograft is a new, easy, and cheaper technique for the management of pterygium where the fibrin formed as a part of the normal clotting process acts as a glue to hold the graft to the scleral bed., This study was conceptualized to compare the two most commonly used techniques for conjunctival autograft fixation in pterygium surgery, sutureless, glue-free fixation and sutured conjunctival graft, to generate evidence to manage this condition more effectively.
| Materials and Methods|| |
This prospective, longitudinal study was conducted over a period of 1 year from April 2019 to March 2020 in a tertiary care teaching hospital in North India, after getting permission from Institutional Ethics Committee.
This study included 100 eyes of 100 patients who underwent pterygium surgery with conjunctival autografting. The sample size of 73 was calculated with 5% absolute precision and effect size of 1 (confidence level 95%). The sample size of 100 patients was taken with adjustment of 20%. Patients who fulfilled the following criteria were included in the study. Written informed consent was taken from each patient after explaining the purpose of the study.
Patients of any age and either gender with primary pterygium.
Recurrent pterygium, history of previous ocular surgery or trauma, glaucoma, unexplained visual acuity (<6/12), retinal pathology requiring surgical intervention.
Patients were divided into two groups A and B of 50 patients each by block permuted randomization done using online software sealed envelope. Group A which included 50 patients, who underwent pterygium excision with sutureless and glue-free conjunctival autografting and Group B, which also included 50 patients underwent pterygium excision with conjunctival autograft sutured with 10'0 interrupted nylon sutures.
Preoperatively, detailed ocular history, uncorrected and best-corrected visual acuity were recorded. A detailed slit lamp examination was performed, intraocular pressure was recorded and retinal examination was done with 90 D slit-lamp biomicroscopy.
Peribulbar anesthesia with 2% lignocaine and 0.5% bupivacaine in 1:1 ratio was given preoperatively. The body of the pterygium was dissected 4 mm from the limbus, down to the bare sclera and the head of the pterygium was gently avulsed from the cornea. The thickened portion of the conjunctiva and the immediate adjacent and subjacent Tenon's capsule showing tortuous vasculature were excised. The size of the graft to be taken was measured with Castroviejo-caliper. An oversized graft of 1 mm larger than the defect, was taken from the supero-temporal quadrant of conjunctiva with the help of conjunctival scissors. No fluid or air was used for preparing the graft. No Cautery was used for any active bleeding.
In group A, the graft was placed on bare sclera and positioned to maintain the limbus-limbus orientation. The graft was kept apposed to the scleral bed by applying mild pressure with nontoothed forceps for 10 min. In group B, the graft was anchored with interrupted 10-0 nylon sutures by taking episcleral bites at the corners to maintain the limbus to limbus apposition of the graft.
Both the groups were eye patched for 24 h. Topical antibiotic-steroid drops and lubricating eye drops were started postoperatively. Sutures were removed 2 weeks later in Group B.
The total surgical time was recorded from the first conjunctival cut to the removal of the lid speculum. Postoperatively, both the groups were compared with regards to complications and symptoms such as pain, foreign body sensation, watering, redness, photophobia, etc. Patients were followed up for a period of 6 months (day 1, day 7, 2 weeks, 1 month, 3 months, and 6 months).
All the data were entered in Microsoft excel and subsequently expressed as percentages and proportions. The quantitative data were expressed as mean (±standard deviation [SD]). The data was analyzed using OpenEpi online software version 3 by t-test. A P < 0.05 was considered statistically significant and all P values used were two-tailed.
| Results|| |
In this study, 100 eyes of 100 patients with nasal pterygium were studied. The demographic profile of patients is shown in [Table 1]. Both the groups were comparable with respect to age, gender, and laterality distribution of pterygium.
The mean operative time between the two groups is shown in [Table 2].
There was a statistically significant difference between the two groups (P = 0.009) with regards to mean operating time, with mean (±SD) operating time being lower in the sutureless and glue-free autograft group.
The postoperative complications in both the groups are shown in [Table 3]. All the patients completed the 6 month follow-up. The symptoms in both the groups were maximum in 1st week after the surgery and resolved earlier in Group A (in 2 weeks) as compared to Group B (1 month). Two patients had displacement of the graft in Group A. Both these occurred within 10 weeks after the procedure. One patient developed recurrence in Group A at the end of 6 months after the procedure and two patients developed recurrence of pterygium in Group B. One patient had recurrence at 3 months and the second patient developed recurrence at the end of 6 months. Other graft-related complications like retraction, wrinkling, and shrinkage were not observed in this study. Also, there were no complications like symblepharon formation, suture-cut through, scleral thinning, sclera necrosis, conjunctival cyst formation, Dellen formation, and pain postoperatively.
| Discussion|| |
Many different surgical techniques have been described for the management of pterygium. The aim of the surgery should be not only to excise the pterygium but also to prevent or minimize its recurrence. Mostly, the recurrence occurs within the first 6 months after the excision. One such technique that minimizes the recurrence is pterygium excision with limbal conjunctival autografting. It was first described by Kenyon et al. Conjunctival limbal autograft maintains a smooth ocular surface and re-establishes the barrier function of the limbus, thereby lowering the recurrence rate. Conjunctival autograft can be attached by various methods like sutures, biological adhesives like fibrin glue and autologous fibrin. The use of sutures may cause various complications like conjunctival inflammation and Langerhan's cell migration into the cornea, increased operation time, patient discomfort, Dellen formation, symblepharon, or graft rupture.,,,
Another method of fixation of conjunctival autograft is by use of tissue adhesives like fibrin glue. It has various advantages like shorter operation time, easier fixation of graft, and less recurrence rates. However, it has various disadvantages like high cost, transmission of infection particularly Parvovirus B-19. The anaphylactic reaction has also been reported after the use of (TISSEEL) fibrin sealant due to bovine protein aprotinin.
In the present study, consisting of 100 patients, who were divided into two groups, mean operating time in group A was 24.35 ± 1.22 min and 28.62 ± 1.78 min in Group B. Sharma et al. reported mean operative time of 23.20 ± 1.55 min and 37.76 ± 1.89 min in sutureless, glue-free graft and sutured conjunctival autograft groups, respectively. Similarly, Elwan also reported, the mean operating time of 24 ± 5.64 min in sutureless and glue-free conjunctival limbal autografting which and 28.64 ± 6.45 min in suturing of conjunctival limbal autograft.
In this study, post-operative symptoms like watering and foreign body sensation were noted in 10% of patients in sutureless and glue-free autograft and in 80% of patients in sutured conjunctival autograft. The symptoms were maximal on the 1st day and 1st week after the surgery and decreased over a period of 1 month in both the groups, earlier in group A. Similarly, Sharma et al. noted postoperative symptoms in 20% of patients in the sutureless autograft group and in 80% of patients in sutured conjunctival autograft group. Elwan and Malik et al. also reported more symptoms in sutured conjunctival autograft group, which decreased over a period of 1 month.,
Postoperative complications were also more in sutured conjunctival autograft group in our study. Two patients in the sutureless conjunctival autograft group developed graft displacement within 1 week after the procedure. Recurrence was seen in one patient in the sutureless conjunctival autograft group and in two patients in the sutured conjunctival group. Graft edema was seen in two patients in Group A and three patients in Group B. Sharma A et al. noted one case each of conjuntival granuloma formation and recurrence, in sutured conjunctival autograft group in their study and graft edema was seen in two patients in sutureless conjunctival autograft group and in three patients in sutured conjunctival autograft group. They reported no complications like graft displacement, wrinkling, retraction in their study. Malik et al. reported graft retraction in three eyes and recurrence in one eye with sutureless conjunctival autograft. Elwan reported conjunctival edema in 8 (16%) patients and 6 (6%) patients, recurrence in 3 (6%) patients and 8 (8%) patients, and granuloma formation in none and 3 (3%) patients for sutureless and glue-free and sutured limbal conjunctival autograft respectively. Bhargava et al. noted graft displacement in 16 (5.33%) patients and recurrence in three patients at the end of 3 months in their study.
The supero-temporal site for donor graft was chosen, as it gets covered by the upper eyelid, enabling better healing and cosmesis of the donor site. A very thin conjunctival autograft, free of any Tenon capsule is required for the successful take-up of the graft. None of the patients, in this study, developed complications like symblepharon formation, suture-cut through, scleral thinning, sclera necrosis, conjunctival cyst formation, and Dellen formation.
| Conclusion|| |
Sutureless and glue-free conjunctival autografting is less time-consuming and is associated with lesser postoperative complications as compared to sutured conjunctival autografting. The absence of foreign material, cost-related factor, and absence of suturing make it more feasible.
Patients with temporal pteygium and patients with both nasal and temporal pterygium were excluded from the study.
Our sincere thanks to all the patients for their follow-up and compliance in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Schulz KF, Altman DG, Moher for the CONSORT Group. CONSORT 2010 Statement: Updated guidelines for reporting parallel group randomized trials. BMJ 2010;340:C332.
Rosenthal JW. Rosenthal chronology of pterygium therapy. Am J Ophthalmol 1953;36:1601.
Gross J, Wegener AR, Kronschläger M, Holz FG, Schönfeld CL, Meyer LM. Ultraviolet radiation exposure triggers neurokinin-1 receptor upregulation in ocular tissues in vivo
. Exp Eye Res 2018;174:70-9.
Tseng SC. Concept and application of limbal stem cells. Eye (Lond) 1989;3 (Pt 2):141-57.
Kheirkhah A, Safi H, Molaei S, Nazari R, Behrouz MJ, Raju VK. Effects of pterygium surgery on front and back corneal astigmatism. Can J Ophthalmol 2012;47:423-8.
D'Ombrain A. The surgical treatment of pterygium. Br J Ophthalmol 1948;32:65-71.
Kunitomo N, Mori S. Studies on the pterygium: A treatment of the pterygium by mitomycin C instillation. Acta Soc Ophthalmol Jpn 1963;67:601-07.
Mahar PS, Nwokora GE. Role of mitomycin C in pterygium surgery. Br J Ophthalmol 1993;77:433-5.
Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-70.
Akbari M, Soltani-Moghadam R, Elmi R, Kazemnejad E. Comparison of free conjunctival autograft versus amniotic membrane transplantation for pterygium surgery. J Curr Ophthalmol 2017;29:282-6.
Starck T, Kenyon KR, Serrano F. Conjunctival autograft for primary and recurrent pterygia: Surgical technique and problem management. Cornea 1991;10:196-202.
Koranyi G, Seregard S, Kopp ED. Cut and paste: A no suture, small incision approach to pterygium surgery. Br J Ophthalmol 2004;88:911-4.
Foroutan A, Beigzadeh F, Ghaempanah MJ, Eshghi P, Amirizadeh N, Sianati H, et al.
Efficacy of autologous fibrin glue for primary pterygium surgery with conjunctival autograft. Iran J Ophthalmol 2011;23:39-47.
Gilmore OJ, Reid C. Prevention of intraperitoneal adhesions: A comparison of noxythiolin and a new povidone-iodine/PVP solution. Br J Surg 1979;66:197-9.
Malik KP, Goel R, Gutpa A, Gupta SK, Kamal S, Mallik VK, et al.
Efficacy of sutureless and glue free limbal conjunctival autograft for primary pterygium surgery. Nepal J Ophthalmol 2012;4:230-5.
de Wit D, Athanasiadis I, Sharma A, Moore J. Sutureless and glue-free conjunctival autograft in pterygium surgery: A case series. Eye (Lond) 2010;24:1474-7.
Adamis AP, Starck T, Kenyon KR. The management of pterygium. Ophthalmol Clin North Am 1990;3:611-23.
Soliman Mahdy MA, Bhatia J. Treatment of primary pterygium: Role of limbal stem cells and conjunctival autograft transplantation. Eur J Ophthalmol 2009;19:729-32.
Suzuki T, Sano Y, Kinoshita S. Conjunctival inflammation induces Langerhans cell migration into the cornea. Curr Eye Res 2000;21:550-3.
Ti SE, Chee SP, Dear KB, Tan DT. Analysis of variation in success rates in conjunctival autografting for primary and recurrent pterygium. Br J Ophthalmol 2000;84:385-9.
Kim HH, Mun HJ, Park YJ, Lee KW, Shin JP. Conjunctivolimbal autograft using a fibrin adhesive in pterygium surgery. Korean J Ophthalmol 2008;22:147-54.
Elwan SA. Comparison between sutureless and glue free versus sutured limbal conjunctival autograft in primary pterygium surgery. Saudi J Ophthalmol 2014;28:292-8.
Koranyi G, Seregard S. Kopp ED. Cut and paste: Ano suture, small incision approach to pterygium surgery. Br J Ophthalmol 2004;88:911-4.
Oswald AM, Joly LM, Gury C, Disdet M, Leduc V, Kanny G. Fatal intraoperative anaphylaxis related to aprotinin after local application of fibrin glue. Anesthesiology 2003;99:762-3.
Sharma A, Raj H, Gupta A, Raina AV. Sutureless and glue-free versus sutures for limbal conjunctival autografting in primary pterygium surgery: A prospective comparative study. J Clin Diagn Res 2015;9:C06-9.
Bhargava P, Kochar A, Joshi R. Pterygium excision followed by sutureless and gluefree infero-temporal conjunctival autograft. DJO 2019;30:32-5.
[Table 1], [Table 2], [Table 3]