|Year : 2015 | Volume
| Issue : 3 | Page : 308-312
Is the surgical technique of a sutureless and glue-free conjunctivolimbal auto graft after pterygium excision complications free?
Sayli Bhalchandra Kulthe1, Amit P Bhosale1, Prachi U Patil1, Harshal T Pandve2
1 Department of Ophthalmology, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
2 Department of Community Medicine, Smt. Kashibai Navale Medical College and General Hospital, Pune, Maharashtra, India
|Date of Web Publication||15-May-2015|
Sayli Bhalchandra Kulthe
S-9/303, Sun Paradise Phase-2, Anand Nagar, Sinhagad Road, Pune - 411 051, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Sutures or fibrin glue have been used to fix a conjunctival graft after pterygium excision. A new surgical technique of using patient's own blood to affix the conjunctival graft after excision of pterygium has been introduced. This technique is safe, economical and reduces complications related to the use of foreign materials. Aim: The aim was to evaluate the surgical technique of a sutureless and glue-free graft for pterygium surgery in terms of complications such as loss of graft, graft dehiscence, and recurrence. Materials and Methods: This was a prospective interventional study. All patients that came to the outpatients department from July 2012 to December 2012 were included in the study. Pterygium excision with conjunctivolimbal autografting without using suture or glue was carried out in all patients. Patients were followed-up postoperatively up to 6 months. They were examined mainly for postoperative complications. Results: A total of 79 eyes of 74 patients underwent suture less glue-free autologous conjunctivolimbal graft after pterygium excision. There were 53 female (mean age-46.85 years standard deviation (SD) 10.59) and 26 male (mean age-45.04 years SD 17.27) patients. There were 77 cases of primary pterygium and two cases of recurrent pterygium. Medial edge recession of the graft was seen in one case (1.2%), whereas two cases (2.5%) had lost graft on the first postoperative day. There were no recurrences at the end of 6 months. Conclusion: The surgical technique of using a sutureless and glue-free conjunctivolimbal autograft is safe and cost-effective. However, this technique is associated with few complications such as medial edge recession and loss of graft.
Keywords: Fibrin glue, pterygium, sutureless and glue-free auto-graft pterygium surgery
|How to cite this article:|
Kulthe SB, Bhosale AP, Patil PU, Pandve HT. Is the surgical technique of a sutureless and glue-free conjunctivolimbal auto graft after pterygium excision complications free?. Med J DY Patil Univ 2015;8:308-12
| Introduction|| |
Pterygium is a pinkish triangular wedge-shaped growth of conjunctival tissue. It proliferates as a vascularized granulomatous tissue to invade the corneal surface.  It is an ocular surface disease and its prevalence varies from 0.7% to 31% in different geographical regions. 
In addition to the obvious cosmetic concerns, it can induce corneal astigmatism. The induced corneal astigmatism may cause significant visual impairment and may require surgery. It is influenced by age and solar radiation. 
Sutures or glue is used to affix the conjunctival autograft after excision of the pterygium. Recently, a new technique of using patient's own blood present at the graft bed to fix the graft has been introduced. Sutures and glue being foreign materials are associated with complications such as infection, granuloma formation, chronic inflammation, hypersensitivity reactions or recurrence.  This technique is also cost effective when compared to the techniques using sutures or glue.
Recurrence is a problem with pterygium surgeries. This has been significantly reduced with the introduction of the fixation of conjunctival autograft after pterygium excision.  The rate of recurrence with sutures is approximately 15%, while it is approximately 10-15% with glue. 
In this study, we aim to find out whether this new technique of a sutureless and glue-free graft is associated with any complications such as graft dehiscence, loss of graft and recurrence.
| Materials and Methods|| |
This was a prospective interventional study. All patients from age 18 to 75 years attending the ophthalmology outpatients department of a tertiary hospital from July 2012 to December 2012 were included in the study. Indications for pterygium surgery were:
- Progressive pterygium either invading or threatening visual axis.
- Visual impairment due to astigmatism.
- Irritation and inflammation.
- Restricted movements.
- Cosmetic. Patients having Grade II, III and IV progressive pterygium were included in the study.
Patients with ocular pathology other than refractive error such as history of previous ocular surgery (except pterygium surgery), trauma, pseudopterygium and atrophic pterygium were excluded from the study. Written informed consent was obtained from all the participants. All methods adhered to the tenets of the Declaration of Helsinki Principles for research in human subjects. The study was approved by the Institutional Research Ethics Committee.
All patients went through general ophthalmic examination. Pterygium was graded depending on the extent of corneal involvement. Grade I - crossing the limbus, Grade II - midway between limbus and pupil, Grade III - reaching up to pupillary margin, Grade IV - crossing pupillary margin. Before the surgery, a comprehensive investigation was done including patient's age, gender, medical, and ocular history. Routine investigations (blood sugar levels both fasting and postprandial, urine routine and microscopy, hemogram and electrocardiography) and preanesthetic check-ups were done. Best corrected visual acuity measurement, noncontact tonometry, slit lamp examination, and anterior segment photography were performed preoperatively and postoperatively at each visit. Probe test was done to rule out pseudopterygium.
This surgical technique was essentially similar to that described by de Wit et al.  Surgery was done under peribulbar anaesthesia with good orbicularis oculi akinesia. Superior rectus bridle suture was taken which helped in obtaining a good conjunctival graft from 12 O'clock position. The body of the pterygium was dissected 2-3 mm from the limbus down to the bare sclera and reflected over the cornea. The pterygium head and cap were avulsed using artery forceps, followed by careful excision of the corneal remnants. During avulsion of the pterygium head, counter traction was applied with a cotton bud. Only thickened portions of the conjunctiva and the immediate adjacent and subjacent Tenon's capsule showing tortuous vasculature were excised. Excessive dissection of Tenon's was avoided. Wherever possible, hemostasis was allowed to occur spontaneously without the use of cautery. The size of the defect in mm 2 was measured with Castroviejo's callipers. Careful dissection between graft conjunctiva and Tenon's layer was done while fashioning the 0.5 mm oversized conjunctivo limbal graft from the supero-temporal bulbar conjunctiva. The limbal edge of the graft was carefully positioned at the host limbal tissue edge. We did not make any attempt to directly close the full extent of the wound, allowing natural graft positioning without tension. The scleral bed was viewed through the transparent conjunctiva. To ensure that the residual bleeding does not lift the graft, small central hemorrhages were tamponaded with direct compression using nontooth forceps until hemostasis was achieved. The stabilization of the graft was tested centrally and on each free edge to ensure firm adherence to the sclera. Surgery time was noted from the first incision until the lid speculum was removed. Eye patch was given and removed after 24 h of surgery.
Postoperatively, antibiotic-steroid eye drops (ofloxacin and prednisolone acetate) were given 4 times a day initially and tapered over 6 weeks. Along with these drops, lubricating eye ointment (hydroxyl propyl methyl cellulose 2%) was also given to patients for 1-2 weeks. Lubricating eye drops carboxy methyl cellulose 0.5% were given for 1-month postoperatively.
Surgical duration was recorded and the patients were followed-up on the first day after surgery and then at 8 th day, 15 th day, 1-month, 3 months and 6 months postoperatively. The graft-recipient site attachments were examined and subjective symptoms of patients were recorded at every follow-up. Slit lamp examination and anterior segment photography were done at each visit. Preoperative and postoperative visual acuity, along with complications was recorded. Subjective comments related to comfort were asked to each patient. Recurrence was defined as the presence of fibrovascular tissue regrowth extending beyond the surgical limbus onto clear cornea as agreed by Sebban and Hirst. 
| Results|| |
A total of 79 eyes of 74 patients underwent sutureless and glue-free autologous conjunctivolimbal auto graft after pterygium excision. There were 53 female (mean age-46.85 years standard deviation (SD)-10.59) and 26 male (mean age-45.04 years SD-17.27) patients [Table 1]. 77 patients had primary pterygium and two patients had recurrent pterygium. One patient with primary pterygium had a cyst within the pterygium.76 patients had a nasal pterygium, two patients had temporal pterygium and one patient had a double headed pterygium. Eight patients had Grade I pterygium, 33 had Grade II, 29 had Grade III and nine patients had Grade IV pterygium. Majority of patients-57 were farmer by occupation. Mean surgical time was 18 min (± 1.3). Out of 79 eyes, graft of 76 eyes remained in place at the end of 6 months follow-up. Medial edge recession of the graft was seen in one case (1.2%) and two cases (2.5%) had lost graft on the first postoperative day [Figure 1]. Patients were examined postoperatively on 1 st day, 8 th day, 15 th day, 1-month, 3 months and 6 months [Figure 2]a and b. All patients whose graft was in place improved cosmetically. There were no recurrences at the end of 6 months.
|Figure 1: Rate of complications after suture glue-free autograft for pterygium surgery|
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|Figure 2: (a) Preoperative photo of pterygium. (b) Postoperatively after 6 months|
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|Table 1: Results of suture less and glue-free conjunctivolimbal autograft after pterygium excision|
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| Discussion|| |
There are various methods for the treatment of pterygium, bare sclera technique, use of antimitotic agents, amniotic membrane transplantation and autologous conjunctival or conjunctivolimbal transplantation being important. In 1985 Kenyon et al.  proposed that a conjunctival autograft of the bare sclera could be used in the treatment of recurrent and advanced pterygium. In autologous conjunctivolimbal auto graft technique, bulbar conjunctiva including limbal tissue is fixed on the exposed scleral bed after pterygium excision, either with the help of sutures or fibrin glue. Studies have been done favoring the use of fibrin glue over sutures. ,,, Both the techniques have their pros and cons in terms of postoperative comfort, surgical time, postoperative complications, cosmesis and recurrence.
This technique uses patient's own blood for fixation of the conjunctival or conjunctivolimbal auto graft. It avoids the use of foreign materials such as suture and glue associated with increased inflammation, infection and hypersensitivity reactions. This technique is also cost effective. In 2010 de Wit et al.  presented a case series describing a simple technique of using a sutureless and glue-free technique previously described by one of the authors,  to fix conjunctivolimbal autograft using naturally occurring fibrin at the bare scleral wound site.
In this study, we operated on 79 eyes of 74 patients. There was no recurrence however loss of graft [Figure 3] was observed in two cases, and one graft had a medial edge recession [Figure 4]. In the present study, both the cases with lost graft had Grade III pterygium. This could be because patients accidentally rubbed the operated eye (s). In these cases, despite of taking all necessary precautions required for the procedure, the graft was lost. Whether the loss of graft is associated with the grade of pterygium needs to be evaluated. In the present study, there were comparatively fewer cases of Grade III and IV pterygium.
|Figure 3: Complication: Medial edge recession of the graft on the first postoperative day|
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These patients were advised to undergo amniotic membrane grafting after 6 weeks but they were not willing for another surgery. These patients were hence treated as per bare sclera technique.
According to Dr. Mitra,  "The main disadvantage of this technique is the risk of graft loss in the immediate postoperative period." In a study by Dr. Mitra,  19 patients underwent sutureless glue-free graft fixation and were followed-up for 6 months.  Of these 19 patients, 17 had primary, and two had recurrent pterygium. Medial edge recession was seen in one case in their study.
In a similar study carried out on 40 patients of the primary nasal pterygium, graft dehiscence occurred in two eyes, graft retraction was seen in three eyes, and recurrence was seen in one eye.  None of these complications occurred in any of the patients in our study.
In the present study, the mean surgical time was 18 (± 1.3) min. The mean surgical time reported by de Wit et al. was 14 (1.4) min.  Some studies comparing the efficacy of suture and glue technique in pterygium surgery have reported the mean surgical time for the suture group as 41.45 ± 3.20  and17 min (range: 12-30 min),  whereas the mean surgical time for the glue group has been reported as 23.42 ± 13.34  and 10 min (range: 6-13).  The difference in surgical time is due to its dependency upon the technique. The time taken with the technique using sutures to fix the graft is more as compared to glue and suture less and glue-free technique.
In this study, we operated on 77 cases of primary pterygium and two cases of recurrent pterygium. Out of the two patients with recurrent pterygium one had recurrent pterygium with a pyogenic granuloma which was proved in histopathological study [Figure 5]a and b. None of the patients with recurrent pterygium had recurrence. A case of primary pterygium had cyst, which showed only pterygium tissue in histopathology report. All the patients where graft remained in situ had good cosmesis at the end of 6 months. This was reported by the previous studies as well. ,
|Figure 5: (a) Recurrent pterugium with pyogenic granuloma. (b) Postoperative 6 months|
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The follow-up period for this study was 6 months. However, the mean time for appearance of any complication, including recurrence was reported by one study which compared the four commonly used surgical techniques for pterygium surgery was 4 months.  Koranyi et al.  also reported that there were recurrences in their patients within 2-3 months of surgery.
| Conclusion|| |
This technique is cost effective, reduces complications related to the use of foreign materials, reduces surgical time when compared to the technique using sutures and is also more comfortable for the patients. However, this surgery is associated with few complications such as medial recession and loss of graft, which should be investigated further.
Limitations of the study
Our study has few limitations. The follow-up period of 6 months is short. Ideally the follow-up period should be more than 6 months. It was a nonrandomized study. The results of this technique should be investigated in a prospective randomized controlled trial with a larger study population and for a longer duration.
| Acknowledgment|| |
Special thanks to Dr. Suvarna K. Gokhale, Professor and Head of Department, Department of Ophthalmology, Smt. Kashibai Navale Medical College and General Hospital (SKNMC and GH), Pune, India and all the staff members of the Department of Ophthalmology at SKNMC and GH, Pune, India.
| References|| |
Garg A. Clinical signs and symptoms of pterygium. In: Garg A, El Toukhy E, Nassaralla BA, Morekar S, editors. Surgical and Medical Management of Pterygium. 1 st
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Asokan R, Venkatasubbu RS, Velumuri L, Lingam V, George R. Prevalence and associated factors for pterygium and pinguecula in a South Indian population. Ophthalmic Physiol Opt 2012;32:39-44.
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.
Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-70.
Sebban A, Hirst LW. Pterygium recurrence rate at the Princess Alexandra Hospital. Aust N Z J Ophthalmol 1991;19:203-6.
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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.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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