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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 2  |  Page : 86-90

Comparison of fibrin glue and autologous blood for conjunctival autograft fixation in pterygium


Department of Ophthalmology, Mahatma Gandhi Mission's Medical College and Hospital, Kamothe, Navi Mumbai, Maharashtra, India

Date of Web Publication10-Aug-2017

Correspondence Address:
Saurabh Shrivastava
Department of Ophthalmology, Mahatma Gandhi Mission's Medical College and Hospital, Plot No. 1 and 2, Sector - 1, Kamothe, Navi Mumbai - 410 209, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kjo.kjo_17_17

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  Abstract 


Aim: The aim of this study is to compare the outcome of conjunctival autograft (CAG) surgery for pterygium using autologous serum versus fibrin glue.
Materials and Methods: A prospective, randomized controlled trial was carried out on 40 patients over a period of 2 years. Group I (20 eyes) underwent CAG with fibrin glue and Group II (20 eyes) underwent CAG with autologous serum. Postoperatively, the parameters noted in both the groups were the time taken for surgery in both the groups, postoperative outcomes such as redness and discomfort during blinking, outcome of the graft (graft edema, graft retraction, graft rejection, graft displacement, and graft loss), and recurrence of the pterygium.
Results: In Group I (autologous serum), the mean surgical time was 34.8 min (standard deviation [SD] = 3.664912), whereas in Group II (fibrin glue), the mean surgical time was 22.95 min (SD = 3.086047). The intensity of postoperative discomfort was greater in Group I (autologous serum) than Group II (fibrin glue) on postoperative visits. However, the difference was not statistically significant. Graft rejection was observed in one patient belonging to the fibrin glue group, after 1 month postoperatively, which eventually by the end of 3 months led to graft loss. We found decreased postoperative inflammation and decreased recurrence rate at both a 3- and 6-month time period with the use of fibrin glue compared with autologous serum.
Conclusion: Fibrin glue is generally considered safe; however, since it is made from human plasma, it carries the risk of transmitting infections. There was marked reduction in the operating time in fibrin glue group as compared with the autologous blood group. Cost of the surgery was more with fibrin glue. The graft edema, graft loss, graft retraction, and displacement of the graft were more with the use of fibrin glue. However, the difference was not statistically significant.

Keywords: Autologous serum, conjunctival autograft, fibrin glue


How to cite this article:
Patkar P, Shrivastava S, Ramakrishnan R, Kanhere M, Riaz Z. Comparison of fibrin glue and autologous blood for conjunctival autograft fixation in pterygium. Kerala J Ophthalmol 2017;29:86-90

How to cite this URL:
Patkar P, Shrivastava S, Ramakrishnan R, Kanhere M, Riaz Z. Comparison of fibrin glue and autologous blood for conjunctival autograft fixation in pterygium. Kerala J Ophthalmol [serial online] 2017 [cited 2021 May 7];29:86-90. Available from: http://www.kjophthal.com/text.asp?2017/29/2/86/212749




  Introduction Top


Pterygia that extend far across the eye causing cosmetic embarrassment and visual problems due to induced astigmatism, and those causing chronic ocular irritation due to tear film disturbance may require removal. During the past decade, the debate over the best approach to pterygium surgery has centered on whether the surgeons should use sutures, mitomycin C, amniotic membrane or fibrin glue to affix the conjunctival graft. All the approaches have their pros and cons in terms of such factors as surgical time, postoperative complications, cosmesis and recurrence. The ideal procedure to minimize postoperative recurrence, as of now, is conjunctival autograft (CAG). The most common method of securing CAG using sutures has the drawbacks of long surgical time, risk of complications such as granuloma formation and significant patient discomfort.[1] Technique of graft fixation with commercial fibrin glue has a potential risk of transmitted infection and high cost.

A new technique of autograft fixation has emerged where we needed to apply neither glue nor sutures. Patients' graft adhered because of the fibrinous reaction in the patients' own blood. Very few studies have been carried out in the Indian subcontinent to compare the outcomes of CAG fixed with autologous blood serum and CAG fixed with fibrin glue. Our aim is to compare the results of limbal CAG fixed with autologous serum with those of fibrin glue in primary pterygium excision. There are two types of tissue adhesives, i.e., synthetic adhesives (e.g., cyanoacrylate derivatives) and biologic adhesives (e.g., fibrin-based adhesives). Fibrin-based adhesives, in contrast to cyanoacrylate glue, have a lower tensile strength and slower polymerization; but, being biologic and biodegradable, they may be used under a superficial covering layer (e.g., conjunctiva, amniotic membrane) and induce minimal inflammation. The commercial tissue kit (ReliSeal™ ) contains freeze-dried powder and diluents that are combined to form a two component system. A sealant protein solution composed of human fibrinogen, plasminogen, fibronectin, and factor XII in a bovine aprotinin solution and a sealant setting solution composed of human thrombin reconstituted in a calcium chloride solution. When the two solutions are mixed, fibrinogen is converted to fibrin by thrombin and factor XIII cross-links the fibrin monomers to form a semirigid fibrin clot. Fibrin and fibronectin get cross-linked with the collagen in tissue. This explains the high adherence of human fibrin glue to collagen-rich tissue such as corneal stroma. Fibrin forms covalent bonds, hydrogen bonds, and electrostatic bonds to tissue.[2]

When human tissue is injured, bleeding ensues. Once the coagulation cascade is triggered, activated factor X selectively hydrolyses prothrombin to thrombin; fibrinogen is converted to fibrin. Thrombin also activates factor XIII, which stabilizes the clot, by promoting polymerization and cross-linking of the fibrin chains to form long fibrin strands in the presence of calcium ions. This is the final common pathway for both extrinsic and intrinsic pathways of coagulation in vivo. This mechanism is used to induce tissue adhesion of CAG to bare sclera.


  Materials and Methods Top


A 2-year prospective, randomized controlled trial was carried out (December 2014 to October 2016). The study was carried out on 40 patients who presented to the Department of Ophthalmology. After taking informed consent and permission of the ethics committee, detailed history regarding the patient's name, age, sex, occupation, address, presenting symptoms, duration, progression, and associated conditions was recorded. Anterior segment examination of the patients was done preoperatively. Pterygium excision was done by a single operating surgeon at our hospital under local anesthesia, and then the patients were followed up on postoperative day 1, day 4, day 7, 1 month, 3rd month, and 6th month. A total of 40 patients were randomly divided into two groups of 20 each. Group I (20 eyes) underwent CAG with fibrin glue and Group II (20 eyes) underwent CAG with autologous serum.

Patients with a progressive nasal pterygium above the age of 40 years who did not have any ocular surface diseases (e.g., blepharitis, Sjogren's syndrome, and dry eye); non-diabetics, who were not on any anticoagulants, having no previous history of ocular surgery or trauma and those not having atrophic pterygium, pseudopterygium, or pterygium with cystic degeneration, were included in the study.

Patients developing infections in the postoperative period were excluded from the study.

After the usual surgical preparation of the eye, stay sutures were taken over the temporal limbus with 6-0 Mersilk sutures. Incision was given on the conjunctiva, above the pterygium, at the limbus with 15 number Bard Parker blade. Head of the pterygium was dissected from the cornea with a crescent blade (Webel edge). The corneal surface was further smoothed with a crescent blade. The body of the pterygium was dissected from the overlying conjunctiva using Westcott scissors and then excised. Tenon's tissue was also removed from under the conjunctiva. Conjunctival defect at the limbus was measured with a Castroviejo Caliper, and a marking of the size more than 0.5 mm than the defect was done on the superior-temporal bulbar conjunctiva of the same eye for taking the graft. Subconjunctival saline injection was given over the superior-temporal bulbar conjunctiva thus raising the destined size of flap. Westcott scissor was used to harvest the free conjunctival-limbal autograft [Figure 1]. Care was taken to include the limbal stem cells. Meticulous dissection was done to remove most of the Tenon's tissue in the autograft. The conjunctival graft was then moved to the area of the conjunctival defect, with care taken to maintain the limbus to limbus and stromal side down orientation. At this stage, depending on the group in which the patients were allocated to, the autograft was secured. In Group I, autograft was adhered to the underlying scleral bed by glue [Figure 2] and [Figure 5]. In Group II, the autograft was placed over the serum bed formed over the sclera by bleeding vessels of the excised pterygium [Figure 3] and [Figure 4]. Pooling of blood at the site to be grafted should be avoided and bleeders causing excessive bleeding should be cauterized. The fibrin glue was taken out from the deep freeze and thawed to room temperature. The preparation was performed in a separate room while properly maintaining the temperature by an independent nurse. The first component that is the fibrinogen solution is prepared by mixing the fibrinogen powder with the aprotinin (bovine) solution. The second component that is the thrombin solution is prepared by mixing the thrombin powder with the water for injection provided in the kit. Both the components are withdrawn in two separate syringes and are placed into the duploject injector. A mixer nosecone, topped by a blunt applicator needle, is attached to the 2-syringe nozzle to facilitate mixing of the two components from the syringe. When the common plunger is depressed, the fibrin sealer solution and the thrombin solution are combined in the nosecone, in equal volumes, to form the resulting fibrin sealant that is directly applied to the designated tissues. Gentle pressure is given for 2 min in case of fibrin glue. For autologous serum, gentle pressure was given for 3 min followed by waiting a period of 7 min for adherence of graft. The total time taken for both the procedures was noted from when the lid speculum was placed until its removal at the end of surgery. Patching of the eye was done after giving subconjunctival dexamethasone and gentamycin injections at donor site. Eye patch was removed on the first postoperative day in both the groups. After the surgery, all patients were prescribed topical steroids (prednisolone acetate) and topical antibiotics (moxifloxacin hydrochloride) and lubricating eye drops 4 times daily for 2 weeks, then tapered off weekly over next 3 weeks. Follow-up was done on postoperative day 1, day 4, after 1 week, after 1 month, after 3 months, and after 6 months [Figure 8]. The parameters noted in both the groups were the time taken for surgery in both the groups, postoperative outcomes such as redness and discomfort during blinking, outcome of the graft (graft edema, graft retraction, graft rejection, graft displacement, and graft loss), and recurrence of the pterygium.
Figure 1: Conjunctival harvesting from superior bulbar conjunctiva

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Figure 2: Conjunctival autograft with fibrin glue

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Figure 3: Attaching conjunctival autograft with autologous blood

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Figure 4: Conjunctival autograft with autologous blood serum on postoperative day 1

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Figure 5: Autograft with fibrin glue on post operative day 1

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Figure 6: Graft displacement postoperative day 1 in autologous blood technique

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Figure 7: Graft retraction

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Figure 8: Acceptance of graft after 6 months

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Statistical analysis

The data were entered in Microsoft Excel and analyzed using Stata Version 13. We calculated the means and standard deviations for the linear variables and proportions for categorical variables. The means between groups were compared using the t-test for unpaired data. The proportions were compared using the Chi-square test or the Fisher's exact test (for low expected cell counts). A P < 0.05 was considered to be statistically significant.


  Results and Discussion Top


Ours was a prospective, comparative study conducted at a tertiary care center. The study compared the outcome of CAG surgery for pterygium using autologous serum versus fibrin glue. It was conducted to assess and compare the mean surgical time, postoperative outcomes of the graft, and the total cost of the surgery among the patients undergoing the pterygium excision surgery with CAG using autologous serum and fibrin glue. Hilgers have demonstrated a higher prevalence of pterygium among males.[3] Similarly, in the Chennai glaucoma study, 44.5% were male and 55.54% were female. Our study showed almost equal gender distribution, i.e., 55% of males and 45% of females. Number of males and females were equally affected in all age groups. The Barbados eye study done in 2009 revealed racial predilection in the incidence of pterygium.[4]

The degree of discomfort due to pterygium was studied preoperatively. We found that 55% patients had mild discomfort, 35% had moderate, and 4% had severe discomfort. The grading of pterygium was done according to the classification given by Kanski, according to which out of 40 patients, 25 patients (62.50%) had grade 2 pterygium and 15 patients (37.50%) had grade 3 pterygium. Singh et al. reported a mean surgical time of 14.74 ± 2.35 min in fibrin glue group, and mean surgical time of 17.45 ± 2.89 min in autologous serum group. In our study, Group I (autologous serum), the mean surgical time was 34.8 min (standard deviation [SD] = 3.664912); whereas in Group II (fibrin glue), the mean surgical time was 22.95 min (SD = 3.086047). There was a statistically significant difference observed between the 2 groups. We found that 6 (30%) patients complained of mild discomfort, 9 (45%) patients complained of moderate discomfort and 5 (25%) patients complained of severe discomfort in autologous serum group on day 1, whereas 11 (55%) patients had mild, 6 (30%) moderate, and 2 (10%) had severe postoperative discomfort in fibrin glue group (P = 0.225). Thus, the intensity of postoperative discomfort was greater in Group I (autologous serum) than Group II (fibrin glue) on postoperative visits. However, the difference was not statistically significant.

Subconjunctival hemorrhage was graded according to its presence in all the four quadrants. On postoperative day 1, subconjunctival hemorrhage in the autologous serum group was 65% in the nasal quadrant, 55% in the temporal, and 50% in inferior and superior quadrants each and that of fibrin glue group was 60% in nasal quadrant, 55% in temporal, 40% in inferior, and 60% in superior quadrant. We found no significant difference in either group.

Koranyi et al. reported subconjunctival hemorrhage under the graft in 1 patient in fibrin glue group, resolving in 3 weeks.[5] The hemorrhages resolved completely by 3 months. Graft edema on the postoperative day 1 was present in 16 patients of Group I which subsided till the 1st month. In Group II, it was noted in 18 patients on the postoperative day 1 which reduced to one patient at the end of 1 month. It may probably be due to inadequate dissection of pterygium tissue which led to thick grafts due to persistent Tenon's capsule in some patients. Furthermore, poor compliance to the instillation of steroid eye drops was noted in one patient of Group II who developed severe graft edema. Graft retraction was seen in 1 (5%) patient in autologous serum group and in 3 (15%) patients in fibrin glue group. However, the difference was not statistically significant.

In our study, graft rejection was observed in one patient belonging to the fibrin glue group, after 1 month postoperatively, which eventually by the end of 3 months led to graft loss. This was seen in the first case of autograft fixation using fibrin glue and might be due to a lot of manipulations in harvesting the graft and application of the glue due to inexperience.

In a study conducted by Singh et al., graft displacements were more common in grafting with no glue no suture group (10%) than in fibrin glue group.[6] In our study, graft displacement was seen in 1 (5%) patient of autologous serum group and 2 (10%) patients in the fibrin glue group [Figure 6] and [Figure 7]. Karalezi et al. in his study reported graft displacement in 2 patients in fibrin glue group.[4] Malik et al. reported graft dehiscence was seen in 2 (5%) patients in no glue no suture patients.

In our study, there was a 5% (1 eye) graft loss rate in the autologous serum group, compared with 10% (2 eyes) in the fibrin glue group. This was not statistically significant compared to the other studies. The possible explanation for the graft loss can be due to lesser duration of patching the eye postoperatively. Malik et al. patched the patients for 48 h and experienced no graft loss. In our study, patients were patched for about 18 h.

Recurrence was defined as any regrowth of conjunctiva exceeding 1.0 mm onto the cornea. The recurrence rates were studied at 3- and 6-month postoperatively. It was found that 1 patient in autologous serum group who had graft loss on postoperative day 1, showed recurrence (5%) on the 6th month postoperatively whereas no recurrence was found in the fibrin glue group. Our recurrence rate in the autologous serum group was comparable to those found in the other studies (2.5%– 10%).[6] In our study, we have found decreased postoperative inflammation and decreased recurrence rate at both a 3- and 6-month time period with the use of fibrin glue compared with autologous serum.


  Conclusion Top


Fibrin glue is generally considered safe; however, since it is made from human plasma, it carries the risk of transmitting infectious agents such as parvovirus and prions.[4] Furthermore, anaphylactic reactions have been reported after the use of tissue adhesive agents. The overall cost burden was lesser in autologous serum cases than in the fibrin glue cases since synthetic glue is costly. There was marked reduction in the operating time in fibrin glue group as compared with the autologous blood group. Cost of the surgery was more with fibrin glue. The graft edema, graft loss, graft retraction, and displacement of the graft were more with the use of fibrin glue. However, the difference was not statistically significant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-70.   Back to cited text no. 1
    
2.
Thompson DF, Letassy NA, Thompson GD. Fibrin glue: A review of its preparation, efficacy, and adverse effects as a topical hemostat. Drug Intell Clin Pharm 1988;22:946-52.  Back to cited text no. 2
    
3.
Anguria P, Kitinya J, Ntuli S, Carmichael T. The role of heredity in pterygium development. Int J Ophthalmol 2014;7:563-73.  Back to cited text no. 3
    
4.
Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-70.  Back to cited text no. 4
    
5.
Koranyi G, Seregard S, Kopp ED. The cut-and-paste method for primary pterygium surgery: Long-term follow-up. Acta Ophthalmol Scand 2005;83:298-301.  Back to cited text no. 5
    
6.
Sharma MK. Sutureless and glue free limbal conjunctival auto graft for primary pterygium surgery. Nepal J Ophthalmol 2013;5:139-40.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]


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