|Year : 2022 | Volume
| Issue : 2 | Page : 137-143
Comparative study of sutureless and glue-free versus conjunctival autograft with sutures in primary pterygium surgery
K Jipina, NV Latha, Sikha Radhakrishnan, KK Praveena, AV Asha
Department of Ophthalmology, Government Medical College, Kannur, Kerala, India
|Date of Submission||03-Apr-2021|
|Date of Decision||14-Apr-2021|
|Date of Acceptance||21-Apr-2021|
|Date of Web Publication||30-Aug-2022|
Dr. K Jipina
Department of Ophthalmology, Government Medical College, Kannur - 670 503, Kerala
Source of Support: None, Conflict of Interest: None
Context: Sutureless glue-less surgery (SGF) is a newer alternative to the conventional conjunctival autograft with sutures (CAGS) techniques used for pterygium surgery. Aims and Objectives: To compare the safety, efficacy, and complications of SGF technique versus CAGS in the management of primary pterygium. Subjects and Methods: We performed a hospital based prospective study among 46 patients who underwent pterygium excision during an 18-month period from 2017 to 2018. Results: The duration of SGF procedure was <15 min with fewer incidences of overall symptoms postoperatively (P < 0.001) which were significantly higher in the CAGS group. The duration of symptoms was 4 days for SGF and 4 weeks for CAGS group. Although signs like graft edema and retraction were more in the SGF group in the immediate postoperative period, it resolved by 6 weeks. Three cases of recurrence were noted in the SGF group, but this was statistically insignificant. No graft loss occurred. Paired t-test showed that there is a significant reduction in astigmatism and improvement in keratometric values in both groups, with greater change in SGF group, however, this was not statistically significant. Conclusion: Sutureless and glue-free technique is a safe, effective, time-saving, and economical option for the management of pterygium with less postoperative symptoms. SGF has more postoperative signs which resolved in 6 months. The recurrence rate was higher in SGF but within the expected range reported in the literature.
Keywords: Astigmatism, conjunctival autograft with sutures, graft uptake, pterygium surgery, sutureless and glue free
|How to cite this article:|
Jipina K, Latha N V, Radhakrishnan S, Praveena K K, Asha A V. Comparative study of sutureless and glue-free versus conjunctival autograft with sutures in primary pterygium surgery. Kerala J Ophthalmol 2022;34:137-43
|How to cite this URL:|
Jipina K, Latha N V, Radhakrishnan S, Praveena K K, Asha A V. Comparative study of sutureless and glue-free versus conjunctival autograft with sutures in primary pterygium surgery. Kerala J Ophthalmol [serial online] 2022 [cited 2022 Dec 4];34:137-43. Available from: http://www.kjophthal.com/text.asp?2022/34/2/137/355051
| Introduction|| |
Pterygium is a “wing-like” growth consisting of conjunctival epithelium and hypertrophied subconjunctival connective tissue. Symptoms range from ocular surface irritation to decreased vision from astigmatism and visual axis obscuration.
There are many treatment methods currently in practice, both surgical and medical. Failure in treatment is often due to our lack of understanding of real pathogenesis, and its propensity for recurrence.
The conventional methods of sutured or glue fixation of autograft has complications and there is a trend towards use of sutureless and glue-free (SGF) grafting. Therefore, a comparative study would throw light on the two techniques, comparing their merits and demerits.
| Subjects and Methods|| |
Ours was a prospective study of 48 patients who had attended the outpatient department of ophthalmology during an 18-month period. This included subjects undergoing pterygium excision from our college. Patient inclusion criteria were aged <18 years of either sex, unilateral and primary pterygium. Those with pseudopterygium, ocular surface infections, history of pterygium surgery, any bleeding abnormalities and anti-coagulant therapy were excluded from the study.
Approval for study protocol was granted by the Hospital Institutional Review Board comprising of Ethical and Research Committee. Written informed consent was obtained from all the patients.
Consecutive patients were selected, detailed demographics and ocular evaluation were recorded. Type of pterygium, location, size, and extent onto the cornea were noted. Other significant ocular history and examination findings were also recorded (i.e., visual acuity assessment, retinoscopy, refraction, keratometry, and fundus examination). Blood pressure and random blood sugar were also checked prior to surgery.
Two surgeons at the study institute performed the SGF techniques based on their experience and expertise while the remaining surgeons performed conjunctival autografts with sutures (CAGS).
Relevant intraoperative data collected included technique of surgery, type of conjunctival autografting, number of sutures, suture material used, and duration of surgery.
Postoperative follow-up was done at Day 1, Week 1, 1-month, and 6-months. Patient's comfort level, symptoms if any, visual acuity and keratometric values were recorded. Slit-lamp examination to assess for subconjunctival hemorrhage, graft stability, graft uptake, graft retraction, corneal surface, and donor area was done. All these parameters along with refraction, keratometric values, and recurrence of the pterygium were recorded at 1-month and 6 months. Further, appropriate statistical method was used to analyze the collected data.
Surgical technique was systematically followed in all cases under strict aseptic precautions. The eye was thoroughly cleaned and draped. Povidone-iodine 5% eye drops were instilled in the conjunctival sac and washed. All surgeries were done under topical anesthesia with lignocaine 4%. Eye speculum placed. Pterygium was dissected from cornea with No. 15 Bard-Parker blade then separated from underlying sclera and excised. Remaining subconjunctival degenerative part of pterygium was excised with Westcott scissor. Corneal and limbal surfaces were smoothed by scraping using Tooke's knife or Bard-Parker blade. Cautery was avoided. The bare scleral area was measured with Castroviejo calipers. For harvesting conjunctival autograft, the eyeball was rotated down and in. The calipers were dipped in trypan blue dye and an area measuring 1 mm greater than the bare sclera was demarcated. In superotemporal bulbar conjunctiva 1cc of the local anesthetic, lignocaine was injected to facilitate separation of conjunctiva from Tenon's capsule. Blunt dissection of the conjunctiva was carried out using Westcott scissors. Autograft was cut and gently slid into place over the bare sclera in its correct anatomical orientation.
For patients in the CAGS group, four interrupted sutures were used at all four corners of the graft with 10-0 nylon. If the graft was long, 1–2 more sutures were applied. In SGF group, no suture was used. Hemostasis was allowed to occur spontaneously without cautery to provide autologous fibrin to glue the graft naturally in position. Ironing of graft was done with iris repositor. After making host conjunctiva as envelop, graft was placed beneath it. Scleral bed was viewed through transparent conjunctiva to ensure residual bleeding does not relift the graft. The patient was then asked to adduct or abduct his/her eye to see whether the graft remained in place with ocular movements. If adherence was satisfactory, speculum was removed carefully. Eye was patched for 24 h.
Postoperatively, patients were given antibiotic steroid combination of moxifloxacin and dexamethasone eye drops (six times for 1st week and then in tapering doses over 1 month) and lubricating eye drops (0.5% carboxy methyl cellulose sodium eye drop four times a day for 1 week in SGF cases and for 1 month in CAGS cases). Patients were instructed to avoid rubbing their eyes. Postoperatively, all patients were asked to come for follow-up at Day 1, Week 1, 1-month and V6-months for evaluating graft apposition, keratometry and recurrence. Sutures were removed after 1 month.
The primary outcomes of interest were postoperative discomforts like pain, foreign body sensation, photophobia, and signs such as hyperemia, chemosis, graft dehiscence, graft retraction, or graft loss. The secondary outcomes of interest included the duration of surgery and postoperative complications.
Descriptive statistical tools (frequency, percentage, mean, Standard deviation [SD]) and Inferential statistical tools (t-test, Chi-square test, analysis of variance) were used. SPSS version 24 (SPSS Inc., Chicago, IL, USA) was used to analyze the data. P < 0.05 was considered statistically significant. Paired and independent t-test were used to compare the outcomes.
| Results|| |
Forty-eight patients were initially enlisted out of which two did not meet the inclusion criteria. A total of 46 patients were selected for the purpose of this study.
Patients belonged predominantly to the age group of 61–80 years, (mean ± SD; 60.58 ± 12.8). Mean age in SGF group was 57.35 years and in the CAGS group was 64.7 years. Lower and upper limits for age were 23 years and 86 years, respectively.
We noted a female predominance 27 (59%), of which 18 belonged to SGF group and 9 to CAGS group. Male patients were 19 (41%), of which 7 belonged to SGF group and 12 to CAGS group. Surgical techniques used were SGF in 25 (54%) cases and CAGS in 21 cases (46%).
Pterygia were predominantly on the nasal region, 37 cases (80%) and rest 9 cases (20%) on the temporal region. Of these nasal pterygia, 21 were excised and autografted by SGF technique and 16 underwent CAGS; of the temporal pterygia, 4 had SGF technique and 5 had CAGS technique.
Of the 25 cases in the SGF group, 12 pterygia were encroaching upto one-third of the area of the cornea between limbus and pupillary margin; 12 between one-third and two-third of the area and one crossed the pupillary margin. Of the 21 cases in the CAGS group, 11 pterygia were encroaching up to one-third of the area of the cornea between limbus and pupillary margin; 10 between one-third and two-third of the area and none crossed the pupillary margin.
The duration of SGF procedure was less compared to CAGS technique [Table 1].
The only postoperative symptom noted in the SGF group was redness while a significant number of CAGS cases had other symptoms like foreign body sensation and epiphora [Figure 1]. Further, patients underwent through postoperative slit-lamp examination at each follow-up [Figure 2] and [Table 2].
There was a significant reduction in astigmatism and improvement in keratometric values in both the groups; but was more in the SGF group, however, this was not statistically significant [Figure 3], [Figure 4] and [Table 3], [Table 4].
|Figure 3: Trend of keratometry and astigmatism following sutureless and glue-free procedure|
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|Table 3: Independent t-test analysis comparing outcomes of keratometry and astigmatism in conjunctival autografts with sutures and sutureless glue-free procedure|
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|Table 4: Paired t-test analysis of keratometry and astigmatism in sutureless glue-free and conjunctival autografts with sutures procedure|
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Final graft uptake was satisfactory in both the groups [Figure 5] and [Figure 6].
|Figure 5: LE–Pod1 photograph showing good graft apposition following sutureless and glue-free conjunctival autografting|
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|Figure 6: LE–Pow1 photograph of the same patient showing good graft uptake|
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The postoperative astigmatism did not differ significantly between the two surgical groups at follow up on day 1 (P = 0.410), week 1 (P = 0.923), and 1 month (P = 0.736) and 6 months (P = 0.618).
| Discussion|| |
Conventional surgical procedures have favorable outcomes. Surgeons however are exploring various alternatives that can further reduce postoperative discomfort and recurrence. Limbal conjunctival autograft has a low recurrence and complication rate, but is more technically demanding, complex, time-consuming and can result in limbal stem cell deficiency of the donor site.,
Symptoms such as foreign body sensation, redness, and epiphora were much less in sutureless glue-free group as compared to CAGS group. The severity of symptoms was maximum at the first postoperative day for both the groups; this lasted up to 4 days in the SGF group compared to 4 weeks in CAGS group.
Natung et al. and various authors. had similar observations in his study.,,
Ashok et al. reported postoperative symptoms in 5 (20%) patients in SGF group and 20 (80%) patients in sutured group. We noted results similar to Elwan who showed that postoperative signs and symptoms were significantly lower in the first postoperative month as well as significantly higher overall patient satisfaction in sutureless compared to sutured autograft.
Graft edema was reported more in the SGF group in the immediate postoperative period [Figure 7]. This may be because advanced pterygia were noted more in the SGF group. Edema resolved between 1 and 6 weeks' period [Figure 8]. This is consistent with a previous study that reported 16% edema in the sutureless glue-free group and 6% edema in the sutured group respectively. Sharma et al. also reported graft edema in 2 (8%) eyes in SGF group and 3 (12%) eyes in sutured group which resolved after 1 week.
|Figure 7: LE–Pod1 photograph showing mild graft edema following sutureless and glue-free procedure|
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|Figure 8: LE–Pom 1 photograph showing resolved graft edema and good graft uptake|
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There was slight graft retraction in the area away from the limbal margin in few cases of SGF and one case in CAGS group. Overall, no cases of graft loss occurred. No active intervention was instituted and the exposed area epithelialized adequately on follow-up without compromising surgical or cosmetic results. The donor site also re-epithelialized completely within few days after surgery. In the study by Natung et al., graft stability was better in sutured group Boucher et al., reported 15% graft loss in the sutureless glue-free group. We found similar results with graft retraction more common in the SGF group. In Dr. Mitra's study of 19 patients, two patients experienced a medial edge recession.
In our study, we noted 3 cases (6.8%) of recurrence which occurred in the SGF group within 6 months after surgery; but it was statistically insignificant in terms of method of autografting. The recurrence rate in our study is consistent with previous studies that have reported recurrence rates from 16% to 39% in high-risk populations and 2.5%–10% in all grades of pterygium.,
Natung et al. reported that at 6 months, 4 (26.6%) patients in SGF group had recurrence whereas, in the sutured group, five patients (33.3%) had recurrence, the difference of which again was not statistically significant (P = 0.446). Choudhury et al. and Sati et al., also found equal recurrence rate in their studies., As per their study, sutures do not incite more inflammation than the nonsuture groups as postoperative steroids take care of the postoperative inflammation. According to them it is the barrier effect of conjunctival autograft that plays an important role in preventing recurrences. Therefore, comparing a suture group with in situ blood coagulum group is justified. Meanwhile de Wit et al., reported no recurrence in 15 eyes within a mean follow up period of 9.2 months.
Analysis shows that there is a significant reduction in astigmatism and improvement in keratometric values in both SGF and CAGS groups. However, in our study, the reduction is more in the SGF group, but it was not statistically significant.
Altan-Yaycioglu et al. in his study found out that there is a significant correlation between the pre and postoperative astigmatic values (ρ = 0.351). Some studies show no correlation between these two parameters., Similar to our results, Wu et al. identified significant correlation between differences in refractive cylindrical power before and after surgery.
There are only limited studies comparing the effect of different surgical approaches on astigmatism. Yilmaz et al. compared astigmatic changes following different types of surgeries including conjunctival autografting, limbal-conjunctival autograft, baresclera and baresclera with mitomycin. The authors found a statistical difference between groups for mean topographical astigmatism and surgically-induced astigmatism (P = 0.033 and 0.030, respectively).
Fibrin glue is effective to attach the conjunctival autograft in pterygium surgeries,,, but has the risk of transmission of human infection of parvovirus B19 and hepatitis b virus,, is costly and cannot be afforded by patients from poor socio-economic status. Autologous blood has advantages in that the procedure is easy to perform with shorter duration, less overall discomfort and economical for the patient and the disadvantage is uncertainty about graft retention, position, and loss which is comparatively rare.
There are several limitations to our study that limit generalization to a larger population. The follow-up period is short and a longer follow-up period of a year or more may help us understand the long-term sequelae and performance of the graft. The study was not a randomized intervention trial and patient groups were determined by the experience of the surgeon in performing the procedure. Further studies with a larger sample size, longer duration of follow up and the use of medications like mitomycin C will give further insight into the management of pterygium.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Duke-Elder S, Leigh AG. In: Duke-Elder S, editor. System of Ophthalmology. Vol. 8. London: Henry Kimpton Publishers; 1965. p. 573-85.
Luthra R, Nemesure BB, Wu SY, Xie SH, Leske MC, Barbados Eye Studies Group. Frequency and risk factors for pterygium in the Barbados eye study. Arch Ophthalmol 2001;119:1827-32.
Lu P, Chen X, Kang Y, Ke L, Wei X, Zhang W. Pterygium in tibetans: A population-based study in China. Clin Exp Ophthalmol 2007;35:828-33.
Natung T, Keditsu A, Shullai W, Goswami PK. Sutureless, glue-less conjunctival autograft versus conjunctival autograft with sutures for primary, advanced pterygia: An interventional pilot study. J Clin Diagn Res 2017;11:C04-7.
Rangu RV, Wanjari A, Akhade N. Study of sutureless and glue-free conjunctivalautograft. Int J Recent Trends Sci Technol 2014;10:480-82.
Mishra S, Mayuri B, Panigrahi D. Role of serum assisted conjunctival autograft in the management of primary pterygium. J Evol Med Dent Sci 2017;6:3371-5.
Ashok S, Hans R, Vikram RA. Suture less and glue free limbal conjunctival autografting following pterygium excision. JK Sci J Med Educ Res 2015;17:68-71.
Elwan SA. Comparison between sutureless and glue free versus sutured limbal conjunctival autograft in primary pterygium surgery. Saudi J Ophthalmol 2014;28:292-8.
Boucher S, Conlon R, Teja S, Teichman JC, Yeung S, Ziai S, et al.
Fibrin glue versus autologous blood for conjunctival autograft fixation in pterygium surgery. Can J Ophthalmol 2015;50:269-72.
Mitra S. Autoblood as Tissue Adhesive or Conjunctivalautograft Fixation in Pterygium Surgery. Poster Presented at the Annual Meeting of the American Academy of Ophthalmology. Orlando, FL; October 22nd
Chen PP, Ariyasu RG, Kaza V, LaBree LD, McDonnell PJ. A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium. Am J Ophthalmol 1995;120:151-60.
Manning CA, Kloess PM, Diaz MD, Yee RW. Intraoperative mitomycin in primary pterygium excision. Ophthalmology 1997;104:844-48.
Choudhury S, Dutta J, Mukhopadhyay S, Basu R, Bera S, Savale S, et al.
Comparison of autologous in situ
blood coagulum versus sutures for conjunctival auto grafting after pterygium excision. Int Ophthalmol 2014;34:41-8.
Sati A, Shankar S, Jha A, Kalra D, Mishra S, Gurunadh VS. Comparison of efficacy of three surgical methods of conjunctival autograft fixation in the treatment of pterygium. Int Ophthalmol 2014;34:1233-9.
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.
Altan-Yaycioglu R, Kucukerdonmez C, Karalezli A, Corak F, Akova YA. Astigmatic changes following pterygium removal: Comparison of 5 different methods. Indian J Ophthalmol 2013;61:104-8.
] [Full text]
Errais K, Bouden J, Mili-Boussen I, Anane R, Beltaif O, Meddeb Ouertani A. Effect of pterygium surgery on corneal topography. Eur J Ophthalmol 2008;18:177-81.
Bahar I, Loya N, Weinberger D, Avisar R. Effect of pterygium surgery on corneal topography: A prospective study. Cornea 2004;23:113-7.
Wu PL, Kuo CN, Hsu HL, Lai CH. Effect of pterygium surgery on refractive spherocylinder power and corneal topography. Ophthalmic Surg Lasers Imaging 2009;40:32-7.
Yilmaz S, Yuksel T, Maden A. Corneal topographic changes after four types of pterygium surgery. J Refract Surg 2008;24:160-5.
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.
Bahar I, Weinberger D, Dan G, Avisar R. Pterygium surgery: Fibrin glue versus Vicryl sutures for conjunctival closure. Cornea 2006;25:1168-72.
Cagatay HH, Gokce G, Ekinci M, Koban Y, Daraman O, Ceylan E. Long-term comparison of fibrin tissue glue and vicryl suture in conjunctival autografting for pterygium surgery. Postgrad Med 2014;126:97-103.
Hino M, Ishiko O, Honda KI, Yamane T, Ohta K, Takubo T, et al.
Transmission of symptomatic parvovirus B19 infection by fibrin sealant used during surgery. Br J Haematol 2000;108:194-5.
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.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3], [Table 4]