Clinical Outcome of Fibrin Glue versus Sutures in Conjunctival Autografts in Patients Undergoing Pterygium Excision - A Prospective Study from Kalaburagi, Karnataka

BACKGROUND Pterygium removal is prone for recurrence. Use of conjunctival autografting is considered the most suitable approach that can lower the recurrence. Traditionally, the conjunctival autograft (CAG) is attached to the sclera by suturing. Recently fibrin glue has been used as an alternative to suturing. Advantages being shortened operating time, improved postoperative comfort and absence of suture related complications. Fibrin glue (Baxter TISSEEL kit) is a biological tissue which has a fibrinogen component and a thrombin component prepared by processing plasma. On activation of human fibrinogen by thrombin it imitates the final stage of the coagulation cascade and acts as a tissue adhesive. Fibrin glue is absorbable, relatively easy to use and can be kept at room temperature or in a refrigerator. We wanted to compare the postoperative outcomes in patients undergoing pterygium surgery with conjunctival autografting using fibrin glue (fibrin glue group) in comparison to suturing with 10 - 0 nylon (suture group). METHODS This was a prospective study carried out at M.R. Medical College, Kalaburgi, in the Department of Ophthalmology. Patients with pterygium were enrolled into the study after taking informed and written consent. Clinical grading of pterygium was done as Grade 1 - < 2 mm onto cornea, Grade 2 – 2 to 4 mm onto the cornea, Grade 3 - > 4 mm onto the cornea. 100 subjects were randomly divided into 2 groups of 50 patients each undergoing pterygium surgery between Nov 2018 and Oct 2019. Group 1: Conjunctival autograft with 10 0 nylon suture. Group 2: Conjunctival autograft with fibrin glue. A post-operative comfort scale was used to assess pain, foreign body sensation and lacrimation. These patients were followed up on postoperative day 1, one week, 1 month for postoperative signs and symptoms and 6 months for any recurrence of pterygium. RESULTS Patients in the fibrin glue group experienced significantly less pain, foreign body sensation and lacrimation on day-one, 1 week and at 1 month after surgery, compared to those in the suture group. Other complications like graft oedema, graft retraction, corneal scarring, sub graft haemorrhage were noted in both the groups. At the end of 6 months follow up, no recurrence was noticed in both the groups. CONCLUSIONS The use of fibrin glue for attaching autografts in pterygium surgery is an effective method with global autograft success, less post-operative discomfort like pain, foreign body sensation, lacrimation and less chance of recurrence. KEYWORDS Pterygium, Conjunctival Autograft, Suture, Fibrin Glue

Evaluation of changes in the keratometric values after pterygium excision with conjunctival autografting in different grades of pterygium

To study the changes in keratometric values after pterygium excision with conjunctival autograft in different grades of pterygium. A retrospective, comparative study was done on 75 patients of various grades of pterygium who underwent excision surgery with conjunctival autograft. Preoperative and postoperative details of all the patients on 1, 7 and 30 day were taken into account including detailed ocular examination, best-corrected visual acuity, slit-lamp biomicroscopic examination, keratometric details and posterior segment examination. Net astigmatism was calculated preoperatively and on post-op examinations. Mean of difference in preoperative and post operative net astigmatism is calculated and compared in different grades of pterygium. Our study showed that there are significant changes in net astigmatism after pterygium excision mainly in grade 3 pterygium. Difference in mean net astigmatism at the end of 1 month from preoperative values was 2.39±0.73 in Group C, 1.45±0.5 in Group B and 0.49±0.24 in group C and this difference is significant. The amount of keratometric astigmatism is proportional to grades of pterygium (size of pterygium) and pterygium excision reduces the induced astigmatism and it varies according to grades.

Treatment of Mooren’s ulcer coexisting with a pterygium using an intrastromal lenticule obtained from small-incision lenticule extraction: case report and literature review

The coexistence of Mooren’s ulcer and a pterygium is an extremely rare ocular condition that has been infrequently reported in the literature to date. We herein present the first case of treatment of Mooren’s ulcer coexisting with a pterygium using a lenticule obtained by myopic small-incision lenticule extraction (SMILE). A 61-year-old woman presented with a 3-month history of recurrent ocular pain and red eye caused by Mooren’s ulcer coexisting with a pterygium. She received topical immunosuppressive and anti-infection treatments for almost 3 months. However, her ocular symptoms and signs did not substantially improve. Therefore, we performed lamellar keratoplasty with a corneal lenticule obtained by SMILE, followed by pterygium excision combined with conjunctival autografting. The patient recovered well with no complications or recurrence 1 year postoperatively. Our success suggests that combined surgery may be an effective management for coexistence of Mooren’s ulcer and a pterygium if conservative treatments fail. A corneal lenticule obtained by SMILE can be used as the lamellar keratoplasty graft in such patients.

Characteristics and recurrence of pterygium in Saudi Arabia: a single center study with a long follow‐up

Background This study described the clinical features of patients with pterygium and analyzed the recurrence rate of conjunctival autografting alone, conjunctival autografting combined with intraoperative mitomycin C, and amniotic membrane grafting. Methods A retrospective cohort study of primary pterygium was conducted between January 2017 and February 2020. Factors associated with pterygium severity and recurrence were analyzed by univariate analysis and logistic regression models. Results The study included 292 patients with an average age of 53.3 ± 14.1 years, while the number of operated cases was 94. Pterygia involving the cornea were observed in 55 % of the cases. The overall rate of recurrence for the three procedures was 17 %. The average time of recurrence was 14.2 ± 11.9 months, with 37 % of the recurrences occurring after the first year. The only factor associated with a significant risk of recurrence was dry eye disease in both univariate (p = 0.021) and multivariate analysis (p = 0.026). The recurrence rates following conjunctival autografting with and without mitomycin C were 15.6 and 15.8 %, respectively. The recurrence rate following the amniotic membrane graft was twofold (OR= 2.02) (27 %) that following the conjunctival autograft (15.8 %). Conclusions The only factor associated with the recurrence of pterygium was dry eye disease. More than one-third of recurrences developed after the first year, which stresses the importance of a long follow-up. The recurrence rate in our study following conjunctival graft was slightly higher compared to the literature mainly due to differences in study areas, populations, and follow-up periods.

A COMPARATIVE STUDY TO EVALUATE THE OUTCOME OF SUTURES VERSUS FIBRIN GLUE IN CONJUNCTIVAL AUTOGRAFT TECHNIQUE FOR PRIMARY PTERYGIUM EXCISION

Background: Pterygium is degenerative condition of the subconjunctival tissue which proliferates as vascularized granulation tissue and is characterized by formation of a triangular fold of conjunctiva encroaching on the cornea leading to visual impairment, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence can be a problem. Now, Fibrin glue is being tried since few years to secure grafts in place of the sutures. The objective of this study was to compare duration of surgery, immediate postoperative complications which includes an inflammation, subconjunctival hemorrhage, patient comfort, graft stability between the uses of fibrin glue versus sutures. Methods: A total of 40 patients having primary pterygium were included in the study. 20 patients were underwent pterygium excision surgery and conjunctival autografting using absorbable vicryl 8-0 suture and 20 patients underwent pterygium excision surgery and conjunctival autografting using fibrin glue. These 2 groups were compared in terms of duration of the surgery, inflammation, degree of postoperative discomfort, subconjunctival haemorrhage and graft stability at postoperative day 1. Results: The mean surgery time in fibrin glue group was 15 minutes and mean surgery time in suture group was 28 minutes (p=0.000). Fibrin glue group had significantly lesser inflammation (p=0.001) as well as postoperative discomfort (p=0.000) compared to suture group at postoperative day 1. There was no significant difference found in the degree of subconjunctival haemorrhage between the fibrin glue versus sutures groups (p=0.887 and p=0.797 at day 1). The grafts secured with fibrin glue were as stable as those secured with the sutures (p=0.745, 0.644 at day 1). Conclusion: The fibrin glue group in conjuctival autografting had significantly less surgery time, which also produces significantly less postoperative discomfort as well as inflammation with grafts being as stable as those secured with sutures. Fibrin glue can be used regularly if patients can be pooled together and operated on, by making it cost effective procedure.

Evaluation of Conjunctival Autografting Augmented with Mitomycin C Application versus Ologen Implantation in the Surgical Treatment of Recurrent Pterygium

Objectives. To evaluate the safety and efficacy of augmenting conjunctival autografting with intraoperative mitomycin C (MMC) application versus Ologen implantation in the management of recurrent pterygium. Materials and Methods. This prospective randomised study included 63 eyes of 63 patients, with recurrent nasal pterygium, who presented to the outpatient clinic of Menoufia University Hospital in Shebin El Kom and Manshiet Soltan from January 2016 to December 2019. Patients were randomly enrolled into two groups. Group A included 32 eyes of 32 patients who underwent conjunctival autografting augmented with the topical application of MMC (0.2 mg/mL), and group B included 31 eyes of 31 patients who underwent conjunctival autografting augmented with Ologen implantation. All the patients underwent follow-up examinations for a period of 24 months. During each visit, a complete ophthalmic examination was performed. Pterygium regrowth of 1 mm or more, over the cornea, was considered a recurrence. Results. In the MMC group, no recurrence was reported during the 24-month follow-up period. In the Ologen implantation group, recurrence was reported in 2 (8%) eyes. The time interval from surgery to recurrence was 5 months in one case and 8 months in the other. No other serious postoperative complications were reported, and there was no statistically significant difference between the groups in this regard. Conclusion. Ologen implantation with conjunctival autografting shows promising results in the surgical management of recurrent pterygium with mild non-vision-threatening postoperative complications comparable to that of MMC application with conjunctival autografting. Registration number: ClinicalTrials.govNCT04419038.

TUCK IN CONJUNCTIVALAUTOGRAFTING WITH IN SITU LIMBAL STEM CELL TRANSPLANTATION IN CASE OF RECURRENT PTERYGIUM IN CENTRAL INDIA

AIM: To report outcome and recurrence with Tuck in conjunctival autografting with in situ limbal stem cell transplantation in case of recurrent pterygium in central India where cost is a limiting factor in use of any sutures, Amniotic membrane, Fibrin glue, Mitomycin or Avastin. METHODS: A randomized, non-comparative interventional and prospective clinical study was carried out on 50 patients of recurrent nasal and temporal pterygium at MGM Medical college and Hospital, Jamshedpur from August 2019 to September 2020. Patients with cystic atrophic and Inflamed pterygium, pseudo pterygium, other ocular disorders like Sjogren’s syndrome, blood clotting disorders, glaucoma medication, stents or filtering bleb were excluded from the study. RESULTS: Mean age was32.2 years. Mean follow up was 12.2 months. Outcome measures were cosmetic satisfaction, recurrence rate, graft edema, graft dislocation, graft failure and loss of graft. CONCLUSION: Pterygium being a local limbal stem cell deficiency , its surgical treatment by replenishment of limbal stem cells by tuck in conjunctival autografting with in situ limbal stem cell transplantation is a viable option In cases of recurrent pterygium and is a cheap alternative alleviating need of any sutures, tissue adhesive , antimitotic drugs ,anti VEGFS ,with a lesser intraoperative time, excellent cosmetic result and low recurrence rate.

Outcome Of The Use Of Autologous Blood Serum, Fibrin Glue And Vicryl Suture In Conjunctival Autograft Transplant Following Pterygium Surgery.

Background: Pterygium is a common ophthalmological problem in India. Excision of pterygium with conjunctival autograft is the main line of treatment. Many modifications of surgical techniques have been tried like conjunctival autografting with fibrin glue, sutures and autologous serum. All these modalities have their pros and cons. We compared these techniques for conjunctival autografting following pterygium surgery. Methods: A randomized interventional study was performed on 60 eyes with primary nasal pterygium. After pterygium excision, the bare sclera was covered with a conjunctival autograft, which was fixed using autologous blood serum(in Group A, n=20), fibrin glue(in Group B, n=20) and vicryl suture (8-0) (in Group C, n=20). The patients were examined on postoperative Day 1, 1 week, 1month, 3 month and 6 month. The main outcome measures were operative time ,autograft stability, postoperative discomfort, autograft thicknes, pterygium recurrence and granuloma formation. Results: The mean operative time was significantly shorter in group A(23.60 min) followed by Group B (25.20 min) and Group C(28.15 min)(p-value <0.0001).Postoperative discomfort measured on visual analogue scale was minimal in fibrin group (p-value=0.0008) and maximum in suture group. Graft displacement was found in 2(10%) patient in autologous blood group (p value=0.349) while Graft oedema, granuloma & recurrence was noted in suture group only(p value=0.362). Conclusions: The conjunctival autografting with fibrin glue proved to be better method than autologous serum and suture, as it had very less postoperative discomfort, no recurrence, minimal edema and less graft displacement.