Pterygium Surgery with Conjunctival Autograft(CAG)- No glue, no stitch technique

Gyan Bhaskar; Anita Ambastha; Bibhuti P Sinha; MS Ali; Piyush Kumar; Rajnee Sinha

ORIGINAL ARTICLE

Year : 2019 | Volume : 5 | Issue : 2 | Page : 155-157

Pterygium Surgery with Conjunctival Autograft(CAG)- No glue, no stitch technique

Gyan Bhaskar¹, Anita Ambastha², Bibhuti P Sinha³, MS Ali², Piyush Kumar⁴, Rajnee Sinha⁵
¹ Additional Professor, Regional Institute of Ophthalmology, IGIMS, Patna, Bihar, India
² Associate Professor, Regional Institute of Ophthalmology, IGIMS, Patna, Bihar, India
³ Professor, Regional Institute of Ophthalmology, IGIMS, Patna, Bihar, India
⁴ Senior Resident, Regional Institute of Ophthalmology, IGIMS, Patna, Bihar, India
⁵ Junior Resident, Regional Institute of Ophthalmology, IGIMS, Patna, Bihar, India

Date of Submission	04-Jun-2019
Date of Acceptance	17-Jul-2019
Date of Web Publication	12-Aug-2019

Correspondence Address:
M S Ali
Associate Professor, Regional Institute of Ophthalmology, IGIMS, Patna-800014, Bihar
India

Source of Support: None, Conflict of Interest: None

Abstract

Introduction :
Suturesare used to fixed the graft in pterygium surgery not only time-consuming process but also lead to local complications such as discomfort, scarring, granuloma formation, or infection. A Plasma-derived products fibrin glue may produce possible hypersensitivity reactions, post-operative foreign body sensation. In this study a simple method was described for achieving conjunctival autograft adherence during pterygium surgeryusing autologous blood as a bio -adhesive to avoid potential complications associated with the use of fibrin glue or sutures. Aim of this study was to know the outcome of pterygium surgery with limbal conjunctival autograft without sutures or fibrin glue.
Material and methods:
It was a prospective interventional study on 40 eyes of 40 patients who presented with primary pterygium to our outpatient department fulfilling the inclusion and exclusion criteria.Post-operative Examination done on Day- 1, end of 1st,2ndand 4th week then after 3rd and 6thmonth. On each visit assessment was done for Graft displacement, Retraction, Inflammatory reaction,Graft failure, Discomfort, Recurrenceand Success rate was assessed.Data was collected and analysed.
Results :
Outof 40 patients, age of patients ranges from 15 to 73years, male was 30 and female pt. was 10 and right eye was involved in 24 cases and left eye in 16 cases. average surgical time was 18.50±2.00 min.successrate was 95%, one case had graft retraction and one had graft displacement.
Conclusion :
This is the simple technique for pterygium surgery with comparable success rate, cost effective, quick and also prevent potential adverse reactions encountered with the use of foreign materials.

Keywords: Autograft, glue, pterygium, limbal stem cell

How to cite this article:
Bhaskar G, Ambastha A, Sinha BP, Ali M S, Kumar P, Sinha R. Pterygium Surgery with Conjunctival Autograft(CAG)- No glue, no stitch technique. J Indira Gandhi Inst Med Sci 2019;5:155-7

How to cite this URL:
Bhaskar G, Ambastha A, Sinha BP, Ali M S, Kumar P, Sinha R. Pterygium Surgery with Conjunctival Autograft(CAG)- No glue, no stitch technique. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2023 Mar 27];5:155-7. Available from: http://www.jigims.co.in/text.asp?2019/5/2/155/301102

Introduction :

Since the days of Susruta, pterygia have been recognized as triangular sheet of fibro vascular tissue that appears on the epibulbar conjunctiva and cornea. Disturbing both, thepatient because of their unsightly appearance and the surgeon because of their tendency to recur. Successful management of pterygium is a constant challenge for ophthalmologists due to high recurrence rate and sight threatening complications of different surgical techniques, provoke to look for new and safer modalities of treatment.

In 1985, Kenyon et al.^[1] was reported that a conjunctival autograft was used to cover the bare sclera for the management of recurrent and advanced pterygium. the recurrence rate of pterygium surgery is varying between 2% and 39% which is depend on the surgeon’s skill and experience.^[1],[2] Sutures are used for fixation of graft, this technique has the disadvantage of a relatively longer surgical time and the risk of suture-related complications such as granuloma formation, giant papillary conjunctivitis as well as significant patient discomfort after surgery.

Fibrin-based adhesives are gaining importance because of its biological and biodegradable properties, and are used instead of sutures under conjunctiva without inducing inflammation. Tissue adhesives of different types had been used in various studies to attach conjunctival grafts and were associated with a shorter operative time and reduced postoperative complaints.^[3]

Pterygium excision with conjunctival autograft has yield good results because it maintains the conjunctival limbal cell and restores the anatomy which existed before the corneal invasion caused by the pterygium. Pterygium excision with autologous conjunctival grafting seems to be the best method, giving both low recurrence rate and high safety.^[4],[5] The recurrence in most cases is seen within 6 months but can sometimes occur later.^[6]

In this study limbal conjunctival autograft was used to cover the scleral bare area after excision of pterygium using Autologous blood as bio adhesive to fix the graft. Aimed to know the outcome of pterygium surgery with conjunctival autograft using autologous blood as a bio adhesive.

Material and Methods :

It was aprospective interventional study done on 40 eyes atregional institute of ophthalmology (RIO),IGIMS Patna from January 2012 to December 2013.Properhistory and preoperative evaluation weredone in all the patients.Size of pterygium was measured with slit lamp.

Inclusion criteria

Primary pterygium
Sizeof pterygium Up to? 4mm but not involving of visual axis

Exclusion Criteria

Suspected /known case glaucoma
Ocular surface disorders
Double pterygium
Pseudo pterygium
Patient on multiple medication
Patient is not willing to join the study
Pterygium involving the visual axis.
Recurrent pterygium

Informed and written consent were taken from all the patients and guardian. All surgery was performed under local anaesthesiaby same surgeon.

Procedure: Pterygium was dissected from corneal to scleral side using 15 No. BP blade&/or crescent blade to excise the corneal lamellae adjacent to the head of pterygium. Superficial keratectomy was done beneath the pterygium up to the limbus. Conjunctiva was dissected with tenon’s capsule and itwas excised completely. Sclera is scraped to remove all the tissue Then moderate haemostasis was obtained.Conjunctival auto graft was taken from supero-temporal part of same eye (.5mm) more as the size of dissected area [Figure 2]&[Figure 3]. Following complete removal of tenon’s from the graft and scleral bed, scleral vessels were prick by 26 G hypodermic needle for fresh bleeding over scleral bared areaand coagulum allowed to spread over it [Figure 3]. Conjunctival auto graft was deposited over the bared area and margin ofconjunctiva opposed to each other and waited for 5minutes [Figure 4] then pad and bandage was applied for 24 hours. Post-operative topical antibiotic and steroids was given for 15 days, caboxymethylcellulose 0.5% was applied for 21 days. oral analgesic was given as per requirement. Post-operative examination was done on day- 1, end of 1 ,2 & 4 Weeks then after 3rd & 6th month. On each visit, assessment was done for graft displacement, retraction, Inflammatory reaction, graft failure, discomfort and recurrence. Success rate was assessed by no recurrence of pterygium, no displacement of graft (Operation site is not different from the normal appearance).

Figure 1: pre-op.

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Figure 2: conjunctival graft and fresh blood,

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Figure 3: conjunctival graft and fresh blood,

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Figure 4: placement of graft

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Results :

Out of 40 patients, age of patients ranges from 15 to 73years, male was 30 and female pt. was 10 and right eye was involved in 24 cases and left eye in 16 cases. Average surgical time consumption was noted from insertion of wire speculum and removal of wire speculum with the help of stop watch. it was 18.50 ± 2.00 min.12 patient. had up to 2mm of pterygium, 20 pt. had,>2mm to 4mm, 8pt. had >4mm but not involving the visual axis. No intra operative complication was noted.Post-operative complication was noted at day-1 in two cases one had graft retraction and other had graft displacement [Table 1]. Success rate was observed 95%. Two failed cases are healed by bare sclera technique and further managed by amniotic membrane graft [Table 2].

Table 1 : Post-opera

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Table 2 : Failed case management (n=02)

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Discussion :

Blood thrombin acts on fibrinogen to remove four low molecular weight peptides from each molecule of fibrinogen leading to the forming one molecule of fibrin monomer. Fibrin monomer polymerized with other fibrin monomer molecule to form fibrin fibre that can constitute a reticulum of blood clot which acts as a bio adhesive. Onthese properties of blood, we decided to perform pterygium surgery without using suture or fibrin glue to fix the conjunctival graft tissue.

Inthis study, the suture less and glue less method was described to evaluate the patient’s discomfort, postoperative pain and surgical time, postoperative patching, healing time, restrictions in normal life and success rate after the surgery.

Soliman Mahdy MA^[7] reported the pterygium excision with conjunctival autograft, using interrupted 8-0 vicryl sutures with non-buried knots. Patients did experience moderate pain sensation with watering and itching with sutures. The presence of the sutures causes significantly more postoperative pain and irritation. This may be due to the sutures themselves and/or the inflammatory process around the sutures during degradation. Further study by Jagdish Bhatia et al^[8] reported using no glue and no suture technique instead of sutures for graft placement causing significantly less postoperative pain and discomfort and shortens surgery time significantly. It was also highly cost effective.

DeWit et al.^[9] reported no recurrence and no transplant dislocations in their study of 15 cases using no suture, no glue technique. Malik et al.[10] reported recurrence in one eye (2.5%) out of 40 cases and dehiscence in 2 cases. Rathi et al.[11] reported in their study of fifty cases, recurrence in one eye (2%) and graft loss in one eye (2%).

Although incidence of dehiscence is very low and almost similar in all studies including ours, recurrence rate is variable. Recurrence rate in our study is little higher (5%) as compared to studies done by Malik et al. (2.5%) and by Rathi et al. (1%), but is non-significant.

The cost of surgery is another very important factor. The cost of fibrin glue is quite high. Another problem is its availability. Fibrin glue is not easily available to various eye clinics. Thus, the material cost of the no glue and no suture method became significantly lower than that of the sutures or using fibrin glue. In addition, the time cost is significantly lower than that of with sutures.

Limitation :

Our study has limitation that it comprised a small study population of the designated area and shorter follow up period. not done in recurrent pterygium

Conclusion :

Noglue and no suture technique instead of sutures when attaching the conjunctival transplant in pterygium surgery causes significantly less postoperative pain and discomfort and shortens surgery time significantly. It is highly cost effective too.

Source of Funding: Self

Conflict of Interest: None

References

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