|Year : 2018 | Volume
| Issue : 1 | Page : 16-19
Sutureless and glue-free conjunctival autograft for pterygium surgery: A preliminary report about Libyan experience
Naeima M Elzlitni, Sabah S Eldressi, Samar A Bukhatwa
Department of Ophthalmology, Faculty of Medicine, University of Benghazi, Benghazi, Libya
|Date of Submission||03-Feb-2018|
|Date of Acceptance||19-Feb-2018|
|Date of Web Publication||05-Apr-2018|
Dr. Samar A Bukhatwa
Department of Ophthalmology, Faculty of Medicine, University of Benghazi, Benghazi
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to evaluate the efficacy and outcome of sutureless and glue-free conjunctival autograft for the management of primary pterygium in terms of complications such as loss of graft, graft dehiscence, and recurrence rate. Materials and Methods: A case series study was carried out in March 2015 at Nastaein private sanatorium, Zlitin, Libya. Twenty-seven eyes of 23 patients with primary pterygium were included in this study. Pterygium excision with conjunctival autografting without using sutures or glue was done to all patients. The patients were followed up postoperatively after 1 h, 1st day postoperatively, and then 1 week, 4 weeks, 3 months, 6 months, and 12 months. Results: The mean age of the patients was 55.9 ± 8.55 years (range: 43–71 years); 65% were male. Mean follow-up time was 10.2 ± 2 months. Changes of visual acuity were not noticed in any of these patients. Only one patient (3.7%) developed edge recession of the graft on the 1st postoperative day due to a wrong measurement of the size of the graft, and no other complications were noted. Cosmesis was excellent in all cases and no recurrence was noted. Conclusions: Sutureless and glue-free conjunctival autograft for primary pterygium surgery is a safe and effective way for the management of primary pterygium.
Keywords: Conjunctiva, pterygium, pterygium surgery, recurrence, sutureless and glue-free conjunctival autograft
|How to cite this article:|
Elzlitni NM, Eldressi SS, Bukhatwa SA. Sutureless and glue-free conjunctival autograft for pterygium surgery: A preliminary report about Libyan experience. Libyan Int Med Univ J 2018;3:16-9
|How to cite this URL:|
Elzlitni NM, Eldressi SS, Bukhatwa SA. Sutureless and glue-free conjunctival autograft for pterygium surgery: A preliminary report about Libyan experience. Libyan Int Med Univ J [serial online] 2018 [cited 2018 Apr 22];3:16-9. Available from: http://journal.limu.edu.ly/text.asp?2018/3/1/16/229384
| Introduction|| |
A pterygium is a triangular fibrovascular subepithelial growth of degenerative bulbar conjunctival tissue over the limbus onto the cornea. Initially, the symptoms of irritation and redness can be controlled by lubricant eye drops, but when vision is affected by pterygium growth and astigmatism, surgery is considered.
Pterygium surgery has changed significantly over time. Previous surgical procedures for the management of pterygium include bare scleral closure and simple conjunctival closure, which are simple and time-saving procedures but have a high recurrent rate, and conjunctival autograft technique in which hemorrhage under the autograft, corneal delen near the limbus, and epithelial inclusion cysts were also reported.
The major well-known postoperative complications of pterygium surgery are recurrence and infection and these are relatively common with the use of sutures.
The use of fibrin glue improved postoperative patient comfort and resulted in lower recurrence rates compared with suturing.,, However, in spite of these favoring effects, the fibrin glue causes the risk of transmitting infections and reactions.
All these led to the development of sutureless and glue-free conjunctival autografting. Pterygium excision with sutureless and glue-free conjunctival autografting is gaining popularity due to its simpler technique and recurrence-free nature.,,
| Materials and Methods|| |
This case series study was carried out in 2015 in Nastaein private sanatorium Zlitin Libya. Twenty-seven eyes of 23 patients with primary pterygium were included in this study. Patients complained of marked discomfort and irritation unrelieved by medical management, rapid growth with cosmetic concerns, and encroachment of the pupillary area threatening the visual axis or blurred vision from induced astigmatism. According to the tenets of the Declaration of Helsinki for research in human subjects, written informed consent was obtained from all the patients before inclusion in the current study. Patients of all ages and of either sex presenting with primary nasal pterygia were included in this study, and detailed medical and ophthalmic history, including gender, age, and previous eye surgery, was taken. Exclusion criteria included recurrent pterygium, retinal pathology requiring surgical intervention, glaucoma, and a history of previous trauma or ocular surgery.
Preoperative ophthalmic evaluation included uncorrected and best-corrected visual acuity, slit-lamp examination, fundoscopy, and tonometry for all cases.
The surgical approach adopted was similar to others that have been previously reported: ,, in each case, subconjunctival anesthesia and sedation were administered and a lid speculum was used. Local anesthesia (xylocaine 2%) was used to balloon the pterygium separating it from the sclera. The head of the pterygium was dissected from the cornea up to the limbal margin and excised using Westcott scissors. The fibrovascular tissue underlying the pterygium was then exposed by a blunt and sharp dissection, up to the point of insertion of the medial rectus muscle, and then excised. The corneal bed of the pterygium was scraped with a crescent knife and hemostasis was allowed to occur spontaneously without the use of cautery. The superior quadrant of bulbar conjunctiva was injected with 1 cc of local anesthesia (xylocaine 2%) to facilitate separation of the conjunctiva from Tenon's capsule, and then conjunctiva was dissected from 10 to 1 o'clock position in such a way that the graft becomes 1 mm larger than the bare sclera in all the directions (measured with Castroviejo calipers). The graft was placed on the bare sclera in such a way so as to maintain the original orientation of the juxtalimbal border toward the cornea. The scleral bed was observed through the transparent conjunctiva to certify that bleeding does not lift the graft. Small central hemorrhages were tamponaded with direct compression. The free graft was held in position for 15 min by the application of gentle pressure over it with a lens spatula. The stabilization of the graft was tested with a Merocel spear centrally and on each free edge to ensure that it is firmly adherent to the sclera. The patients were instructed to close the eye for 1 h and after examination eye bandage was applied for 24 h.
All patients were examined after 1 h, and then eye bandage was applied for 24 h. After removal of the patch, the patients were advised not to rub the eye and a combination of topical antibiotics and steroids was administered 4 times a day for 2 weeks and tapered over the next 4 weeks. The patients were followed up postoperatively after 24 h, 1 week, 4 weeks, 3 months, 6 months, and 12 months. Visual acuity, slit-lamp examination, and tonometry were done to assess any hemorrhage, wound gape, graft shrinkage, chemosis, graft dehiscence, pterygium recurrence, and cosmetic result.
Statistical analysis was performed using Microsoft office Excel version 2016. Continuous variables are expressed as mean ± standard deviation. Categorical data are expressed as numbers and percentages.
| Results|| |
A total of 27 eyes of 23 patients were included in this study. The mean age of the patients was 55.9 ± 8.55 years (range: 43–71 years), of which 65% were male. The mean follow-up time was 10.2 ± 2 months. Changes of visual acuity were not noticed in any patient. Only one patient (3.7%) developed medial edge recession of the graft on the 1st postoperative day due to a wrong measurement of the size of the graft, and no other complications (graft retraction, dehiscence, or loss) were noted. Cosmesis was excellent in all cases and no recurrence was noted. Pterygium recurrence was defined as the presence of fibrovascular re-encroachment extending beyond the surgical limbus at any time during the study.
| Discussion|| |
Although many surgical methods have been developed for the treatment of pterygium, the major concern about pterygium surgery is that there is no existing effective technique to prevent postoperative recurrence.
In this study, 27 eyes (of 23 patients) underwent sutureless and glue-free conjunctival autografting surgery. The mean follow-up time was 10.2 ± 2 months. The only complication occurred was medial edge recession of the graft that developed to one patient (3.7%) due to a wrong measurement of the size of the graft. No other complications were noted. Cosmesis was excellent in all cases and no recurrence was noted.
Generally, all recurrences after pterygium surgery appear within a year. Hirst et al. showed that there is a 50% chance for a recurrence after pterygium surgery to occur within 4 months and a 97% chance within 1 year. In another article on recurrence time, it was shown that 1-year follow-up is optimal, which is consistent with the follow-up time used in this study.
It was reported that the main disadvantage of sutureless and glue-free conjunctival autografting technique is the risk of graft loss in the immediate postoperative period. No case of graft loss took place in this study.
In a study by Malik et al. done on forty eyes with pterygium, total graft dehiscence occurred in two eyes (5%), graft retraction in three eyes (7.5%), and recurrence was seen in one eye (2.5%). In another study done on 21 patients, recurrence was observed in one patient (4.76%). In this study, the only complication seen was medial edge recession of the graft in one patient (3.7%) due to wrong measurement of the size of graft during surgery. No other complications were reported and the most important was that by the end of 1 year, no recurrence occurred and all patients were satisfied.
| Conclusion|| |
Sutureless and glue-free conjunctival autograft for primary pterygium surgery is cost-effective with less surgical time, fewer complications, more comfortable for patients, and easy to learn and teach. We recommend this technique to be the first choice for surgical treatment.
Limitation of the study
The main limitation of this study is the small number of patients. Larger number of patients are needed to confirm this conclusion.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kanski Jack J. Bowling Brad: Clinical Ophthalmology: A Systematic Approach. 7th
ed. Edinburgh; New York: Elsevier/Saunders; 2011. p. 131-44.
Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-70.
Youngson RM. Recurrence of pterygium after excision. Br J Ophthalmol 1972;56:120-5.
Syam PP, Eleftheriadis H, Liu CS. Inferior conjunctival autograft for primary pterygia. Ophthalmology 2003;110:806-10.
Kheirkhah A, Casas V, Sheha H, Raju VK, Tseng SC. Role of conjunctival inflammation in surgical outcome after amniotic membrane transplantation with or without fibrin glue for pterygium. Cornea 2008;27:56-63.
Farid M, Pirnazar JR. Pterygium recurrence after excision with conjunctival autograft: A comparison of fibrin tissue adhesive to absorbable sutures. Cornea 2009;28:43-5.
Karalezli A, Kucukerdonmez C, Akova YA, Altan-Yaycioglu R, Borazan M. Fibrin glue versus sutures for conjunctival autografting in pterygium surgery: A prospective comparative study. Br J Ophthalmol 2008;92:1206-10.
Pan HW, Zhong JX, Jing CX. Comparison of fibrin glue versus suture for conjunctival autografting in pterygium surgery: A meta-analysis. Ophthalmology 2011;118:1049-54.
Prasanna Shankar Babu TG, Lavanya P. Shreeraja Y, Praveenkumar, Raviprakash D. Autograft technique for pterygium surgery with no glue and no suture. Int J Ocul Oncol Oculoplasty 2016;2:186-9.
Dasgupta S, Vats V, Mittal SK. Pterygium excision with suture- free, glue-free conjunctival autograft (SFGF-CAG): Experience of a tertiary care hospital of the Northern India. J Clin Ophthalmol Res 2016;4:143-8. [Full text]
Gitte TR, Karad HT, Kulkarni M, Mashayak A. Sutureless and Glue-Free Conjunctival Autograft in Pterygium Surgery. Peoples J Sci Res 2017;10:46-50.
Sarnicola V, Vannozzi L, Motolese PA. Recurrence rate using fibrin glue-assisted ipsilateral conjunctival autograft in pterygium surgery: 2-year follow-up. Cornea 2010;29:1211-4.
Kandavel R, Kang JJ, Memarzadeh F, Chuck RS. Comparison of pterygium recurrence rates in hispanic and white patients after primary excision and conjunctival autograft. Cornea 2010;29:141-5.
Ayala M. Results of pterygium surgery using a biologic adhesive. Cornea 2008;27:663-7.
Tan DT, Chee SP, Dear KB, Lim AS. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. Arch Ophthalmol 1997;115:1235-40.
Hirst LW, Sebban A, Chant D. Pterygium recurrence time. Ophthalmology 1994;101:755-8.
Avisar R, Arnon A, Avisar E, Weinberger D. Primary pterygium recurrence time. Isr Med Assoc J 2001;3:836-7.
Malik KP, Goel R, Gutpa A, Gupta SK, Kamal S, Mallik VK, et al.
Efficacy of sutureless and glue free limbal conjunctival autograft for primary pterygium surgery. Nepal J Ophthalmol 2012;4:230-5.
Mansour HO. Comparison between sutured and sutureless glue free conjunctival autograft in primary pterygium. EJPMR 2017;4:1-4.