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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 17  |  Issue : 2  |  Page : 114-118

The outcome of sutureless glue-free conjunctival autograft for recurrent pterygium


Department of Ophthalmology, Faculty of Medicine, Al Azhar University, Damietta, Egypt

Date of Submission22-Mar-2018
Date of Decision19-Jun-2018
Date of Acceptance02-Jun-2019
Date of Web Publication23-Oct-2019

Correspondence Address:
Ali A Ghali
2nd District, 2nd Block, Eng. Hassaballah Alkafrawy Street, New Damietta, 34518
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_15_18

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  Abstract 


Aim To evaluate and analyze the surgical outcome of suture-free, glue-free conjunctival autograft after excision in recurrent pterygium.
Patients and methods A retrospective study of 23 eyes of 21 patients with recurrent pterygium was done, and excision was performed in all eyes. Free conjunctival autograft was taken from superior quadrant of the same eye, and bare sclera was covered without the use of sutures or fibrin glue, allowing natural autologous coagulum of the recipient bed to act as a bioadhesive. The eye was patched for 48 h. Postoperatively, patients were put on topical eye drops (tobramycin and dexamethasone) for 6 weeks. All patients were examined after 48 h and followed for 1, 4, 12, and 24 weeks for postoperative results and complications.
Results Of 23 eyes, only seven (30.43%) had subconjunctival hemorrhage, three (13.04%) had graft recession, and two (08.69%) eyes had totally dislodgement of the graft and three (13.04%) eyes had partial displaced. Overall, four eyes had intraocular pressure more than 25 mmHg after 48 h of operation, and two of them took antiglaucoma drugs to control intraocular pressure during the follow-up period. At the end of follow-up time, only three (13.04%) eyes with graft recession were observed. Recurrence of pterygium was noted in one case.
Conclusion Suture-free, glue-free conjunctival autograft after excision in recurrent pterygium is easy, simple, safe, fast, and effective procedure with acceptable recurrence rate.

Keywords: graft, Pterygium, Recurrent, Sutureless


How to cite this article:
Ghali AA, Hassan RE. The outcome of sutureless glue-free conjunctival autograft for recurrent pterygium. Al-Azhar Assiut Med J 2019;17:114-8

How to cite this URL:
Ghali AA, Hassan RE. The outcome of sutureless glue-free conjunctival autograft for recurrent pterygium. Al-Azhar Assiut Med J [serial online] 2019 [cited 2019 Nov 22];17:114-8. Available from: http://www.azmj.eg.net/text.asp?2019/17/2/114/269758




  Introduction Top


Pterygium is a triangular fibrovascular encroachment of the bulbar conjunctiva over the cornea. It represents one of the most common ocular surface degenerative disorders that leads to chronic irritation, impairment of cosmoses, and decreased visual acuity secondary to either irregular astigmatism or development of visual axis blockage by the increased growth [1],[2]. Pterygium is popular worldwide but seen mostly in the tropical and subtropical areas, especially in outdoor workers with prolonged exposure to ultraviolet rays, hotness, dryness, as well as environmental pollution. These factors lead to damage of the limbal stem cells which are responsible for regeneration of the corneal epithelium cells that resist overgrowth of the conjunctival fibrovascular tissue over the cornea. Other factors contribute to development of the pterygium such as genetic susceptibility and ocular surface disorders [2],[3].

Many surgical techniques are used for management of pterygium. Excision with bare sclera was the most common surgical procedure in spite of the high recurrence rate [3]. Other methods with variable reported successes were developed later as a modification of excision with bare sclera in an attempt to decrease the higher recurrence rate. The excision had been combined with the use of adjunct such as mitomycin C, beta irradiation, conjunctival autograft, or amniotic membrane graft [4],[5]. Numerous studies reported that use of limbal conjunctival autograft for both primary and recurrent pterygium is an encouraging surgical method for treatment of pterygium not only owing to much less recurrence rate in comparison with excision with bare sclera but also owing to decreased complications related to the use of antimetabolites and beta irradiation, especially serious consequences such as scleral necrosis and persistent epithelial defect [6],[7]. Some studies reported high success rate after preoperative subconjunctival injection of triamcinolone acetonide (TAAc) combined with excision and conjunctival autograft, particularly in recurrent cases [8]. Glue is widely used as an easy method for fixation of the graft, for shorter time of surgery, and for reduction in postoperative discomfort, but it has some disadvantages like high cost, the risk of infections, and inactivation [9],[10],[11]. Herein, sutureless glue-free limbal conjunctival autograft and conventional sutured autograft for treatment of primary pterygium have been compared. The study concluded that sutureless and glue-free conjunctival autograft technique is an easy, safe, and effective technique and prevents potential complications encountered with the use of foreign materials in comparison with conventional sutured conjunctival autograft [12].


  Patients and methods Top


All patients of recurrent pterygium ([Figure 1],[Figure 2],[Figure 3]A & [Figure 4]B) underwent complete ophthalmological evaluation including visual acuity, refraction, slit lamp biomicroscopy, measurement of intraocular pressure (IOP), and extraocular muscle movement. Exclusion criteria include glaucoma or ocular hypertension, previous superior conjunctival surgery, cicatricial ocular surface disorder, and collagen vascular disease. Informed written consent was obtained from all patients according to ethical committee instructions.
Figure 1 Picture of a recurrent pterygium after excision with bare sclera. The image shows there is involvement of the pterygium apex to the visual axis.

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Figure 2 Picture of a preoperative recurrent pterygium in a 42-year-old male patient after previous excision with bare sclera.

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Figure 3 A 57-year-old male patient with right recurrent nasal pterygium. (a) Preoperative photograph shows the extent of the pterygium. (b) 1-day postoperative picture. (c) 1-week postoperative picture. (d) 1-month postoperative picture.

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Figure 4 A 51-year-old female patient with right nasal recurrent pterygium. (a) Preoperative picture showing the extent of the pterygium. (b) A 2-day postoperative picture shows recession of the conjunctival graft.

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Operative technique

After insertion of an eyelid speculum, under peribulbar anesthesia, 3–4 ml of xylocaine 2% is injected in infratemporal approach, which is augmented by subconjunctival injection of mepivacaine hydrochloride 3%, mixed with 0.2 ml TAAc. Under complete aseptic measures, all patients were operated on with surgical microscope. Separation of the pterygium was starting at its neck near the limbus, followed by separation of the conjunctiva from the body of the pterygium by blunt conjunctival scissors as near as the caruncle. Tenon’s tissue was separated from overlying conjunctiva, undermined, and excised. Then the fibrous tissue was resected with conjunctival scissor leaving clean conjunctival borders, with taking care to medial rectus muscle to be involved. TAAc deposits were seen and removed. Pterygium was excised without application of cautery to the scleral bed to form blood clot on the bed. The conjunctiva above and below the pterygium was fashioned to create a rectangular area of bare sclera. Residual fibrovascular tissue over the cornea was peeled by toothed forceps from limbal to the center of the cornea after creating a flap by a No. 15 Baird-Parker blade.

Special forceps or stay suture was used to rotate the globe downward for good exposure of the superior bulbar conjunctiva, and then the proper size of the limbal conjunctival graft was determined. The upper angle of the conjunctiva is grasped by fine forceps, and blunt conjunctival scissor was used to separate the conjunctiva from the underlying Tenon’s capsule. The final graft was kept as thin as possible. The autograft was then displaced to place over the bare sclera in the correct anatomical place with nontooth forceps. Proper massage of the graft against sclera using a strabismus hook was a routine step for graft stability. Dryness of the edges of the graft was the final step before removal of the speculum carefully. Combined tobramycin and dexamethasone eye ointment was applied, and then the eye was patched firmly for 2 days.

The harvest site wound remains as it is for spontaneous re-epithelialization. Postoperative topical combination of corticosteroid/antibiotic (tobramycin and dexamethasone) drops and ointment was used for 6 weeks. Systemic nonsteroid anti-inflammatory tablets were prescribed for 1 week. Patients were followed up and photographed ([Figure 3]B, C & D and [Figure 4]B) postoperatively on the second day and at 1, 4, and 12 weeks for graft dislodgement, recession, subconjunctival hemorrhage, best-corrected visual acuity, IOP, recurrence, or other complications.


  Results Top


A total of 23 eyes of 21 patients were included in this study. The mean age of the patients was 34±2 years. The male and female representation was 12 (56.52%) and 10 (43.47%), respectively. Preoperative data of patients are shown in [Table 1]. Mean operation time was 20±6 min.
Table 1 Preoperative data

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All the patients were examined after 48 h following operation for graft dislodgement, recession, edema, and subconjunctival hemorrhage. Of 23 eyes, only seven (30.43%) had subconjunctival hemorrhage, three (13.04%) had graft recession, and two (08.69%) eyes had graft dislodgement totally and three (13.04%) partially displaced. Overall, four eyes had IOP more than 25 mmHg after 48 h of operation. Moreover, three (13.04%) cases of graft recession were observed at 3 months of follow-up time. Recurrence of pterygium was noted in one case that had total dislodgement of the graft. In addition, two cases were administered antiglaucoma (dorzolamide and timolol) drugs to control IOP during the follow-up period. Postoperative complications are shown in [Table 2].
Table 2 Postoperative complications

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  Discussion Top


Pterygium is one of the most common ocular surface disorders that leads to many undesirable ocular effects such as chronic irritation, bad cosmoses, and defect vision. The high recurrence rate after successful excision remains a main challenge. The optimal treatment that cancel recurrence and complications was the target of research for many years. Many techniques including conjunctival autograft have been tried to achieve this goal. The results of variable adjunctive therapies like beta irradiation, thiotepa, 5-fluorouracil, and mitomycin C decreased recurrence but serious complications have been reported [2],[13],[14],[15]. Some studies published also high success rate after preoperative subconjunctival injection of TAAc followed by excision and conjunctival autograft, particularly in recurrent cases, but increased IOP was postoperatively noted [8].

Three different methods have been used for fixation of the graft on the bed. One of them is suturing of the conjunctival graft either with absorbable or nonabsorbable sutures. It has good cosmetic results without serious intraoperative complications. However, the procedure takes longer surgical time, and suture-related complications have been documented [8],[12]. Fibrin glue has been used to fix the graft and eliminate the suture-related complications with faster surgery, but it has many drawbacks like increased cost, availability, irritation, biodegradability of glue, and recurrence [16].

Recently, some authors introduced a new technique using patient’s own blood as a bioadhesive substance on the excised bed of the pterygium for fixation of conjunctival autograft without sutures or fibrin glue. This technique has eliminated several disadvantages encountered with others methods of fixation [12],[17],[18]. In this study, we found that time of surgery was decreased. There was one case of recurrence (8.97%) related to total dislodgment and loss of the graft, and three (13.04%) cases had graft recession. Increase in IOP in four (17.39%) cases can be explained by usage of subconjunctival TAAc and medically controlled during the follow-up time. Although there were a series of recurrent cases in our study, the results were comparable to other studies with similar techniques [12],[17],[18].


  Conclusion Top


Suture-free, glue-free conjunctival autograft after excision in recurrent pterygium is an easy, simple, safe, fast, and effective procedure with acceptable recurrence rate. It is an encouraging modality to overcome complications related to graft fixation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lin A, Stern G. Correlation between pterygium size and induced corneal astigmatism. Cornea 1998; 17:28–30.  Back to cited text no. 1
    
2.
Hirst LW. The treatment of pterygium. Surv Ophthalmol 2003; 48:145–180.  Back to cited text no. 2
    
3.
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; 115:1235–1240.  Back to cited text no. 3
    
4.
Ma DH, See LC, Hwang YS, Wang SF. Comparison of amniotic membrane graft alone or combined with intraoperative mitomycin C to prevent recurrence after excision of recurrent pterygia. Cornea 2005; 24:141–150.  Back to cited text no. 4
    
5.
Ti SE, Chee SP, Dear KB, Tan DT. Analysis of variation in success rates in conjunctival autografting for primary and recurrent pterygium. Br J Ophthalmol 2000; 84:385–389.  Back to cited text no. 5
    
6.
Shimazaki J, Yang HY, Tsubota K. Limbal autograft transplantation for recurrent and advanced pterygia. Ophthalmic Surg Lasers 1996; 27:917–923.  Back to cited text no. 6
    
7.
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. 7
    
8.
Ghali AA. Combined subconjunctival triamcinolone and autograft for treatment of pterygium. Sci Events Egypt Ophthalmol Soc 2009; 2:9–11.  Back to cited text no. 8
    
9.
Ayala M. Results of pterygium surgery using a biologic adhesive. Cornea 2008; 27:663–667.  Back to cited text no. 9
    
10.
Kim HH, Mun HJ, Park YJ, Lee KW, Shin JP. Conjunctivolimbal autograft using a fibrin adhesive in pterygium surgery. Korean J Ophthalmol 2008; 22:147–154.  Back to cited text no. 10
    
11.
Koranyi G, Seregard S, Kopp ED. Cut and paste: a no suture, small incision approach to pterygium surgery. Br J Ophthalmol 2004; 88:911–914.  Back to cited text no. 11
    
12.
Elwan SAM. Comparison between sutureless and glue free versus sutured limbal conjunctival autograft in primary pterygium surgery. Saudi J Ophthalmol 2014; 28:292–298.  Back to cited text no. 12
    
13.
Mackenzie FD, Hirst LW, Kynaston B, Bain C. Recurrence rate and complications after beta irradiation for pterygia. Ophthalmol 1991; 98:1776–1780.  Back to cited text no. 13
    
14.
Chapman-Smith JS. Pterygium treatment with triethylene thiophosphoramide. Aust N Z J Ophthalmol 1992; 20:129–131.  Back to cited text no. 14
    
15.
Cheng HC, Tseng SH, Kao PL, Chen FK. Low-dose intraoperative mitomycin C as chemo-adjuvant for pterygium excision. Cornea 2001; 20:24–29.  Back to cited text no. 15
    
16.
Marticorena J, Rodríguez-Ares MT, Touriño R, Mera P, Valladares MJ, Martinez-de-la- Casa JM, Benitez-del-Castillo JM. Pterygium surgery: conjunctival autograft using a fibrin adhesive. Cornea 2006; 25:34–36.  Back to cited text no. 16
    
17.
Goswami MK, Asaduzzama MD. Sutureless and glue free conjunctival auto grafting after pterygium excision. IMC J Med Sci 2016; 10:36–38.  Back to cited text no. 17
    
18.
Sharma A, Raj H, Gupta A, Raina AV. Sutureless and glue free versus sutures for limbal conjunctival autografting in primary pterygium surgery: a prospective comparative study. J Clin Diag Res 2015; 9:NC06–NC09.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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