|Year : 2021 | Volume
| Issue : 1 | Page : 21-25
A comparative study of conjunctival-limbal autograft with fibrin clot and glue techniques for pterygium
Vishnu Teja Gonugunta1, Kirti Nath Jha2, Krishnagopal Srikanth2, Chinmayee Pabolu3
1 Department of Cornea and Refractive Surgery Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
2 Department of Ophthalmology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India
3 Department of Glaucoma Services, Aravind Eye Hospital, Madurai, Tamil Nadu, India
|Date of Submission||03-Jun-2021|
|Date of Decision||17-Jul-2021|
|Date of Acceptance||19-Jul-2021|
|Date of Web Publication||01-Nov-2021|
Dr. Vishnu Teja Gonugunta
Department of Cornea and Refractive Surgery Services, Aravind Eye Hospital, Madurai - 625 020, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Introduction: Pterygium is a common conjunctival disorder seen in tropical countries. Surgery is the permanent treatment. Various methods of graft fixation include sutures, fibrin clot, and glue techniques. Fibrin clot (autologous serum) technique involves the utilization of the patient's oozed blood from the episcleral vessels to serve as natural glue adhering the graft to the underlying sclera, whereas commercial glue involves the use of two components for firm adherence of the graft. Aim: The aim of this study is to observe and compare the complication rates, outcomes, and recurrence with fibrin clot and glue techniques for pterygium. Materials and Methods: One hundred and twenty-six eyes of 126 patients with primary pterygium were operated under peribulbar anesthesia by a single surgeon after doing the routine clinical examination. Group A included 63 eyes where the fibrin clot technique was used for graft adherence and Group B included 63 eyes where commercial glue was used for fixing the graft. Pterygium was excised, and a conjunctival-limbal autograft was taken from the superior bulbar conjunctiva of the same eye. In the fibrin clot (autologous serum) technique, natural hemostasis was encouraged, and the graft was placed over the oozed blood, left undisturbed for 10 min. In the glue technique, hemostasis was achieved and graft was transplanted over the glue and left undisturbed for 2 min. Eye patch was removed the next day of surgery. Preoperative and postoperative photographs were taken. Standard postoperative treatment was given. Follow-up was carried on day (postoperative day) 1, 15, 30, 90, 180, and 300. Results: The mean surgical time was 29.3 and 19.6 min in Group A and Group B, respectively. Graft retraction and graft edema were noted in four patients (6.3%) in fibrin clot technique, and graft edema was noted in five patients (7.9%) in Group B, which resolved on subsequent visits with conservative management. No recurrence was noted in either group. No other postoperative complications were noted in both groups. Conclusion: Fibrin clot (autologous serum) and glue techniques do not use sutures, thus avoid the cost of sutures and suture-related discomfort and complications. Fibrin clot (autologous serum) is more economical than the glue technique. Cosmetic outcome in the immediate postoperative period is better with glue than fibrin clot technique. Long-term outcome is the same in both groups. Autologous serum avoids the transmission of prion diseases possible with glue method. Both the techniques are equally safe and efficient.
Keywords: Autologous serum, commercial glue, conjunctival autograft, conjunctival-limbal autograft, fibrin clot, fibrin glue, pterygium
|How to cite this article:|
Gonugunta VT, Jha KN, Srikanth K, Pabolu C. A comparative study of conjunctival-limbal autograft with fibrin clot and glue techniques for pterygium. J Ophthalmol Clin Res 2021;1:21-5
|How to cite this URL:|
Gonugunta VT, Jha KN, Srikanth K, Pabolu C. A comparative study of conjunctival-limbal autograft with fibrin clot and glue techniques for pterygium. J Ophthalmol Clin Res [serial online] 2021 [cited 2022 Oct 1];1:21-5. Available from: http://www.jocr.in/text.asp?2021/1/1/21/329781
| Introduction|| |
Pterygium is an abnormal fibrovascular growth of the subconjunctival tissue onto the cornea. It is a common pathology, seen especially in the tropical and subtropical regions. It is caused by increased sunlight exposure, dust, dryness, heat, and wind. In the initial stages of pterygium formation, it is usually symptomless. Otherwise, patients may present with mild ocular discomfort, irritation, and watering from the eye due to irregular ocular surface. As the pterygium increases in size, it may become a cosmetic problem to the patient and interferes with vision due to the induced astigmatism.
The treatment of pterygium is mainly surgical. The indications of surgery include cosmetic deformity, marked discomfort and irritation unrelieved by medical management, and limitation of ocular motility and obscuring the visual axis.
Current surgical treatment includes simple excision of pterygium (the bare sclera technique), excision combined with one of the procedures such as conjunctival autograft, conjunctival-limbal autograft (CLAG) with or without sutures, with fibrin clot technique (autologous serum) or glue, amniotic membrane graft, and adjunctive therapy. However, there is no surgical technique that achieves no recurrence and complications.
Today, conjunctival autograft transplantation and CLAG transplantation remain the two popular techniques for treating primary and recurrent pterygium. The important role of limbal stem cells in preventing recurrence has been the basis for adopting CLAG transplantation as a preferred technique.
A healthy limbus acts as a barrier for conjunctival overgrowth onto the cornea. Since limbal stem cells are damaged in pterygium, the inclusion of stem cells into the graft was hypothesised to prevent recurrence and maintain anatomical and physiological reconstruction after pterygium surgery and studies have confirmed it. Recent reports suggest CLAG transplantation with fibrin clot and glue techniques are superior over sutures technique with improved comfort, decreased surgical time, reduced surgical complications and recurrence rates.,
There are few studies from India on the comparison of CLAG with fibrin clot and glue techniques. We aim in this prospective, observational study to report the surgical complications and recurrence of pterygium with fibrin clot and glue techniques in pterygium surgery and also to compare our results with previous studies.
To observe and report the surgical complications and recurrence rate of pterygium using fibrin clot and glue techniques in the CLAG transplantation in pterygium surgery.
| Materials and Methods|| |
This was a longitudinal study carried out at the Ophthalmology Department in a Medical College in Pondicherry from 2013 to 2016. The study had adhered to the tenets of the declaration of Helsinki and was approved by the Institutional Review Board. Cases with primary pterygium who reported at the ophthalmology outpatient department-seeking surgery were included. A detailed history was taken. The examination included: Best-corrected visual acuity, ocular motility, keratometry, intraocular pressure (IOP) by applanation tonometry, anterior segment, and fundus examination. Preoperative and postoperative photographs were taken. Glue was prepared from a commercially available Tisseel kit. Tisseel Duo Quick (Baxter, Vienna, Austria) is a two-component tissue adhesive that mimics the natural fibrin formation. The glue has two components. One consists of fibrinogen mixed with factor XIII and aprotinin. The other component is a thrombin-CaCl2 solution. The two components are prepared in two separate syringes. A stop-watch was used to measure the time from the time of taking the superior rectus bridle suture to the end of surgery till graft adherence was checked.
Pterygium excision with CLAG transplantation surgery was done under peribulbar anesthesia. All patients received antibiotic eye drop (ciprofloxacin 0.3%) four times a day started from the day before surgery. The surgery was carried out under an operating microscope in a major operation theater [Figure 1]. The eyelids were retracted with a lid speculum and a superior rectus bridle suture was applied using 5-0 silk. A piece of cotton soaked in normal saline was kept over the cornea to avoid it from drying [Figure 1]b. About 0.5 ml saline was injected under the body of the pterygium using a 26-gauge needle mounted on a 2 ml syringe. Two radial incisions were made in the conjunctiva and the Tenon's capsule, at the upper and the lower limits of the body of the pterygium. The incisions, about 5 mm in length, were extended away from the limbus. The body of the pterygium including the Tenon's capsule was cut between the two radial incisions using a pair of sharp conjunctival scissors. The head of the pterygium was avulsed by reverse stripping using slow and deliberate traction applied to the free end of the belly of the pterygium that was held parallel to the cornea. The fibrovascular tissue underneath the conjunctiva was dissected on the canthus side up to the insertion of the horizontal rectus muscle, taking care not to cause any injury to the rectus muscle [Figure 1]d. When bleeding occurred, cautery was not used in the fibrin clot technique but was used in the glue technique to achieve hemostasis.
|Figure 1: Intraoperative steps in pterygium excision with conjunctival-limbal autograft transplantation. (a) left nasal pterygium (b) pterygium is cut at the limbus (c) after excising off the pterygium (d) excision of subconjunctival tissue (e) lateral margins of the graft are cut. The posterior margin is being cut (f) graft lying on the cornea with the limbal side still attached (g) graft transplantation (h) well apposed graft|
Click here to view
The donor tissue was harvested from the same eye. For this purpose, the eyeball was rotated down by holding the superior rectus bridle suture. The appropriate size of the upper bulbar conjunctiva was measured with Castroviejo caliper and marked with trypan blue. The marked out conjunctiva was elevated with the subconjunctival injection of normal saline using a 26G needle. A pair of conjunctival scissors was used to make two parallel incisions in the conjunctiva along with the trypan blue marks [Figure 1]e. The conjunctival graft was dissected free from the underlying Tenon's capsule. The use of plane conjunctival forceps helps in preventing button holing of the graft. When the posterior and lateral limits of the graft were made free, blunt dissection proceeded towards the cornea. This dissection was continued into the peripheral cornea for about 0.5–1 mm beyond the limbal vascular arcade. The conjunctival graft was then excised using a pair of sharp Vannas scissors. The graft was transferred onto the conjunctival defect and secured.
In the fibrin clot (autologous serum) technique, the four corners of the graft were then secured over the bare sclera with limbus to limbus orientation and epithelial surface away from the bare sclera and natural hemostasis was encouraged and the graft was left undisturbed for 10 min.
In the glue technique, bare sclera was cauterised if necessary and was kept dry. The graft was placed over the cornea with its epithelial side lying in contact with the corneal epithelial surface and brought near the limbus adjacent to the bare sclera created. Thrombin solution first followed by fibrinogen components were applied over the bare sclera and then graft was transferred onto the bare sclera maintaining limbus to limbus orientation and keeping the graft epithelium surface away from the bare sclera. The graft was spread over the bare sclera with a McPherson forceps and excess glue was removed. The graft was left undisturbed for 2 min. Graft adherence was confirmed with a sterile cotton bud.
The donor site was left bare for spontaneous healing. At the end of the surgery, a drop of ciprofloxacin-dexamethasone eye drop was instilled into the conjunctival sac, and the eye was patched. The patch was removed the next day. Postoperative treatment included topical ciprofloxacin-dexamethasone eye drop, 6 times a day, from the day after surgery for 1 week. Subsequently, the antibiotic-steroid eye drop was tapered over 4 weeks. All patients were reviewed at 2 weeks, 1, 3, 6, and 10 months following surgery. The patients were advised to wear a pair of dark glasses during the first 2 postoperative weeks. At every review, visual acuity, IOP, Keratometry readings were noted, and slit-lamp examination was done to look for graft position and signs of recurrence. Photographs of the operated eyes were taken.
We graded recurrence according to the grading system developed by Prabhasawat et al. According to this, Grade 1 indicates a normal appearance of the operated site; Grade 2 indicates the presence of fine episcleral vessels without any fibrous tissue in the operated area, not crossing the limbus; Grade 3 indicates a conjunctival recurrence with fibrous tissue, and Grade 4 indicates a corneal recurrence with fibrovascular tissue invading the cornea.
| Results|| |
Our study patient population included 126 eyes of 126 patients with primary pterygium. Group A included 63 eyes operated with fibrin clot (autologous serum) technique and Group B included 63 eyes operated with glue technique. The mean age of the patients and age distribution of the study population according to age in both the groups is shown in [Table 1]. Pterygium was noted more in the rural than urban population possibly due to the increased exposure to the sunlight in rural groups owing to their occupation as farmers. The demographics of the study patients in the two groups are shown in [Table 2]. Details of the pterygium are shown in [Table 3].
We followed up on our cases for a minimum of 10 months. We did not notice recurrence in any of our patients during the follow-up period in either group [Figure 2] and [Figure 4]. [Table 4] summarizes the results. There were no intraoperative complications. We noticed minimal graft retraction in four patients in group A (fibrin clot group) on the 1st postoperative day. Pressure patching with ciprofloxacin eye ointment was done for 48 h, and the graft retraction decreased in subsequent visits at 15 days and 1-month follow-up. Graft edema was noted in four patients in Group A [Figure 3] and five patients in Group B.
|Figure 2: No recurrence with fibrin clot (autologous serum) technique (a) left nasal pterygium (b) postoperative day (POD) 1-month (c) POD 3 months d) POD 10 months|
Click here to view
|Figure 3: Resolution of graft oedema with fibrin clot (autologous serum) technique over time (a) right nasal pterygium (b) graft oedema postoperative day (POD) 1 (c) decrease in oedema by POD 15 (d) complete resolution of oedema POD 1 month|
Click here to view
|Figure 4: No recurrence with glue technique (a) RE nasal pterygium (b) postoperative day (POD) 1-month c) POD 10 months|
Click here to view
| Discussion|| |
Surgery is the treatment of choice for pterygium. Various methods have been explained for excision and graft fixation with various rates of recurrence. Though graft fixation with sutures is used commonly, more surgical time, postoperative discomfort, suture related complications and the need for suture removal in follow-up visits make other methods to be preferred over suture technique. Fibrin clot (autologous serum) and commercial glue are popularly used techniques nowadays because of good results superior to suture technique.
Of the 126 eyes, we did not notice recurrence in any of the two groups during a follow-up period of 10 months. Our results are similar to de Wit et al. and Sharma et al., who also did not notice recurrence with the fibrin clot method in 15 and 25 eyes, respectively [Figure 2]. In the glue technique, no recurrence was noted by Marticorena et al. in 20 eyes during a follow-up of 26 weeks.
Graft retraction was noted in 4 patients (6.3%) in Group A in our study. This is similar to 7.5% of 40 patients in the Malik KPS et al. study. In Group B, we didn't notice graft retraction. Similar results were noticed in Koranyi et al. study (no retraction) and retraction rates were as low as 2.7% in 111 eyes in the Vincenzo et al. study. Graft retraction resolved during further follow-up in group A with conservative management.
Graft oedema was noted in 4 patients (6.3%) in Group A [Figure 4], 5 patients (7.9%) in Group B in our study. Similar findings were noted in other studies Koranyi et al. and Marticorena et al. (15%) with fibrin glue technique and Sharma et al. (8%) in fibrin clot technique. Graft edema was noticed in immediate postoperative visits, resolved with the continuation of conservative treatment of antibiotic-steroid eye drop in further follow-up.
Subconjunctival hemorrhage is a known complication in the fibrin clot method as hemostasis is encouraged, the blood clot gets absorbed and becomes cosmetically acceptable within few days. The fibrin glue technique, on the other side, requires a dry scleral surface before applying the glue components and minimal cautery may be needed to arrest the bleeders. Hence, postoperative subconjunctival hemorrhage is less common with glue technique and immediate postoperative cosmetic outcome is better with glue than fibrin clot technique.
Other complications such as graft displacement due to reverse placement of graft, granuloma, and graft dehiscence were not noticed in our study because we were careful in the meticulous dissection of graft from the sub Tenons and in maintaining the graft orientation. Although the risk of transmission of prion infections and anaphylaxis was noted rarely with glue, we did not notice any in our patients with glue in Group B.
The average surgical time was 29.3 min in Group A and 19.6 min in Group B. The time is taken though similar to other studies,, it varies according to the surgeon's experience.
| Conclusion|| |
The fibrin clot technique is a novel technique for the treatment of primary pterygium. The suture-related complications and suture cost are avoided. The fibrin glue technique is also a safe technique apart from the rare possibility of transmission of prion diseases. Although the fibrin glue technique is expensive compared with other techniques, postoperative patient's discomfort is minimal with better immediate postoperative cosmesis. We found similar results with fibrin clot and glue techniques.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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.
Jha KN. Conjunctival-limbal autograft for primary and recurrent pterygium. Med J Armed Forces India 2008;64:337-9.
Garg A. Surgical and Medical Management of Pterygium. New Delhi: Jaypee Brothers Medical Publishers; 2009.
Hirst LW. Prospective study of primary pterygium surgery using pterygium extended removal followed by extended conjunctival transplantation. Ophthalmology 2008;115:1663-72.
Kwok LS, Coroneo MT. A model for pterygium formation. Cornea 1994;13:219-24.
Mahdy ME, Bhatia J. Treatment of primary pterygium: Role of limbal stem cells and conjunctival autograft transplantation. Oman J Ophthalmol 2009;2:23.
] [Full text]
Koranyi G, Seregard S, Kopp ED. Cut and paste: A no suture, small incision approach to pterygium surgery. Br J Ophthalmol 2004;88:911-4.
Prabhasawat P, Barton K, Burkett G, Tseng SC. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology 1997;104:974-85.
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 Diagn Res 2015;9:C06-9.
Marticorena J, Rodríguez-Ares MT, Touriño R, Mera P, Valladares MJ, Martinez-de-la-Casa JM, et al.
Pterygium surgery: Conjunctival autograft using a fibrin adhesive. Cornea 2006;25:34-6.
Malik KP, Goel R, Gupta SK, Kamal S, Malik VK, Singh S. Efficacy of sutureless and glue-free limbal conjunctival autograft for primary pterygium. Nepal J Ophthalmol 2012;4:230-5.
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.
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.
Singh PK, Singh S, Vyas C, Singh M. Conjunctival autografting without fibrin glue or sutures for pterygium surgery. Cornea 2013;32:104-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]