|Year : 2017 | Volume
| Issue : 2 | Page : 81-86
Cut-and-place technique of pterygium excision with autograft without using sutures or glue: Our experience
Jagdish Bhatia1, Mathew Varghese1, Bindu Narayanadas1, Arti Bhatia2
1 Department of Ophthalmology, Rustaq Hospital, Rustaq, Oman
2 Medical Officer, Rustaq Polyclinic, Oman
|Date of Web Publication||29-Jun-2017|
Department of Ophthalmology, Rustaq Hospital, P. O. Box: No. 421, PC 329, Rustaq
Source of Support: None, Conflict of Interest: None
| Abstract|| |
BACKGROUND: Conjunctival sutures used in pterygium surgery are not only time-consuming process but also may lead to local complications such as discomfort, scarring, granuloma, or infection. Plasma-derived products such as fibrin glue may produce possible hypersensitivity reactions whereas the risk of viral transmission remains theoretically possible. We describe a simple method of achieving conjunctival autograft adherence during pterygium surgery avoiding potential complications associated with the use of fibrin glue or sutures.
MATERIALS AND METHODS: After pterygium excision and fashioning of the autologous conjunctival graft, the recipient bed is encouraged to achieve natural hemostasis and relative desiccation before graft placement. Excessive hemorrhage in the graft bed is tamponed. Graft adherence and positioning is examined 12–15 min after surgery.
RESULTS: A total of 205 cases of pterygium underwent excision with conjunctival autograft without using sutures or glue. Mean follow-up time was 14.6 months. Cosmesis achieved was excellent in all cases. There were no intraoperative complications seen. Recurrence was seen in 6.8% of cases (14 cases). Nasal gaping was seen in 36% of cases (74 cases), which healed spontaneously without any surgical intervention.
CONCLUSION: This simple technique for pterygium surgery is not only cost effective and quick but also may prevent potential adverse reactions encountered with the use of foreign materials and in this large series provided safe and comparable results to current methods.
Keywords: Autograft, glue, pterygium
|How to cite this article:|
Bhatia J, Varghese M, Narayanadas B, Bhatia A. Cut-and-place technique of pterygium excision with autograft without using sutures or glue: Our experience. Oman J Ophthalmol 2017;10:81-6
|How to cite this URL:|
Bhatia J, Varghese M, Narayanadas B, Bhatia A. Cut-and-place technique of pterygium excision with autograft without using sutures or glue: Our experience. Oman J Ophthalmol [serial online] 2017 [cited 2020 Jan 18];10:81-6. Available from: http://www.ojoonline.org/text.asp?2017/10/2/81/209113
| Introduction|| |
Pterygium is a wing-shaped conjunctival encroachment onto the cornea generally situated on the nasal side. Pterygium is more frequent in areas with more ultraviolet radiation, in hot, dry, windy, dusty, and smoky environments. Ultraviolet light-induced damage to the limbal stem cell barrier with subsequent conjunctivalization of the cornea is the currently accepted etiology of this condition.
Besides cataract surgery, pterygium excision is perhaps one of the most common surgical procedures for the general ophthalmologist. Pterygium surgery is under continuous modifications in the quest for reducing relapse rates. Surgical removal is the treatment of choice. Current surgical methods to prevent pterygium recurrence include conjunctival autograft with limbal to limbal orientation, conjunctival flap and conjunctival rotation autograft surgery, and amniotic membrane transplant. All these techniques involve the use of sutures or fibrin glue and are therefore vulnerable to associated complications.
In 1985, Kenyon et al. proposed that a conjunctival autograft of the bare sclera could be used in the treatment of recurrent and advanced pterygium. Conjunctival autografting after pterygium excision is associated with very low rates of recurrence and complications and hence a preferred technique everywhere. The surgeon's skill and experience affect the recurrence rate, which varies between 2% and 39% with this technique., Nevertheless, because of graft suturing, this method has the disadvantage of a relatively longer surgical time and also carries the risk of suture-related complications such as granuloma formation and giant papillary conjunctivitis as well as significant patient discomfort after surgery.
Because of its biological and biodegradable properties, fibrin-based adhesives are gaining importance 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.
Pterygium excision with conjunctival autograft has exhibited good results because it maintains the ocular surface even and restores the anatomy which existed before the corneal invasion caused by the pterygium, anchoring the denuded scleral bed with sutures such as Vicryl or by means of tissue glues. Both techniques yield excellent results for reducing the number of recurrences in this type of surgery. In addition, patients' comfort for the first few days after surgery is also an important factor in this type of intervention. Pterygium excision with autologous conjunctival grafting seems to be the best method, giving both low recurrence rate and high safety., The recurrence in most cases is seen within 6 months but can sometimes occur later.
Recent reports favor the use of fibrin glue above sutures with improved comfort, decreased surgical time, and reduced complication and recurrence rates. Suture-related complications include infection, granuloma formation, and chronic inflammation, whereas plasma-derived fibrin glue has the potential risk of prion disease transmission and anaphylaxis in susceptible individuals.
In the present study, we sought to determine the safety and efficacy of using glueless and sutureless technique of conjunctival autografts and to compare the results of such technique with the use of Vicryl sutures in patients undergoing pterygium excision. To do this, we planned a prospective study to evaluate operation time, postoperative patients' comfort, and pterygium recurrence.
| Materials and Methods|| |
A prospective clinical trial was designed to compare the postoperative ocular discomfort and the surgery time for no suture, no glue autologous conjunctival transplants in pterygium surgery. Patients referred to our hospital for pterygium surgery were enrolled in the study.
This prospective study included 205 cases of pterygium of 196 patients with vascular, progressive pterygium, who underwent pterygium excision with conjunctival autografting using no sutures and no glue technique from January 2012 to November 2015.
Pterygium was graded depending on the extent of corneal involvement: Grade I – crossing the limbus, Grade II – mid-way between limbus and pupil, Grade III – reaching up to pupillary margin, and Grade IV – crossing pupillary margin. Surgeries were performed by two very experienced surgeons who have vast exposure in surgical management of pterygium. Both of them used similar technique in all cases to avoid any surgical bias regarding recurrence. Exclusion criteria from the study were unwilling patients, where pterygium surgery was performed twice before, where previous pterygium was done with autograft (we prefer amniotic membrane graft in these cases), and where follow-up of at least 9 months was not available.
Patients' data collected included age at the time of surgery, sex, past ocular, medical, and surgical history, indication for surgery, visual acuity before and after surgery, surgical technique and complications, postoperative medications, postoperative complications, recurrence, and final cosmesis.
Anesthesia is achieved with a peribulbar block with mixture of bupivacaine 0.5% and lidocaine 1%. Superior rectus bridle suture was used in every case as it helps in obtaining a good conjunctival graft from superotemporal position. The body of the pterygium is dissected 4 mm from the limbus, down to the bare sclera, and reflected over the cornea. The use of mitomycin C 0.02% was required (in 52 of cases) in cases of recurrent pterygium or in an extremely inflamed pterygium in a high-recurrence risk patient (young patients). The pterygium head is avulsed using toothed forceps followed by careful beaver blade (number 15) excision of corneal remnants. Hemostasis was allowed to occur spontaneously without the use of cautery as little oozing is useful as it helps in adherence of graft to the bed.
Careful dissection between donor graft conjunctiva and Tenon's layer is used while fashioning the 1 mm oversized conjunctivolimbal Tenon's free graft from the superotemporal bulbar conjunctiva. Care was taken to obtain the autograft as thin as possible without Tenon's tissue [Figure 1]. The limbal edge of the graft was cut to contain a thin rim of corneal epithelium. The graft was quickly flipped over to the sclera. Proper orientation was maintained, with the epithelium side up and the limbal edge toward the limbus. After the graft was positioned, about 2–3 min was used to smooth out the graft and press it gently to the scleral bed, attaching the graft firmly. The scleral bed is viewed through the transparent conjunctiva, and to prevent relift of the graft due to residual bleeding, direct compression of the small central hemorrhages using needle holder or Mcpherson forceps was done until hemostasis was achieved. It gets attached to the bed due to coagulation of fibrin from the little oozing of blood under the flap. The tissue was left for about 10–12 min in place.
The stabilization of the graft was tested with a Weck-cel spear centrally and on each free edge to ensure firm adherence to the sclera. The speculum was removed carefully without disturbing or displacing the graft. The lids are closed, and pressure bandage was applied for 24 h. Surgery time was noted from the first incision until the lid speculum was removed. Subconjunctival injection was not used due to possibility of lifting of the graft.
Postoperatively, steroid (dexamethasone) drops were initially given 4 to 6 times a day and tapered over 4 weeks while antibiotic (ofloxacin) drops were administered 4 times a day for 4 weeks.
| Results|| |
A total of 205 pterygium of 196 patients (mean age 47.7 years with standard deviation [SD] ±9.2 years) underwent pterygium excision with autologous conjunctival graft with no suture, no glue technique. There were 156 male and 49 female patients. One hundred and eighty seven patients had primary pterygium and 18 had recurrent pterygium. All of them signed informed consent. Mean follow-up time was 14.6 months (range: 9–18 months). The mean surgical time was 35 min (SD ±7).
There were no intraoperative complications reported except in two cases where we had to use sutures for securing the graft as we noticed graft was not attaching well with undersurface in these two patients. Visual acuities were not affected in any of the patients. Patients rated their cosmesis as excellent in all cases [Figure 2],[Figure 3],[Figure 4], and photographic comparison of nasal to temporal conjunctiva at last review revealed no obvious cosmetic defects. Postoperative pain on day 1 after surgery was consistently rated as ≤3 out of 10 on a visual analog score. As majority of the patients in our study were not literate enough, so proper counseling was done by Arabic-speaking staff in the department, and all patients were instructed how to use the visual analog score during the postoperative week. Visual analog score is a simple scale, consists of a 10 cm line anchored at one end by a label “no pain” and at the other end by “worst possible pain.” The patient marks on the line how severe the pain is at the moment. Pain did not increase in any case after the 1st postoperative day.
Follow-up was done by operating surgeon for first 3 months, and after 3 months, follow-up was done by other nonoperating ophthalmologists to avoid bias regarding recurrence rate.
There were two cases with transplant loss on the 1st postoperative day and were treated as bare sclera technique. In one of the cases of graft loss, the patient did have recurrence and underwent resurgery elsewhere. The second case did not have any recurrence. Neither transplant necrosis nor excessive postoperative bleeding was seen. A yellowish transplant serous edema was sometimes observed and was slightly more common in the mitomycin used group. This resolved later, spontaneously. At early follow-up, a small amount of gaping at the nasal edge of the graft was seen in 74 cases (36%), and this gaping healed spontaneously without any surgical intervention [Figure 5]. This nasal gaping does not increase risk of recurrence or failure. The transplants healed with excellent cosmetic result. The donor site healed without any problem except in two cases which showed granuloma formation at the harvested site and had to be removed surgically [Figure 6]. Granuloma formation is not unusual in pterygium surgery. The formation of Tenon's granuloma may occur within 1–4 weeks after pterygium surgery as a proliferative, inflammatory lesion; it is a form of pyogenic granuloma. Due to excessive inflammation and localized irritation at the site of exposed Tenon's tissue, granulomas can occur at harvested site. Pyogenic granuloma has been recognized as a postoperative complication after pterygium surgery.
| Discussion|| |
There have been many attempts to optimize pterygium surgery. The aim is to excise the pterygium and prevent its recurrence.
The sutureless and glueless method described here was developed to address patients' discomfort, especially postoperative pain and surgical time. In addition, postoperative patching, healing time, and restrictions in normal life after surgery were of concern.
Evaluating pain is not easy. Patients report different sensitivity for the same stimulus. In addition, they have different capacity to withstand the pain. Furthermore, they have different ability to report their experience. In this paper, we have shown that the use of no sutures, no glue technique when securing the autologous conjunctival graft in pterygium surgery causes significantly less pain than using sutures. During our previous study, where we did pterygium excision with conjunctival autograft, we have tried interrupted 8–0 Vicryl sutures with nonburied 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. On the other hand, patients reported remarkably little pain when we started with no glue, no suture technique.
Surgical time was also significantly shorter in no glue, no suture technique (35 min) as compared with sutured technique 45–50 min. This method entails shorter surgical time as no suturing was required.
The cost of surgery is another very important factor to be considered. 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.
The total recurrence rate in this study is 6.8% (number of patients 14), which is slightly more to our previous study  of pterygium excision with autograft using suture where we had recurrence of 4.7%. We feel that the rate of recurrence between sutured graft (4.7%) and nonsutured graft (6.8%) is definitely significant. Although the sample size in our sutured graft study was small (43 cases), so we are not very sure about the exact reason behind this, but we feel that with sutures in place, graft and stem cell are more firmly attached against the limbus and therefore reducing the recurrence rate. Further evaluation of the recurrence rate is needed with even larger series. de Wit et al. reported no recurrence and no transplant dislocations in their study of 15 cases using no suture, no glue technique. Malik et al. reported recurrence in one eye (2.5%) out of 40 cases and dehiscence in 2 cases. Rathi et al. 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 higher (6.8%) as compared to studies done by Malik et al. (2.5%) and by Rathi et al. (1%). Primary reason for this significant variation most probably is that these studies were performed on less number of patients as compared to our extensive study of 205 cases. Secondarily, pterygium in Oman tends to be more aggressive and vascular due to climatic conditions.
Our study has limitation that it comprised a small study population of the designated area.
| Conclusion|| |
Using no glue 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.
In summary, the salient features of our study with 205 pterygium excisions with autograft using no glue and no sutures are as follows:
- It is safe and effective in reducing early postoperative complications and patients' discomfort
- This innovative technique in pterygium surgery with autograft significantly shortens the duration of surgery (on an average 35 min)
- Graft was lost in two cases on the 1st postoperative day
- In two cases, autograft did not attach well intraoperatively, so we had to use sutures for securing the graft well
- Nasal gaping is seen in 36% of cases (74 cases). We could not find the cause behind this high number of cases with nasal gaping. All the cases with nasal gaping healed well in due course of time and did not require any surgical intervention
- Two cases reported with granuloma formation at the graft harvested site which was removed surgically
- We report recurrence rate of 6.8% (14 cases), which is slightly higher than pterygium surgery with autograft using sutures
- This technique works well with the use of mitomycin C and in recurrent pterygium
- From the patients' perspective, greater comfort allows a more rapid return to their normal lifestyle and productivity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]