|Year : 2016 | Volume
| Issue : 3 | Page : 143-148
Pterygium excision with suture-free, glue-free conjunctival autograft (SFGF-CAG): Experience of a tertiary care hospital of the Northern India
Sushobhan Dasgupta, Vatsala Vats, Sanjeev Kumar Mittal
Department of Ophthalmology, Sri Guru Ram Rai Institute of Medical and Health Sciences and Sri Mahant Indiresh Hospital, Patel Nagar, Dehradun, Uttarakhand, India
|Date of Submission||30-May-2015|
|Date of Acceptance||22-Jun-2016|
|Date of Web Publication||19-Sep-2016|
Department of Ophthalmology, Sri Guru Ram Rai Institute of Medical and Health Sciences and Sri Mahant Indiresh Hospital, Patel Nagar, Dehradun - 248 001, Uttarakhand
Source of Support: None, Conflict of Interest: None
Aim: To evaluate and analyze the surgical outcome of suture-free, glue-free conjunctival autograft (SFGF-CAG) after pterygium excision. Design: Prospective, interventional, hospital-based study. Materials and Methods: Sixty eyes of sixty patients with primary pterygium were graded, and excision was performed by the single surgeon. To prevent recurrence, free CAG was taken from inferotemporal or inferior quadrant from 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 24 h. Postoperatively, patients were put on topical eye drops (moxifloxacin 0.5%, loteprednol etabonate 0.5%, and carboxymethyl cellulose 1%) for 6 weeks. The outcomes were assessed in terms of any recurrence, complication(s), and operative time at each follow-up visit on day 1, 7, 15, 30, 120, and 180. Results: There were 44 females (73%) and 16 males (27%). The mean age of all the patients was 38.92 ± 11.2 years, range 18–60 years. Cosmetic blemish was the chief indication of surgery (42 eyes, 70%). Recurrence occurred in one eye (2%) and graft-related complication took place in one eye (2%; graft dehiscence). Resurgery was required in the latter (2%) as the former refused the same. No other complication was noted. An average surgical time was 16 ± 2 min. Conclusion: The recurrence, complication rate, and the operative time of SFGF CAG seem to be comparable with the current techniques in practice, without adding possible potential hazard of the surgical adjunct.
Keywords: Complications, pterygium, recurrence, suture-free glue-free conjunctival autograft
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2016 [cited 2021 Feb 25];4:143-8. Available from: https://www.jcor.in/text.asp?2016/4/3/143/190788
Cosmetic disfigurement, recurrent inflammation, visual impairment, diplopia from motility restriction, and difficult to wear contact lens are the main indications of surgery (i.e., pterygium excision). The results of pterygium surgery are often compromised by postoperative recurrence, which is the leading cause of surgical failure in a significant number of cases. Risk factors for the recurrence are geographic location, age, gender, morphology and grade of pterygium, and the type of surgical technique., Most of the recurrence takes place within first 6 months postoperatively, and it has been attributed to the upregulation of the inflammatory process.
Conventional surgical procedure(s) practiced nowadays to prevent recurrence, alone or in combination, are conjunctival flap, conjunctival rotational autograft, amniotic membrane graft (AMG), or free conjunctival autograft (CAG) or limbal CAG (LCAG) with surgical adjunct (e.g., suture, commercial fibrin glue, intra- or post-operative 0.02% mitomycin C [MMC]), with variable postoperative recurrence and/or success rate(s).
Till recent years, CAG surgery with the use of fibrin glue, sutures, or MMC was generally regarded as the procedure of choice where surgery is indicated for the treatment of primary and recurrent pterygium, primarily because of its comparable recurrence rate, efficacy, and long-term safety in contrast to other procedures., However, using these surgical adjunct has surgical risks and complications too.,,
We were in search of a technique which has a comparable recurrence and complication rate at the expense of avoiding surgical adjunct (and hence, adjunct-related complication) without compromising the total surgical time.
The purpose of our study was to evaluate and analyze the outcome of suture-free, glue-free CAG (SFGF CAG) following pterygium excision utilizing patient's own natural serum bed for graft adherence without using surgical adjunct (such as suture, fibrin glue, or MMC), in terms of its postoperative recurrence, complication(s), including operative time. To the best of our knowledge, the outcome of such procedure has not been yet documented in this journal.
| Materials and Methods|| |
This prospective study comprised sixty eyes of sixty patients undergoing pterygium surgery at our tertiary care hilly urban referral hospital of the Northern India. Subjects included in the study were from 18 to 60 years of age having primary pterygium involving any eye. Necessary approval from Institutional Medical Ethics Committee was obtained beforehand. Eyes with any pathology which would hamper wound healing such as active infection or inflammation, symblepharon, past ocular surgery within last 6 months, trauma, and systemic diseases such as diabetes mellitus, collagen vascular disease, pregnancy, and bleeding disorders were excluded. Written informed consent was taken from each patient. Preoperative ocular examination included refraction and assessment of best-corrected visual acuity, slit lamp biomicroscopy, baseline intraocular pressure (IOP)-measurement by Goldmann applanation tonometer, fundus examination, and photographic documentation of the pterygium. Wherever patient was found to be taking oral nonsteroidal anti-inflammatory drug (NSAID) and/or anticoagulant, they were discontinued 1 week before surgery. Grading of the pterygium was done as Grade I-pterygium head up to the limbus, Grade II-head between the limbus and a point midway between limbus and pupillary margin, Grade III-head between a point midway between limbus and pupillary margin and pupillary margin, and Grade IV-crossing pupillary margin. All the surgeries were done under a microscope by the same single surgeon (Sushobhan Dasgupta) using the same technique. The eye was anesthetized with topical proparacaine 0.5%, one drop every 10 min interval, repeated twice. Taking all aseptic precautionary, eyelid was then separated by a speculum, and subconjunctival and subpterygial 0.5 ml lignocaine solution (xylocaine 2%) was injected. Gentle massage over the lesion was applied by cotton-tipped applicator for few seconds [Figure 1]a. The neck of the pterygium was then lifted up with the help of fine-toothed forceps, while the head of the pterygium was gently avulsed from the cornea by placing closed tips of a curved corneal scissors or Iris repository underneath the neck of the pterygium mass, keeping the same constant tractional force throughout [Figure 1]b. While doing this, the patient was asked to fix his gaze temporally. Gentle dissection was then carried out in-between the conjunctiva and the sclera with the help of an angled or curved Vannas scissors (World Precision Instruments, Inc., FL, USA), to resect at least 4–5 mm the pterygium mass that included both the superior and inferior border. Neither cautery nor saline irrigation was used throughout the surgery, except tamponade with cotton-tipped applicator whenever required to check excess hemorrhage. The size of the bare sclera defect was then measured with Castroviejo calipers (World Precision Instruments, Inc., Fl, USA). Corneal care was taken by applying viscoelastics throughout the procedure. Now, the patient was asked to fix his gaze upward, and approximately 0.5 ml xylocaine 2% was used to balloon up an inferotemporal or inferior conjunctival flap [Figure 1]c. Vannas scissor was used to make a fine film of 0.5 mm oversized, free conjunctival graft, carefully avoiding inclusion of tenon, or making buttonhole within it [Figure 1]d. The graft was then laid over the bare sclera ensuring same limbus to limbus orientation [Figure 1]e. We waited for 10 min for hemostasis to occur. In cases, where the surgeon appreciated the lack of adequate amount of bleed at the recipient site, episcleral blood vessel was intentionally punctured to create bleeding. The eye was then patched for 24 h with 0.5% moxifloxacin eyedrop. Any intraoperative complication, as well as the operative time, was documented from the recorded video of the whole surgery. Next day, the eye was assessed for symptom, graft adherence, or any complication(s) under slit lamp. Postoperatively, patient was put on topical moxifoxacin 0.5% eye drop four times daily for 2 weeks (Vigamox®, Alcon, Inc., USA), loteprednol etabonate 0.5% eye drop four times daily for first 2 weeks thereafter tapered over next 4 weeks (L-Pred™, Allergan, Inc., USA), and carboxymethyl cellulose 1% eye drop four times daily for 6 weeks (Refresh Liquigel ®, Allergan, Inc., USA). Thereafter, an attempted follow-up of cumulative 6 months (at postoperative day 1, 7, 15, 30, 120, and 180) was done to every patient. At each postoperative visit, thorough slit lamp examination, tonometry, and photo documentation were done, and any recurrence, complication(s), or any complaint were recorded. The primary outcome measure was the recurrence and the secondary measures were complication(s) and surgical time. We defined (1) “recurrence” as the reappearance of fibrovascular growth at the site of previous pterygium excision extending beyond the limbus onto the clear cornea. (2) “Complication” as any adverse event related to (a) the surgery in the intra- and post-operative period, (b) the graft itself, or (c) the drugs prescribed.
|Figure 1: (a) Gentle massage applied following xylocaine 2% infiltrated at the pterygium mass. (b) Avulsion of pterygium head and cap being done. (c) Inferior bulbar conjunctiva ballooned up by injecting xylocaine 2% solution. (d) Free-conjunctival autograft prepared from inferior bulbar conjunctiva. (e) After final positioning and fashioning of free-conjunctival autograft at the recipient bed|
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| Results|| |
A total of sixty eyes of sixty patients underwent primary pterygium excision followed by SFGF CAG. The mean age of all patients was 38.92 ± 11.2 years, range - 18–60 years. There were 44 females (73%) and 16 males (27%) with an insignificant difference in mean age (38.83 ± 9.2 years and 38.88 ± 6.5 years, respectively, P = 0.98, t-test), with the highest incidence seen among 40–50 years aged (29 eyes, 48%). Grade II pterygium was found to be the most common grade (34 eyes, 57%), followed by Grade III (19 eyes; 32%) and Grade I (7 eyes; 12%). No one had Grade IV, bilateral, temporal, or double-head pterygium [Table 1]. Most common indication of surgery was cosmetic blemish (42 eyes, 70%), followed by recurrent inflammation (15 eyes, 25%). Mean operative time was 16 ± 2 min, range 14–18 min. Follow-up ≥6 months observed in 100% patients. Postoperatively, recurrence was seen in one patient (2%) at 3½ months follow-up, who did not turn up for resurgery.
Partially displaced graft (hence, graft-related complication) was noticed in one patient (2%) at the first postoperative day, who underwent resurgery (2%), whereby the graft was reposited and sutured in its proposed site under regional anesthesia that finally resulted in uneventful recovery without any recurrence. No other complication(s) related to the graft, surgery, or drugs were evident until the end of our study. Mean difference between pre- and post-operative IOP was insignificant (14 ± 3 mmHg and 15 ± 3 mmHg, respectively; P = 0.07, t-test). Demographic and clinical data are presented in [Table 2]. Photographic documentation at different stages of follow-up depicted in [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e.
|Figure 2: (a) Preoperative appearance of the left eye showing Grade 2 pterygium. (b) At postoperative day 7. The left eye showing well-positioned graft with mild subconjunctival hemorrhage. (c) One month postoperatively, the left eye showing well-taken graft with no complication. (d) Three month postoperatively, the left eye showing well-taken graft with no complication. (e) Six month postoperatively, the right eye showing well-taken graft with no complication|
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| Discussion|| |
The modern concern of avoiding recurrences and complications while offering rapid recovery safely with minimal discomfort has encouraged surgeons to revise the conventional surgical methods for pterygium despite very favorable outcomes. A recently reported meta-analysis by Kaufman et al. indicated the superiority of CAG and LCAG over AMG, as well as the associated risk of vision-threatening complications with MMC. Other studies although reported LCAG to have very few recurrence and complication rate but seems to be more technically demanding, more complex, and time-consuming, may even worriedly result in limbal stem cell deficiency of the donor site., Luanratanakorn et al. in their study concluded that AMG has a significantly higher recurrence than free CAG. Further, it adds extra cost to surgery, its procurement is cumbersome and requires surgical expertise. The risk of contamination is another problem as strict sterilization protocol to be maintained during its processing.
Nonetheless, CAG, AMG, or LCAG requires either suture, fibrin glue, or autologous blood as an additional surgical adjunct to secure the graft in place.
Suturing is more time consuming, lead to higher postoperative discomfort, higher recurrence, and complications than others, such as prolonged healing, fibrosis, and granuloma formation., Commercial Fibrin glue, although have the advantage of avoiding suture related complication(s), but is not easily available everywhere, especially in the remote areas, and it involves cost. Further, they carry the risk of transmission of prions and parvovirus B19., Anaphylaxis, even death also has been reported from its use, where bovine protein aprotinin is the allergen to be believed. Whereas, in-house preparation of autologous blood is expensive, requires sophisticated laboratory backup, and at least 24 h of processing and the resultant product has a variable concentration of clotting components (thrombin, fibrinogen).,
Although scanty data exist, recent reports on SFGF CAG by different Indian authors,,,,,,,,,,,,, such as Kurian et al., Singh et al., Choudhuri et al., Kulthe et al., Sharma et al., and Mitra, are very encouraging and comparable with our present study. Whereas, studies conducted in the United Kingdom by de Wit et al. and Shaw et al. amazingly show no complication or recurrence at all [Table 3]. The reason for recurrence in one patient (2%) in our study could be attributed to the inadvertent inclusion of tenon in the graft or because of the aggravated tissue response related to his younger age, rather than because of the surgical method. The inclusion of tenon in the graft, graft edema, or subgraft hemorrhage has been linked with recurrence by several authors., Vigorous eye rubbing led to postoperative partial graft dehiscence at the first postoperative day in another patient (2%), who required resurgery (2%) as similarly reported by Hall et al. None other patient in our study had shown any graft-related complication(s) such as excess graft edema, or subgraft hemorrhage, graft loss or necrosis, infection, cyst or dellen formation, symblepharon, and granuloma. We have observed some amount of graft dehiscence from the host conjunctiva (up to 0.5 mm) is common because of graft shrinkage or ocular movement. This is well-tolerated and does not need to be surgically addressed as long as the graft is secure in its place, and it heals up well. Mitra reported, “The main disadvantage of SFGF CAG is the risk of graft loss in the immediate postoperative period, but once the graft stays in place for the first 24–48 h, it is going to stick around.” de Wit et al. in their similar study postulated that there is an even tension across the whole graft interface and no direct tension on the free graft edges as with sutures, thus reduced the stimulus for subconjunctival scar tissue formation.
|Table 3: Comparison of different studies on suture-free, glue-free conjunctival autograft|
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Average operative time in our study was 16 ± 2 min (standard deviation), which compares favorably with other studies as well, and definitely lesser than the suturing technique and possibly the extra time taken to prepare fibrin glue [Table 3].,,,,,,,
In our study, other associated finding(s) that needs to be mentioned here: first, intraoperatively in all the cases, use of topical along with subconjunctival injectable anesthetics helped us to achieve total analgesia without compromising globe motility and patient's compliance, with consequent easier dissection of the pterygium tissue, as well as the graft. The technique of avulsion adopted by us helped to achieve smoother cornea within few seconds, which seems to reduce the surgical time that goes to scrape off the corneal remnants. Furthermore, minimal need for surgical instruments such as cautery, needle with its holder, makes such procedure minimally traumatic. Second, postoperatively in all the cases, donor site healed well without any complication thus helping to retain the superior conjunctiva undisturbed for the possible need for future glaucoma surgery, and loteprednol etabonate 0.5% eye drop seems to be safe and effective anti-inflammatory drug having devoid of any complication such as IOP-spike. Several studies reported similar to this finding.,,
Koranyi et al., who invented the technique of “Cut and Paste-Method”-technique for pterygium surgery using Fibrin glue, reported that this technique has very short learning curve and can be taught and explained easily by qualified consultants but simultaneously they also believe that surgeon's general qualities and devotion affect surgery time, complications, and recurrence rate more than the learning curve of the method., Though, till date, literature search reveals no similar study has been done on SFGF CAG, we here postulate that this relatively newer technique is easier to learn and perform, but simultaneously emphasize the paramount importance of the need to adopt special precaution in patient selection, meticulous pterygium tissue excision, taking tenon free slightly oversized graft, leaving the subgraft area free of hemorrhage, and waiting period of at least 10 min at the end of surgery which gives clue to the overall success as advocated by Mitra  and Shaw et al.
We had in our study some limitations too. Study population and follow-up time were relatively smaller, that it was nonrandomized and thus may seem to have a gender bias, noncomparative, recurrent cases were excluded. There was neither any attempt to quantify adhesive strength of autologous blood nor to correlate learning curve, visual improvement, and socioeconomic factors that could otherwise have affected the surgical outcome, directly or indirectly.
| Conclusion|| |
Though there seem to be several unresolved factors related to the graft adherence, we found the recurrence, complication rate, and the operative time of SFGF CAG comparable with the current techniques in practice, without adding possible potential hazard of the surgical adjunct. However, a randomized multicenter trial with a larger cohort and longer follow-up is warranted to substantiate our findings.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]