Pterygium Surgery with Conjunctival

Autograft without Suture or Fibrin Glue

ABSTRACT
Background: To research the efficacy of pterygium excision with conjunctival autograft
without suture or fibrin glue.
Methods: After pterygium excision and preparing of autologous conjunctival graft, the
recipient bed is encouraged to achieve natural haemostasis before graft placement. Excessive
haemorrhage in the graft bed is tamponaded without cautery. Graft adherence and positioning
is examined 15 minutes after surgery. Cases were reviewed to obtain details of complications
and recurrence.
Results: Twenty seven eyes of 27 patients with pterygium underwent conjunctival autograft
with natural patients own blood acting as bioadhesive or fixative, without suture. The mean
age is 54 years old (SD 9.86), 13 males and 14 females. Mean follow up time was 4.0 months
(SD 1.85). The rate of recurrences which followed up for 6 months is 8.33% (1 patient),
9.09% (1 patient) which followed up for 3 months and no recurrences in patients which
followed up for 1 month. The complications regarding graft displacement was 2 patients
(7.4%), 2 patients with graft retraction (7.4%), and 1 patient with loss of graft (3.7%). The
other complications were not found and cosmesis was excellent.
Conclusion: This study suggests that autologous fibrin in blood works as bioadhesive and
can be used as alternative method for graft fixation in pterygium surgery.
 Safety and Efficacy of Fibrin Glue versus Vicryl
Sutures in Recurrent Pterygium with Amniotic
Membrane Grafting
Abstract
Purpose: The study aimed to compare surgical outcomes with likely toxic side effects
when using pterygium excision and amniotic membrane grafting with fibrin glue versus
Vicryl sutures.
Method: This is a prospective randomized study. Patients were classified into two
groups: group 1 consisted of 20 patients with Vicryl-sutured grafts, and group 2 consisted
of 20 patients with fibrin-glued grafts that were prepared from autologous blood. Results
including surgery time, patient discomfort, complications and recurrence rates within 1, 6
and 12 months were analyzed. Results: The study demonstrated that there was a
statistically significant decrease in surgery time in the fibrin glue group (the procedure
took 17 min) relative to the sutured group (28 min; p ! 0.05). Additionally, both
postoperative pain and discomfort were noted significantly less often in the fibrin glue
group. Complications were also decreased in the fibrin glue group. Conclusion: The
study revealed that the use of fibrin glue in pterygium surgery with amniotic membrane
grafting was safer, less toxic and less time-consuming, and resulted in fewer
complications than graft surgery with sutures.

Introduction
A pterygium is a fibrovascular growth of actinically damaged conjunctiva that extends across
the limbus, invading the cornea. It is a common external eye condition, affecting different
individuals, especially in the tropical and subtropical regions, with a reported prevalence of
27% worldwide [1] . The primary indication for surgical removal of a pterygium is
decreased visual acuity that may be the result of encroachment of the lesion onto the visual
axis, induced irregular astigmatism or broken precorneal tear film. Other indications for
surgical intervention include discomfort and irritation unresponsive to conservative therapy,
restricted ocular motility, difficulty with contact lens wear, anticipated keratorefractive
surgery and unacceptable appearance [2] . Major adjuncts for prevention of pterygium
recurrence are application of antimetabolites and conjunctival or limbal grafts. Although
many other therapeutic modalities have been proposed, further studies of their efficacy and
safety are required.
Recently, preserved human amniotic membrane has been advocated for the
management of many ocular surface disorders such as persistent corneal epithelial defects,
ocular surface reconstruction for conjunctival neoplasms or scarring, chemical or thermal
burns, advanced ocular cicatricial pemphigoid, Stevens-Johnson syndrome, corneal scarring
and coverage of conjunctival defects after pterygium excision [4] . Amniotic membrane, the
innermost layer of the placental or fetal membrane, consists of a thick basement membrane
and an avascular stroma. Various effects of the amniotic membrane observed after the
transplantation of amniotic membrane include rapid epithelialization, backing of the normal
epithelial phenotype and a reduction in inflammation, vascularization and scarring. The
amniotic membrane acts as a substrate for surface epithelialization.
Suturing is a time-consuming task in ophthalmology, and sutures induce both
irritation and redness, which ar frequent problems following that case. Postoperative wound
infection and corneal graft rejection are examples of possible suture-related complications. To
prevent these complications, ophthalmic surgeons are switching to sutureless surgery.
Recently, several developments have established many adhesive tissues such as cyanoacrylate
glue and fibrin glue as very attractive alternatives to sutures. Possible and promising new
applications for adhesive tissue forms are to provide a platform for tissue engineering.
Currently, tissue glue is used to conduct conjunctival closure and graft fixation following
pterygium surgery and other ophthalmic procedures.
Fibrin glue is a blood-derived absorbable product that is relatively easy to use.
Additionally, it can be stored at room temperature or in a refrigerator. Despite the fact that the
use of fibrin as a biologic adhesive was introduced in 1909, its first surgical use occurred in
1944 [3] . In 1993, Cohen and McDonald [4] first described the use of fibrin glue during
pterygium surgery. Many authors [6,7] have proven that the use of conjunctival grafts in
pterygium surgery with fibrin glue produces a better surgical outcome with regard to
postoperative inflammation and pain as well as surgical procedure time and postoperativem
recurrence when compared with sutures.

Patients and Methods

This was a prospective, randomized study that was performed in the Ophthalmology
Department at Zagazig University Hospital, Zagazig, Egypt. The protocol for the research
project was approved by a suitably constituted ethics committee of the institution, and the
study conformed to the provisions of the Declaration of Helsinki, 1995 (revised in Tokyo in
2004). The subjects gave informed consent, and patient anonymity was preserved.
We performed a prospective, randomized clinical study of 40 eyes from 40 patients diagnosed
with recurrent pterygium who had been operated on only once. Patients were randomized
according to the following criteria:
- All subjects were patients at the outpatient clinic during the period of the study and
presented a history of previous pterygium surgery
Patient age at baseline was not restricted
The criteria for recurrence were based on the presence of conjunctival tissues invading 2
mm from the limbus.
After pterygium removal, 20 eyes underwent amniotic membrane transplantation using fibrin
glue or 8-0 Vicryl sutures after giving consent for surgery. Pterygium excision was performed
under local anesthesia (0.4% benoxinate HCl as surface anesthesia, and 2% subconjunctival
lidocaine as infiltrative anesthesia); the pterygium was excised with dissection of the
underlying Tenon capsule. Fixation of the grafts was performed by dividing eyes into two
groups with balanced inclusion criteria: group 1 consisted of 20 eyes subjected to the use of
8-0 Vicryl interrupted absorbable sutures, and group 2 consisted of 20 eyes subjected to fibrin
glue graft fixation.
Fibrin glue was prepared according to Panda et al. [3] , using autologous blood from the same
patient (10 ml venous blood samples collected in heparin-coated glass tubes) sent to the
clinical pathology laboratory. Briefly:
The sample was centrifuged (10,000 rpm) to separate the plasma from red blood cells
Plasma separation was then performed
The plasma was centrifuged to produce a precipitate containing fibrinogen and a
supernatant containing thrombin; the precipitate was resuspended in a small volume of the
supernatant and used as the fibrinogen component
Two 26-gauge syringes were used; the first was filled with the precipitated fibrinogen, and
the second was filled with the supernatant thrombin
After drying and proper homeostasis of the bare scleral area, 0.2 ml thrombin was applied
to the bed, and the inner surface of the amniotic membrane graft was coated with fibrinogen
The graft was then applied to its bed, avoiding wrinkling, and fibrinogen was transformed
into fibrin by thrombin over 2 min
An acceptable fibrin clot was achieved during graft fixation
 The patients were advised not to rub their eyes.

Topical steroid and antibiotic drops were used for 7 days in all cases. Follow-up and
examination of the patients using slit lamps were performed postoperatively, and 2 days, 7
days, 1 month, 6 months and 1 year later.
Comparative data were obtained for the following parameters:
surgery time;
postoperative pain (i.e. discomfort that was scaled according to patient complaints, and
whether there was any sensation of foreign bodies or dull aching that caused ocular pain);
postoperative ocular inflammation;
postoperative graft necrosis and loss;
postoperative subconjunctival hemorrhage;
postoperative conjunctival granuloma;
postoperative recurrence and corneal vascularization of 1 2 mm from the limbus;
postoperative scleral and corneal necrosis.
Statistical analysis of the results used unpaired t tests and determination of p values,
with statistical significance set at p ! 0.05.

Results
This study included 40 eyes from 40 patients diagnosed with recurrent pterygium. The study group
included 28 males (70%) and 12 females (30%) between 29 and 63 years old (mean age: 51 years).
The surgery time for the suture group (group 1) was between 23 and 31 min (mean time: approx. 27
min). The surgery time for the fibrin glue group (group 2) ranged from 11 to 19 min (mean time:
approx. 15 min), which is significantly decreased (p ! 0.05) relative to group 1. The difference in
surgery time was mainly due to the period of graft fixation; the time used for pterygium excision was
the same in both groups.
We found that postoperative pain and discomfort were marked in 4 patients (20%) in group 1
compared with 2 patients (10%) in group 2. Postoperative inflammation and redness were also
decreased in group 2 (4 patients, relative to 12 in group 1). Both results are statistically significant (p !
0.05) ( table 1 ). The recurrence rate was higher in the sutured group within 1 year of follow-up: 2
cases (10%) were recorded in group 1 relative to 1 case (5%) in the fibrin glue group (p 1 0.05). We
also found 1 case (5%) of graft sloughing in the fibrin glue group, and 4 cases (20%) of dislodged
sutures in the suture group. Furthermore, 10 cases presented postoperative subconjunctival
hemorrhage (50%) in the suture group, and 2 (10%) in the fibrin glue group. We also had 1 case (5%)
of postoperative conjunctival
granuloma in group 1. However, no cases of postoperative scleral necrosis were reported
from either group.

Discussion
Pterygium surgery is an annoying procedure for many patients and surgeons. Postoperative
recurrence of the,pterygium is considered one of the most common comval granuloma, but no
such cases in the fibrin glue group. Our results agree with Dayanir et al. [11] and Ozdamar et
al. [12] , who stated that the use of conjunctival sutures may stimulate the stratified
epithelium, vascularization, fibroblasts and lymphomonocyte cells to migrate under the
conjunctiva leading to excessive granulation. Also, Koranyi et al. [13] demonstrated a
statistically significant decrease in recurrence rate with the use of fibrin glue when compared
with the use of sutures. They postulated that a possible reduction in the migration of
fibroblast cells caused by rapid adhesion of the graft with fibrin glue might lead to decreased
postoperative inflammation and recurrence.
complications, apart from those concerning the cosmetic appearance of the eye after
surgery. Postoperative pain and discomfort, in addition to inflammation, are frequent
occurrences following pterygium surgery. Thus, surgical procedures were and still are
performed to produce a minimal rate of recurrence and other postoperative complications.
Conjunctival grafting is one such procedure

The present study was designed to use fibrin glue prepared from patients autologous blood,
which is considered the safest method for management because using blood from another
patient carries the risk of bloodtransmitted diseases. This was demonstrated by Panda
et al. [3] , who used homologous blood previously treated by solvent/detergent treatment to
eradicate viral infections (as recommended by Evenson and Rollag [8] for the use of
homologous blood). The present study revealed that the use of fibrin glue decreased surgery
time to 15 min compared with 27 min for sutures. These data agree with Hall et al. [6] , who
reported a mean surgery time with fibrin glue of 12 min relative to 26 min for suture use.
Less postoperative recurrence, inflammation, redness, pain and discomfort were
reported from the fibrin glue group compared with the Vicryl suture group. This is in
agreement with previous reports [1, 5, 9] on fibrin glue use in conjunctival graft fixation. Ti
and Tseng [10] demonstrated that the use of sutures placed in the conjunctiva increases
inflammation during the postoperative period, increasing the risk of pterygium recurrence.
This is due to the inflammation leading to migration of Langerhans cells to the cornea, which
is an important triggering factor for recurrence. Additionally, these factors may contribute to
the granulomatous reaction of conjunctival sutures. Indeed, we had 1 patient in the suture
group who presented with postoperative conjunctival granuloma, but no such cases in the
fibrin glue group.
Our results agree with Dayanir et al. [11] and Ozdamar et al. [12] , who stated that the use of
conjunctival sutures may stimulate the stratified epithelium, vascularization, fibroblasts and
lymphomonocyte cells to migrate under the conjunctiva leading to excessive granulation.
Also, Koranyi et al. [13] demonstrated a statistically significant decrease in recurrence rate
with the use of fibrin glue when compared with the use of sutures. They postulated that a
possible reduction in the migration of fibroblast cells caused by rapid adhesion of the graft
with fibrin glue might lead to decreased postoperative inflammation and
recurrence.

Conclusions
Pterygium excision with amniotic membrane grafting is considered a successful procedure
that achieves a lower incidence of recurrence and better surgical results. The present study
revealed that the use of fibrin glue (prepared from autologous blood) in conjunctival graft
attachment to the scleral bed was safer and less time-consuming, and resulted in fewer
postoperative complications, than the use of Vicryl-sutured grafts.