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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.
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.