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95
Nepalese Journal of Ophthalmology
Bista D et al
Sutureless Glue Free Versus Sutured Limbal Conjunctival
Autografts In Primary Pterygium Surgery
Nepal J Ophthalmol 2021; Vol 13 (26): 95-104
Original Article
Sutureless Glue Free Versus Sutured Limbal Conjunctival
Autografts In Primary Pterygium Surgery
Dikshya Bista1, Raghunandan Byanju2, Maria Alexsandronva Gautam2
1Geta Eye Hospital, Geta, Kailali, Nepal
2Bharatpur Eye Hospital, Bharatpur, Chitwan, Nepal
ABSTRACT
Introduction: Surgical excision is the denitive treatment for pterygium. Following excision, conjunctival
autograft is usually preferred. Various methods for grafting with sutures, glue or autologous serum from
the recipient bed are in use. The objective of this study was to compare surgical outcomes of sutureless
glue free conjunctival autograft with sutured (vicryl 8-0) conjunctival autograft in primary pterygium
excision.
Materials and methods: A prospective randomized interventional study was carried out in 100 eyes with
primary pterygium. They were divided into two groups for conjunctival graft adhesion; sutureless glue
free (group 1; n=50 eyes) and sutured with absorbable (vicryl 8-0) suture (group 2; n=50 eyes). Time
taken for surgery, complications, postoperative symptoms and overall satisfaction score were noted. The
patients were followed up on day 1, day 14 and 6 weeks after surgery. Recurrence was noted till 1 year
after surgery.
Results: The mean age was 46.76 ± 11.97 years (group 1) and 47.24±12.76 years (group 2). Group 1
had shorter duration of surgery (p<0.001), less postoperative complaints (p<0.001) and better patient
satisfaction (p<0.001) than group 2. Postoperative complications and gain in visual acuity in both the
groups were not clinically signicant. Recurrence was not signicant in both groups until 1 year of follow
up.
Conclusion: Pterygium surgery with sutureless glue free conjunctival autograft had fewer postoperative
complaints and better patient satisfaction than pterygium surgery with sutured conjunctival autograft. The
postoperative complications, recurrence were comparable to conventional sutured technique.
Key words: Fibrin glue, Glue-free pterygium surgery, Pterygium, Recurrence, Sutureless glue free
conjunctival autograft.
Financial Interest : Nil Received : 20.09.2020
Conict of Interest : Nil Accepted : 06.03.2021
Corresponding Author
Dr. Dikshya Bista
Geta Eye Hospital,
Geta, Kailali, Nepal.
E-mail: dr.dikshya12@gmail.com
Access this article online
Website: www.nepjol.info/index.php/NEPJOPH
DOI: https://doi.org/10.3126/nepjoph.v13i2.31347
Copyright © 2021 Nepal Ophthalmic Society
ISSN: 2072-6805, E-ISSN: 2091-0320
This work is licensed under a Creative Commons
Attribution-NonCommercial-NoDerivatives 4.0
International License (CC BY-NC-ND).
96 A biannual peer-reviewed academic journal of Nepal Ophthalmic Society
INTRODUCTION
Pterygium is a brovascular proliferation of
subconjunctival tissue towards the cornea
which is more common on the nasal side. It is
thought to be caused by ultraviolet rays, hot
dry climate, dust, wind (Hill and Maske, 1989).
Surgical excision is the treatment of choice for
pterygium.
Simple surgical excision technique leaving bare
sclera is not favored due to high recurrence rates
(Youngson, 1972). Recurrences occur mostly
within a year of surgery (Avisar et al., 2001;
Hirst et al., 1994). Several techniques like beta
irradiation, Mitomycin C, amniotic membrane
transplantation have been tried to reduce the
recurrence rate (Kawasaki et al., 2003; Lam et
al., 1998; Monselise et al., 1984).
Conjunctival autograft with limbal to limbal
orientation reduces the chances of recurrence
as stem cells in the limbus act as a barrier for
conjunctival cells (Salman and Mansour, 2011)
. The autograft could be held at the graft site by
sutures, brin glue or autologous brin from the
graft recipient site.
Sutureless techniques either with brin glue or
autologous brin have shown to be comfortable
postoperatively (Elwan, 2014; Yan et al., 2019;
Yüksel et al., 2010). It is said to have lesser
complications, shorter surgery time and reduced
rate of recurrence (Koranyi et al., 2005, 2004).
The cost of the brin glue has been a limiting
factor for its use (Yüksel et al., 2010). A better
alternative for it would be letting brin at the
recipient bed to hold the graft as in a sutureless
and glue-free technique.
In this study, both techniques were compared
in terms of operative time, complications,
postoperative symptoms, overall satisfaction
and recurrence. Sutureless technique can be
a better alternative if patients have similar
postoperative results with less discomfort.
MATERIALS AND METHODS
Hundred eyes of 100 patients were randomised
into two groups; either sutureless and glue
free autograft (group 1; n=50 eyes), or sutured
absorbable (vicryl 8-0) autograft (group 2;
n=50 eyes) technique of autograft adhesion.
All patients underwent surgery under local
anaesthesia by a single surgeon and were
followed up on day 1, day 14, 6 weeks after
surgery. Recurrence was observed until 1 year
after surgery. During follow up, visual acuity,
complaints of patients and any complications
related to surgery were noted.
Peribulbar anesthesia with 2% lignocaine and
0.5% bupivacaine was given preoperatively.
An eyelid speculum was inserted. The body of
the pterygium was excised around 4 mm from
the limbus and it was removed by avulsion.
The head of the pterygium was detached using
a crescent knife. The body was dissected from
the overlying conjunctiva using blunt and sharp
dissection. The subconjunctival pterygium
tissue, the thickened segment of conjunctiva
and adjacent Tenon’s capsule were excised
leaving bare sclera. Size of the bare sclera
was measured with callipers. Conjunctival
autograft was taken from the superior quadrant
after giving subconjunctival injection lidocaine
which facilitates separation of conjunctiva from
Tenon’s capsule. The conjunctiva was dissected,
Bista D et al
Sutureless Glue Free Versus Sutured Limbal Conjunctival Autografts In Primary Pterygium Surgery
Nepal J Ophthalmol 2021; Vol 13 (26): 95-104
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Nepalese Journal of Ophthalmology
around 2 mm more than the size measured at the
recipient bed, by Westcott’s scissors. It was then
separated upto the limbus and cut. Forceps was
used to slide the graft towards the recipient bed.
In group 1, a small bleed with autologous serum
from the scleral bed was used to adhere the graft
to the recipient site. Sometimes a small blood
vessel in the scleral bed was punctured for
autologous serum. The conjunctival autologous
graft was kept at the recipient scleral bed and
gently pressed with a spatula; the edges of the
graft were pinched with toothed forceps to the
surrounding conjunctiva. The adhesion of the
graft was ensured by moving the graft slightly.
Then it was padded and bandaged for 18
hours-20 hours till the patient came for follow
up the next day.
In group 2, the conjunctival graft was kept in
place and 8-0 vicryl suture was applied, 1st at
two limbal edges and then sutured as needed
and eye was pad and bandaged till they were
followed up the next day.
Time taken for the surgery and intraoperative
and postoperative complications were noted.
Patients were started on antibiotics-steroid
eye drops on the next day and were tapered
gradually.
The postoperative symptoms were assessed by
a preformed questionnaire including grading
of symptoms for pain, foreign body sensation
and photophobia. It was scored as 0 to 3 (0 =
Nothing; 1 = mild; 2 = moderate; 3 = severe)
and a mean score was given for each symptom
in each group (Elwan, 2014).
The mean score was calculated and the result
was analyzed statistically using one way Anova.
The overall satisfaction score was recorded
at 6 weeks follow up as four grades:
0 = unsatised; 1 = low satisfaction; 2 =
moderate satisfaction; 3 = high satisfaction
(Elwan, 2014). The data was analysed using
Fischer’s exact test.
Recurrences were observed during follow up
and dened as encroachment of bro-vascular
connective tissue across the limbus and onto the
cornea for any distance (Hirst et al., 1994).
Bista D et al
Sutureless Glue Free Versus Sutured Limbal Conjunctival Autografts In Primary Pterygium Surgery
Nepal J Ophthalmol 2021; Vol 13 (26): 95-104
Figure 1: Postoperative clinical photograph showing sutureless conjunctival autograft.
98 A biannual peer-reviewed academic journal of Nepal Ophthalmic Society
RESULTS
100 eyes of 100 patients were included in
the study. 50 underwent sutureless glue free
conjunctival autograft and 50 underwent sutured
conjunctival autograft. Nasal pterygium was
present in all cases. There were 55 female and
45 male in the study. 56 pterygia were present
on the right side.
The mean age was 46.76 ± 11.97 years (group
1) and 47.24±12.76 years (group 2) which was
not signicant statistically (p>0.05)
Figure 2 : Clinical photograph showing graft uptake at (from left to right) immediate, 2
weeks and 6 weeks post-surgery.
The time taken for surgery in group 1 was 20.18
± 2.08 minutes and 22.14 ±1.79 minutes in
group 2(p<0.001).
In the sutureless group, postoperatively, 2 (4%)
eyes had graft dehiscence, which was due to
rubbing of the eyes after opening the dressing
on day 1. Autograft was re-sutured in these
cases on the next day. 3(6%) eyes had graft
haemorrhage; these were seen in cases where
vessels were punctured intentionally during
surgery for better adhesion of graft.
Table 1: Demographic prole of study population.
Group 1 (N=50) Group 2 (N=50)
Mean age 46.76 ± 11.97 47.24 ± 12.76
Gender
Male 42%(n=21) 48%(n=24)
Female 58%(n=29) 52%(n=26)
Laterality
Right 58%(n=29) 54%(n=27)
Left 42%(n=21) 46%(n=23)
Bista D et al
Sutureless Glue Free Versus Sutured Limbal Conjunctival Autografts In Primary Pterygium Surgery
Nepal J Ophthalmol 2021; Vol 13 (26): 95-104
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At the 2nd week of follow-up, graft oedema
was seen in 4(8%) cases, which resolved later.
4(8%) cases had graft retraction which was due
to oedema. At 6 weeks follow up 1 (2%) eye
had granuloma at the area of exposed Tenon
which was excised.
In the sutured group, there was no graft
dehiscence. On day 1, 3 (6%) eyes had graft
haemorrhage, which was present due to suturing
and trauma to vessels. At week 2, 1 (2%) case
had dellen which was treated with removal of
suture and lubricants. 1(2%) cases had graft
retraction due to oedema which resolved at 6
weeks follow-up. 1 (2%) eye had foreign body
granuloma which was excised.
The postoperative complication in either
group was not statistically signicant. Other
postoperative complications such as scleral
necrosis, graft necrosis or scleral thinning were
not detected.
Table 2: Post-surgical complications.
Complication Group 1 Group 2
Number Percentage Number Percentage
Graft hemorrhage 3 6% 3 6%
Granuloma 1 2% 1 2%
Dellen 0 0% 1 2%
Graft retraction 4 8% 1 2%
Graft dehiscence 2 4% 0 0%
Conjunctival edema 4 8% 1 2%
Graft necrosis 0 0% 0 0%
Scleral necrosis 0 0% 0 0%
Scleral thinning 0 0% 0 0%
Figure 3: Complications: Suture granuloma (right), early subconjunctival hemorrhage in
sutureless group (left).
Bista D et al
Sutureless Glue Free Versus Sutured Limbal Conjunctival Autografts In Primary Pterygium Surgery
Nepal J Ophthalmol 2021; Vol 13 (26): 95-104
10 0 A biannual peer-reviewed academic journal of Nepal Ophthalmic Society
Postoperatively, the mean score was noted for
pain, foreign body sensation and photophobia
(Table 3). On day 1, mean score for pain was
1.14, foreign body sensation was 1.16, and
photophobia was 0.64 in group 1. In group 2,
mean score for pain was 1.62, foreign body
sensation was 1.68 and photophobia was 1.22;
(p value <0.001).
At week 2, in group 1, mean pain score was
0.22, foreign body sensation was 0.38 and
photophobia was 0.06. In group 2, mean pain
score was 0.52, foreign body sensation was 0.76
and photophobia was 0.22 (p<0.05).
At week 6, mean pain score was 0 in group 1 and
0.14 in group 2(p<0.05), foreign body sensation
was 0.04 in group 1 and 0.18 in group 2
(p>0.05). None of the patients had photophobia
at 6th week in both the groups.
At 6 weeks, the patient satisfaction score was
statistically signicant for group 1(p<0.001).
Gain in visual acuity in both the groups was not
clinically signicant.
There was no recurrence in either group till 6
weeks of follow up. At 1 year of follow-up, 4
eyes (8%) in-group 1 and 5 eyes (10%) in group
2 had recurrence which was statistically not
signicant between groups.
DISCUSSION
Several surgical techniques from simple
excision leaving bare sclera to conjunctival
limbal autograft are explained for the
management of pterygium. Pterygium
recurrence following primary pterygium
surgery with bare sclera technique is around
six times higher than with conjunctival
Table 3: Mean score for postoperative symptoms.
Postoperative
symptoms
Day 1 Day 14 Day 42
Group 1 Group 2 Group 1 Group 2 Group 1 Group 2
Pain 1.14 1.62 0.22 0.52 0 0.14
Foreign body sensation 1.16 1.68 0.38 0.76 0.04 0.18
Photophobia 0.64 1.22 0.66 0.22 0 0
Table 4: Postoperative satisfaction score.
Group 1 Group 2
Unsatised 0 0
Low satisfaction 6 1
Moderate satisfaction 28 49
High Satisfaction 16 0
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autograft placement (Sánchez-Thorin et al.,
1998). Ma et al (2000) explained that the
proliferation of subconjunctival broblasts and
vascular cells was due to surgical trauma and
subsequent postoperative inammation.
The deposited proteins further contribute to
pterygium recurrence. Techniques have been
developed to lower recurrences by using
limbal conjunctival autograft and also by
using adjunctive therapies like Mitomycin C,
beta irradiation, 5-uorouracil (Frucht-Pery
and Ilsar, 1994; Salman and Mansour, 2011).
Limbal auto-grafts can act as a barrier against
conjunctival invasion onto the cornea and also
supply stem cells of the corneal epithelium
(Salman and Mansour, 2011).
In autologous conjunctival graft technique, the
graft can be adhered to the bare sclera by sutures,
brin glue or autologous brin from the scleral
bed. (Gröner, 2008). Sutureless technique either
with brin glue or autologous brin can have
less discomfort than sutured technique when
securing the graft.(Elwan, 2014; Yan et al., 2019;
Yüksel et al., 2010) Fibrin glue which is used
as an alternative to sutures for adhesion of the
autologous graft, decreases postoperative pain
and shorten the surgery time. (Koranyi et al.,
2005). However, cost of the product has always
been a factor limiting its use (Yüksel et al., 2010)
Plasma derived products have been shown to
have viral contaminants mostly hepatitis virus,
Parvovirus B19 and prions despite inactivation.
(Gröner, 2008) This leads to threat of spread of
infection using the brin glue.
Sutureless glue-free technique has fewer
postoperative complaints and no risk of disease
transmission as with brin glue. (Sati et al.,
2014; Sharma et al., 2015).
In this study, demographic proles of cases are
not signicant. The age group included in the
study is comparable to the age group in dierent
studies. (Elwan, 2014; Sharma et al., 2015)
In our study, the mean surgical time for
sutureless technique was 20.18 ± 2.08 minutes
which was less as compared to sutured technique
( 22.14 ±1.79 minutes); (p<0.001). The time
taken for surgery is comparable and even faster
in group 1. This was similar to other studies
where sutureless technique required lesser time
for surgery.(Elwan, 2014; Sati et al., 2014)
Graft dehiscence is a common complication in
sutureless surgery mostly when brin glue is
used. Alireza et al (2011) described the rate of
dehiscence to be 13.3 % when autologous brin
was used to adhere the graft and attributed the
cause to low levels of thrombin and brinogen.
In our study, 2 (4%) eyes in group 1 had graft
dehiscence, which was due to rubbing of eyes.
It presented as an early complication and the
autograft was re-sutured. There was no graft
dehiscence in-group 2. Our study had lesser
dehiscence than a study done by Elwan (2014)
where 8% cases had graft dehiscence in the
sutureless group. Its incidence was low in the
sutureless group (1.3%) in a study done by
Huda and Khaleque, (2019).
Bista D et al
Sutureless Glue Free Versus Sutured Limbal Conjunctival Autografts In Primary Pterygium Surgery
Nepal J Ophthalmol 2021; Vol 13 (26): 95-104
10 2 A biannual peer-reviewed academic journal of Nepal Ophthalmic Society
Graft oedema was seen in 4(8%) cases in group
1 and 1(2%) case in group 2. It was not present
in cases where the autograft was punctured
intentionally and was also lesser in group 2.
This could be due to escape of uid from the
punctured site during suturing. In a study by
Elwan (2014) it was present in 16% in group
1 and 6%in group 2, which is more than our
case. It was present in 8% in group 1 and 12%
in group 2 in a study by Sharma et al(2015)
which is dierent from our study. It resolved
spontaneously within 6 weeks of surgery and
required no intervention.
At second week 4(8%)case in the sutureless
group and 1 (2%) in the sutured group had graft
retraction which resolved at 6 weeks follow up
and was due to graft oedema. It was less than
the cases described by Elwan, (2014) where
12% cases in sutureless and 6% cases in sutured
groups had graft retraction. Alireza et al., (2011)
reported 20% of cases with graft retraction in a
sutureless group. Only 3.9%cases in sutureless
and 4% cases in sutured groups had retraction
in a study done by Huda and Khaleque, (2019).
One (2%) eye in each group had granuloma,
it was in the area where Tenon was exposed
in group 1 and foreign body granuloma was
present in group 2. Excision of granuloma
was done in both cases. The mean score for
postoperative symptoms; pain, foreign body
sensation and photophobia were less in group
1 than in group 2. The symptoms were reported
more severe in group 2 on day 1 and 14 but later
at 6 weeks it was similar to group 1 (Table 3).
This is similar to a study conducted by Elwan,
(2014) where he reported lower postoperative
symptoms in sutureless groups than with
sutures. Postoperative symptoms were reported
to be lesser in the sutureless group in many
studies (Sati et al., 2014; Sharma et al., 2015;
Yan et al., 2019).
In our study, the patient satisfaction score was
signicantly higher in group 1(p<0.001) (Table
4) which is comparable to a study by Elwan,
(2014).
The recurrence at one year of follow-up was
8% in-group 1 and 10% in group 2, which was
clinically not signicant. Similarly shown in a
study by Elwan (2014) where the recurrence rate
was 6% in the sutureless group, and 8% in the
sutured group taken after three months. Sharma
et al., (2015) showed a lower recurrence rate for
both techniques-0% for sutureless and 4% for
sutured. Longer follow up and larger sample
size would give us better information on the
recurrence.
CONCLUSION
Sutureless and glue-free conjunctival autograft
surgery has fewer postoperative complaints
and better patient satisfaction than sutured
conjunctival autograft. The postoperative
complications and recurrence of both techniques
were comparable.
Bista D et al
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