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Sutureless and glue-free limbal-conjunctival autograft in primary and recurrent pterygium: A pilot study

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  • Air Force Central Medical Establishment

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Purpose: To evaluate and analyze the outcomes of sutureless and glue-free limbal-conjunctival autografting in cases of primary as well as recurrent pterygium. Methods: This prospective interventional study was carried out between February 2019 and February 2020 at a tertiary care hospital in North India. A. total of 70 patients with pterygium underwent sutureless and glue-free limbal-conjunctival autograft. The patients were divided into two groups: group 1 patients with primary pterygium (n = 45), group 2 patients with recurrent pterygium (n = 25). The patients were followed up till 12 months postoperatively. Results: The mean age of the patients in group 1 and group 2 was 37.04 ± 8.69 years and 32.52 ± 6.49 years, respectively (P = 0.04). Postoperatively, no recurrence was recorded in group 1. Recurrence was noticed in two patients (8%) of group 2. The BCVA changed from 78.73 ± 9.86 letters to 80.15 ± 7.29 letters (P = 0.45) and from 79.6 ± 6.44 letters to 79.8 ± 5.86 letters (P = 0.45) in group 1 and group 2, respectively. Graft edema was found in seven (15.55%) cases of group 1 and four (16%) cases of group 2. Graft retraction was found in two (4.44%) cases of group 1 and three (12%) cases of group 2. Conclusion: Sutureless and a glue-free limbal-conjunctival autograft is a safe and effective treatment option for primary as well as recurrent pterygium.
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© 2022 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
Original Article
Sutureless and glue-free limbal-conjunctival autograft in primary and
recurrent pterygium: A pilot study
Vikas Sharma, Ankuj Tinna1, Anuradha Singh2, Atul K Singh, Vikas Ambiya3
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Website:
www.ijo.in
DOI:
10.4103/ijo.IJO_1895_21
PMID:
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Purpose:
   Methods: 
 total
           
n
nResults:
                     
P
 P
P

 Conclusion: 
              
pterygium.
Key words:
   1Department
2Department
 3Department of

    
        

  
 

  

[1][2]
[3] are thought

   
[4] 


 
[5]
[6]    

  
    



[11] 
  











   


Methods

   


Inclusion criteria
Patients of all ages and either sex with primary nasal pterygium

  


Cite this article as: Sharma V, Tinna A, Singh A, Singh AK, Ambiya V.
Sutureless and glue-free limbal-conjunctival autograft in primary and recurrent
pterygium: A pilot study. Indian J Ophthalmol 2022;70:783-7.
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  
Exclusion criteria

   
      




     
  

   

 
   
   

   
   


pterygium. The goals of the pterygium surgery were


    





Surgical procedure



Fig. 1a].
    
      
      
  

     
     
    

     
  
2.
 


  

      


  
 
  
     


Figure 1: Steps of SLGF‑‑LCAG surgery. (a) Cleaning of anterior surface (b) Marking of pterygium (c) Ballooning of pterygium (d) Excision of
pterygium (e) Avulsion of pterygium from corneal surface (f) Marking the graft (g) Separation of the graft from tenon by inltration (h) Dissection
of the graft (i) Spreading the graft over cornea after excision (j and k) Spreading out the graft over recepient area (l) Well adhered graft on
completion of procedure
d
h
c
g
b
f
a
e
k l
i j
 
Sharma, et al.: Sutureless and glue‑free limbal‑conjunctival autografting in primary and recurrent pterygium: A pilot study

   







    











Statistical analysis
  


 P value less than

Results
     
     
  


 P 
     





   

      


   
  
P  
     
P






   
  







Discussion
    
     









    
Table 1: Summary of the demographic data and results
Group 1 (Primary pterygium group) Group 2 (Recurrent pterygium group)
No of patients (n) 45 25
Male 25 16
Female 20 09
Age, range (years) 24‑54 22‑45
Age mean±SD 37.0±8.69 32.52±6.49
Recurrence, no. of patients (%) Nil 2 (8%)
Best‑corrected visual acuity (ETDRS VAS±SD)
Baseline
Final
78.733±9.86
80.15±7.29
79.6±6.44
79.8±5.86
Graft‑related complications
Graft edema
Graft retraction
Graft loss
Cyst
7 (15.55%)
2 (4.44%)
0
0
4 (16%)
3 (12%)
0
2 (8%)
Figure 3: Well‑adhered autograft after 48 h of eye patching postoperatively
  
 



    












    
   
     
   [21]

[22]
Foroutan et al.[21]


   
  et al[23] Singh et al[24] 
et al[25] Kulthe et al.[26] Sharma et al and Mitra, are
   



the aggravated tissue response related to the younger age


     
authors.

et al.




     
Figure 2: Complications. (a) Graft edema (b) Graft retraction (c) Tenon cyst (d) Early recurrence (e) Advance recurrence
d
c
b
a
e
 
Sharma, et al.: Sutureless and glue‑free limbal‑conjunctival autografting in primary and recurrent pterygium: A pilot study
  


     


   
      



of the graft [Fig. 3
       

graft loss are minimal.
Conclusion
     



  

  

 

  


Financial support and sponsorship

Conicts of interest

References
   

 

       

   
    


       
et al
 

         

   
  

 

    


 

      


   


   
 

   
    

    

 


 

     
  

   
   

   


 
et al  


    
    

    
   


   
   

 
et al.  in situ 


     



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
 
Fixation in Pterygium Surgery. Poster Presented at the Annual
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... Moreover, there may be buried suture knots buried under the conjunctival graft using RI method. When the RI suture is removed, part of the conjunctival graft tissue needs to be cut open, which may cause bleeding and pain [27][28][29] . ...
Article
AIM: To report a technique used with intermittent sliding-lock-knot (ISLK) fixation for limbal conjunctival autografts in pterygium surgery and compared with those of routine intermittent (RI) fixation. METHODS: Consecutive patients with primary pterygium who had undergone pterygium excision combined with limbal conjunctival autograft transplantation between March 2021 and March 2022 at our institute were retrospectively analyzed. Primary outcome measures were mean duration of surgery and suture removal, degree of conjunctival hyperemia on postoperative day 1, pain score at suture removal, postoperative symptoms at 6mo, including conjunctival hyperemia, foreign body sensation, and graft stability. RESULTS: Ninety-eight patients underwent monocular surgery and were divided into ISLK (51 eyes) and RI (47 eyes) groups according to the type of conjunctiva autograft fixation method planned. There was no significant difference in mean duration of surgery between the two groups (18.59±2.39min vs 18.15±2.20min, P=0.417); however, compared to the RI group, shorter suture removal times were observed in the ISLK group [0.58min (0.42-0.87) vs 3.00min (2.21-4.15), P<0.001]. The degree of conjunctival hyperemia on postoperative day 1 was milder in the ISLK group (P<0.001). Pain scores at suture removal were lower in the ISLK group than in RI group [1 (0-3) vs 2 (1-4), P<0.001]. Postoperative symptoms at 6mo were comparable between the groups (P=0.487), with no recurrence. CONCLUSION: ISLK is an innovative method for limbal conjunctival autograft fixation after pterygium excision. Compared to RI fixation, ISLK facilitates suture removal and reduces discomfort, with comparable surgery duration and less conjunctival hyperemia.
Article
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Introduction: Sutureless and glue-free conjunctival autograft as a treatment modality for primary pterygium is recently gaining popularity but conventional technique of suturing conjunctival autograft is still practised widely. Aim: To compare the outcome of sutureless and glue-free technique with sutures for limbal conjunctival autografting in management of primary pterygium. Materials and Methods: A prospective interventional study was carried out in 50 consecutive eyes with primary nasal pterygium requiring surgical excision. Simple excision under local anaesthesia was performed followed by closure of the bare sclera by sutureless and glue-free conjunctival autograft in 25 eyes of 25 patients (group 1) and by the conventional method of suturing conjunctival autograft using interrupted 10-0 nylon sutures in 25 eyes of 25 patients (group 2), followed by bandaging for 24 hours in both the groups. Surgical time was recorded for both the techniques. Postoperative discomfort was assessed using preformed questionnaires. The patients were followed up for 6 months. During follow up, graft related complications and recurrence if any were noted. Results: Mean surgical time for group 1 (23.20±1.55 minutes) was significantly less as compared to group 2 (37.76±1.89 minutes); (p=0.001). Postoperative symptoms were seen in less number of patients (20%) and were of shorter duration (2 weeks) in group 1 as compared to group 2 with 20 (80%) patients having symptoms lasting for 4 weeks; (p
Article
Full-text available
Context: Sutures or fibrin glue have been used to fix a conjunctival graft after pterygium excision. A new surgical technique of using patient′s own blood to affix the conjunctival graft after excision of pterygium has been introduced. This technique is safe, economical and reduces complications related to the use of foreign materials. Aim: The aim was to evaluate the surgical technique of a sutureless and glue-free graft for pterygium surgery in terms of complications such as loss of graft, graft dehiscence, and recurrence. Materials and Methods: This was a prospective interventional study. All patients that came to the outpatients department from July 2012 to December 2012 were included in the study. Pterygium excision with conjunctivolimbal autografting without using suture or glue was carried out in all patients. Patients were followed-up postoperatively up to 6 months. They were examined mainly for postoperative complications. Results: A total of 79 eyes of 74 patients underwent suture less glue-free autologous conjunctivolimbal graft after pterygium excision. There were 53 female (mean age-46.85 years standard deviation (SD) 10.59) and 26 male (mean age-45.04 years SD 17.27) patients. There were 77 cases of primary pterygium and two cases of recurrent pterygium. Medial edge recession of the graft was seen in one case (1.2%), whereas two cases (2.5%) had lost graft on the first postoperative day. There were no recurrences at the end of 6 months. Conclusion: The surgical technique of using a sutureless and glue-free conjunctivolimbal autograft is safe and cost-effective. However, this technique is associated with few complications such as medial edge recession and loss of graft.
Article
Background: A pterygium is a fleshy, wing-shaped growth from the conjunctiva, crossing over the limbus onto the cornea. Prevalence ranges widely around the world. Evidence suggests that ultraviolet light is a major contributor in the formation of pterygia. Pterygia impair vision, limit eye movements, and can cause eye irritation, foreign body sensation, and dryness. In some susceptible patients, the pterygium can grow over the entire corneal surface, blocking the visual axis.Surgery is the only effective treatment for pterygium, though recurrences are common. With simple excision techniques (that is, excising the pterygium and leaving bare sclera), the risk of recurrence has been reported to be upwards of 80%. Pterygium excision combined with a tissue graft has a lower risk of recurrence. In conjunctival autograft surgery, conjunctival tissue from another part of the person's eye along with limbal tissue is resected in one piece and used to cover the area from which the pterygium was excised. Another type of tissue graft surgery for pterygium is amniotic membrane graft, whereby a piece of donor amniotic membrane is fixed to the remaining limbus and bare sclera area after the pterygium has been excised. Objectives: The objective of this review was to assess the safety and effectiveness of conjunctival autograft (with or without adjunctive therapy) compared with amniotic membrane graft (with or without adjunctive therapy) for pterygium. We also planned to determine whether use of MMC yielded better surgical results and to assess the direct and indirect comparative costs of these procedures. Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 10, 2015), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to November 2015), EMBASE (January 1980 to November 2015), PubMed (1948 to November 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to November 2015), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (last searched 21 November 2014), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 23 November 2015. Selection criteria: We included in this review randomized controlled trials that had compared conjunctival autograft surgery (with or without adjunctive therapy) with amniotic membrane graft surgery (with or without adjunctive therapy) in people with primary or recurrent pterygium. Data collection and analysis: Two review authors independently screened search results and assessed full-text reports from among the potentially eligible trials. Two review authors independently extracted data from the included trials and assessed the trial characteristics and risk of bias. The primary outcome was the risk of recurrence of pterygium at 3 months and 6 months after surgery. We combined results from individual studies in meta-analyses using random-effects models. Risk of recurrence of pterygium was reported using risk ratios to compare conjunctival autograft with amniotic membrane transplant. Main results: We identified 20 studies that had analyzed a total of 1947 eyes of 1866 participants (individual studies ranged from 8 to 346 participants who were randomized). The studies were conducted in eight different countries: one in Brazil, three in China, three in Cuba, one in Egypt, two in Iran, two in Thailand, seven in Turkey, and one in Venezuela. Overall risk of bias was unclear, as many studies did not provide information on randomization methods or masking to prevent performance and detection bias.The risk ratio for recurrence of pterygium using conjunctival autograft versus amniotic membrane transplant was 0.87 (95% confidence interval (CI) 0.43 to 1.77) and 0.53 (95% CI 0.33 to 0.85) at 3 months and 6 months, respectively. These estimates include participants with primary and recurrent pterygia. We performed a subgroup analysis to compare participants with primary pterygia with participants with recurrent pterygia. For participants with primary pterygia, the risk ratio was 0.92 (95% CI 0.37 to 2.30) and 0.58 (95% CI 0.27 to 1.27) at 3 months and 6 months, respectively. We were only able to estimate the recurrence of pterygia at 6 months for participants with recurrent pterygia, and the risk ratio comparing conjunctival autograft with amniotic membrane transplant was 0.45 (95% CI 0.21 to 0.99). One included study was a doctoral thesis and did not use allocation concealment. When this study was excluded in a sensitivity analysis, the risk ratio for pterygium recurrence at 6 months' follow-up was 0.43 (95% CI 0.30 to 0.62) for participants with primary and recurrent pterygium. One of the secondary outcomes, the proportion of participants with clinical improvement, was analyzed in only one study. This study reported clinical outcome as the risk of non-recurrence, which was seen in 93.8% of participants in the conjunctival limbal autograft group and 93.3% in the amniotic membrane transplant group at 3 months after surgery.We did not analyze data on the need for repeat surgery, vision-related quality of life, and direct and indirect costs of surgery due to an insufficient number of studies reporting these outcomes.Thirteen studies reported adverse events associated with conjunctival autograft surgery and amniotic membrane transplant surgery. Adverse events that occurred in more than one study were granuloma and pyogenic granuloma and increased intraocular pressure. None of the included studies reported that participants had developed induced astigmatism. Authors' conclusions: In association with pterygium excision, conjunctival autograft is associated with a lower risk of recurrence at six months' after surgery than amniotic membrane transplant. Participants with recurrent pterygia in particular have a lower risk of recurrence when they receive conjunctival autograft surgery compared with amniotic membrane transplant. There are few studies comparing the two techniques with respect to visual acuity outcomes, and we identified no studies that reported on vision-related quality of life or direct or indirect costs. Comparison of these two procedures in such outcome measures bears further investigation. There were an insufficient number of studies that used adjunctive mitomycin C to estimate the effects on pterygium recurrence following conjunctival autograft or amniotic membrane transplant.
Article
Purpose: To evaluate the efficiency and safety of using autologous fibrin glue for attachment of a conjunctival autograft in primary pterygium surgery Methods: In this prospective interventional case series, 15 eyes from 13 patients with primary nasal pterygium were included for conjunctival autograft surgery. On the operation day, thrombin and fibrinogen were prepared from the patient's own blood in two separate sealed tubes in the blood transfusion center. Autologous fibrin glue was applied over the bare sclera for attachment of the free conjunctival autograft to the surrounding conjunctiva and sclera. The anatomic outcomes of flap, surgical time, recurrence rate, and other complications were evaluated on days 1, 3, and 7 and at months 1, 6, and 9 and 3 year after operation. A patient's pain was evaluated using a 5-point scale from Lim-Bon-Siong et al grading at all visits. Results: Of the 13 patients, 76.9% were male. The mean age of the patients was 37.26±12.61 (SD) years (range 23-60). The mean follow-up period was 34.67±2.96 months (range 25-36). Three eyes (20%) developed autograft retraction that resolved completely with continued eye patching. Two eyes (13.33%) developed total graft dehiscence, and sutures were used for reattachment of the graft in its correct position. Two eyes (13.33%) developed recurrence of pterygium, one of them had already a total graft dehiscence. In 13 eyes (86.66%), the conjunctival grafts were appropriately adhered to the bed and surrounding conjunctiva without suturing in the final visit. In the first postoperative day, ocular pain was recorded as grade 1 in 11 eyes (73.3%), grade 2 in 3 eyes (20%), and grade 3 in 1 eye (6.6%). In all patients, ocular pain disappeared during the 5 days after operation, except for two patients who needed suturing for graft reattachment, in whom ocular pain continued for 2 weeks. No other complications were found during follow-up. Conclusion: This case series suggests that autologous fibrin glue is a safe and useful alternative method for graft fixation in pterygium surgery.
Article
AIM To study the efficacy and safety of amniotic membrane graft as an adjunctive therapy after removal of primary pterygium, and to compare the clinical outcome with conjunctival autograft and topical mitomycin C. METHODS 80 eyes of 71 patients with primary pterygia were treated with excision followed by amniotic membrane graft. The result was compared retrospectively with 56 eyes of 50 patients receiving conjunctival autograft, and 54 eyes of 46 patients receiving topical mitomycin C. Patients were followed for at least 6 months, and the averaged follow up periods for the three groups were 13.8, 22.8, and 18.4 months, respectively. RESULTS There were three recurrences (3.8%) in the amniotic membrane graft group, three recurrences (5.4%) in the conjunctival autograft group, and two recurrences (3.7%) in the topical mitomycin C group. There was no significant difference in recurrence rate among the three groups (p = 0.879). No major complications occurred in the amniotic membrane graft group or the conjunctival autograft group. One case of infectious scleritis due to scleral ischaemia occurred in the topical mitomycin C group. CONCLUSION This study showed that amniotic membrane graft was as effective as conjunctival autograft and mitomycin C in preventing pterygium recurrence, and can be considered as a preferred grafting procedure for primary pterygium.
Article
Aims To assess the efficacy of securing conjunctival autograft (CAG) without glue or sutures, using the patient's own blood at the surgical site, and to compare it with the current accepted standard of using fibrin glue for graft adherence, in pterygium surgery. Methods A single-centre, prospective, randomised controlled trial was carried out in 200 eyes of patients with primary pterygia who were advised pterygium excision with CAG. Enrolled participants were assigned to Group I or II by randomisation. After excision of pterygium, they underwent CAG with autologous blood in Group I (100 eyes) and CAG with fibrin glue in Group II (100 eyes). During follow-up of 1 year, the eyes were assessed for graft adherence and recurrence. Results Of the 200 eyes randomised, 6 eyes that did not complete intended follow-up were excluded from final analysis. Of the 194 eyes (Group I n=96, Group II n=98), on the first postoperative day, 3 eyes in Group I (3.13%) had total graft dislodgement requiring regrafting from another site or reattachment with glue. In Group II also 2 eyes (2.04%) had graft dislodgement on the first postoperative day requiring regrafting from another site. During the 1-year follow-up, 6 eyes in Group I (6.25%) and 8 eyes in Group II (8.16%) developed recurrence. Conclusions Feasibilty of adherence of the graft without glue in pterygium surgery is promising and has results comparable with the fibrin glue technique in terms of long-term outcome and recurrence, suggesting the potential for autologous blood to replace fibrin glue in graft fixation. Trial registration number Clinical Trial Registry, India: CTRI/2013/06/003764 and UTN: U1111-1140-6572.
Article
Our aim was to compare the efficacy and safety of autologous in-situ blood coagulum versus sutures for attaching conjunctival limbal autografts (CAG) among patients undergoing primary pterygium excision over a period of 1 year. Thirty-two eyes of 32 patients with primary pterygium were randomly divided in into two groups: group I (16 eyes) underwent CAG with 10-0 monofilament nylon sutures and group II (16 eyes) underwent CAG with patient's own in-situ blood coagulum acting as bioadhesive or fixative followed by bandaging for 48 h. Patients were followed up postoperatively on the 2nd day, 1 week, 2 weeks, 4 weeks, and 12 months. All the surgeries were done by the same surgeon. Graft success, recurrence rate, operating time, patient comfort, graft retraction or any other complication were studied. The duration of surgery was significantly less (P < 0.001) in group II (mean duration 15 ± 2 min) than group I (mean duration 67 ± 2 min). Postoperative symptoms were fewer for group II than group I. Rate of recurrence was equal in both groups (one patient in each group, 6.25 %). But complications regarding graft failure and graft retraction were more common in group II (two patients, 12.5 %) than group I (one patient, 6.25 %); however, the difference was not statistically significant (Z = 0.61). Thus, autologous in-situ blood coagulum is a useful method for graft fixation in pterygium surgery with shorter operating time and less postoperative discomfort.
Article
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