Clinical study of sutureless and glue free conjunctival autograft in pterygium surgery

 

Satish Desai^1*, Amol T Wanjari²

 

¹Assistant Professor, PG. Student, Department of Ophthalmology, Government Medical College, Miraj, Maharashtra, INDIA.

Email: [email protected]

 

Abstract          In this paper we study outcome of sutureless and glue free conjunctival autograft in pterygium surgery. To study pattern of astigmatism induced due to primary pterygium. To study the different complications after sutureless and glue free   conjunctival autograft in pterygium surgery. To study change in astigmatism after pterygium surgery by sutureless and glue free   conjunctival autograft.

Keywords: pterygium surgery.

 

INTRODUCTION

In 1985, Kenyon et al proposed that a conjunctival autograft of the bare sclera could be used in treatment of recurrent and advanced pterygium. Recent reports favour the use of fibrin glue above sutures with improved comfort, decreased surgical time, reduced complication and recurrence rates have been reported. Suture-related complications include infection, granuloma formation, and chronic inflammation, whereas plasma-derived fibrin glue has the potential risk of prion disease transmission and anaphylaxis in susceptible individuals. Plasma-derived products such as fibrin glue may produce possible hypersensitivity reactions whereas the risk of viral transmission remains. We study sutureless and glue free [SGF] conjunctival auto graft of achieving conjunctival autograft adherence during pterygium surgery avoiding potential complications associated with the use of fibrin glue or sutures.

• Pterygium is a elastotic degenaration of subconjunctival tissue. It proliferates as vascularized granulation tissue.Prevalence rate - 0.3% to 29% in different parts of the world. Treatment of choice – Surgical Removal.

 

MATERIAL AND METHODS

After obtaining the approval of the Institutional Ethics Committee (Govt Medical College,Miraj.) and written consent from the patients,20 patients will be included.

Inclusion Criteria

• Patient with primary nasal pterygium i.e. no previous operation for excision of pterygium
• Patient with no other ocular disorder

Exclusion Criteria

• Patients with previous history of pterygium surgery.
• Patient with blood disorder -like coagulation factor deficiency.
• Any other ocular disorder like blepharitis, dry eye.

Proforma of the study

Written consent of all patients included in the study was taken after fully explaining the procedure and purpose of the study to the patients. A detailed proforma is devised containing all essential details for each individual. The patients were been asked about their name, age, sex, occupation and address. A complete ophthalmic history was taken which included complaints of growth of fleshy mass-its onset, duration and progress, associated with any other ocular complaints like diminision of vision, foreign body sensations, redness, pain, watering of eyes, discharge from eyes, photophobia, history of injury and past history. Before surgery, a comprehensive clinical examination was done which included

• Snellen visual acuity measurement
• Applanation tonometry
• Slit-lamp examination
• Keratometry
• Anterior segment photography
• Routine investigation.

A record was made of the intraoperative complications occurring during the surgery and their management. The patients were examined on slit lamp on the 1 st postoperative day. The follow-up of the patients was done after 2week, at 1 month, at 6month.On each follow-up patients complaints, patients satisfaction level, visual acuity, slit lamp examination and anterior segment photography was done.

MATERIALS: Snellen’s vision chart, Slit lamp, Applanation tonometer, Keratometer

Type of Study: A Prospective, Interventional

Sample Size: 20 eyes with primary progressive nasal pterygium

Duration of study: August 2012-July 2013.

Place of study: Government Medical college and Hospital,Western Maharashtra.

BEFORE SURGERY

• Medical and ocular history
• Snellen visual acuity measurement
• Slit lamp examination
• Anterior segment photography
• Keratometry.
• All the patients were informed about study design, procedure and written informed consent was obtained from all the patients.
• Type of Surgery Pterygium excision with sutureless and glue free conjunctival autografting was perfomed in all patients.

• Haemostasis (spontaneously) over the bare sclera.
• Don’t use cautery.
• If no blood is available to provide autologous fibrin  small veins and capillaries are purposely ruptured.

Graft - Careful dissection between donor graft conjunctiva and Tenon's layer ( 1mm oversized ).

 

 

• Site- superotemporal bulbar conjunctiva
• Position of graft -The limbal edge of the graft is carefully positioned at the host limbal tissue edge.

 

The edges are held with foreceps for 3 – 5 min.

 

 

Figure 1: Pterygium before surgery

Figure 2: Pterygium 1^st post-operative day:

Figure 3: Pterygium 1 month post-operative

RESULTS

Table 1

No.  Of Eyes	20
Location	Primary Progressive Nasal Pterygium
Mean Operation Time	16 Min
Mean Graft Size	24mm²
Complications	Graft Edema Graft Retraction

COMPLICATIONS

Table 2

OBSERVATIONS: Age distribution: The mean age of patients was 52.6 year (Range 24-83).

 

 

 

 

GRADES OF PTERYGIUM

 

Figure 4: Post operative pain value on Visual Analogoue Scale

 

Table 3

Surgical Time: The mean surgical time was 16 minute.

Surgical Time: The mean surgical time was 16 minute.

 

 

Table 4: Pre operative and post operative difference in astigmatism

 

COMPLICATIONS: GRAFT EDEMA -2 Eyes (10%)

Figure 5: Treatment -Frequent steroid and antibiotic eye drops instillation.

GRAFT RETRACTION – 2 Eyes (10%)

Treatment -a continuation of patch therapy (48-72 hours) until secondary re epithelialization of the defect occurred without suturing.

ADVANTAGES

• NO GRAFT DEHISCENCE
• NO RECURRENCE OF PTERYGIUM
• There are no expenses like
• SUTURE (cost Rs. 500 )
• COMMERCIAL GLUE (cost Rs. 1500).

Surgical methods and related complications

• Suture
• chronic inflammmation
• Granuloma formation
• Bare sclera
• High recurrence
• Amniotic Membrane
• Requires costly donor tissue
• Fibrin Glue
• Prions Disease
• Hypersensitivity
• Mitomycin C Thiotepa, B Irrd
• Risk of corneal or scleral necrosis.

 

Table 5: Comparision with other studies

STUDY	Our Study	Mitra S et al.	de Wit D et al	Malik KP et al
No. Of patient Duration	20 6 months	19 6 months	15 9.2 months	40 12 months
Surgical time	16min	11 min	14 min	-
Chemosis	2 (10%)	_	_	3 (7.5%)
Retraction	2 (10%)	2 (10.5%)	_	3 (7.5%)
Dehiscence	_	_	_	2 ( 5% )
Recurrence	_	_	_	(2.5%) at 6 months

 

CONCLUSION

Sutureless and glue free conjunctival autografting is a safe, effective and economical option for the management of primary pterygium. It produces lesser postoperative pain and it requires shorter surgical time. No cases of graft dehiscence, recurrence of pterygium during the follow up period.

 

 

REFERENCES

1. Mitra S et al. Autoblood as Tissue Adhe- sive for Conjunctival Autograft Fixation in Pterygium Surgery. Poster presented at the Annual Meeting of the American Academy of Ophthalmology; Oct. 22 and 23, 2011; Orlando, Fla.
2. Wit D, Athanasiadis I, Sharma A, Moore J (2010). Sutureless and glue free conjunctival autograft in pterygium surgery: a case series. Eye 24: 1474-77.
3. Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985; 92: 1461
4. Tan D. Conjunctival grafting for ocular surface disease. Curr Opin Ophthalmol 1999; 10: 277–281
5. Pan HW et al. Ophthalmology. 2011;118(6): 1049-1054.
6. Hirst LW. Extensive Incision and Conjunc- tival Transplantation for Pterygium: Results of 1,000 Surgeries. Presented at World Cor- nea Congress; April 7-9, 2010; Boston