Introduction: Pterygium takes its name from Greek word pterygos meaning 'wing'. AIM: To compare duration of surgery, post-operative complication, patient discomfort and graft stability between uses of suture less glue free versus suture for fixating conjunctival graft after primary pterygium excision and also compare the recurrence rate between two methods of primary pterygium excision after 6 months. Methods This study includes 100 patients to comparative study to evaluate the outcome of suture versus suture less glue free conjunctival Autograft for primary pterygium excision was conducted in department of ophthalmology at MBS Hospital, Kota from October 2021 to October 2023 after obtaining ethical committee clearance, all the patient underwent primary pterygium excision by single experienced surgeon using the same standard technique the patient per examined on post operative Day-1, one week, 1 month,3 months and 6 months, The technique used in our study is simple randomization technique. This technique maintains complete randomization of patient assignment to a particular groupSTATISTICAL ANALYSIS P value < 0. 05 was taken as significant data entry was done in Microsoft Excel for statistical purpose Results This perspective comparative study conducted on 100 in which 50 patients underwent primary pterygium excision with suture less technique and 50 patients with conjunctivalautografting with 10-0 nylon suture. A major proportion of patient were in the age group 41 - 50 years ( 30 patients 30%) , majority of patients were female numbering 68 patients ( 68%) while males were 32 number (32%), majority of patient had Grade-2 pterygium being 62 in number( 62%) while 28 patient (28%) had Grade -1 and 10 patients (10% ) had great 3 pterygium The socialist glue free group had significantly laser post operative discomfort compared to Suture group. At post operative day one, week 1(p=0.000 at both day-1 and week -1). The difference was not significant. At first month postoperatively (P=0.077). And none of the patient in either group had any discomfort at 3 and 6 month The suture lessGlue free group had significantly lesser post-operative inflammation compared to Suture group at post-operative day 1 and week 1(p=0.001 at both day-1 and week 1). One patient in Suture group was had Suture Granuloma at third month postoperative follow up which was excised. Conjunctival graft secured with auto logos blood were at stable is those secured with such a day-1 and weak -1 1st, 3rd, and 6th month postoperatively. In 4 patients recurrence were noted in each of groups Conclusion: Glue free limbal conjunctival Autograft is safe effective economical and its surgical outcomes following primary pterygium surgery are comparable to conventional suture limbal conjunctival Autograft with lower post-operative suture related complications, less patient discomfort and greater patient satisfaction
Pterygium takes its name from Greek word pterygos meaning 'wing' and was described by Hippocrates Galenand others. The term pterygium was introduced to the English language in 1875 by Walton.
It’s a degenerative condition of subconjunctival tissue which proliferate as vascularized granulation tissue to invade the cornea destroying the superficial layer of stroma and moments membrane the whole being covered by conjunctival epithelium. More common in countries near to equator in hot and sunny climate in farmers in person who do not wear sunglasses and its twice more common in men than women. There is plethora of surgical and medical measures currently available for pterygium with no consensus regarding the ideal treatment. Conjunctival autografting after pterygium excision is associated with very low rate of recurrence and complications when compared with the other techniques. Nevertheless graft suturing has the disadvantage of longer surgery time and complications such as granuloma formation, Giant papillary conjunctivitis and significant patient discomfort after surgery. Lately fibrin based glue for conjunctival autografting have been used to minimize operating time and this comfort associated with sutures but it has potential risk of transmission of prion disease and analysis in susceptible individuals.
The scenario of developing countries like India the patient’s own in-situ blood coagulum activing as a bio adhesive or fixator to fix the conjunctival Autograft has emerged as a cost effective and safe option along with the minimal patient discomfort. Suture less grafting has been used successfully in gingival graft and represent similar mucosal membrane tissue environment to the conjunctiva of eye. Compared to developed countries, studies comparing outcome of suture lessglue free and suture having fewer. It will be advantageous to adopt the better of the two technique in the future and attempt is being made in this study to compare and evaluate the safety and efficacy of social is glue free limbal conjunctival.
Autograft and conventional sutured Autograft in department of ophthalmology at MBS Hospital, KotaPHYSICAL CHARACTERISTICS OF PRIMARY PTERYGIUM
A pseudopterygium is similar to a true pterygium in appearance, But it lacks organization into recognizable part like (cap, had and body) it tend to occur outside the interpalpebral space. It is loosely adherent to the corneal limbus such that small muscle hook or canalicular Probe may be passed under the body without resistance. A pseudopterygium is a fibro vascular scar arising in the bulbar conjunctiva that extent on to the cornea. Pseudopterygium are the result of previous surface inflammation from causes such as from chemical burns, cicatrizing conjunctivitis, surgery or peripheral corneal ulceration
TYPES OF PTERYGIUMS
Progressive pterygium is an actively growing fleshy, vascular, and inflamed looking pterygium, in stationery pterygium the head looks pale and sparsely vascularized and stops growing it may develop Stocker line, while regressive pterygium is a pale thin papery, grey anemic and membranous pterygium
Also, TOWNSEND CLASSIFICATION based on risk factors slit lamp examination and extent on corneal involvement
Depending on risk factor
Slit Lamp grading system based on relative translucency of body of pterygium (Tan's classification)
Classification based on extent of corneal involvement
Grade 1- between limbus and a point Midway between limbus and pupillary margin
Grade 2- Head of pterygium present between a point Midway between limbus and pupillary margin
Grade 3- crossing the people are marginrecurrent pterygium
Regrowth of pterygium after primary excision is called recurrent pterygium. Pathologically it differs from primary pterygium as it is fibro vascular tissue growing on two cornea without elastotic degeneration. It involves underline sclera episclera and Tennon’s capsule and grow on to the corneal stroma where it is firmly adherent to the underlying tissue. Recurrence is more common in younger patient with thick aggressive primary pterygium and patient with the aggressive post-operative inflammatory reaction
Prabhasawat et al have given criteria to grade the final appearance after surgery for pterygium to help identified true recurrence
Grade -1 indicate that the appearance of the operated site was not different from the normal appearance
Grade -2 indicates that there were some fine Episcleral vessels in the excise area extending up to but not beyond the limbus and without any fibrous tissue
Grade- 3 indicates that were additional fibers tissue in the excised area that did not invade the corneal
Grade-4 represent at true recurrence with fiber vascular tissue in invading the cornea
Time of recurrence in 50% chance of the recurrence within the first 120 days and 97% chance there would be recurrence by 12 month after surgery
RISK FACTORS OF PTERYGIUM
Nasal side is more common due to focusing of light from side to the nasal limbus, most common age is between 22-40 years, pterygium is twice common in male then in female patients true pterygium is condition found chiefly in Sunny hot industry region in the world as in people more exposed to these climatic conditions such a fisherman, farmer, construction worker, roofers, and beachgoers, Inheritance is dominant with low Penetrance, rather more of environmental stimuli
CLINICAL SIGN AND SYMPTOMS of pterygium -small pterygia are asymptomatic. In symptomatic patient the main symptoms are irritation foreign body sensation,epiphora, redness when inflamed, cosmetic disfigurement and diminished vision (encroachment of the visual Axis) diplopia due to limitation of movement in the horizontal direction and astigmatism that can be caused by the last pterygia when size reaches the critical size (extension to > 40% of corneal radius), they induced visually significant asymmetric with -the- rule astigmatism changes
Attributed to the actions of matrix metalloproteinases (MMPs), which, influenced by genetic and environmental factors, contribute to the local invasive nature of this disease.
ETIOPATHOGENESIS OF PTERYGIUM
Many theories have been proposed like radiation damage by UV A and UV B energy, immunological mechanism in form of Ig E Ig G were found to be deposited pterygium connective tissue stroma and also plasma cells and Lymphocytes raising the possibility of a type 1 hypersensitivity reaction. Many researchers advocated pingecula to be precursor of pterygium. It was found to be a patch of the degeneration with proliferation of hyaline and elastic tissue in the connective tissue of conjunctiva, inflammatory theories in which chronic inflammation in the form of conjunctivitis or episcleritis initiates this process,
Numerous other theories also given like -chronic character theory, local tear film abnormalities, abnormal expression of wheat 53 gene, chronic inflammation with production of pterygium,
Angiogenesis factor, apoptosis and related gene expression, human papilloma infection (HPV)
Limbal stem cell deficiency and epithelial abnormalities the classic sign or clinical Hallmark of limbo deficiency include conjunctival in growth, vascularization, chronic inflammation, destruction of basement membrane and fibrous ingrowth these sign are clearly present in pterygium and therefore many researchers today have suggested that it is a manifestation of localized interpalpebral limbal stem cell dysfunction or deficiency, perhaps as a consequence of UV light related stem cell destruction.
Role of cytokines and growth factor
The fibroblast in the region had respond to TGF beta signaling differently from normal conjunctival tissue and over expressed bFGF and IGF2 the TGF beta family contains potent cytokines involved in the scarring and Fibrosis process in wound healing and repair. Tseng hypothesized that in the various transformed phenotypes over expression of MMPs bFGF and IGF2 is intrinsically linked with the regulated TGF beta signaling. This may explain that Pterygium propensity for growth, invasion into the coronal stroma as well as its fibro vascular and inflammatory response.
HISTOPATHOLOGICAL feature of pterygium outlined by Fuchs in 1890s. These include and increase the number of thick and Elastic fiberhyaline degeneration of connective tissue concretion and epithelial changes Hogan and Alvarado stated that the elastic material with within pterygium is formed from the following sources degenerative collagens, preexisting elastic fiber, Abnormal fibroblastic activity and abnormal ground substance.
MANAGEMENT PTERYGIUM
MEDICAL MANAGEMENT
Mild symptom of photophobia and injection from a small pterygium can often be managed by avoiding smoke and dust field environment. Topical preservative free lubricants, vasoconstrictor and mild non-penetrating corticosteroids can safely relieve symptoms when used judiciously.
SURGICAL MANAGEMENT
Indication for surgical treatment of pterygium includes 1. Proximity of visual Axis resulting in diminution of vision 2. Encroachment of visual Axis 3. Significant astigmatism leading to visual debility.4. Restriction of ocular movement causing diplopia. 5. Atypical appearance such as possible dysplasia6.symptomatic growth 7. Cosmetic concerns 8. recurrence is most problematic outcome and its prevention forms the motivation for evolving different surgical techniques
The principles of pterygium excisions are;
Complete removal of all pterygium tissue at bowman's plane and the sclera
Minimizing scarring and irregular astigmatism at the cornea
Minimizing scleral damage
PATIENTS AND METHODS
This study titled ‘A Comparative study to evaluate the outcome of suture versus suture less glue free conjunctival autograft for primary pterygium excision’ was conducted in the department of ophthalmology at MBS Hospital Kota from October 2021 to October 2023 after obtaining ethical committee clearance
100 patients are included in study who were attending outpatients department of ophthalmology at
MBS Hospital Kota during study period, who fulfilled the inclusion and exclusions criteria were selected
INCLUSION CRITERIA
patient with primary pterygium consenting for surgery and with any of the following indication for surgery encroachment upon visual Axis including visually significant astigmatism of 1 D or more causing recurrent inflammation or cosmetically bothersome to the patient
EXCLUSION CRITERIA
Recurrent pterygium
Atrophic pterygium
Patient on anticoagulants
Patient with preexisting glaucoma
Patients with immune system disease, eyelid or ocular surface disease example blepharitis sjogren syndrome and dry eye disease
Method of study
Data was collected using a piloted proforma meeting the objectives of the study by means of personal interview with the patient after informed consent. Patient fulfilling the inclusion and exclusion criteria were included in the study. All patients underwent a comprehensive of ophthalmological examination including visual acuity, refraction, slit lamp biomicroscopy measurement of intraocular pressure, extraocular movement and dilated fundoscopy. Interior segment photography was perform for the documentation of terrorism size and morphology proper test was done to rule out pseudopterygium
Undilated eye grading of pterygium
Grade 1- between limbus and a point Midway between limbus and pupillary margin
Grade 2- Head of pterygium present between a point Midway between limbus and pupillary margin
Grade 3- crossing the pupillary margin
SURGICAL TECHNIQUE
The study include 100 patients of whom 50 patient underwent pterygium excision with suture less glue free conjunctival autograft and 50 patients underwent pterygium excision with conjunctival autografting using 10-0 nylon sutures. The patients were randomly selected for the two groups but once assigned to a particular a group there explained about the surgical technique and informed consent for the surgery was taken all surgery were done by a single senior surgeon
All cases were taken upperibulbar block. The involved eye underwent sterile preparation and draping. Lid speculum applied. Pterygium excision was done either by avulsion technique or head of the pterygium dissected from Apex using surgical blade (15 number) taking care to follow the surgical plane in the pterygium followed by excision of conjunctive extent. Underlying Tenon was removed up to the bare sclera. Then inferior temporal quadrant of bulbar conjunctiva was injected with 1 CC of local anesthesia (xylocaine 2%) to facilitate separation of conjunctiva from Tenon capsule. A thin Tenon free conjunctival graft was harvested taking care not to buttonhole to the conjunctiva and to include limbal stem cell in the graft. The size of the defect was measured with the Castroviejo caliper. Care was also taken to see it that harvested graft was about 1 mm larger than the size of bare sclera. In patient in the suture a group the graft with the epithelial side up was placed to the bare sclera and was secured with the 4 to 6 future using 10-0 Nylon. All the sutures were buried underneath. Eye was bandaged with the eye drop moxifloxacin 0.5%
In patient in the suture less glue free group bare sclera was made to bleed by scrapping it with the surgical blade (15 number) hemostasis was allowed to occurs spontaneously without use of cautery to provide autologous fibrin to glue the conjunctival Autograft naturally in position without tension conjunctival Autograph was taken as described . Now the graft was flipped to bare sclera epithelial side up and press the gently to the milking out any excess blood and the scleral bed was viewed through the transparent conjunctiva to ensure that residual bleeding did not lift the graft. The graft was held in position for 10 minutes by application of gentle pressure over the graft with fine non tooth forceps. Stabilization of graft was tested with marcel sponge centrally and on each free age to ensure firm adherence to the sclera. Eye was bandaged for 48 hours after installing eye Drop moxifloxacin 0.5%
In both groups the duration of surgery was calculated from the time after securing superior rectus suture up to the time with lid speculum was removed
FOLLOW UP
After 48 Hour bandage was removed and patients were examined and started on steroid, antibiotic eye drop 6 time a day follow up visit were it 1st week, 3rd week and 3 and 6 month post operatively. Any loose suture were removed in the follow up. Exposed or loose sutures were removed after 1 month. Steroid, antibiotic drops were tapered depending on resolution of inflammation. On each follow up is it patient were evaluated for degree of discomfort inflammation subcontinental hemorrhage craft stability and recurrence of pterygium. Pterygium recurrence was defined as any fibro vascular growth that has pass the limbus by >1 mm.
Outcome measures were graded as follows
GRADING OF POSTOPERATIVE DISCOMFORT
Grade; 0 -none or no symptom
Grade- 1 very mild or that symptoms easily tolerated it
Grade; 2- Mild or that symptom causes some discomfort
Grade- 3 moderate or that symptom partially interface with the daily activities
Grade- 4 severe or that symptom interface completely with the usual activity or sleep
GRADING OF INFLAMMATION
Grade- 0 no dilated corkscrew vessel in graft
Grade- 1-1 bright red corkscrew vessel crossing the graft bed margin
Grade 2-2 dilated corkscrew vessel crossing the graft bed margin
Grade3- 3 bright red corkscrew crossing the graft bed margin
Grade 4- > 3 bright red to dilated corkscrew vessel crossing the graft bed margin
GRADING OF SUBCONJUCTIVAL HEMORRHAGE
Grade; 0 - None
Grade- 1 < 25% of size of graft
Grade 2 < 50% of graft of size
Grade- 3 < 75% of size of graft
Grade- 4 hemorrhages involving the entire graft
GRADING OF GRAFT STABILITY
Grade-; 0- All 4 sides of graft to margin are well apposed
Grade-; 1 -Gapping /displacement of one side of the graft bed junction Grade: 2 -Gapping /displacement of two side of graft bed junction
Grade; 3- Gaping /displacement of three side of graft bed junction
Grade; 4-Graft completely displays from the bed.
TABLE1; Age Distribution
Age group (in years) |
Number of patients |
Percentage |
<20 |
2 |
2% |
21-30 |
28 |
28% |
31-40 |
28 |
28% |
41-50 |
30 |
30% |
51-60 |
6 |
6% |
61-70 |
6 |
6% |
SEX |
||
Female |
32 |
32.0 |
Male |
68 |
68.0 |
2 Patients were aged below 20 yrs, 28 patients between 21-30 yrs, 28 patients between 31-40 yrs, 30
Patients between 31-40, 30 patients between 41-50, 6 between 51-60 yrs and 6 between 61-70 years
Out of 100 patients, 32 (32.0%) patients were females and 68 (68%) patients were male
TABLE-2 Pterigium Grading Distribution
Grading |
Number of patients |
Percentage |
G1 |
28 |
28% |
G2 |
62 |
62% |
G3 |
10 |
10% |
TOTAL |
100 |
100% |
Out of 10 eyes with pterygium 28 were grade 1, 62 were grade 2 and 10 of grade
TABLE-3 Mean Duration Of Surgery
Technique |
Mean duration of surgery |
Sutureless |
16 minute |
Suture |
25.50 minute |
The mean duration of surgery in suture less glue free was found to be 16 minute (range14-19 minute). The mean duration of surgery in suture group is 25.50 minute (range 21-30 minute). The differed between the 2 group was found tobe highly significant (p=0.000)
TABLE -4 Distribution According To Discomfort Grading On Postoperative Day 2
Discomfort grading |
No. of patients in suture less group |
No. of patients in suture group |
G0 |
6 |
0 |
G1 |
30 |
12 |
G2 |
12 |
32 |
G3 |
2 |
6 |
G4 |
0 |
0 |
Figure Showing Distribution According To Discomfort On Post-Operative Day 2
TABLE -5 Distribution According To Subconjuctival Haemorrhage Grading On Postoperative 2
SCH Grading |
No. of patients in suture less glue free group |
No. of patients in suture group |
G0 |
34 |
32 |
G1 |
10 |
14 |
G2 |
6 |
6 |
G3 |
0 |
0 |
G4 |
0 |
0 |
0n day 2 sutures less glue free group 34 patients had grade 0 and 10 patients had grade 1, 6
Patients had grade 2 and none had grade 3 and 4 subconjunctivalhemorrhage. In suture group 32 patients had grade 0 subconjunctivalhemorrhage, 14 patients had grade 1 and 6 patients had grade 2 subconjunctivalhemorrhage, while no patients noticed grade 4 and 5 subconjunctivalhemorrhage. The difference between the group was not statistically significant (p=0.887)
TABLE 6 Distribution According To Graft Stability Grading On Postoperative Day2
Graft stability grading |
No. of pts in suture less glue group |
No. of pts in suture group |
G0 |
42 |
44 |
G1 |
8 |
6 |
G2 |
0 |
0 |
G4 |
0 |
0 |
On day 2 in suture less glue free group 42 patients had grade 0 and 8 patients had grade 1 , none of patients of grade 3 and 4 graft stability, while in suture group 44 and 8 patients had grade 0 and 1 graft stability, but none of patients noted grade 3 and 4 graft stability. The difference between two group was not found stastically significant (p=0.745)
TABLE 7 Distribution According To Discomcomfort Week 1
Discomfort grading |
No. of patients in suture less glue free group |
No. of patients in suture group |
G0 |
30 |
2 |
G1 |
16 |
22 |
G2 |
4 |
18 |
G3 |
0 |
8 |
G4 |
0 |
0 |
At 1 week postoperative follow up in suture less glue free group 30 patients had group 0, 16 had grade 1, 4 had grade 2, and none had grade 4 discomfort. In suture group 2 patients had grade 0,22 and 18 patients had grade 1 and grade 2 discomfort respectively, While none of patients reported grade 4 discomfort at 1 week follow up. Difference between two group found to be statistically significant (p=0.000).
TABLE8- Distribution According To Subconjuctival Haemorrhage (Sch) At Postoperative Week 1
SCH GRADING |
No. of patients in suture less glue free group |
No. of pts in suture group |
G0 |
36 |
38 |
G1 |
10 |
8 |
G2 |
2 |
4 |
G3 |
0 |
0 |
G4 |
2 |
0 |
At 1 week postoperative follow up in suture less glue free group 36 patients had grade 0 inflammation .10,2 and2 patients had grade 1 ,2 and 4 subconjunctivalhemorrhage, but no patients had grade 3 SCH at 1 week follow up. In suture group 38 patients had grade 0, 8 and 4
Patients had grade 1 and2 SCH, while none of patients reported grade 3 and 4 SCH at 1 week follow up. The difference between two group was not found to be stastically significant (p=0.797).
At 1 month post-operative follow up, none of patients in suture less glue free group had any discomfort. Only 6 patients in suture group complained of grade 1 discomfort. The difference between two groups was not stastically significant. None of the patients in either group had any inflammation, subconjunctivalhemorrhage or graft instability
At 3 month follow up none of patients in either group had any discomfort, inflammation, subconjunctivalhemorrhage and graft instability, except for 2 patients in suture group who showed suture granuloma at 3rd month follow up. They were excised. 4 patients in suture less glue free group showed pterygium recurrence. 2 at 3rd month and other 2 at 4rth month follow up. 4 patients in suture group showed recurrence, 2 at 4rth month, 1 at 5th month and other at 6th month follow up.
Table9 showing distribution to recurrence
Post-Operative Period |
No. of patients in suture less glue free group |
No. of patients in suture group |
1st month |
0 |
0 |
2nd month |
0 |
0 |
3rd month |
2 |
0 |
4rth month |
2 |
2 |
5th month |
0 |
1 |
6th month |
0 |
1 |
TOTAL |
4 |
4 |
Major proportion of patient were in the age group 41 -50 years (30 patient 30%). Majority of patient were female number in 68( 68%) while male were 32 in number( 32% ).Majority of patient had grade 2 pterygium being 62 number (62%) while 28 patients (28%) had grade1 and 10 (10%) had grade 3 pterygium
The mean duration of surgery in suture lessglue free group i.e.16.0 minutes was found to be significantly shorter than that in suture group i.e. 25.5 minutes (p=0.000), the suture lessglue free group has significantly lesser postoperative discomfort compared to suture group at postoperative day 1 and week 1 (p=0.000 at both day 1 and week 1) the difference was not significant at 1st month postoperatively (p=0.077) and none of patients in either group had any discomfort at 3rd and 6th months. The suture lessglue free group had significantly lesser postoperative inflammation compared to suture group at postoperative day 1 and week 1 (p=0.01 at both day-1 and week 1). None of patients in either group showed any inflammation at 1st, 3rd, 6th months except for 1 patient in suture group who had suture granuloma at 3rd month postoperative follow up which was excised. No significant difference was found in degree of postoperative sub conjunctival hemorrhage between the two groups at day 1 and week 1
(p=0.887 and p=0.797 respectively. None of the patient had sub conjunctival hemorrhage at 1st , 3rd ,and 6th months postoperatively. Conjunctival Graft secured with autologous Blood were as stable as is those secured the suture at day 1 week 1, 1st 3rd and 6th month post operatively (p= 0.745, p= 0. 644 at day 1 and week 1 respectively) 4 pterygium recurrence were noted in each group of each of groups no side effects or complication associated with the use of autologous Blood fixator.
CONCLUSION
This prospective comparative study was conducted in the department of Ophthalmology, MBA Hospital, Kota between October 2021 to October 2023 and total of 100 patient were studied who were selected by simple random sampling .50 patient under when primary pterygium excision and conjunctival autografting with fibrin glue and 50 with 10-0 nylon suture.
Amongst the various techniques, pterygium excision combined with conjunctival autografting including limbal stem cells has been associated with lowest recurrence rates. Previously suturing was the method used to secure the grafts. However disadvantages of this includes increase in postoperative time, significant postoperative discomfort, inflammation, graft edge scalloping and other complications like suture granulomas ,fibrin glue offers an alternative for graft attachment but it is expensive and carries risk of anaphylaxis in susceptible individuals as well as risk of transmission of parvo virus B19 and prions . Therefore allowing autologous Blood to act as fixator provides a cheap and safe option.
In our study we found that suture lessglue free conjunctival Autograft use was associated with significantly shorter duration of surgery, lesser postoperative discomfort and inflammation compared to suturing, suture lessglue free conjunctival Autograft were as stable as those attached with sutures, there was no difference in the degree of subconjunctivalhemorrhage. The recurrence rates were found to be similar in two groups. This suture lessglue free limbal conjunctival autograft is safe, effective, and economic and its surgical outcomes following primary pterygium surgery are comparable to conventional suture limbal conjunctival autografting with lower postoperative suture related communications, less patients discomfort and greater patient’s satisfaction.