|Year : 2017 | Volume
| Issue : 1 | Page : 23-27
Fibrin glue versus suture technique for pterygium excision: A prospective study in tertiary-based rural hospital
Surendra P Wadgaonkar, Rachana Rajpat Tiwari, Preeti A Patil, Bhimrao S Kamble
Department of Ophthalmology, ACPM Medical College, Dhule, Maharashtra, India
|Date of Submission||16-Jun-2015|
|Date of Acceptance||13-Apr-2016|
|Date of Web Publication||6-Dec-2016|
Rachana Rajpat Tiwari
D-2 101, Brahmand Housing Complex, Ghodbandar Road, Thane West - 400 607, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study is to compare the results of conjunctival closure in pterygium surgery using fibrin adhesive versus vicryl sutures. Materials and Methods: This study was carried out in the premises of rural-based tertiary hospital. A comparative prospective study was performed in fifty patients (fifty eyes) with primary nasal pterygium. They were randomized to undergo pterygium surgery using either 8-0 vicryl sutures (25 eyes) or fibrin glue (25 eyes) to attach the conjunctival autograft from August 2014 to February 2015. Mean follow-up was 14 months. Outcome measures were duration of surgery, complication, postoperative discomfort, and recurrence of pterygium. Clinical assessment was performed on days at 1, 7, and 14 days, and every 2 months thereafter. Statistical Analysis: All data were evaluated by using SPSS version 19.0 (Released 2010, IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.) package program. Mann-Whitney U-test was used for the comparison of symptoms and signs of two groups. Unpaired t-test was used to compare two groups in terms of surgery time as well as recurrence rates. Results: Average operative time was 15.76 min (range 12-20 min) in the fibrin glue and 33.56 min (range 30-45 min) in the suture group (P < 0.001). The symptoms such as pain, photophobia, foreign body sensation, watering and conjunctival, and chemosis were significantly less in the subjects treated with glue than suture (for chemosis and photophobia [P = 0.001]; for pain and watering [P < 0.001]). Three cases of recurrence in the suture group and one case of pyogenic granuloma in the fibrin glue group were reported. Conclusion: The use of fibrin glue in pterygium surgery significantly reduces operative time and patient symptoms, pain, and discomfort.
Keywords: Conjunctival excision, fibrin glue, pterygium excision
|How to cite this article:|
Wadgaonkar SP, Tiwari RR, Patil PA, Kamble BS. Fibrin glue versus suture technique for pterygium excision: A prospective study in tertiary-based rural hospital. J Clin Ophthalmol Res 2017;5:23-7
|How to cite this URL:|
Wadgaonkar SP, Tiwari RR, Patil PA, Kamble BS. Fibrin glue versus suture technique for pterygium excision: A prospective study in tertiary-based rural hospital. J Clin Ophthalmol Res [serial online] 2017 [cited 2023 Jun 8];5:23-7. Available from: https://www.jcor.in/text.asp?2017/5/1/23/195305
A pterygium is a fibrovascular neoformation which arises in the conjunctiva and grows toward the surface of the cornea which causes foreign body sensation, burning, watery eyes, and blurred vision.  Therapeutic options for pterygium are surgical. Excision of pterygium with bare sclera technique is the most commonly practiced method in India having high recurrence rate. Use of tissue sealants such as fibrin glue which mimics the final steps of natural clotting mechanism is also increasingly becoming popular to achieve the same purpose. There is paucity of published data comparing fibrin glue versus suture from the Indian subcontinent. Hence, we conducted this study to compare the results of conjunctival closure in pterygium surgery using fibrin adhesive versus vicryl sutures.
| Materials and Methods|| |
The study was conducted as per national and international guidelines for conducting research in human subjects. The protocol was submitted to the departmental and institutional review board, and the study was initiated only after obtaining the approval from the board. We designed a prospective interventional clinical study to report the long-term outcomes of sutureless pterygium surgery and to compare it to conventional pterygium surgery (with sutures). Clinical data collection was undertaken following appropriate ethical approval. Fifty consecutive patients (fifty eyes) who presented at the outpatient department of our rural-based tertiary hospital were included in the study after obtaining a well-informed consent, explaining the purpose, and potential risk of the surgical intervention.
- Primary unilateral nasal pterygium consenting for surgery and with any of the following indications for surgery - encroachment on visual axis, inducing visually significant astigmatism, causing recurrent irritation, or cosmetically bothersome to the patient. (progressive pterygium)
- Pterygium growth >1 mm over the cornea horizontally from the limbus.
- Patients on anticoagulants
- Patients with preexisting glaucoma
- Patients with immune system disease, eyelid or ocular surface diseases, for example, blepharitis, Sjögren syndrome, and dry eye
- History of previous ocular surgery or trauma.
The patients were allocated to Groups A and B according to their willingness to spend for the surgery. Vicryl suture cost Rs. 600 and fibrin glue cost Rs. 3000. After the full preoperative assessment, 25 patients underwent pterygium excision with conjunctival autograft secured with 8-0 vicryl sutures, and they were allocated to Group A. The other 25 patients underwent pterygium excision with conjunctival autograft secured with fibrin glue, and they were allocated to Group B. The degree of growth of the pterygium was evaluated in terms of the following two parameters: The length of the invading head from the limbus and density of the pterygium alone. The length of the invading head was calculated using a slit lamp, and the density of the pterygium was graded according to the system used by Tan et al. (Type 1: Atrophic, Type 2: Mild inflammation, and Type 3: Moderate/severe inflammation or showing active growth). All the cases were compulsorily done under operating microscope, and all surgical procedures were performed by the same surgeon to ensure consistency. Surgery time was noted from the first incision until the removal of the lid speculum. Best-corrected visual acuity (BCVA), slit-lamp examination, and determination of intraocular pressure were performed after the operation. The pre- and postoperative corneal astigmatism was measured among both the groups and compared. Postoperative complications were examined including dehiscence, dislodge, ridge, subgraft hemorrhage, chemosis, contracture, and granuloma and degree of inflammation. Recurrence of pterygium was defined as newly developed fibrovascular tissue invading the cornea to cross the limbus.
The study was conducted as per national and international guidelines for conducting research in human subjects. The protocol was submitted to the departmental and institutional review board, and the study was initiated only after obtaining approval from the board. Written informed consent was obtained from each patient regarding their participation in the study. The patients were then alternately sampled for performing surgery using fibrin glue method or suture method after explaining the potential risk and benefits of each technique.
All the data were analyzed using SPSS software version 19. Mean (standard deviation), paired t-test, unpaired t-test, and Mann-Whitney U-test were used to compare the data.
Under peribulbar block, the head of the pterygium was peeled from the cornea after giving a cut at its neck and body. The pterygium was excised with conjunctival scissors. Limboconjuctival defect was measured with the help of calipers, and 1 mm oversized free limboconjuctival graft was harvested from the superotemporal bulbar conjunctival quadrant of the same eye. The graft was moved to nasal area and placed over the bare sclera with stromal side down and limbus to limbus orientation. In Group A patients, 8-0 vicryl sutures were used so that four corners of the graft were anchored to the episclera with single sutures. Three sides were then sutured to the recipient conjunctiva with numerous sutures sparing the limbal side. The sutures were cut flush to minimize irritation [Figure 1]a and b. In Group B, a drop of sealer protein solution (human fibrinogen concentrate in protein) and that of thrombin solution (thrombin in water for injection) which constitutes the fibrin glue was applied to the bare sclera area. The prepared conjunctival autograft was slid onto the bare sclera in proper anatomical orientation; cotton buds were used to smoothen the graft, and 3 min interval was given to allow the graft to adhere [Figure 2]a-d. The eyewas patched with a sterile eye pad in both groups.
|Figure 1: (a) Preoperative photograph of the suture group (b) postoperative photograph suture group|
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|Figure 2: (a) Preoperative glue group (b) intraoperative with the free graft (c) intraoperative graft attached with fibrin glue (d) postoperative glue group|
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Postoperative follow-up: All patients were put on steroid (fluorometholone) eye drops four times daily for 2 weeks followed by twice daily for 2 weeks and an antibiotic drop (ofloxacin) for 2 weeks. The first dressing was done on the next day and at 1, 7, and 14 days. Patients were followed up every 2 months thereafter. Patients were asked to fill out a questionnaire on the postoperative day 1 and during every follow-up examination until the first month, grading their symptoms (pain, photophobia, and watering) on a scale (pain grade 0: no pain grade 1: pain on movement grade 2: pain at rest) (photophobia grade 0: no photophobia grade 1: mild grade 2: severe) (watering grade 0: no watering grade 1: outdoors in wind grade 2: indoors). Recurrence was evaluated at every follow-up and was defined as any fibrovascular growth that passed the corneal limbus by more than 1 mm.
| Results|| |
A total of fifty patients (fifty eyes) underwent surgical excision of nasal pterygium, and all patients completed the 6-month follow-up [Table 1].
|Table 1: Demographic data of patients in the fibrin glue and suture group|
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Average operative time was 15.76 min (range, 12-20 min) in the fibrin glue group and 33.56 min (range, 30-45 min) in the vicryl suture group. The operating time was significantly less in the glue group versus suture group (P = 0). Bleeding was seen in two patients of suture group (Group A). Patient complaints of pain, foreign body sensation, stinging, and watering were scored for each group, and values were compared with Mann-Whitney U-test. All the four complaint scores at the 1 st and 7 th days were significantly lower in fibrin group [for chemosis and photophobia (P = 0.001) for pain and watering (P < 0.001)] [Table 2]. Preoperative BCVA (best corrected visual acuity) was (suture group with visual acuity 6/6 (28%) and with 6/9 (60%) with 6/12 (12%). For Glue group with visual acuity 6/6 (16%) with 6/9 (36%) with 6/12 (48%) and BCVA day 1 postoperative was (suture group with visual acuity 6/6 (88% ) 6/9 (12%) and for glue group with visual acuity 6/6 (100%) (P = 0.83) and BCVA at 1 month after the operation was 6/6 in both groups. Corneal astigmatism was (suture group = 2.256 diopters) (glue group = 2.372 diopters) significantly reduced in the both group to (suture group = 0.392 diopters) (glue group = 0.368 diopters. There was no significant difference noted between the two groups with regard to postoperative correction of BCVA and corneal astigmatism. There were 2 episodes of subconjunctival hemorrhage in the suture group (8%) and none in glue group. There was 1 episode of pyogenic granuloma in the fibrin glue group (4%). There were no other complications recorded. There were 2 cases of recurrence in group A at 6 months follow-up, and further, one case was added at 1-year follow-up. No recurrence was found in group B. The recurrences occurred in the 4 th (1 patient) and 6 th months (1 patient), 10 months (1 patient) in the suture group [Table 3].
|Table 2: Symptoms of patients in fibrin glue and suture groups (day 1 and day 14 postoperative)|
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|Table 3: Complications associated with pterygium excision in the fibrin glue and suture groups (6 months and 1-year follow-up)|
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| Discussion|| |
Studies have evidenced limbal stem cell (LSC) dysfunction in pterygium and the barrier role that LSC plays against conjunctival overgrowth on the cornea. Their deficiency at the limbus allows conjunctivalization of corneal epithelium along with fibrovascular tissue overgrowth. This phenomenon is true for primary and recurrent pterygium. Thus, one can aim to reduce the number of recurrences by including the LSC in conjunctival autograft. Excision of the pterygium with conjunctival autografting is considered to be the procedure of choice in terms of efficacy and long-term stability. , It was reported that the recurrence rate in the case of conjunctival autografting was much lower than that in the case of primary closure or amniotic membrane grafting.  The transplantation of conjunctivo-limbal autograft helps to cover the LSC deficiency.  Care should be taken to include the limbal part while harvesting the graft so that stem cells are included.  Adjunctive therapies such as mitomycin C, β-irradiation, and excimer laser have also been used to decrease the recurrence rate of pterygium in spite of potentially sight-threatening side effects. ,,
Treatment of pterygium with conjunctival autografts or amniotic membrane grafts after pterygium excision is reported to have the best and comparable success rates. These grafts have traditionally been affixed to the bare sclera bed using sutures. The presence of these sutures is believed to initiate a mild inflammatory response giving rise to symptoms of pain, grittiness, and watering postoperatively and therefore, negating the purpose of the surgical intervention. The inflammatory response to these sutures is also believed to be the cause of recurrence, albeit low, in these patients. The time consumption for the placement of sutures during surgery and the need to remove them later on makes it a lengthy and tedious process. Fibrin glue is a blood-derived product which consists of a fibrinogen component and a thrombin component. It imitates the final stages of the coagulation cascade when two components are mixed. Fibrin glue has also found its application in neurosurgery for the repair of dural leaks and for the treatment of atrophic rhinitis. ,, In ophthalmology, fibrin glue is being used in strabismus surgery, corneal surgery, amniotic membrane transplantation, and conjunctival closure following pterygium. ,, In our study, one case of pyogenic granuloma was observed in fibrin glue group during the 3 rd month follow-up and no cases of it in suturing group. The exact mechanism involved in the formation of pyogenic granuloma has not been completely elucidated, but associations with abnormal vascular endothelial cell growth, cytokine abnormalities, and fibroblasts activation have been postulated. , We believe that pyogenic granulomas in this study were associated with a hyperactive inflammatory change in the circumstance of abundant vascular endothelial cell growth factors originated from ischemic tissue damage. Therefore, we need to take caution not to make conjunctival wound margins maladapted when we use the glue. It can lead to fibrosis or recurrence, causing the harms to outweigh the advantages of less inflammation in the glued conjunctiva. There was no significant difference between the preoperative and postoperative BCVA. Furthermore, there was no significant difference between the degrees of correction of corneal astigmatism between the two groups. This suggested that both the techniques are equally good in these aspects. There were three episodes of subconjunctival hemorrhage in the suture group. Uy et al.,  in their series of 22 patients, used fibrin glue in 11 patients, and 10/0 nylon suture in other 11 patients and compared two groups in terms of postoperative pain, foreign body sensation, and watering complaints. They concluded that all the complaints were significantly less in fibrin group [Table 4]. A significant difference was noted between the incidence of pain, photophobia, chemosis, and watering among the day 1 postoperative patients of fibrin glue group versus the suture group. This correlates with the other studies suggesting all symptoms are significantly less in glue group. All the postoperative patients recovered by day 14 postoperative in the suture group.
|Table 4: Systematic analysis about pterygium recurrence after surgery using a conjunctival autograft|
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The recurrence rate of pterygium, depending on the surgery type such as glue-assisted or suture-assisted autografting, has been a matter of controversy. Some reports , documented that the fibrin glue group showed lower recurrence rates than the suture group, whereas other reports  stated the converse. Hall et al.  reported similar recurrence rates for the two groups. In our study, the small number of cohort patients and a short follow-up period could not determine the long-term recurrence rate of glue-assisted pterygium surgery. Nevertheless, we believe that less inflammation in the earlier postoperative stage may be related to a small chance of recurrence; this hypothesis corresponds with the result of a previous report on the correlation between inflammation and recurrence.  In our study, there were 2 cases of recurrence in Group A at 6 months follow-up and further 1 case at 1-year follow-up. There was no recurrence in Group B. Yüksel et al.  conducted a prospective study on 58 cases and observed patients symptoms were significantly less in the fibrin glue group as compared to the suture group. There were 2 cases and 1 case of recurrence in the suture group and fibrin glue group, respectively. Farid and Pirnazar  conducted a retrospective study to evaluate the rate of recurrence after pterygium excision with autograft in 47 eyes. The recurrence rate in tissue adhesive group was 3.7% compared to 20% in suture group (P = 0.035). Karalezli et al.  compared the use of fibrin glue versus sutures for fixating conjunctival autografts in 50 patients undergoing pterygium excision. Pterygium recurrence was not observed in fibrin glue group and two eyes (8%) in suture group (P < 0.05). However, according to Marticorena et al., Uy et al.,  and Koranyi et al.,  there was no recurrence in either group.
Regarding other complications in glue-assisted pterygium surgeries, previous reports did not present much of a difference between glue-assisted and conventional pterygium surgeries.
| Conclusion|| |
The use of fibrin glue to attach the free conjunctival autograft in pterygium surgery produces shorter operating time, less postoperative discomfort, and no recurrence rate compared to 8-0 vicryl sutures. Shorter surgery time logically translates into lower infection risk and saves valuable operating theater time. The patient stands to benefit on account of an earlier return to normal life due to greater postoperative comfort.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]