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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 7  |  Issue : 1  |  Page : 62-67

Efficacy of autologous fibrin glue versus sutures in reducing astigmatism following pterygium surgery: A 1-year randomized controlled study


1 Department of Ophthalmology, Vydehi Institute of Medical Sciences, RGUHS, Bengaluru, Karnataka, India
2 Department of Ophthalmology, Shri.B.M.Patil Medical College, BLDE University, Bijapur, Karnataka, India
3 Department of Glaucoma and Anterior Segment, MM Joshi Eye Institute, Hubli, Karnataka, India

Date of Submission11-Jun-2021
Date of Decision01-Oct-2021
Date of Acceptance27-Oct-2021
Date of Web Publication27-Jun-2022

Correspondence Address:
Dr. Sheetal Vishwanath Girimallanavar
Staff Quarters A4, VIMS n RC, EPIP Area, Nallurhalli, Whitefield, Bengaluru - 560 066, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_60_21

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  Abstract 


AIM: To evaluate the astigmatic changes before and after pterygium surgery and to study the effect of autologous fibrin glue over sutures in terms of efficacy in reducing corneal astigmatism.
SETTINGS AND DESIGN: Randomized controlled trial.
SUBJECTS AND METHODS: Forty-four patients with primary pterygia were taken up and divided as follows: Conjunctival autograft with autologous fibrin glue as Group 1 (n = 22) and autograft with 8-0 vicryl sutures as Group 2 (n = 22). All patients were preoperatively assessed for visual acuity, anterior, posterior segments, and Keratometric values using Bausch-Lomb keratometer on postoperative day 1, 7, 1 month, and 3 months.
STATISTICAL ANALYSIS: Mann–Whitney test was performed to compare the median keratometric astigmatic changes preoperatively and postoperatively between the groups. P < 0.05 was considered statistically significant.
RESULTS: 50.5 was the mean age and 14.81 standard deviation (SD) in Group 1 and 48.86 was the mean and 13.23 SD in Group 2. Group 1 had 40.9% males and 59.1% females, Group 2 had 54.5% males and 45.5% females. The preoperative keratometric values significantly decreased postoperatively in both groups and the median postoperative keratometric value was significantly reduced in Group 1 (0.5) as compared to Group 2 (1.25). Pterygium excision using autologous blood was more effective in reducing corneal astigmatism.
CONCLUSION: Pterygium excision surgery reduces corneal astigmatism and thus improves visual acuity. Autologous blood is better option to attach the conjunctival autograft than sutures in reducing astigmatism.

Keywords: Autologous blood, conjunctival autograft, keratometric astigmatism, pterygium


How to cite this article:
Girimallanavar SV, Mudhol R, Kori VS. Efficacy of autologous fibrin glue versus sutures in reducing astigmatism following pterygium surgery: A 1-year randomized controlled study. BLDE Univ J Health Sci 2022;7:62-7

How to cite this URL:
Girimallanavar SV, Mudhol R, Kori VS. Efficacy of autologous fibrin glue versus sutures in reducing astigmatism following pterygium surgery: A 1-year randomized controlled study. BLDE Univ J Health Sci [serial online] 2022 [cited 2022 Aug 16];7:62-7. Available from: https://www.bldeujournalhs.in/text.asp?2022/7/1/62/348286



Pterygium having an incidence rate of 0.3%−29% is prevalent in the different parts of the world.[1],[2] Pterygium affects vision by encroachment on the pupillary area or by inducing astigmatism due to (1) size of the pterygium, (2) tear film pooling adjacent to the growth, (3) and Pterygium exerting mechanical traction on the cornea.[3] Corneal topography, keratometry, and refraction can be used to measure the induced corneal astigmatism.[3],[4],[5],[6],[7] Pterygium excision surgery helps in reducing the corneal astigmatism and we have studied that the technique of using autologous blood in attaching conjunctival autograft is more efficacious than the procedure of using sutures in terms of reducing astigmatism.


  Subjects and Methods Top


This randomized controlled study was conducted at an outpatient ophthalmology department of a tertiary hospital for a period of 1 year. A total number of 44 patients with primary pterygium were divided into two groups of 22 each based on computer-generated randomization. Group 1 (n = 22) underwent pterygium excision with conjunctival autograft using autologous blood and Group 2 (n = 22) using sutures. All patients were taken informed written consent at the beginning of the study. Patients with bleeding abnormalities, ocular surface infections, ocular trauma, recurrent pterygium, and on anticoagulant therapy were excluded from the study. Follow-up of all patients was done for a minimum period of 3 months to the maximum period of 2 years. The study was approved by the Ethical and Research Committee at the beginning of the study.

Demographic data such as age, sex, occupation, and complaints were documented in the data collection tool. Visual acuity was measured using Snellen's chart,[8] and best-corrected visual acuity was recorded. Slit-lamp biomicroscope was used to evaluate the anterior segment and document the various characteristics of pterygium such as site, type, and grading of the pterygium.

Grading of pterygium

It was graded depending on how much of cornea was involved by the fleshy growth as follows: Grade 1: Growth touching the limbus, Grade 2: Growth crossing the limbus over the cornea, Grade 3: Growth reaching the pupillary margin, and Grade 4: Growth crossing the pupillary margin.[3]

Study group

All patients were divided into two groups by computer randomization:

  • Group 1 − Conjunctival autograft using autologus blood
  • Group 2 − Conjunctival autograft using sutures.


Pterygium was categorized nasal or temporal based on the site and those having both nasal and temporal in the same eye were diagnosed as “Double headed or winged pterygium.”[1] Various investigations such as keratometry, bleeding time, clotting time, intraocular pressure, lacrimal syringing, random blood sugar, and blood pressure were performed. Bausch and Lomb keratometer was used to record and compare the difference in keratometric values or median keratometric astigmatic changes postoperatively from the preoperative values in both the groups.

All the evaluations were performed by a single person, and all surgical procedures were performed by a single experienced surgeon to reduce interobserver bias.

Surgical procedure and follow up

Under peribulbar anesthesia, the lids were separated using wire speculum. Superior rectus bridle suture was applied. The pterygium tissue along with the tenons capsule was dissected and excised taking care of not injuring the underlying medial rectus muscle. The size of the conjunctival graft required over the bare area after pterygium excision was measured using Castroviejo calipers. Appropriate sized graft was harvested from superotemporal conjunctiva using Westcott scissors. Care was taken to get a thin graft without button holing. The graft was excised taking the limbal tissue to be included.

In Group 1 patients, the conjunctival limbal graft was moved on to the cornea. The graft was then rotated and moved on the scleral recipient bed using nontoothed forceps without allowing it to wrinkle. The scleral bed was noted for any residual bleeding to ensure it does not uplift the graft. Small central hemorrhages under the graft observed were tamponaded using direct compression over the graft. Finally the graft was allowed to adhere by leaving it over the area for 8–10 min with applying mild pressure over the graft.

In Group 2 patients, the conjunctival autograft was moved onto the cornea. The graft was then rotated and moved on the sclera recipient bed with a nontoothed forceps. A limbus-limbus orientation was maintained. The graft was smoothened out in its bed and interrupted 8-0 vicryl sutures were placed to hold the graft in place.

At the end, superior rectus bridle suture was removed. Antibiotic drops were instilled and the eye was padded and bandaged.

All the patients were evaluated for uncorrected visual acuity, best-corrected visual acuity, keratometry using Bausch and Lomb keratometer, anterior segment evaluation using slit lamp, fundus evaluation using slit-lamp biomicroscope, and 90D lens both preoperatively and on day 1, 1 week, 1 month, and 3 months postoperatively. The values obtained at 3 months were considered to be final values and were compared to preoperative values and analyzed.

The images of postoperative pictures of the eyes by both the methods and preoperative and postoperative pictures of double headed pterygium are presented in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8].
Figure 1: Conjunctival autograft with autologus blood day1

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Figure 2: Conjunctival autograft with autologus blood 6weeks

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Figure 3: Conjunctival autograft with autologus blood 3months

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Figure 4: Conjunctival autograft with sutures day1

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Figure 5: Conjunctival autograft with sutures 3months

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Figure 6: Double headed pterygium preop

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Figure 7: Double headed pterygium day1

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Figure 8: Double headed pterygium 6weeks

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Statistical analysis

Data were entered in MS Excel and analyzed using the SPSS software version 21 (IBM, Bengaluru, Karnataka, India). Mann–Whitney U test was performed to compare the median. The data were expressed in terms of median and quartiles. At 95% confidence interval, P < 0.05 was considered statistically significant.


  Results Top


All the patients completed the follow-up period of 3 months, and none was lost to follow-up. [Table 1] shows summary of the demographic characteristics of both the groups. The mean age of patients in Group 1 and Group 2 was 50.5 ± 14.81 years and 48.9 ± 13.23 years, respectively. There was no statistically significant difference between the groups in terms of gender, grade, type, site, occupation, and presenting complaints. However, significant association was found between the two groups statistically in terms of operating time, postoperative compliance, and reduction in keratometric astigmatism.
Table 1: Demography and clinical characteristics of the two groups

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The pre- and postoperative corneal astigmatism was compared between the two groups on day 1, 1 week, 4 weeks/1 month, and 3 months. The changes in corneal astigmatism were significant at all visits. The median change of postoperative astigmatism was 0.5(Q1-0.25 and Q3-1.75) in Group 1 and 1.12 (Q1-0.69 and Q3-2.56) in Group 2 presented in [Table 2] which was statistically significant.
Table 2: Comparison of preoperative and postoperative corneal astigmatism

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The Mann–Whitney U between the groups preoperatively was 155.5 and postoperatively was 144.5 with P values between the groups preoperatively 0.036 and postoperatively 0.021 presented in [Table 3] which was found statistically significant with a P < 0.05.
Table 3: Comparison of postoperative changes in corneal astigmatism at 3 months between the two groups

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A significant reduction in postoperative astigmatism was observed in all the grades of pterygium in both the groups.

There was a significant difference in the outcomes of the two groups. Thus, we concluded that keratometric astigmatism induced by pterygium is significantly reduced by pterygium surgery and the astigmatism is better reduced by the method of using autologous blood in attaching the conjunctival graft than using sutures apart from having added advantages of shorter operative time and lesser postoperative complications [Table 3].


  Discussion Top


Thirty–thirty-nine years is found to be the age of maximum incidence of pterygium.[1],[9] Our study showed female predominance in one group, although literature shows male predominance which may be attributed to the fact that majority seek treatment for cosmetic purposes.[1] Exposure to smoke while cooking might in addition contributes to the development of pterygium as most women in our study were from the rural background.[1],[10] Nasal side is more commonly involved[1],[11], which is comparable with our study. Grade 2 pterygia were the maximum compared to Grade 1 and 3.[1]

Visual impairment is caused by pterygium by refractive changes by induced astigmatism or by the involvement of visual axis.[12] Our study was conducted to study the corneal astigmatic changes after pterygium surgery and also to compare the efficacy in reducing corneal astigmatism between using autologous blood and sutures in attaching the conjunctival autograft.

The mainstay of treatment for pterygium is surgical excision.[3] Successful pterygium excision surgery helps in improving visual acuity by reducing astigmatism and clearing the visual axis of the pterygium growth.[12] Study done by Maheswari et al. found significant improvements in visual acuity after ptergium surgery in all grades of ptergium (P < 0.05).[3] Similarly, Misra et al. observed that pterygium surgery helped in significantly improving mean best-corrected visual acuity from 6/7.5 preoperatively to 6/6 at 1 month (P = 0.001).[3],[13]

It has been proven that pterygium induced astigmatism significantly reduces after pterygium excision.[3] A study by Mohite et al. showed that pterygium excision surgery caused reduction of mean keratometric astigmatism from 3.046 ± 1.2D to 1.486 ± 0.63D (P < 0.001)[3],[4]. Thus, they concluded that pterygium surgery helps in reducing pterygium induced corneal astigmatism.[3] A similar study by Cinal et al. showed that pterygium related corneal topographical changes can be partially reversed by pterygium surgery, although some changes might remain due to scarring[3],[14].Bahar et al. in their study found that there was a reduction of 3.12–2.5D of astigmatism after surgery with no change in the axis.[15] Soriano et al. concluded through their study that pterygium surgery caused a significant reduction in corneal astigmatism from 2.41D to 1.29D.[16]

These results were comparable to our study as we have also found significant reduction in mean corneal astigmatism after pterygium surgery.

Since horizontal diameter of the cornea is increased due to pterygium causing stretching and flattening of the cornea horizontally, the amount of astigmatism also increases according to the increasing grade of pterygium.[17] Several studies conducted in the past have proven that increase in the size of the pterygium increases the amount of induced corneal astigmatism.[3] A study conducted by Gumus et al. found a significant correlation between the size of pterygium and induced corneal astigmatism.[3],[18] Seitz et al. concluded that the preoperative astigmatism increases with the size of the pterygium extending from 2.5 mm.[3],[19] In our study also, it was found that mean astigmatism was more in higher grades of pterygium which was comparable with the results of the above-mentioned studies.

Our study also compared the effectiveness of the technique of using autologous blood in attaching the conjunctival autograft to age old practiced sutures in reducing corneal astigmatism (as sutures placed for anchoring the graft near limbus which can include part of the cornea or scleral tissue can itself induce some minimal astigmatism) and found that the median reduction of postoperative astigmatism of 0.5 in Group 1 was statistically significant than 1.12 in Group 2.

Besides these advantages, the study had few limitations which included size of the sample which was small, a shorter follow-up period to assess the recurrence rate of pterygium and majority of our participants were included from single institution which could not truly represent the characteristics of the whole population. Hence, longer duration studies are needed to study the effect of autologous blood on the recurrence rate of pterygium versus sutures and for generalizability larger sample size from different centres is required.


  Conclusion Top


Pterygium is associated with significant astigmatism in majority of cases. Surgical excision helps in significantly reducing pterygium induced astigmatism. Vision also improves with pterygium excision. In our study, there was significant reduction in corneal astigmatism in both the groups after pterygium excision surgery and it was found that the technique of using autologous blood as an adhesive to attach conjunctival autograft was a better alternative to sutures in terms of reducing corneal astigmatism along with having added advantages of shorter operating time and better postoperative compliance.

Declaration of patient consent

The authors declare of having taken all patients appropriate consent forms. All the patients have given their consent for their relevant clinical information and images to be included in the journal. They also understand that their names or initials will not be published and it will be taken care that their identity is kept confidential, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rekha BK, Girimallanavar SV. Efficacy of autologus fibrin glue versus sutures for conjunctival autograft in pterygium surgery: A 1-year randomized controlled study. J Clin Ophthalmol Res 2020;8:24-9.  Back to cited text no. 1
  [Full text]  
2.
Malik KP, Goel R, Gutpa A, Gupta SK, Kamal S, Mallik VK, et al. Efficacy of sutureless and glue free limbal conjunctival autograft for primary pterygium surgery. Nepal J Ophthalmol 2012;4:230-5.  Back to cited text no. 2
    
3.
Garg P, Sahai A, Shamshad MA, Tyagi L, Singhal Y, Gupta S. A comparative study of preoperative and postoperative changes in corneal astigmatism after pterygium excision by different techniques. Indian J Ophthalmol 2019;67:1036-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Mohite US, Dole NB, Jadhav SS. Effectiveness of pterygium surgery on corneal astigmatism. Med Pulse Int J Opthalmol 2017;3:12-7.  Back to cited text no. 4
    
5.
Manhas A, Manhas RS, Gupta D, Kumar D. Astigmatism and visual acuity before and after pterygium excision followed by sutureless and glue free conjunctival autograft. Int J Sci Res 2018;7:376-8.  Back to cited text no. 5
    
6.
Yilmaz S, Yuksel T, Maden A. Corneal topographic changes after fourtypes of pterygium surgery. J Refract Surg 2008;24:160-5.  Back to cited text no. 6
    
7.
Oh JY, Wee WR. The effect of pterygium surgery on contrast sensitivity and corneal topographic changes. Clin Ophthalmol 2010;4:315-9.  Back to cited text no. 7
    
8.
Kay H. New method of assessing visual acuity with pictures. Br J Ophthalmol 1983;67:131-3.  Back to cited text no. 8
    
9.
Mikaniki E, Rasolinejad SA. Simple excision alone versus simple excision plus mitomycin C in the treatment of pterygium. Ann Saudi Med 2007;27:158-60.  Back to cited text no. 9
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10.
Bisen RK, Desai RJ, Mehta F, Billore OP, Randeri JK, Jain P, et al. comparison of cut and paste (No suture) with cut and suture technique of pterygium surgery. New Delhi; AICO2009 Preceedings; 2009.  Back to cited text no. 10
    
11.
Rao SK, Lekha T, Mukesh BN, Sitalakshmi G, Padmanabhan P. Conjunctival-limbal autografts for primary and recurrent pterygia: Technique and results. Indian J Ophthalmol 1998;46:203-9.  Back to cited text no. 11
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12.
Maheshwari S. Effect of pterygium excision on pterygium induced astigmatism. Indian J Ophthalmol 2003;51:187-8.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Misra S, Craig JP, McGhee CN, Patel DV. A prospective study of pterygium excision and conjunctival autograft with human fibrin tissue adhesive: Effects on vision, refraction, and corneal topography. Asia Pac J Ophthalmol (Phila) 2014;3:202-6.  Back to cited text no. 13
    
14.
Cinal A, Yasar T, Demirok A, Topuz H. The effect of pterygium surgery on corneal topography. Ophthalmic Surg Lasers 2001;32:35-40.  Back to cited text no. 14
    
15.
Bahar I, Loya N, Weinberger D, Avisar R. Effect of pterygium surgery on corneal topography: A prospective study. Cornea 2004;23:113-7.  Back to cited text no. 15
    
16.
Soriano JM, Janknecht P, Witschel H. Effect of pterygium operation on preoperative astigmatism. Prospective study. Ophthalmologe 1993;90:688-90.  Back to cited text no. 16
    
17.
Shukla D, Dandaliya I, Mittal P, Mathur M. Comparitive evaluation of keratometric changes after pterygium excision surgery. J Clin Ophthalmol Res 2019;7:110-2.  Back to cited text no. 17
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18.
Gumus K, Erkilic K, Topaktas D, Colin J. Effect of pterygia on refractive indices, corneal topography, and ocular aberrations. Cornea 2011;30:24-9.  Back to cited text no. 18
    
19.
Seitz B, Gutay A, Kuchle M, Kus MM, Langenbucher A. Pterygiumgrosse, Hornhauttopographie and Visus-eine prospective klinische querschnittstudie. Klin Monbl Augenheilkd 2001;218:609-15.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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