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Long–Term Comparison of Fibrin Tissue Glue and Vicryl Suture in Conjunctival Autografting for Pterygium Surgery a
b
a
a
Halil Huseyin Cagatay MD , Gokcen Gokce MD , Metin Ekinci MD , Yaran Koban MD , Ozlem a
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Daraman MD & Erdinç Ceylan MD a
Assistant Professor, Kafkas University, Faculty of Medicine, Department of Ophthalmology, Kars, Turkey b
Specialist, Sarikamis Military Hospital, Department of Ophthalmology, Kars, Turkey
c
Specialist, Erzurum Training and Research Hospital Ophthalmology Clinic, Erzurum, Turkey Published online: 28 May 2015.
Click for updates To cite this article: Halil Huseyin Cagatay MD, Gokcen Gokce MD, Metin Ekinci MD, Yaran Koban MD, Ozlem Daraman MD & Erdinç Ceylan MD (2014) Long–Term Comparison of Fibrin Tissue Glue and Vicryl Suture in Conjunctival Autografting for Pterygium Surgery, Postgraduate Medicine, 126:1, 97-103 To link to this article: http://dx.doi.org/10.3810/pgm.2014.01.2729
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C L I N I C A L F E AT U R E S
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Long-Term Comparison of Fibrin Tissue Glue and Vicryl Suture in Conjunctival Autografting for Pterygium Surgery Halil Huseyin Cagatay, MD 1 Gokcen Gokce, MD 2 Metin Ekinci, MD 1 Yaran Koban, MD 1 Ozlem Daraman, MD 1 Erdinç Ceylan, MD 3 Assistant Professor, Kafkas University, Faculty of Medicine, Department of Ophthalmology, Kars, Turkey; 2Specialist, Sarıkamis Military Hospital, Department of Ophthalmology, Kars, Turkey; 3 Specialist, Erzurum Training and Research Hospital Ophthalmology Clinic, Erzurum, Turkey 1
DOI: 10.3810/pgm.2014.01.2729
Abstract
Purpose: Pterygium is a common clinical entity that usually causes visual impairment, astigmatism and cosmetic problems. Although many surgical techniques to treat pterygium have been proposed, no single method, with minimal patient complications, has yet been accepted and established. Excision combined with conjunctival autograft is the most often used procedure for the treatment of primary pterygium, and the technique is associated with minimized recurrence rates in patients. The purpose of our study was to compare visual and refractive outcomes, complications, and recurrence rates with the use of fibrin glue versus 8.0 vicryl suture in pterygium surgery performed with conjunctival autograft. Materials and Methods: Our retrospective, comparative study included 106 eyes of 106 patients operated on for primary pterygium, between the years 2011 and 2012, and followed for $ 12 months. Patients were divided into 2 treatment groups: Group 1, vicryl suture use (n = 53), and Group 2, fibrin tissue glue (n = 53). Patient follow-up periods were 21.15 ± 5.3 months for Group 1 and 22.06 ± 5.2 months for Group 2. Results: Demographics and preoperative/follow-up clinical characteristics of patients revealed no significant differences between the 2 patient groups. Additionally, no significant differences were found between the patient groups in visual acuity level changes and refractive values. Although the rates of recurrence (7.5% in Group 1 and 1.9% in Group 2; P = 0.36) and graft dehiscence (Group 1, 7.5% compared with Group 2, 3.8%; P = 0.67) were slightly higher for patients in the suture group, differences did not reach significance. Conclusions: Our study results suggest that conjunctival autografting with fibrin glue has favorable visual and refractive results for patients, and is associated with lower complication rates, compared with use of the traditional 8.0 vicryl suturing technique. We suggest that fibrin tissue glue provides adequate adhesion and that graft loss will not be a problem if protective shields are used in patients postoperatively. The appropriate surgery technique should be selected by considering the advantages and disadvantages of each procedure. Keywords: conjunctival autograft; dehiscence; fibrin glue; pterygium; recurrence
Introduction
Correspondence: Gokcen Gokce, MD, Sarıkamis Military Hospital, Department of Ophthalmology, Kars, Turkey. Tel: +9-050-549-27620 Fax: +9-474-413-6264 E-mail: [email protected]
Pterygium is a wing-shaped growth of fibrovascular conjunctiva that extends onto the cornea.1–9 Pterygium is a common clinical entity that usually causes visual impairment, astigmatism and cosmetic problems.10 Surgical treatments for patients with pterygium include bare sclera excision, primary closure, conjunctival autografting, amniotic membrane transplantation, and adjunctive treatment. Bare sclera excision is the simplest and quickest method of removal but pterygium recurrence rates are very high (30‒80%).1–2 Primary closure is suitable only in cases of small pterygia and recurrence rates range from 2% to 69%.1–2 Because of high recurrence rates after surgery, special techniques should be in place to reduce
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recurrence of pterygium. Many surgical techniques have been proposed, but no single reported method has yet been shown to have minimal patient complications and very low recurrence rates.1–2 Excision combined with conjunctival autograft is the most often used surgical procedure for minimizing recurrence rates in the treatment of patients with primary pterygium. Recurrence rates with use of excision and conjunctival autograph range from 2% to 40%. Recurrence after conjunctival autografting may be explained by both inadequate excision of the inferior or superior portion of the subconjunctival fibrovascular tissue and smaller grafts.1–5 Excessive cauterization during excision may lead to insufficent vascularization of the graft. Additionally, the presence of Tenon’s capsule can cause graft retraction. Sutures do not affect wound healing and can cause additional trauma to the surgical site. Suturing the graft may lead to patient discomfort, which, in turn, can cause early breaking of the sutures due to eye rubbing.1–2 As suturing the graft tissue is a time-consuming procedure with some disadvantages, sutureless surgeries have begun to replace it, and fibrin tissue glue has become a popular way to attach conjunctival autografts.11–12 Fibrin tissue glues
have been used in a wide spectrum of ophthalmic procedures, including conjunctival closure in strabismus, and in vitreoretinal and glaucoma surgery. As fibrin tissue glue is a biologic material, it has been suggested that it may cause less inflammation and lower recurrence rates.2 Sutures act as a foreign body and can cause more severe inflammation and higher recurrence rates in patients.2 Fibrin tissue glue shortens the duration of the surgical procedure and provides for rapid, effective treatment of pterygium. Although fibrin tissue glue significantly reduces operative time and increases patient comfort,10,13,14 the technique is open to various complications, including wound dehiscence, Tenon’s cyst, and corneal epithelial erosion. Graft dehiscence refers to partial dislocation of the graft by “dehiscence.” In pterygium surgery, the graft is usually sutured with 7 or 8 sutures. Total dislocation is, therefore, very rare, and in our study, no total dislocation was observed. We compared the visual and refractive outcomes, complications, and recurrence rates in 2 groups of patients who underwent pterygium excision combined with conjunctival autografting. For Group 1, autografting was performed with interrupted 8.0 vicryl sutures; in Group 2, autografting was performed using fibrin glue.
Table 1. Patient Demographics, Pre- and Postoperative Clinical Characteristics Parameter
Group 1, Suture (n = 53)
Group 2, Fibrin Glue (n = 53)
P Value
Men, n (%)
21 (39.6)
17 (32.1)
Women, n (%)
32 (60.4)
36 (67.9)
Age, y ± SD
53.75 ± 10.7 (31–75)
52.08 ± 12.8 (32–89)
0.46b
Follow-up Period, months ± SD (range)
21.15 ± 5.3 (12–32)
22.06 ± 5.2 (12–30)
0.37b
BCVA (logMAR)
0.21 ± 0.2 (0–1)
0.25 ± 0.3 (0–1)
0.57b
Spheric Refraction, D
2.31 ± 2.3, (–)4.50–(+)6.25
3.04 ± 2.7, (–)2.50–(+)8.00
0.40b
Astigmatic Refraction, D
–2.69 ± 2.7, (–)7.00–(+)2.75
–2.97 ± 2.8, (–)9.25–(+)0.50
0.78b
BCVA, logMAR ± SD (range)
0.08 ± 0.1 (0–1)
0.10 ± 0.2 (0–1)
0.65b
Spheric Refraction, D
0.54 ± 1.2, (–)2.50–(+)3.00
0.75 ± 1.2, (–)2.00–(+)1.75
0.69b
Astigmatic Refraction, D
–0.80 ± 0.8, (–)2.50–(+)0.75
–0.69 ± 0.7, (–)1.75–(+)0.50
0.74b
BCVA Improvement, logMAR ± SD (range)
0.13 ± 0.1 (0–0.9)
0.15 ± 0.2 (0–1)
0.68b
Spheric Improvement, D
1.33 ± 1.9, (–)3.00–(+)5.25
1.81 ± 2.4, (–)0.50–(+)6.50
0.58b
Astigmatic Improvement, D
–1.88 ± 2.0, (–)5.00–(+)2.00
–2.40 ± 2.6, (–)7.75–(+)0.50
0.58b
Tenon’s Cyst
3 (5.7)
5 (9.4)
0.71c
Dehiscence
4 (7.5)
2 (3.8)
0.67c
Recurrence
4 (7.5)
1 (1.9)
0.36c
Corneal Epitheliopathy
3 (5.7)
3 (5.7)
1.00c
Sex 0.41a
Preoperative
Postoperative
Complications, n (%)
Pearson X . t test. Fisher exact test. Abbreviations: BCVA, best corrected visual acuity; D, diopter; SD, standard deviation.
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2
b c
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Fibrin Tissue Glue Versus Vicryl Suture in Pterygium Surgery
Materials and Methods
Our study adhered to the tenets of the Declaration of Helsinki. It was approved by the hospital Ethical Committee and informed consent was obtained from each patient participant. We conducted a retrospective comparative study of 106 eyes of 106 consecutive patients from our ophthalmology department, who had been treated with excision and then with either fibrin tissue glue or 8.0 vicryl sutures to attach the conjunctival autograft in primary nasal pterygium, between the years 2011 and 2012. Patients in both treatment groups underwent follow-up for $ 12 months.
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Patient Selection
Before surgery, all patients underwent complete ophthalmic examination, including best corrected visual acuity (BCVA), manifest and cycloplegic refraction, slit-lamp biomicroscopy, and applanation tonometry. Patients were excluded from the study if they had initial findings or a medical history of amblyopia, previous surgery for pterygium in the same eye, other anterior or posterior segment disease that presumably affected BCVA and refraction, glaucoma, ocular surface disease and symblepharon, or connective-tissue disease that could affect wound healing. The size of the pterygium was estimated by slit-lamp examination. Patients meeting both inclusion and exclusion criteria were divided into 2 treatment groups according to attachment method used for the conjunctival autograft: vicryl suture patients as Group 1 (n = 53); fibrin tissue glue patients as Group 2 (n = 53).
Fibrin Tissue Glue
Fibrin tissue glue is a fibrin sealant that simulates the final stage of the coagulation cascade. We utilized a kit consisting of 2 vials containing aprotinin (3000 KIU/mL) and calcium chloride solvents, and 2 vials containing fibrinogen, plasminogen, plasma fibronectin, factor XIII, and thrombin (4 IU/mL) powders. Both solutions are administered simultaneously via a high-speed jet injection system.
Surgical Technique
Patient surgical site and eyelashes were cleaned with 10% povidone iodine and a sterile drape was put in place. All procedures were performed using an operating microscope. In all cases, the pterygium and conjunctival autograft excisions were performed as described by Hall et al.15 Surgeries were performed under sub-Tenon anesthesia. After insertion of a wire speculum, topical anesthesia, using 0.5% proparacaine, hydrochloric acid (HCl) was applied and lidocain HCl 20 mg/mL and epinephrin HCI 0.0125 mg/mL were used as sub-Tenon anesthesia. The pterygium was dissected from the apex. Removal of the pterygium was performed by both blunt dissection and sharp excision of the pterygium body and subconjunctival fibrovascular tissue using Westcott tenotomy scissors and blade. Cauterization of bleeding vessels and bare sclera was avoided. The removed tissue was sent for histopathology. The eye was irrigated with balanced saline solution. No anti-metabolite was used. Patient upper-nasal conjunctiva was harvested and placed into the
Table 2. Recurrence and Graft Dehiscence Rates From Previous Studies Recurrence, n/N (%)
Dehiscence, n/N (%)
Suture
Fibrin Glue
Suture
Fibrin Glue
Group 1
Group 2
Group 1
Group 2
Cha et al
6/30 (20)
1/22 (4.5)
6/30 (20)
7/22 (32)
Hall et al
2/23 (8.7)
0/24 (0)
0/23 (0)
2/24 (8.3)
Bahar et al
3/39 (7.7)
5/42 (11.9)
N/A
N/A
Karalezli et al
1/25 (4)
3/25 (12)
0/25 (0)
2/25 (8)
Koranyi et al
17/123 (13.5)
14/258 (5.3)
2/123 (2)
1/258 (< 1)
Yuksel et al
4/29 (13.7)
2/29 (6.8)
N/A
N/A
Jiang et al
2/20 (10)
1/20 (5)
N/A
N/A
Farid et al
4/20 (20)
1/27 (3.7)
N/A
N/A
Marticorena et al
N/A
0/20 (0)
N/A
N/A
Ozdamar et al
0/12 (0)
0/12 (0)
N/A
N/A
Por et al
N/A
1/29 (3.4)
N/A
0/29 (0)
Ratnalingam et al
11/69 (15.9)
3/68 (4.41)
0/69 (0)
2/68 (2.9)
Ayala et al
N/A
4/88 (4.54)
N/A
N/A
Kim et al
N/A
0/36 (0)
N/A
2/36 (5.6)
Our Study
4/53 (7.5)
1/53 (1.9)
4/53 (7.5)
2/53 (3.8)
Study
Abbreviation: N/A, not applicable.
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Cagatay et al Figure 1. Improvements in patient visual acuity and refractive values.
experienced surgeon (HHC). Postoperatively, a protective eye shield was applied for 1 week. All patients received 10 mg/mL topical prednisolone acetate 4 times daily, and topical ofloxacin 0.3 % 4 times daily for 1 month.
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Main Outcome Measures
Main outcome measures were change in BCVA, measured by the Snellen chart at the last patient visit $ 12 months after surgery (Snellen values were converted to logMAR equivalents), change in refractive values, complications, and recurrence rates. Recurrence was defined as regrowth of pterygium tissue 1 mm beyond the corneoscleral limbus.16–17 For visual acuity improvements within the groups, preoperative logMAR values were compared with those obtained post-treatment (BCVA improvement = logMAR of last postoperative Control–Pretreatment logMAR). For patients with a BCVA $ 0.1, according to the Snellen chart, standard logMAR conversion was performed. Patients with a visual acuity of counting fingers at 6 meters were considered to have an acuity corresponding to 0.1 on the Snellen chart.
Statistical Analysis
Data were expressed as mean ± standard deviation (SD). For statistical analysis, distribution of data was checked for normality using the Kolmogorov-Smirnov test. Fisher exact test and/or X2 were used for discrete variables. The t test was administered for continuous variables. For statistical analyses, SPSS Version 20.0 was used; a P value , 0.05 was considered significant.
Results Patient Demographics lesion. Dimensions of the bare scleral bed were measured with a caliper. The graft was excised to 1 mm larger than the size of the bare sclera at all borders; furthermore, care was taken to make sure the graft was completely free of Tenon’s capsule. The epithelial surface of the graft was marked with a surgical pen and excised with Vannas scissors along the limbal edge. Special care was taken to prevent button holes and graft rollover. The fibrin glue was prepared per directions from the supplying company. Patient conjunctiva were attached with interrupted 8.0 vicryl sutures in Group 1, or with fibrin glue in Group, 2 mm from the limbus, as shown by Bahar et al.10 All knots were buried. The dry scleral bed was maintained with a cellulose sponge until the tissue glue was administered. The upper-nasal donor area was left open in both groups. All surgeries were performed by the same 100
Patient demographics revealed both patient groups to have similar characteristics. Median patient age was 53.75 ± 10.7 (31‒75) years in Group 1 (suture group), and 52.08 ± 12.8 (32‒89) in Group 2 (fibrin glue group); P = 0.46. By sex, there were 21 (39.6%) men in Group 1, and 17 (32.1%) men in Group 2; 32 (60.4%) patients in Group 1 were women, and 36 (67.9%) patients in Group 2 were women; P = 0.41. Length of follow-up for Group 1 was 21.15 ± 5.3 (12‒32) months and 22.06 ± 5.2 (12‒30) months in Group 2; P = 0.37. Patient demographics are presented in Table 1.
Preoperative Clinical Characteristics
The preoperative clinical characteristics of patients were similar (no significant differences) between the groups. BCVA: Group 1, 0.21 ± 0.2 (0‒1); Group 2, 0.25 ± 0.3 (0‒1); P = 0.57. Preoperative spheric refraction: Group 1,
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Fibrin Tissue Glue Versus Vicryl Suture in Pterygium Surgery
2.31 ± 2.3, (‒)4.50—(+)6.25 diopters, Group 2, 3.04 ± 2.7, (‒)2.50—(+)8.00 diopters; P = 0.40. Preoperative astigmatic refraction: Group 1, ‒2.69 ± 2.7, (‒)7.00—(+)2.75; Group 2, ‒2.97 ± 2.8, (‒)9.25—(+)0.50; P = 0.78. Preoperative clinical characteristics of the patients are presented in Table 1.
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Postoperative BCVA and Refractive Values
When the 2 treatment groups were compared with respect to changes in BCVA levels and refractive values, no significant differences were found. Postoperative BCVA: Group 1, 0.08 ± 0.1 (0‒1); Group 2, 0.10 ± 0.2 (0‒1); P = 0.65. Postoperative spheric refraction: Group 1, 0.54 ± 1.2, (‒)2.50—(+)3.00 diopters; Group 2, 0.75 ± 1.2, (‒)2.00— (+)1.75 diopters; P = 0.69. Post-operative astigmatic refraction: Group 1, ‒0.80 ± 0.8, (‒)2.50—(+)0.75 diopters; Group 2, ‒0.69 ± 0.7, (‒)1.75—(+)0.50 diopters; P = 0.74. Postoperative BCVA improvement: Group 1, 0.13 ± 0.1 (0‒0.9); Group 2, 0.15 ± 0.2 (0‒1); P = 0.68. Postoperative spheric improvement: Group 1, 1.33 ± 1.9, (‒)3.00—(+)5.25 diopters; Group 2, 1.81 ± 2.4, (‒) 0.50—(+)6.50 diopters; P = 0.58. Postoperative astigmatic improvement: Group 1, ‒1.88 ± 2.0, (‒)5.00—(+)2.00 diopters; Group 2, ‒2.40 ± 2.6, (‒)7.75—(+)0.50 diopters; P = 0.58. Patient postoperative BCVA and refractive values are presented in Table 1 and Figure 1.
Complications
At the final follow-up examination, pterygium recurrence and wound dehiscence rate were slightly higher for patients in the suture group, Group 1, whereas Tenon’s cyst development was higher in Group 2 patients, the fibrin glue group. However, the differences did not reach statistical significance: Tenon’s cyst: 3 (5.7%) in Group 1, 5 (9.4%) in Group 2; P = 0.71; wound dehiscence: 4 (7.5%) in Group 1, 2 (3.8%) in Group 2; P = 0.67; recurrence: 4 (7.5%) in Group 1, 1 (1.9%) in Group 2; P = 0.36; corneal epitheliopathy: 3 (5.7%) in Group 1, 3 (5.7%) in Group 2; P = 1.00. The rate of complications is presented in Table 1.
Discussion
Recurrence is the most common complication of pterygium surgery.18 Most pterygia recur within the first 6 months after surgery.16 Conjunctival autograft is an accepted and safe method for treating pterysia and reducing recurrence rates.19 Previously, the standard method of attaching conjunctival grafts was by use of sutures.12 With recent widespread use of fibrin tissue glue for closing the conjunctival autograft after
pterygium excision, comparison of the new glue material with traditional suturing has become important for clinicians. Most of the studies conducted so far have shown 1 of the 2 autograph methods as more effective; questionnaires were used to evaluate patient comfort and satisfaction in areas such as pain, photophobia, irritation, epiphora, and itching.10,20 The studies also demonstrated that using fibrin tissue glue significantly reduced surgery time.21–23 Our study has added to the subjective findings by comparing visual and refractive outcomes in patients, as well as complication rates. Pterygium causes vision-threatening, significant changes in patient corneal refractive status, which improves following surgery.24 It has been reported that eyes with more advanced pterygium develop higher corneal astigmatism.25 Surgically-induced astigmatism is another complication that may be encountered, despite successful surgery.25 Sutureless surgery, using fibrin tissue glue, is a possible solution to this astigmatism complication. However, improvement of BCVA and decreases in refractive spherocylinder power were not significantly different between the sutured and sutureless groups in our study. The research literature reports variable results with respect to complication and rates (Table 2). Some studies have shown that fibrin glue produces lower pterygia recurrence rates than suturing,17,20,26−28 whereas other studies have shown the opposite,10,29 and other reports have documented similar recurrence rates for both techniques.15,20,30 Similarly, long-term recurrence and wound dehiscence rates were similar for both groups in our study but they were lower than those found by Cha et al,20 who used nonabsorbable 10-0 nylon sutures, which can affect complications in the early period.28 Recurrence rates in our patient groups were close to those reported by Hall et al.15 In our study, we found a very low dehiscence rate in the fibrin glue group compared with other studies; this may have been achieved by maintaining a dry scleral bed before using the fibrin glue. Additionally, we assume that closing all eyes with a protective shield for 1 week had a positive effect on graft dehiscence by preventing eye rubbing. All dehiscent grafts were re-attached in a second surgery. Corneal epithelial erosions, which resolved after treatment with lubricating drops, tended to occur at a similar rate in both treatment groups. Tenon’s cyst formation, which was predominantly observed in the fibrin glue group, was not resolved with topical corticosteroid treatment after about 14 days; all of the cysts were excised in a second surgery and none recurred. One patient had serious discomfort postoperatively secondary to glue excess; the excess was trimmed away from the ocular surface with scissors under
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slit lamp biomicroscopy in the examination room. Neither graft dislocation nor granuloma development was observed in either group. No infectious disease was reported in any patient during the follow-up period. One limitation of our study was failing to provide complete randomization, due to its retrospective nature. Additionally, race has been reported as a factor that affects recurrence rates16 and our study included only a Caucasian population. A grading system for defining the recurrence of a pterygium has been described.31 According to this system: Grade 1, no difference from normal appearance; Grade 2, thin episcleral vessels present in the excised area, extending to but not passing the limbus; no fibrous tissue present; Grade 3, fibrous tissue that does not invade the cornea; and Grade 4, frank recurrence with fibrovascular tissue that invades the cornea.1,31 However, grading to define the recurrence of pterygium was not used in our study. A simple grading system has been described by Tan et al,32 which classifies the appearance of the pterygium into 3 grades: Grade T1 ‒ atrophic pterygium, episcleral vessels unobscured; Grade T2 ‒ intermediate pterygium, episcleral vessels partially obscured; Grade T3 ‒ fleshy pterygium, episcleral vessels totally obscured. However, again, grading of the pterygium was not done in our study. There are some concerns regarding safety of fibrin glue use, including theoretic risk of anaphylactic reaction and disease transmission. Although the risk is very low, patients should be informed before surgery. None of the patients in our study developed such complications. In conclusion, our study suggests that conjunctival autografting with fibrin glue has favorable visual and refractive results for patients, as well as complication and recurrence rates comparable to the traditional 8.0 vicryl suturing technique. We suggest that fibrin tissue glue provides adequate adhesion, and graft loss will not be a problem if protective eye shields are used postoperatively. Appropriate surgical method should be selected by considering the advantages and disadvantages of each procedure. Larger prospective studies are required to evaluate long-term results.
Conflict of of Interest Statement
Halil Huseyin Cagatay, MD, Gokcen Gokce, MD, Metin Ekinci, MD, Yaran Koban, MD, Ozlem Daraman, MD, and Erdinç Ceylan, MD, disclose no conflicts of interest.
References 1. Küçükerdönmez C. Akova Y. Fibrin glue use and recent surgical developments in pterygium: Part I. Contemporary Ophthalmology. 2009:3;1−6.
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2. Küçükerdönmez C. Akova Y. Fibrin Glue Use and Recent Surgical Developments in Pterygium: Part II. Contemporary Ophthalmology. 2009:4;1−6. 3. Todani A, Melki SA. Pterygium: current concepts in pathogenesis and treatment. Int Ophthalmol Clin. 2009;49(1):21−30. 4. Ang LP, Chua JL, Tan DT. Current concepts and techniques in pterygium treatment. Curr Opin Ophthalmol. 2007;18(4):308−313. 5. Kurna SA, Altun A, Aksu B, Kurna R, Sengor T. Comparing treatment options of pterygium: limbal sliding flap transplantation, primary closing, and amniotic membrane grafting. Eur J Ophthalmol. 2013;23(4):480−487. 6. Mahar PS, Manzar N. Pterygium recurrence related to its size and corneal involvement. J Coll Physicians Surg Pak. 2013;23:120−123. 7. Huerva V, March A, Martinez-Alonso M, Muniesa MJ, Sanchez C. Pterygium surgery by means of conjunctival autograft: long term follow-up. Arq Bras Oftalmol. 2012;75(4):251−255. 8. Kareem AA, Farhood QK, Alhammami HA. The use of antimetabolites as adjunctive therapy in the surgical treatment of pterygium. Clin Ophthalmol. 2012;6:1849−1854. 9. Kaufman SC, Jacobs DS, Lee WB, Deng SX, Rosenblatt MI, Shtein RM. Options and adjuvants in surgery for pterygium: a report by the American Academy of Ophthalmology. Ophthalmology. 2013;120(1):201−208. 10. Bahar I, Weinberger D, Dan G, Avisar R. Pterygium surgery: fibrin glue versus Vicryl sutures for conjunctival closure. Cornea. 2006;25(10):1168−1172. 11. Sharma A, Moore J. Autologous fibrin glue for pterygium surgery with conjunctival autograft. Cont Lens Anterior Eye. 2009;32(5):209. 12. Por YM, Tan DT. Assessment of fibrin glue in pterygium surgery. Cornea. 2010;29(1):1−4. 13. Marticorena J, Rodriguez-Ares MT, Tourino R, et al. Pterygium surgery: conjunctival autograft using a fibrin adhesive. Cornea. 2006;25(1):34−36. 14. Pan HW, Zhong JX, Jing CX. Comparison of fibrin glue versus suture for conjunctival autografting in pterygium surgery: a meta-analysis. Ophthalmology. 2011;118(6):1049−1054. 15. Hall RC, Logan AJ, Wells AP. Comparison of fibrin glue with sutures for pterygium excision surgery with conjunctival autografts. Clin Experiment Ophthalmol. 2009;37(6):584−589. 16. Farid M, Pirnazar JR. Pterygium recurrence after excision with conjunctival autograft: a comparison of fibrin tissue adhesive to absorbable sutures. Cornea. 2009;28(1):43−45. 17. Koranyi G, Seregard S, Kopp ED. The cut-and-paste method for primary pterygium surgery: long-term follow-up. Acta Ophthalmol Scand. 2005;83(3):298−301. 18. Srinivasan S, Dollin M, McAllum P, Berger Y, Rootman DS, Slomovic AR. Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observer masked clinical trial. Br J Ophthalmol. 2009;93(2):215−218. 19. Hirst LW. The treatment of pterygium. Surv Ophthalmol. 2003;48(2):145−180. 20. Cha DM, Kim KH, Choi HJ, Kim MK, Wee WR. A comparative study of the effect of fibrin glue versus sutures on clinical outcome in patients undergoing pterygium excision and conjunctival autografts. Korean J Ophthalmol. 2012;26(6):407−413. 21. Yuksel B, Unsal SK, Onat S. Comparison of fibrin glue and suture technique in pterygium surgery performed with limbal autograft. Int J Ophthalmol. 2010;3(4):316−320. 22. Ayala M. Results of pterygium surgery using a biologic adhesive. Cornea. 2008;27(6):663−667. 23. Kim HH, Mun HJ, Park YJ, Lee KW, Shin JP. Conjunctivolimbal autograft using a fibrin adhesive in pterygium surgery. Korean J Ophthalmol. 2008;22(3):147−154. 24. Maheshwari S. Pterygium-induced corneal refractive changes. Indian J Ophthalmol. 2007;55(5):383−386. 25. Kheirkhah A, Safi H, Molaei S, Nazari R, Behrouz MJ, Raju VK. Effects of pterygium surgery on front and back corneal astigmatism. Can J Ophthalmol. 2012;47(5):423−428.
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Fibrin Tissue Glue Versus Vicryl Suture in Pterygium Surgery 30. Ozdamar Y, Mutevelli S, Han U, et al. A comparative study of tissue glue and vicryl suture for closing limbal-conjunctival autografts and histologic evaluation after pterygium excision. Cornea. 2008;27(5):552−558. 31. Prabhasawat P, Barton K, Burkett G, Tseng SC. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology. 1997;104(6):974−985. 32. Tan DT, Chee SP, Dear KB, Lim AS. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision [published correction appears in Arch Ophthalmol. 1998;116(4):552]. Arch Ophthalmol. 1997;115(10):1235−1240.
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26. Karalezli A, Kucukerdonmez C, Akova YA, Altan-Yaycioglu R, Borazan M. Fibrin glue versus sutures for conjunctival autografting in pterygium surgery: a prospective comparative study. Br J Ophthalmol. 2008;92(9):1206−1210. 27. Jiang J, Yang Y, Zhang M, Fu X, Bao X, Yao K. Comparison of fibrin sealant and sutures for conjunctival autograft fixation in pterygium surgery: one-year follow-up. Ophthalmologica. 2008;222(2):105−111. 28. Ratnalingam V, Eu AL, Ng GL, Taharin R, John E. Fibrin adhesive is better than sutures in pterygium surgery. Cornea. 2010;29(5):485−489. 29. Bahar I, Weinberger D, Gaton DD, Avisar R. Fibrin glue versus vicryl sutures for primary conjunctival closure in pterygium surgery: long-term results. Curr Eye Res. 2007;32(5):399−405.
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Postgraduate Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ipgm20
Long–Term Comparison of Fibrin Tissue Glue and Vicryl Suture in Conjunctival Autografting for Pterygium Surgery a
b
a
a
Halil Huseyin Cagatay MD , Gokcen Gokce MD , Metin Ekinci MD , Yaran Koban MD , Ozlem a
c
Daraman MD & Erdinç Ceylan MD a
Assistant Professor, Kafkas University, Faculty of Medicine, Department of Ophthalmology, Kars, Turkey b
Specialist, Sarikamis Military Hospital, Department of Ophthalmology, Kars, Turkey
c
Specialist, Erzurum Training and Research Hospital Ophthalmology Clinic, Erzurum, Turkey Published online: 28 May 2015.
Click for updates To cite this article: Halil Huseyin Cagatay MD, Gokcen Gokce MD, Metin Ekinci MD, Yaran Koban MD, Ozlem Daraman MD & Erdinç Ceylan MD (2014) Long–Term Comparison of Fibrin Tissue Glue and Vicryl Suture in Conjunctival Autografting for Pterygium Surgery, Postgraduate Medicine, 126:1, 97-103 To link to this article: http://dx.doi.org/10.3810/pgm.2014.01.2729
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C L I N I C A L F E AT U R E S
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Long-Term Comparison of Fibrin Tissue Glue and Vicryl Suture in Conjunctival Autografting for Pterygium Surgery Halil Huseyin Cagatay, MD 1 Gokcen Gokce, MD 2 Metin Ekinci, MD 1 Yaran Koban, MD 1 Ozlem Daraman, MD 1 Erdinç Ceylan, MD 3 Assistant Professor, Kafkas University, Faculty of Medicine, Department of Ophthalmology, Kars, Turkey; 2Specialist, Sarıkamis Military Hospital, Department of Ophthalmology, Kars, Turkey; 3 Specialist, Erzurum Training and Research Hospital Ophthalmology Clinic, Erzurum, Turkey 1
DOI: 10.3810/pgm.2014.01.2729
Abstract
Purpose: Pterygium is a common clinical entity that usually causes visual impairment, astigmatism and cosmetic problems. Although many surgical techniques to treat pterygium have been proposed, no single method, with minimal patient complications, has yet been accepted and established. Excision combined with conjunctival autograft is the most often used procedure for the treatment of primary pterygium, and the technique is associated with minimized recurrence rates in patients. The purpose of our study was to compare visual and refractive outcomes, complications, and recurrence rates with the use of fibrin glue versus 8.0 vicryl suture in pterygium surgery performed with conjunctival autograft. Materials and Methods: Our retrospective, comparative study included 106 eyes of 106 patients operated on for primary pterygium, between the years 2011 and 2012, and followed for $ 12 months. Patients were divided into 2 treatment groups: Group 1, vicryl suture use (n = 53), and Group 2, fibrin tissue glue (n = 53). Patient follow-up periods were 21.15 ± 5.3 months for Group 1 and 22.06 ± 5.2 months for Group 2. Results: Demographics and preoperative/follow-up clinical characteristics of patients revealed no significant differences between the 2 patient groups. Additionally, no significant differences were found between the patient groups in visual acuity level changes and refractive values. Although the rates of recurrence (7.5% in Group 1 and 1.9% in Group 2; P = 0.36) and graft dehiscence (Group 1, 7.5% compared with Group 2, 3.8%; P = 0.67) were slightly higher for patients in the suture group, differences did not reach significance. Conclusions: Our study results suggest that conjunctival autografting with fibrin glue has favorable visual and refractive results for patients, and is associated with lower complication rates, compared with use of the traditional 8.0 vicryl suturing technique. We suggest that fibrin tissue glue provides adequate adhesion and that graft loss will not be a problem if protective shields are used in patients postoperatively. The appropriate surgery technique should be selected by considering the advantages and disadvantages of each procedure. Keywords: conjunctival autograft; dehiscence; fibrin glue; pterygium; recurrence
Introduction
Correspondence: Gokcen Gokce, MD, Sarıkamis Military Hospital, Department of Ophthalmology, Kars, Turkey. Tel: +9-050-549-27620 Fax: +9-474-413-6264 E-mail: [email protected]
Pterygium is a wing-shaped growth of fibrovascular conjunctiva that extends onto the cornea.1–9 Pterygium is a common clinical entity that usually causes visual impairment, astigmatism and cosmetic problems.10 Surgical treatments for patients with pterygium include bare sclera excision, primary closure, conjunctival autografting, amniotic membrane transplantation, and adjunctive treatment. Bare sclera excision is the simplest and quickest method of removal but pterygium recurrence rates are very high (30‒80%).1–2 Primary closure is suitable only in cases of small pterygia and recurrence rates range from 2% to 69%.1–2 Because of high recurrence rates after surgery, special techniques should be in place to reduce
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Cagatay et al
recurrence of pterygium. Many surgical techniques have been proposed, but no single reported method has yet been shown to have minimal patient complications and very low recurrence rates.1–2 Excision combined with conjunctival autograft is the most often used surgical procedure for minimizing recurrence rates in the treatment of patients with primary pterygium. Recurrence rates with use of excision and conjunctival autograph range from 2% to 40%. Recurrence after conjunctival autografting may be explained by both inadequate excision of the inferior or superior portion of the subconjunctival fibrovascular tissue and smaller grafts.1–5 Excessive cauterization during excision may lead to insufficent vascularization of the graft. Additionally, the presence of Tenon’s capsule can cause graft retraction. Sutures do not affect wound healing and can cause additional trauma to the surgical site. Suturing the graft may lead to patient discomfort, which, in turn, can cause early breaking of the sutures due to eye rubbing.1–2 As suturing the graft tissue is a time-consuming procedure with some disadvantages, sutureless surgeries have begun to replace it, and fibrin tissue glue has become a popular way to attach conjunctival autografts.11–12 Fibrin tissue glues
have been used in a wide spectrum of ophthalmic procedures, including conjunctival closure in strabismus, and in vitreoretinal and glaucoma surgery. As fibrin tissue glue is a biologic material, it has been suggested that it may cause less inflammation and lower recurrence rates.2 Sutures act as a foreign body and can cause more severe inflammation and higher recurrence rates in patients.2 Fibrin tissue glue shortens the duration of the surgical procedure and provides for rapid, effective treatment of pterygium. Although fibrin tissue glue significantly reduces operative time and increases patient comfort,10,13,14 the technique is open to various complications, including wound dehiscence, Tenon’s cyst, and corneal epithelial erosion. Graft dehiscence refers to partial dislocation of the graft by “dehiscence.” In pterygium surgery, the graft is usually sutured with 7 or 8 sutures. Total dislocation is, therefore, very rare, and in our study, no total dislocation was observed. We compared the visual and refractive outcomes, complications, and recurrence rates in 2 groups of patients who underwent pterygium excision combined with conjunctival autografting. For Group 1, autografting was performed with interrupted 8.0 vicryl sutures; in Group 2, autografting was performed using fibrin glue.
Table 1. Patient Demographics, Pre- and Postoperative Clinical Characteristics Parameter
Group 1, Suture (n = 53)
Group 2, Fibrin Glue (n = 53)
P Value
Men, n (%)
21 (39.6)
17 (32.1)
Women, n (%)
32 (60.4)
36 (67.9)
Age, y ± SD
53.75 ± 10.7 (31–75)
52.08 ± 12.8 (32–89)
0.46b
Follow-up Period, months ± SD (range)
21.15 ± 5.3 (12–32)
22.06 ± 5.2 (12–30)
0.37b
BCVA (logMAR)
0.21 ± 0.2 (0–1)
0.25 ± 0.3 (0–1)
0.57b
Spheric Refraction, D
2.31 ± 2.3, (–)4.50–(+)6.25
3.04 ± 2.7, (–)2.50–(+)8.00
0.40b
Astigmatic Refraction, D
–2.69 ± 2.7, (–)7.00–(+)2.75
–2.97 ± 2.8, (–)9.25–(+)0.50
0.78b
BCVA, logMAR ± SD (range)
0.08 ± 0.1 (0–1)
0.10 ± 0.2 (0–1)
0.65b
Spheric Refraction, D
0.54 ± 1.2, (–)2.50–(+)3.00
0.75 ± 1.2, (–)2.00–(+)1.75
0.69b
Astigmatic Refraction, D
–0.80 ± 0.8, (–)2.50–(+)0.75
–0.69 ± 0.7, (–)1.75–(+)0.50
0.74b
BCVA Improvement, logMAR ± SD (range)
0.13 ± 0.1 (0–0.9)
0.15 ± 0.2 (0–1)
0.68b
Spheric Improvement, D
1.33 ± 1.9, (–)3.00–(+)5.25
1.81 ± 2.4, (–)0.50–(+)6.50
0.58b
Astigmatic Improvement, D
–1.88 ± 2.0, (–)5.00–(+)2.00
–2.40 ± 2.6, (–)7.75–(+)0.50
0.58b
Tenon’s Cyst
3 (5.7)
5 (9.4)
0.71c
Dehiscence
4 (7.5)
2 (3.8)
0.67c
Recurrence
4 (7.5)
1 (1.9)
0.36c
Corneal Epitheliopathy
3 (5.7)
3 (5.7)
1.00c
Sex 0.41a
Preoperative
Postoperative
Complications, n (%)
Pearson X . t test. Fisher exact test. Abbreviations: BCVA, best corrected visual acuity; D, diopter; SD, standard deviation.
a
2
b c
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Fibrin Tissue Glue Versus Vicryl Suture in Pterygium Surgery
Materials and Methods
Our study adhered to the tenets of the Declaration of Helsinki. It was approved by the hospital Ethical Committee and informed consent was obtained from each patient participant. We conducted a retrospective comparative study of 106 eyes of 106 consecutive patients from our ophthalmology department, who had been treated with excision and then with either fibrin tissue glue or 8.0 vicryl sutures to attach the conjunctival autograft in primary nasal pterygium, between the years 2011 and 2012. Patients in both treatment groups underwent follow-up for $ 12 months.
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Patient Selection
Before surgery, all patients underwent complete ophthalmic examination, including best corrected visual acuity (BCVA), manifest and cycloplegic refraction, slit-lamp biomicroscopy, and applanation tonometry. Patients were excluded from the study if they had initial findings or a medical history of amblyopia, previous surgery for pterygium in the same eye, other anterior or posterior segment disease that presumably affected BCVA and refraction, glaucoma, ocular surface disease and symblepharon, or connective-tissue disease that could affect wound healing. The size of the pterygium was estimated by slit-lamp examination. Patients meeting both inclusion and exclusion criteria were divided into 2 treatment groups according to attachment method used for the conjunctival autograft: vicryl suture patients as Group 1 (n = 53); fibrin tissue glue patients as Group 2 (n = 53).
Fibrin Tissue Glue
Fibrin tissue glue is a fibrin sealant that simulates the final stage of the coagulation cascade. We utilized a kit consisting of 2 vials containing aprotinin (3000 KIU/mL) and calcium chloride solvents, and 2 vials containing fibrinogen, plasminogen, plasma fibronectin, factor XIII, and thrombin (4 IU/mL) powders. Both solutions are administered simultaneously via a high-speed jet injection system.
Surgical Technique
Patient surgical site and eyelashes were cleaned with 10% povidone iodine and a sterile drape was put in place. All procedures were performed using an operating microscope. In all cases, the pterygium and conjunctival autograft excisions were performed as described by Hall et al.15 Surgeries were performed under sub-Tenon anesthesia. After insertion of a wire speculum, topical anesthesia, using 0.5% proparacaine, hydrochloric acid (HCl) was applied and lidocain HCl 20 mg/mL and epinephrin HCI 0.0125 mg/mL were used as sub-Tenon anesthesia. The pterygium was dissected from the apex. Removal of the pterygium was performed by both blunt dissection and sharp excision of the pterygium body and subconjunctival fibrovascular tissue using Westcott tenotomy scissors and blade. Cauterization of bleeding vessels and bare sclera was avoided. The removed tissue was sent for histopathology. The eye was irrigated with balanced saline solution. No anti-metabolite was used. Patient upper-nasal conjunctiva was harvested and placed into the
Table 2. Recurrence and Graft Dehiscence Rates From Previous Studies Recurrence, n/N (%)
Dehiscence, n/N (%)
Suture
Fibrin Glue
Suture
Fibrin Glue
Group 1
Group 2
Group 1
Group 2
Cha et al
6/30 (20)
1/22 (4.5)
6/30 (20)
7/22 (32)
Hall et al
2/23 (8.7)
0/24 (0)
0/23 (0)
2/24 (8.3)
Bahar et al
3/39 (7.7)
5/42 (11.9)
N/A
N/A
Karalezli et al
1/25 (4)
3/25 (12)
0/25 (0)
2/25 (8)
Koranyi et al
17/123 (13.5)
14/258 (5.3)
2/123 (2)
1/258 (< 1)
Yuksel et al
4/29 (13.7)
2/29 (6.8)
N/A
N/A
Jiang et al
2/20 (10)
1/20 (5)
N/A
N/A
Farid et al
4/20 (20)
1/27 (3.7)
N/A
N/A
Marticorena et al
N/A
0/20 (0)
N/A
N/A
Ozdamar et al
0/12 (0)
0/12 (0)
N/A
N/A
Por et al
N/A
1/29 (3.4)
N/A
0/29 (0)
Ratnalingam et al
11/69 (15.9)
3/68 (4.41)
0/69 (0)
2/68 (2.9)
Ayala et al
N/A
4/88 (4.54)
N/A
N/A
Kim et al
N/A
0/36 (0)
N/A
2/36 (5.6)
Our Study
4/53 (7.5)
1/53 (1.9)
4/53 (7.5)
2/53 (3.8)
Study
Abbreviation: N/A, not applicable.
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Cagatay et al Figure 1. Improvements in patient visual acuity and refractive values.
experienced surgeon (HHC). Postoperatively, a protective eye shield was applied for 1 week. All patients received 10 mg/mL topical prednisolone acetate 4 times daily, and topical ofloxacin 0.3 % 4 times daily for 1 month.
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Main Outcome Measures
Main outcome measures were change in BCVA, measured by the Snellen chart at the last patient visit $ 12 months after surgery (Snellen values were converted to logMAR equivalents), change in refractive values, complications, and recurrence rates. Recurrence was defined as regrowth of pterygium tissue 1 mm beyond the corneoscleral limbus.16–17 For visual acuity improvements within the groups, preoperative logMAR values were compared with those obtained post-treatment (BCVA improvement = logMAR of last postoperative Control–Pretreatment logMAR). For patients with a BCVA $ 0.1, according to the Snellen chart, standard logMAR conversion was performed. Patients with a visual acuity of counting fingers at 6 meters were considered to have an acuity corresponding to 0.1 on the Snellen chart.
Statistical Analysis
Data were expressed as mean ± standard deviation (SD). For statistical analysis, distribution of data was checked for normality using the Kolmogorov-Smirnov test. Fisher exact test and/or X2 were used for discrete variables. The t test was administered for continuous variables. For statistical analyses, SPSS Version 20.0 was used; a P value , 0.05 was considered significant.
Results Patient Demographics lesion. Dimensions of the bare scleral bed were measured with a caliper. The graft was excised to 1 mm larger than the size of the bare sclera at all borders; furthermore, care was taken to make sure the graft was completely free of Tenon’s capsule. The epithelial surface of the graft was marked with a surgical pen and excised with Vannas scissors along the limbal edge. Special care was taken to prevent button holes and graft rollover. The fibrin glue was prepared per directions from the supplying company. Patient conjunctiva were attached with interrupted 8.0 vicryl sutures in Group 1, or with fibrin glue in Group, 2 mm from the limbus, as shown by Bahar et al.10 All knots were buried. The dry scleral bed was maintained with a cellulose sponge until the tissue glue was administered. The upper-nasal donor area was left open in both groups. All surgeries were performed by the same 100
Patient demographics revealed both patient groups to have similar characteristics. Median patient age was 53.75 ± 10.7 (31‒75) years in Group 1 (suture group), and 52.08 ± 12.8 (32‒89) in Group 2 (fibrin glue group); P = 0.46. By sex, there were 21 (39.6%) men in Group 1, and 17 (32.1%) men in Group 2; 32 (60.4%) patients in Group 1 were women, and 36 (67.9%) patients in Group 2 were women; P = 0.41. Length of follow-up for Group 1 was 21.15 ± 5.3 (12‒32) months and 22.06 ± 5.2 (12‒30) months in Group 2; P = 0.37. Patient demographics are presented in Table 1.
Preoperative Clinical Characteristics
The preoperative clinical characteristics of patients were similar (no significant differences) between the groups. BCVA: Group 1, 0.21 ± 0.2 (0‒1); Group 2, 0.25 ± 0.3 (0‒1); P = 0.57. Preoperative spheric refraction: Group 1,
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Fibrin Tissue Glue Versus Vicryl Suture in Pterygium Surgery
2.31 ± 2.3, (‒)4.50—(+)6.25 diopters, Group 2, 3.04 ± 2.7, (‒)2.50—(+)8.00 diopters; P = 0.40. Preoperative astigmatic refraction: Group 1, ‒2.69 ± 2.7, (‒)7.00—(+)2.75; Group 2, ‒2.97 ± 2.8, (‒)9.25—(+)0.50; P = 0.78. Preoperative clinical characteristics of the patients are presented in Table 1.
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Postoperative BCVA and Refractive Values
When the 2 treatment groups were compared with respect to changes in BCVA levels and refractive values, no significant differences were found. Postoperative BCVA: Group 1, 0.08 ± 0.1 (0‒1); Group 2, 0.10 ± 0.2 (0‒1); P = 0.65. Postoperative spheric refraction: Group 1, 0.54 ± 1.2, (‒)2.50—(+)3.00 diopters; Group 2, 0.75 ± 1.2, (‒)2.00— (+)1.75 diopters; P = 0.69. Post-operative astigmatic refraction: Group 1, ‒0.80 ± 0.8, (‒)2.50—(+)0.75 diopters; Group 2, ‒0.69 ± 0.7, (‒)1.75—(+)0.50 diopters; P = 0.74. Postoperative BCVA improvement: Group 1, 0.13 ± 0.1 (0‒0.9); Group 2, 0.15 ± 0.2 (0‒1); P = 0.68. Postoperative spheric improvement: Group 1, 1.33 ± 1.9, (‒)3.00—(+)5.25 diopters; Group 2, 1.81 ± 2.4, (‒) 0.50—(+)6.50 diopters; P = 0.58. Postoperative astigmatic improvement: Group 1, ‒1.88 ± 2.0, (‒)5.00—(+)2.00 diopters; Group 2, ‒2.40 ± 2.6, (‒)7.75—(+)0.50 diopters; P = 0.58. Patient postoperative BCVA and refractive values are presented in Table 1 and Figure 1.
Complications
At the final follow-up examination, pterygium recurrence and wound dehiscence rate were slightly higher for patients in the suture group, Group 1, whereas Tenon’s cyst development was higher in Group 2 patients, the fibrin glue group. However, the differences did not reach statistical significance: Tenon’s cyst: 3 (5.7%) in Group 1, 5 (9.4%) in Group 2; P = 0.71; wound dehiscence: 4 (7.5%) in Group 1, 2 (3.8%) in Group 2; P = 0.67; recurrence: 4 (7.5%) in Group 1, 1 (1.9%) in Group 2; P = 0.36; corneal epitheliopathy: 3 (5.7%) in Group 1, 3 (5.7%) in Group 2; P = 1.00. The rate of complications is presented in Table 1.
Discussion
Recurrence is the most common complication of pterygium surgery.18 Most pterygia recur within the first 6 months after surgery.16 Conjunctival autograft is an accepted and safe method for treating pterysia and reducing recurrence rates.19 Previously, the standard method of attaching conjunctival grafts was by use of sutures.12 With recent widespread use of fibrin tissue glue for closing the conjunctival autograft after
pterygium excision, comparison of the new glue material with traditional suturing has become important for clinicians. Most of the studies conducted so far have shown 1 of the 2 autograph methods as more effective; questionnaires were used to evaluate patient comfort and satisfaction in areas such as pain, photophobia, irritation, epiphora, and itching.10,20 The studies also demonstrated that using fibrin tissue glue significantly reduced surgery time.21–23 Our study has added to the subjective findings by comparing visual and refractive outcomes in patients, as well as complication rates. Pterygium causes vision-threatening, significant changes in patient corneal refractive status, which improves following surgery.24 It has been reported that eyes with more advanced pterygium develop higher corneal astigmatism.25 Surgically-induced astigmatism is another complication that may be encountered, despite successful surgery.25 Sutureless surgery, using fibrin tissue glue, is a possible solution to this astigmatism complication. However, improvement of BCVA and decreases in refractive spherocylinder power were not significantly different between the sutured and sutureless groups in our study. The research literature reports variable results with respect to complication and rates (Table 2). Some studies have shown that fibrin glue produces lower pterygia recurrence rates than suturing,17,20,26−28 whereas other studies have shown the opposite,10,29 and other reports have documented similar recurrence rates for both techniques.15,20,30 Similarly, long-term recurrence and wound dehiscence rates were similar for both groups in our study but they were lower than those found by Cha et al,20 who used nonabsorbable 10-0 nylon sutures, which can affect complications in the early period.28 Recurrence rates in our patient groups were close to those reported by Hall et al.15 In our study, we found a very low dehiscence rate in the fibrin glue group compared with other studies; this may have been achieved by maintaining a dry scleral bed before using the fibrin glue. Additionally, we assume that closing all eyes with a protective shield for 1 week had a positive effect on graft dehiscence by preventing eye rubbing. All dehiscent grafts were re-attached in a second surgery. Corneal epithelial erosions, which resolved after treatment with lubricating drops, tended to occur at a similar rate in both treatment groups. Tenon’s cyst formation, which was predominantly observed in the fibrin glue group, was not resolved with topical corticosteroid treatment after about 14 days; all of the cysts were excised in a second surgery and none recurred. One patient had serious discomfort postoperatively secondary to glue excess; the excess was trimmed away from the ocular surface with scissors under
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Cagatay et al
slit lamp biomicroscopy in the examination room. Neither graft dislocation nor granuloma development was observed in either group. No infectious disease was reported in any patient during the follow-up period. One limitation of our study was failing to provide complete randomization, due to its retrospective nature. Additionally, race has been reported as a factor that affects recurrence rates16 and our study included only a Caucasian population. A grading system for defining the recurrence of a pterygium has been described.31 According to this system: Grade 1, no difference from normal appearance; Grade 2, thin episcleral vessels present in the excised area, extending to but not passing the limbus; no fibrous tissue present; Grade 3, fibrous tissue that does not invade the cornea; and Grade 4, frank recurrence with fibrovascular tissue that invades the cornea.1,31 However, grading to define the recurrence of pterygium was not used in our study. A simple grading system has been described by Tan et al,32 which classifies the appearance of the pterygium into 3 grades: Grade T1 ‒ atrophic pterygium, episcleral vessels unobscured; Grade T2 ‒ intermediate pterygium, episcleral vessels partially obscured; Grade T3 ‒ fleshy pterygium, episcleral vessels totally obscured. However, again, grading of the pterygium was not done in our study. There are some concerns regarding safety of fibrin glue use, including theoretic risk of anaphylactic reaction and disease transmission. Although the risk is very low, patients should be informed before surgery. None of the patients in our study developed such complications. In conclusion, our study suggests that conjunctival autografting with fibrin glue has favorable visual and refractive results for patients, as well as complication and recurrence rates comparable to the traditional 8.0 vicryl suturing technique. We suggest that fibrin tissue glue provides adequate adhesion, and graft loss will not be a problem if protective eye shields are used postoperatively. Appropriate surgical method should be selected by considering the advantages and disadvantages of each procedure. Larger prospective studies are required to evaluate long-term results.
Conflict of of Interest Statement
Halil Huseyin Cagatay, MD, Gokcen Gokce, MD, Metin Ekinci, MD, Yaran Koban, MD, Ozlem Daraman, MD, and Erdinç Ceylan, MD, disclose no conflicts of interest.
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