Primary nasal pterygium excision with sutureless and glue-free technique of conjunctival autograft: a case series of 24 eyes

Aim: To evaluate the efficacy and complication of sutureless and glue-free conjunctival autograft for the management of primary pterygium over a period of one year. Methods: Prospective, interventional, hospital-based study. Twenty-four eyes of 24 patients with primary nasal pterygium were graded, and excision was performed by a single surgeon. To prevent recurrence, a free conjunctival autograft was taken from the superior quadrant from the same eye and the bare sclera was covered without the use of sutures or fibrin glue, allowing natural autologous coagulum of the recipient bed to act as a bioadhesive. The eye was patched for 24 hours. Postoperatively, patients were put on topical eye drops (polymixin 0.5%, neomycin 0.5%, and dexamethasone 1%) four times daily for four weeks, and oral antibiotics and methyl prednisolone 3x4 mg per day for 5 days. Patients were followed up postoperatively on day 1, 1 week, 6 weeks, 6 months, and 12 months. They were examined for haemorrhage, wound gape, graft shrinkage, granuloma, graft dehiscence, recurrence, or any other complication. Results: The mean age of the patients was 56.96 ± 11.51 years (range 35-81 years). There were 18 females (75%) and 6 males (25%). The following complications were noted: granuloma in three eyes (12.5 %), overriding graft onto the cornea in three eyes (4.17%), and recurrence in one eye (4.17%). No other complications were noted. Average surgical time was 16 ± 2 minutes. Conclusion: Sutureless and glue-free limbal conjunctival autografting is a treatment modality for primary nasal pterygium with no additional cost and has only one recurrence case in 24 cases.


Introduction
Conjunctival autografting has also been advocated for the management of recurrent pterygium.Limbal conjunctival autograft is currently the most popular surgical procedure.The most common method of autograft fixation is suturing.However, it has its own drawbacks, such as increased operating time, postoperative discomfort, inflammation, buttonholes, necrosis, and giant papillary conjunctivitis. 1 The aim of pterygium surgery should not only be to excise the pterygium, but also to prevent its recurrence.Generally, pterygium recurrences occur within the first six months after surgery.One such method to prevent recurrence is autologous limbal conjunctival grafting.Limbal conjunctival autograft transplantation re-establishes the barrier function of the limbus, and hence, significantly lowers the recurrence rate.It is either attached with sutures or with biological adhesives such as fibrin glue, which is derived from pooled human plasma, or autologous fibrin.Suturing of the autograft is rather difficult and requires surgical experience and technical skill.Suzuki et al. reported that the use of silk or nylon sutures cause conjunctival inflammation and Langerhans cell migration into the cornea. 2he fibrin used commercially for gluing can be substituted by the patients' own blood.If time is given for the blood to collect and then for the graft to adhere to the bare area, adequate adhesion can be achieved.The apposition of the lids to the graft bed facilitates a biological dressing and confers a wound-healing environment.

Materials and methods
This was a prospective, interventional, hospital-based study.Twenty-four eyes of 24 patients with primary nasal pterygium were graded, and excision was performed by a single surgeon.To prevent recurrence, a free conjunctival autograft was taken from the superior quadrant of the same eye and the bare sclera was covered without the use of sutures or fibrin glue, allowing natural autologous coagulum of the recipient bed to act as a bioadhesive.

Inclusion criteria
Patients of all ages and of either sex presenting with primary nasal pterygium.Temporal pterygium was not included, as it is very rare.

Exclusion criteria
Recurrent pterygium, glaucoma, retinal pathology requiring surgical intervention, history of previous ocular surgery or trauma, pseudo pterygium, HIV/hepatitis B.

Surgical technique
Topical anaesthesia was given preoperatively.The body of the pterygium was dissected 4 mm from the limbus down to the bare sclera.The pterygium was removed from the cornea by avulsion.Only the thickened portion of conjunctiva and the immediate adjacent and subjacent Tenon's capsule showing tortuous vasculature were excised.An oversized graft by 1 mm was used after measuring with the Castroviejo caliper.The graft was taken from the superior 12 o'clock position.Care was taken to include as little as possible of Tenon's tissue in the graft.The graft was placed on the bare sclera and positioned so as to maintain the limbus-limbus orientation.The graft was resected with the help of conjunctival scissors.No fluid or air was used for making the graft.The graft was kept exposed to the scleral bed for ten minutes by applying gentle pressure with fine non-toothed forceps.Small bleeds in the scleral bed cause serum to ooze in small quantities, acting as an adhesive.Large bleeds lift the graft from the scleral bed with subsequent complications and should be tamponated before placing the graft.
The eye was bandaged and patched for 24 hours.Postoperatively, patients were put on topical eye drops (polymyxin 0.5%, neomycin 0.5%, and dexamethasone 1%) four times daily for four weeks, as well as oral antibiotics and methyl prednisolone 3x4 mg per day for five days.Patients were followed-up postoperatively on day 1, 1 week, 6 weeks, 6 months, and 12 months.They were examined for haemorrhage, wound gape, graft shrinkage, granuloma, graft dehiscence, recurrence, or any other complication.
Total surgical time was measured from the first conjunctival cut to the removal of the lid speculum, i.e., the time taken from the excision of pterygium to the time to secure the graft on the bed.Postoperative symptoms such as pain, foreign body sensation, watering, redness, photophobia, etc., and complications were documented.Recurrence was defined as a conjunctival growth extending for more than 1 mm over the corneal surface.

Results
The mean age of the patients was 56.96 +/-11.51years (range 35-81 years).There were 18 females (75%) and 6 males (25%).The following complications were noted: granuloma in three eyes (12.5 %), overriding graft onto the cornea in three eyes (4.17%), and recurrence in one eye (4.17%).No other complications were noted.Average surgical time was 16 ± 2 minutes.The case summary for all patients are showed in Table 1.

Discussion
Ashok et al. states that the sutureless and glue-free conjunctival autograft technique is simple, easy, safe, effective, and less time-consuming than the sutured limbal autograft technique, with less postoperative discomfort and adverse events encountered with the use of suture material and the patients. 4his study provided follow-up for up to a year (January 2016 until June 2017), given that pterygium recurrences occur within the first six months after surgery. 5imbal conjunctival autograft transplantation re-establishes the barrier function of the limbus, therefore significantly lowering the recurrence rate.It is either attached with sutures or with biological adhesives such as fibrin glue,