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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 13
| Issue : 1 | Page : 5-8 |
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Management of pterygium using autologous blood for conjunctival graft fixation
Anushree Gupta, Anil Kumar Verma
Department of Ophthalmology, Dr. Radhakrishnan Government Medical College and Hospital, Hamirpur, Himachal Pradesh, India
| Date of Submission | 12-Mar-2022 |
| Date of Acceptance | 23-Sep-2022 |
| Date of Web Publication | 17-Mar-2023 |
Correspondence Address:
Dr. Anushree Gupta
229, Eye Opd, Dr. Radhakrishnan Government Medical College and Hospital, Agriculture Colony, Hamirpur - 177 001, Himachal Pradesh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjopthal.sjopthal_3_22
Aims and Objectives: This study aimed to study the efficacy and surgical outcome of using autologous blood for conjunctival autografting in pterygium excision. Materials and Methods: A prospective, interventional hospital-based study was carried out over 17 eyes of 17 patients having primary or recurrent pterygium. Pterygium excision followed by conjunctiva autografting was performed in all the patients. Conjunctiva graft was fixed to the host bed using autologous blood which was followed by bandaging for 24 h. The patients were followed up postoperatively on day 1, week 1, week 2, month 1, month 3, and for recurrence up to 6 months. They were examined for any complications or recurrence. Results: There were a total of 17 patients, of which 13 were females and 4 were males. The mean age of all the patients was 54.76 ± 8.55 years, range: 41–70 years. Graft-related complication was mild decentration in 1 eye, graft edema in 9 eyes, and lost graft seen in 2 eyes. Recurrence occurred in one eye. No other complication was noted. Good postoperative cosmesis was achieved. Conclusion: Fixation of conjunctival autograft using autologous blood in pterygium surgery is a safe and economical method. The main disadvantage of this procedure is the loss of graft that can occur in the immediate postoperative period.
Keywords: Autologous blood, conjunctival graft, pterygium
How to cite this article:
Gupta A, Verma AK. Management of pterygium using autologous blood for conjunctival graft fixation. Sudanese J Ophthalmol 2021;13:5-8 |
| Introduction | |  |
A pterygium is a wing-shaped fibrovascular proliferation of bulbar conjunctiva on the superficial cornea. The pathogenesis of pterygium is multifactorial with ultraviolet (UV) light exposure due to outdoor work being a major risk factor. Other factors associated with pterygium development are genetic factors, mutations in the p53 tumor suppressor gene, and exposure to dust, wind, or other irritants causing chronic ocular inflammation. The prevalence of pterygium increases steadily with proximity to the equator. Histologically, the subepithelial tissue shows senile elastosis (basophilic degeneration) of the substantia propria with abnormal collagen fibers. There is a dissolution of Bowman's membrane, followed by an invasion of the superficial cornea. The main indications for pterygium surgery are ocular discomfort, visually significant astigmatism, cosmesis, growth of the pterygium over the cornea toward the visual axis, and restricted ocular motility.[1],[2]
Surgery is the mainstay of treatment for pterygium, in which the first step is its excision. The primary complication of pterygium surgery is recurrence defined by the regrowth of fibrovascular tissue across the limbus and onto the cornea. Many different techniques and adjuvants for pterygium surgery have been used with variable recurrence rates.
| Materials and Methods | | |
This was a prospective, noncomparative, interventional case study enrolling 17 patients with primary and recurrent pterygium attending the Ophthalmology OPD of Dr. Radhakrishnan Government Hospital, Himachal Pradesh, from May 2019 to March 2020. They were managed by surgical excision of pterygium with free superotemporal conjunctival autograft from the same eye. Inclusion criteria were primary or recurrent nasal pterygium. Patients with a history of dry eye, conjunctivitis, keratitis, temporal pterygium, symblepharon, collagen vascular disorders, and medications such as aspirin or blood thinners were excluded from the study. Visual acuity, automated refraction, and details of slit lamp were recorded. Preoperative ocular examination included refraction and assessment of best-corrected visual acuity, slit-lamp biomicroscopy, fundus examination, grading of pterygium, and photographic documentation of the pterygium. Approval was taken from Institutional Ethical Committee. Informed consent was obtained.
Grading of the pterygium was done as:[3]
- Grade I – pterygium head up to the limbus
- Grade II – head between the limbus and a point midway between limbus and pupillary margin
- Grade III – head between a point midway between limbus and pupillary margin
- Grade IV – crossing pupillary margin.
Informed consent from all patients was taken before the procedure.
Surgical procedure
The surgeries were performed under peribulbar anesthesia. After painting and draping, the pterygium was dissected from the underlying cornea toward the limbus using the crescent blade. The dissection was continued up to the limbus, thus freeing the pterygium off the cornea. The pterygium mass was excised with a Vannas scissor. Any residual tenon tissue was dissected up to the bare sclera. Any active bleeding was controlled with cotton buds. No cauterization was done. About 0.5 ml of Xylocaine 2% was used to balloon up a conjunctival flap in the superotemporal quadrant. The area of the bare sclera was measured with a caliper and a 0.5-mm oversized tenon-free conjunctival graft was obtained from the supertemporal quadrant of the bulbar conjunctiva using a corneal scissor. A thin film of blood was allowed to form over the bare sclera area. The graft was then laid over the bare sclera. The graft was ironed out on the defect to avoid the collection of subgraft blood. We waited for 3–5 min for fixation to occur. The eye was then patched for 24 h with a 0.5% moxifloxacin eye drop. The patient was put on oral analgesic–anti-inflammatory tablets. Next day, the eye was assessed for symptoms, graft adherence, or any complications under a slit lamp. Postoperatively, patient was put on eye drops of moxifloxacin–loteprednol 0.5% four times daily for 2 weeks and thereafter tapered over the next 4 weeks and carboxymethylcellulose lubricant eye drops four times daily for 6 weeks. The patients were advised to wear UV protective sunglasses postoperatively. The patients were followed up at 1 week, 2 weeks, 1 month, 3 months, and 6 months. At each postoperative visit, the patients were examined on a slit lamp, corneal astigmatism was determined using keratometry and any recurrence or complications were recorded.
| Results | | |
The pterygium was divided into four grades 1–4. Most of the patients (11) had Grade III pterygium [Table 1]. The cases varied between the ages of 21–70 years. Out of 17 patients, 4 were males and 13 females were enrolled. No significant intraoperative complications were noted. The patients were followed up postoperatively on day 1, week 1, week 2, month 1, month 3, and for recurrence up to 6 months, and postoperative complications were noted [Table 2]. Loss of graft was seen in two patients on 1st postoperative day. These two patients were operated for primary pterygium and had no intraoperative complications. Graft edema was seen in 9 eyes that persisted till 1 postoperative week and subsequently subsided [Figure 1]. Graft displacement was observed in 1 case during the first 2 weeks postoperative period. It had displaced anteriorly encroaching on cornea [Figure 2]. It was repositioned under local anesthesia taking aseptic precautions. Graft remained in position on subsequent follow-up. Graft retraction that is the gap between graft edge and host conjunctiva was seen in 3 eyes although the grafts were in place [Figure 3]. The mean corneal astigmatism in 15 eyes out of a total of 17 operated patient's eyes (excluding two patients with lost graft) was preoperatively 2.3D and decreased to 0.65D at 4 weeks postoperatively. Recurrence was seen in one patient at 3 months. This patient had been operated for primary pterygium Grade III and had an uneventful postoperative period with good graft adherence till then. Good cosmetic appearance was achieved in all the patients who had no postoperative complications [Figure 4]. | Figure 1: Postoperative photograph showing graft edema on 1st postoperative day
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| Discussion | | |
Multiple surgical techniques have been developed as leaving the sclera bare leads to a high level of unacceptable recurrence of pterygium. These techniques are conjunctival autograft, limbal conjunctival graft, amniotic membrane transplant, and limbal epithelial transplantation using sutures or fibrin glue.[4]
The bare sclera technique involves excising the head and body of the pterygium while allowing the bare scleral bed to re-epithelialize. High recurrence rates have been documented in various reports.[5]
A conjunctival autograft technique involves obtaining an autograft, usually from the superotemporal bulbar conjunctiva, and suturing the graft over the exposed scleral bed after excision of the pterygium.[6]
Amniotic membrane grafting has also been used to prevent pterygium recurrence. A distinct advantage of this technique over the conjunctival autograft is the preservation of the bulbar conjunctiva.[7]
These grafts can be fixed using different methods such as suture or fibrin glue. The use of sutures is an older technique with the disadvantages of maximum surgical time, postoperative discomfort, chronic inflammation, and granuloma formation. Fixating graft using fibrin glue is faster and simpler and avoids suture-related problems. However, the glue itself is more expensive than sutures and since it is a blood-derived product, it carries the potential risk for transmission of viral diseases.[8],[9]
The use of autologous blood as a natural glue to fixate conjunctiva graft to the excised bed of the pterygium eliminates several problems seen with other methods. This technique is also known as suture-and glue-free autologous conjunctival graft. It affixes the graft into place with the patient's own blood, eliminating the concern of disease transmission.[10],[11]
It is natural and has no extra cost or associated risks of infection or inflammation. Some studies have found surgical time to be reduced and improved postoperative cosmesis.
The main disadvantages of this technique are graft displacement and loss of graft.
These can be minimized by taking a thin graft and avoiding the inclusion of tenon capsule, increasing intraoperative fixating time for the graft to the bulbar conjunctiva, or increasing postoperative bandage time.[12],[13]
| Conclusion | | |
Pterygium excision and conjunctival graft fixation using autologous blood is a safe and economical option for both primary and recurrent pterygium. It avoids postoperative pain and irritation as seen with the use of sutures and provides a better postoperative cosmesis. However, a randomized multicenter trial with a larger cohort and longer follow-up is warranted to substantiate our findings.
Limitation
Our study population and follow-up time were relatively smaller.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Basic and Clinical Science Course. San Francisco, CA, United States: American Academy of Ophthalmology; 2019-2020. Chapter 6, Section 08: External Disease and Cornea; p.141-3.  |
| 2. | Ginger-Eke HA, Ogbonnaya CE, Ezisi CN. PTERYGIUM: Recent trends and perspectives – A review of pathogenesis and current management options. Niger J Ophthalmol 2018;26:89-98. [Full text] |
| 3. | Huda MMU, Khaleque SA. Comparison between Sutureless and Glue Free versus Sutured Limbal Conjunctival Autograft in Primary Pterygium Surgery. Med. Today [Internet]. 2019 Feb. 20 [cited 2022 Oct. 4];31:1-8. |
| 4. | Kumar S, Singh R. Pterygium excision and conjunctival autograft: A comparative study of techniques. Oman J Ophthalmol 2018;11:124-8. [ PUBMED] [Full text] |
| 5. | Salman AG, Mansour DE. The recurrence of pterygium after different modalities of surgical treatment. Saudi J Ophthalmol 2011;25:411-5. |
| 6. | Ang LP, Chua JL, Tan DT. Current concepts and techniques in pterygium treatment. Curr Opin Ophthalmol 2007;18:308-13. |
| 7. | Clearfield E, Hawkins BS, Kuo IC. Conjunctival autograft versus amniotic membrane transplantation for treatment of pterygium: Findings from a cochrane systematic review. Am J Ophthalmol 2017;182:8-17. |
| 8. | Hall RC, Logan AJ, Wells AP. Comparison of fibrin glue with sutures for pterygium excision surgery with conjunctival autografts. Clin Exp Ophthalmol 2009;37:584-9. |
| 9. | Kodavoor SK, Ramamurthy D, Solomon R. Outcomes of pterygium surgery-glue versus autologous blood versus sutures for graft fixation-an analysis. Oman J Ophthalmol 2018;11:227-31. [ PUBMED] [Full text] |
| 10. | Nadarajah G, Ratnalingam VH, Mohd Isa H. Autologous blood versus fibrin glue in pterygium excision with conjunctival autograft surgery. Cornea 2017;36:452-6. |
| 11. | Patkar P, Shrivastava S, Ramakrishnan R, Kanhere M, Riaz Z. Comparison of fibrin glue and autologous blood for conjunctival autograft fixation in pterygium. Kerala J Ophthalmol 2017;29:86-90. [Full text] |
| 12. | Sharma MK. Sutureless and glue free limbal conjunctival auto graft for primary pterygium surgery. Nepal J Ophthalmol 2013;5:139-40. |
| 13. | Bhargava P, Kochar A, Joshi R. Pterygium excision followed by sutureless and gluefree infero-temporal conjunctival autograft.DJO 2019 [cited 2022 Oct 4];30:32-5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]
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