Delta Journal of Ophthalmology

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 18  |  Issue : 3  |  Page : 133--137

Comparison of fibrin glue and autologous serum for conjunctival autograft fixation in pterygium


Saurabh Shrivastava, Priyanka Patkar, Reshma Ramakrishnan, Minal Kanhere, Zahna Riaz 
 Department of Ophthalmology, Mahatma Gandhi Mission’s Medical College and Hospital, Kamothe, Navi Mumbai, India

Correspondence Address:
Saurabh Shrivastava
Department of Ophthalmology, Mahatma Gandhi Mission’s Medical College and Hospital, Plot No. 1 and 2, Sector 1, Kamothe - 410 209, Navi Mumbai
India

Abstract

Aim The aim of the study was to compare the outcome of conjunctival autograft (CAG) surgery for pterygium using autologous serum versus fibrin glue. Materials and methods A prospective, randomized, controlled trial was carried out on 40 patients over a period of 2 years. Twenty eyes underwent CAG with fibrin glue and another 20 eyes underwent CAG with autologous serum. Postoperatively, the parameters noted in both groups were the time taken for surgery in both groups, postoperative outcome like redness and discomfort during blinking, outcome of the graft (graft edema, graft retraction, graft rejection, graft displacement, and graft loss) and pterygium recurrence. Results In the CAG group with autologous serum, the mean surgical time was 34.8 min (SD=3.66), whereas in the group of CAG with fibrin glue the mean surgical time was 22.95 min (SD=3.09), a statistically significant difference (P=0.0000). The intensity of postoperative discomfort was greater in the group with autologous serum than the group with fibrin glue; however, the difference was not statistically significant. Graft rejection was observed in one patient belonging to the fibrin glue group, after 1 month postoperatively, which eventually by the end of the third month, led to graft loss. Conclusion The operating time in the fibrin glue group was significantly less as compared with the autologous serum group. The cost of surgery was more with fibrin glue. Graft edema, graft loss, graft retraction, and displacement of the graft were more with the use of fibrin glue. However, the difference was not statistically significant.



How to cite this article:
Shrivastava S, Patkar P, Ramakrishnan R, Kanhere M, Riaz Z. Comparison of fibrin glue and autologous serum for conjunctival autograft fixation in pterygium.Delta J Ophthalmol 2017;18:133-137


How to cite this URL:
Shrivastava S, Patkar P, Ramakrishnan R, Kanhere M, Riaz Z. Comparison of fibrin glue and autologous serum for conjunctival autograft fixation in pterygium. Delta J Ophthalmol [serial online] 2017 [cited 2022 May 22 ];18:133-137
Available from: http://www.djo.eg.net/text.asp?2017/18/3/133/216919


Full Text

 Introduction



Pterygia that extend far across the eye causing cosmetic embarrassment and visual problems due to induced astigmatism, and those causing chronic ocular irritation due to tear film disturbance may require removal. During the past decade, the debate over the best approach to pterygium surgery has centered on whether the surgeons should use sutures, mitomycin C, amniotic membrane, or fibrin glue to affix the conjunctival graft (CAG). All the approaches have their pros and cons in terms of such factors as surgical time, postoperative complications, cosmesis and recurrence. The ideal procedure to minimize postoperative recurrence, as of now, is CAG [1]. The most common method of securing CAG using sutures has the drawbacks of long surgical time, risk of complications like granuloma formation, and significant patient discomfort [2]. On the other hand, the technique of graft fixation with commercial fibrin glue has the potential risk of transmitted infection and high cost [2].

A new technique of autograft fixation has emerged, where we need to apply neither glue nor sutures. Patients’ graft adhered because of the fibrinous reaction in the patients’ own blood (serum). Very few studies have been carried out in the Indian subcontinent to compare the outcome of CAG fixed with autologous serum and CAG fixed with fibrin glue.

The aim of this study was to compare the results of limbal CAG fixed with autologous serum with those fixed with fibrin glue in primary pterygium excision.

 Materials and methods



A 2-year prospective, randomized, controlled trial was carried out (from December 2014 to December 2016). The study was carried out on 40 patients who presented to the Department of Ophthalmology. After taking informed consent from the patients and permission of the ethics committee, detailed history regarding the patient’s name, age, sex, occupation, address, presenting symptoms, duration, progression, and associated conditions was recorded. Anterior segment examination of the patients was done preoperatively. The grading of the pterygium was done according to the classification given by Kanski et al. [3]. Pterygium excision was done by a single operating surgeon under local anesthesia and then the patients were followed up on postoperative day 1, day 4, day 7, 1 month, third month, and at sixth month. Forty patients (eyes) were randomly divided into two groups of 20 each. Twenty eyes underwent CAG with fibrin glue and another 20 eyes underwent CAG with autologous serum. Patients with progressive nasal pterygium above the age of 40 years who did not have any ocular surface diseases (e.g. blepharitis, Sjogren’s syndrome, and dry eye), nondiabetics, who were not on any anticoagulants, having no previous history of ocular surgery or trauma and those not having atrophic pterygium, pseudopterygium, or pterygium with cystic degeneration were included in the study. Patients developing infections in the postoperative period were excluded from the study.

After the usual surgical preparation of the eye, stay sutures were taken over the temporal limbus with 6-0 silk suture. Incision was given on the conjunctiva, above the pterygium, at the limbus with No 15 Bard–Parker blade (Warden Sergical Pvt Ltd). Head of the pterygium was dissected from the cornea with a crescent blade (Webel edge). The corneal surface was further smoothed with a crescent blade. The body of the pterygium was dissected from the overlying conjunctiva using Westcott’s scissors and then excised. Tenon’s tissue was also removed from under the conjunctiva. Conjunctival defect at the limbus was measured with a Castroviejo calliper and a marking of the size more than 0.5 mm than the defect was done on the superiortemporal bulbar conjunctiva of the same eye, in order to take the required graft. Subconjunctival saline injection was given under the superiortemporal bulbar conjunctiva, thus raising the destined size of graft. Westcott’s scissors were used to harvest the free conjunctival limbal autograft ([Figure 1]). Care was taken to include the limbal stem cells. Meticulous dissection was done to remove most of the Tenon’s tissue in the autograft. The conjunctival graft was then moved to the area of the conjunctival defect, with care taken to maintain the limbus to limbus and stromal side down orientation.{Figure 1}

At this stage, depending on the group in which the patients were allocated to, the autograft was secured. In one group, the autograft was adhered to the underlying scleral bed by fibrin glue. The fibrin glue was taken out from the deep freeze and thawed to room temperature. The preparation was performed in a separate room, with properly maintaining the temperature by an independent nurse. The first component, that is the fibrinogen solution, was prepared by mixing the fibrinogen powder with the aprotinin (bovine) solution. The second component, that is the thrombin solution, was prepared by mixing the thrombin powder with water for injection provided in the kit. Both components were withdrawn in two separate syringes and placed into the duploject injector. A mixer nose cone, topped by a blunt applicator needle was attached to the two-syringe nozzle to facilitate mixing of the two components from the syringe. When the common plunger was depressed, the fibrin sealer solution and the thrombin solution were combined in the nose cone, in equal volumes, to form the resulting fibrin sealant that is directly applied to the designated tissues. Gentle pressure was applied for 2 min in case of fibrin glue ([Figure 2]).{Figure 2}

In the other group, the autograft was placed over the serum bed formed over the sclera by the bleeding vessels of the excised pterygium. Pooling of blood at the site to be grafted should be avoided and bleeders causing excessive bleeding should be cauterized. After placing the graft and spreading it properly, gentle pressure was applied for 3 min followed by a waiting period of 7 min for adherence of the graft ([Figure 3]). The total time taken for each procedure was noted from when the lid speculum was placed until its removal at the end of surgery.{Figure 3}

Patching of the eye was done after giving subconjunctival dexamethasone and gentamycin injections at the donor site. Eye patch was removed on the first postoperative day in both groups. After the surgery, all patients were prescribed topical steroids (prednisolone acetate), topical antibiotics (moxifloxacin hydrochloride), and lubricating eye drops four times daily for 2 weeks, then tapered off weekly over the next 3 weeks. Follow-up was done on postoperative day 1 ([Figure 4] and [Figure 5]), day 4, after 1 week, after 1 month, after 3 months, and after 4 months.{Figure 4}{Figure 5}

The parameters noted in both groups were the time taken for surgery, postoperative outcome like redness and discomfort during blinking, outcome of the graft (graft edema, graft retraction, graft rejection, graft displacement, and graft loss), and recurrence of the pterygium ([Figure 6],[Figure 7],[Figure 8]).{Figure 6}{Figure 7}{Figure 8}

Data were entered into Microsoft Excel and analyzed using SPSS 24 trial version (SPSS Inc., Chicago, Illinois, USA) Microsoft Excel Enterprise 2008. The mean and SD for the linear variables and proportions for categorical variables were calculated.

 Results



This was a prospective, comparative study conducted at a tertiary care center. The present study showed almost equal gender distribution, that is, 55% men and 45% women. A total of 25 (62.50%) patients had grade 2 pterygium and 15 (37.50%) patients had grade 3 pterygium. The degree of discomfort due to pterygium was studied preoperatively. The authors found that 55% of the patients had mild discomfort, 35% had moderate, and 4% had severe discomfort.

In the group using autologous serum, the mean surgical time was 34.8 min (SD=3.66), whereas in the group using fibrin glue the mean surgical time was 22.95 min (SD=3.09). There was a statistically significant difference between the two groups (P=0.0000).

Six (30%) patients complained of mild discomfort, nine (45%) patients complained of moderate discomfort, and five (25%) patients complained of severe discomfort in the autologous serum group on day 1, whereas 11 (55%) patients had mild, six (30%) patients had moderate, and two (10%) patients had severe postoperative discomfort in the fibrin glue group (P=0.225). Thus, the intensity of postoperative discomfort was greater in the group with autologous serum than in the group with fibrin glue, postoperatively. However, the difference was not statistically significant. Subconjunctival hemorrhage was graded according to its presence in the four quadrants. On postoperative day 1, subconjunctival hemorrhage was noted in the autologous serum group in 65% of the patients in the nasal quadrant, in 55% of the patients in the temporal quadrant, and in 50% of the patients in each of the inferior and superior quadrants. On the other hand, in the fibrin glue group, it was noted in 60% of the patients in the nasal quadrant, in 55% of the patients in the temporal quadrant, in 40% of the patients in the inferior quadrant, and in 60% of the patients in the superior quadrant. There was no significant difference between the two groups. The hemorrhages resolved completely by the third month. Graft edema on the postoperative day 1 was present in 16 patients of the group with autologous serum and subsided within the first month. In the group with fibrin glue, it was noted in 18 patients on the postoperative day 1 and persisted in only one patient at the end of the first month. Graft displacement ([Figure 6]) was seen in one (5%) patient of the autologous serum group and in two (10%) patients in the fibrin glue group. Graft retraction ([Figure 7]) was seen in one (5%) patient in the autologous serum group and in three (15%) patients in the fibrin glue group. However, the difference was not statistically significant. Graft rejection was observed in one patient belonging to the fibrin glue group after 1 month postoperatively which eventually by the end of the third month led to graft loss. There was a 5% (one eye) graft loss rate in the autologous serum group, compared with 10% (two eyes) in the fibrin glue group. This was not statistically significant. The recurrence rate was studied at 3-month and 6-month postoperatively. It was found that one patient in the autologous serum group had graft loss on postoperative day 1; the same patient showed recurrence (5%) on the sixth month postoperatively, whereas no recurrence was found in the fibrin glue group.

 Discussion



The present study compared the outcome of CAG surgery for pterygium using autologous serum versus fibrin glue. It was conducted to assess and compare the mean surgical time, postoperative outcome of the graft, and the total cost of the surgery among the patients undergoing pterygium excision surgery with CAG using autologous serum and fibrin glue.

Hilgers have demonstrated a higher prevalence of pterygium among men [4]. The present study showed almost equal gender distribution, that is, 55% men and 45% women. Number of men and women were equally affected in all age groups.

Singh et al. [5], have reported a mean surgical time of 14.74±2.35 min in the fibrin glue group and a mean surgical time of 17.45±2.89 min in the autologous serum group. In the present study, the group with autologous serum had a mean surgical time of 34.8 min (SD=3.664912), whereas in the group with fibrin glue the mean surgical time was 22.95 min (SD=3.086047). There was a statistically significant difference between the two groups.

This study has shown no significant difference in the subconjunctival hemorrhage between the two groups. Uy et al. [6] have reported subconjunctival hemorrhage under the graft in one patient in the fibrin glue group, which resolved in 3 weeks. The hemorrhages resolved completely by the third month. Graft edema was found in more patients in the fibrin glue group than in the autologous serum group. It may probably be due to inadequate dissection of pterygium tissue which led to thick grafts due to persistent Tenon’s capsule in some patients. In addition, poor compliance to the instillation of steroid eye drops was noted in one patient in the fibrin glue group and he developed severe graft edema. No statistically significant difference was observed for graft rejection between the two groups. In this study, the graft rejection was found in the first case of autograft fixation using the fibrin glue and might be due to a lot of manipulations in harvesting the graft and application of the glue due to inexperience. In a study conducted by Singh et al. [5], graft displacement was more common in the no glue, no suture group than in the fibrin glue group. Karalezli et al. [7] in their study have reported graft displacement in two patients in the fibrin glue group. Malik et al. [8] have reported graft dehiscence in 5% of the patients in the no glue, no suture patients. In the present study, graft displacement was seen in 5% of the patients in the autologous serum group and 10% of the patients in the fibrin glue group. Graft loss observed in this study was not statistically significant compared with the other studies. The possible explanation for this can be due to lesser duration of patching the eye postoperatively. Malik et al. [8] have patched the patients for 48 h and experienced no graft loss. In the present study, patients were patched for about 18 h. Recurrence was defined as any regrowth of conjunctiva exceeding 1.0 mm onto the cornea. The recurrence rates were studied at the third and sixth month postoperatively and it was found to be comparable to those found in other studies (2.5–10%) [5],[8].

 Conclusion



The operating time in the fibrin glue group was less compared with the autologous blood group. The overall cost burden was lesser in the autologous serum cases than in the fibrin glue cases. Graft edema, graft loss, graft retraction, and displacement of the graft were more with the use of fibrin glue though the difference was not statistically significant.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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