Thesis Semifinal

A COMPARITIVE STUDY OF THE
EFFECT OF SUTURES, FIBRIN

GLUE AND SUTURELESSGLUEFREE TECHNIQUE FOR
CONJUNCTIVAL AUTOGRAFTING
IN PTERYGIUM EXCISION
SURGERY
THESIS
SUBMITTED TO THE
NATIONAL BOARD OF EXAMINATIONS
FOR
DIPLOMATE OF NATIONAL BOARD
OPHTHALMOLOGY
2015
BY
DR. ADITYA AGGARWAL
DR. MOHAN LAL MEMORIAL GANDHI EYE
HOSPITAL,
ALIGARH.
Dedicat
ed
to my
3
Parents
and
Teacher
s
CERTIFICATE
This to certify that DR ADITYA AGGARWAL is a bona fide

student who has registered for Diplomate of National Board course
in OPHTHALMOLOGY in this hospital from the period of 30 th
MAY 2013 to 29th MAY 2016.
This is to certify that the subject matter of this thesis entitled A
Comparitive Study of the Effect of Sutures, Fibrin Glue and
Sutureless-Gluefree Technique for Conjunctival Autografting in
Pterygium Excision Surgery is the result of original work
undertaken under our supervision and guidance.
The methods of work and results obtained have been verified from
time to time and are genuine to the best of my knowledge.
I am of the opinion that the work and results reported by him in this
thesis would be contributory to the existing knowledge of the
subject.
DR. ARCHNA BHATNAGAR

SAXENA
DR. AJAY KUMAR
Senior Ophthalmic Surgeon
Deputy C.M.O.
Dr. Mohan Lal Memorial
Dr. Mohan Lal Memorial
Gandhi Eye Hospital,
Aligarh
Aligarh
(SUPERVISOR)
(CO-SUPERVISOR)
CERTIFICATE
This to certify that DR ADITYA AGGARWAL is a bona fide
student
who
has
registered
for
DNB
course
in
OPHTHALMOLOGY in this hospital from the period of 30 th MAY

2013 to 29th MAY 2016.
This is to certify that the subject matter of this thesis entitled A
Pterygium Excision Surgery is the result of original work
undertaken under the supervision and guidance of Dr. ARCHNA
BHATNAGAR, Senior Ophthalmic Surgeon, and Dr. AJAY
KUMAR SAXENA, Deputy CMO, Dr Mohan Lal Memorial
Gandhi Eye Hospital, Aligarh.
The methods of work and results obtained have been verified from
time to time and are genuine to the best of my knowledge.
I am of the opinion that the work and results reported by him in this
thesis would be contributory to the existing knowledge of the
subject.
Dr. RAZIA S. KHAN

Chief Medical Officer
Dr Mohan Lal Memorial

Aligarh.
DECLARATION BY THE CANDIDATE
I hereby declare that the subject matter of this thesis entitled A

Pterygium Excision Surgery is the result of bona fide and original
work undertaken by me under the guidance of Dr. ARCHNA
BHATNAGAR, Senior Ophthalmic Surgeon, and Dr. AJAY
KUMAR SAXENA, Deputy CMO, Dr Mohan Lal Memorial
Gandhi Eye Hospital, Aligarh.
This study has been approved by Ethical and scientific committee.
DR. ADITYA AGGARWAL

D.N.B. Student
Dr. Mohan Lal Memorial Gandhi Eye Hospital,
Aligarh.
ACKNOWLEDGEMENT
Though only my name appears on the cover of this dissertation, a lot
many people have contributed to its production. The completion of
this dissertation not only brings an appreciated respite from many,
many months of demanding efforts, but also provides me a welcome
opportunity to acknowledge in writing the many kind souls who help
along the long way.
First of all, I humbly bow down to the Almighty, the invisible power,
who has made all my work possible.
I offer my heartfelt gratitude and profound indebtness to my Chief
Supervisor Dr Archna Bhatnagar who gave me this opportunity to
carry the research work and has offered invaluable support and
guidance since the commencement of the work. I am highly obliged
to her for having painstakingly gone through the script despite her
innumerable commitments.
I express profound sense of reverence to my Co-Supervisor Dr Ajay
Kumar Saxena for his boundless expression of knowledge, constant
supervision and guidance which has gone a long way in ensuring the
completion of this study. His multifaceted personality, skillful
9
approach and constructive criticisms have been a constant driving

force and a measure of perfection to me.
I am thankful to my teacher Dr. P.P. Singh for his valuable
suggestions from time to time.
I owe my gratitude to Dr. Razia S. Khan, Chief Medical Officer for
her constant encouragement and for providing me all possible
facilities during the course of the study.
I am also thankful to Dr. Zishan Khan for his valuable help and
suggestions.
It is with great pleasure, respect and gratitude that I acknowledge my
thanks to my seniors Dr. Divya Singh, Dr. Prashant Jain and Dr.
Shruti Agarwal for their expert advice and constant encouragement
at every stage of this study.
I am also thankful to my juniors Dr. Ankit and Dr. Sneha who stood
by me and helped me take this project towards completion.
Words cannot describe my gratitude to my parents, Mr. Lokesh
Aggarwal and Mrs. Rani Aggarwal, who have always showered
me with all their love, care and affection. Their countless sacrifices,
prayers and wishes have made me the person I am today.
10
I thank my brothers, Dr. Tarun and Dr. Varun, and my sister

Deepti, for helping me through the tough times. They are the best
gift given by God to me. They have always been there in every ups
and downs of my life.
I also thanks my sisters-in-law, Dr. Sheena and Dr. Priya for their
constant love and support.
I am greatly indebted to my loving and understanding wife, Sonam
Aggarwal who constantly and incessantly encouraged me to
accomplish this onerous task that I had undertaken. She patiently
tolerated long hours of my absence during this research and actively
assisted me in the tedious task. I am overwhelmed to have a person
like her as my life partner.
Last but not the least, I wish to thank my patients who have
graciously consented to be a part of this endeavor.
11
Dr. Aditya Aggarwal
12
CONTENTS
SR NO
CONTENTS
PAGE NO
INTRODUCTION
10
REVIEW OF
LITERATURE
25
AIMS AND
OBJECTIVES
49
MATERIAL AND
METHODS
51
RESULTS
62
DISCUSSION
93
CONCLUSION
101
BIBLIOGRAPHY
105
ANNEXURE
119
10
MASTER CHART
126
13
Introduct
ion
14
Pterygium is a Greek word meaning wing of a butterfly. Pterygium

is a fleshy, triangular shaped growth of bulbar conjunctival
epithelium and hypertrophied subconjunctival connective tissue
encroaching onto the cornea. It is a degenerative condition of the
subconjunctival tissues which proliferate as a vascularized
granulation tissue to invade the cornea, destroying the superficial
layers of the stroma and the Bowmans membrane, the whole being
covered by conjunctival epithelium.
A pterygium is made up of three parts: a cap, a head and a body.
1 Cap: An avascular halo like zone at the advancing edge.
2 Head: The triangular apex of the pterygium over the cornea.
3 Body: The main mass over the sclera.
Depending on its extension from the limbus it is of three types:
1 TYPE 1 extends less than 2 mm onto the cornea.
2 TYPE 2 involves up to 4 mm of the cornea.
3 TYPE 3 encroaches onto more than 4 mm of the cornea and
involves the visual axis.
Tan et al
devised a simple grading system which classifies the
appearance of pterygium into three grades.
15
1 GRADE 1- Atrophic pterygium, episcleral vessels under the

body
of
the
pterygium
not
obscured
and
clearly
distinguishable.
2 GRADE 2- Intermediate pterygium, episcleral vessles
partially obscured.
3 GRADE 3- Fleshy pterygium, episcleral vessels totally
obscured.
Pterygium fleshiness was the basis of this simple clinical grading
system.
Depending on progression it may be progressive or regressive
pterygium.
1 Progressive pterygium is thick, fleshy and vascular with a
few infiltrates in the cornea, in front of the head of the
pterygium.
2 Regressive pterygium is thin, atrophic, attenuated with little
vascularity. Deposition of iron (Stockers line) may be seen
sometimes, just anterior to the head of pterygium.
The first ever documentation of pterygium was done by the great
surgeon of ancient India, Sushruta (3000 BC) who called it as
16
Armans.
In India, it is called Nakhoona in Hindi, due to its
resemblance to a nail in its shape.

The prevalence rate of primary pterygium varies from 0.7 to 31% in
various populations around the world.3,4
Pterygium is more frequent in areas with more ultraviolet radiation,
in hot, dry, dusty, windy, and smoky environments. There is also a
hereditary factor.5
Risk of pterygium is increased in people who, in their third decade
of life, works outdoor in an environment with high surface
reflectance of ultraviolet light compared with those who works
indoor. The use of hats and sunglasses is protective.6
Pterygium is perhaps the most obvious of the ophthalmohelioses
(sun-related eye condition) and can blunt sight in various ways.7
Pterygium are nearly always preceded and accompanied by
pinguecula. It occurs in the palpebral fissure area much more often
nasally than temporally, although either or both (double pterygium)
occur. Elevated whitish opacities (islets of Vogt) and an iron
deposition line (Stocker line) may delineate the head of the
pterygium on the cornea. Iron deposits in the epithelium have a
17
yellow-brown coloration. Pooling of tears in the region of

topographic irregularities allows iron from the tear film to be
deposited within the epithelium.8, 9 Hemosiderin pigment is deposited
in lysosomes of the basal epithelial cells.
It may appear similar to pseudopterygium, which is a conjunctival
adhesion to the cornea secondary to previous trauma or
inflammation. A pseudopterygium often has an atypical position and
is not adherent at all points, so a probe can be passed beneath it
peripherally. It forms as a response to an acute inflammatory episode
such as a chemical burn, corneal ulcer (especially if marginal),
trauma and cicatrizing conjunctivitis.
Pterygium is much more prevalent among those who does not uses
glasses or any protective measures for their eyes than among those
who protects their eyes with either spectacles or sunglasses.6
There are several reviews dealing with the etiology of pterygium and
yet a satisfactory explanation remains elusive.
Coroneo has suggested that the anterior segment peripheral focusing
effect causes the UV- B light to be preferentially focused at the nasal
18
limbus and nasal cornea.7 This may account for why pterygium
usually occur nasally.10
In the past, the pathogenesis of pterygium was thought to be related
to disturbance of the tear film spread. New theories include the
possibility of damage to limbal stem cells by ultraviolet light and by
activation of matrix metalloproteinases (MMP). 11 MMPs are the
family of zinc binding endopeptidases, present as secreted,
membrane bound, or intracellulary stored proteins.
Pterygium cells may also cause activation of fibroblasts at the head
of the pterygium, leading to the initial cleavage of fibrillar collagen
in Bowman's layer by the production of MMP-1. 12, 13 MMP-7 may
play a significant role in the angiogenesis that characterizes this
lesion.11
Ultraviolet light is widely accepted to be the single most important
etiologic factor in its causation.14 UV radiation triggers a chain of
events which can produce damage to cellular DNA, RNA and
extracellular matrix.15 UVB also induces expression of cytokines and
growth factors in pterygial epithelial cells, which are considered to
be an important driving force in the development of pterygium.16
19
Tekelioglu and colleagues17 noted the presence of increased levels of

T lymphocytes and inflammatory markers in pterygial tissue as
compared to normal conjunctiva.
Several fibroangiogenic growth factors such as basic firoblast
growth factor (bFGF) and vascular endothelial growth factor
(VEGF) have been shown to be increased in pterygia, suggesting
that growth factor may be involved directly in the pathogenesis of
pterygia.14, 18, 19 Pterygia exhibit significantly lower PEDF but higher
VEGF levels than those in normal corneas and conjunctivae. The
decreased PEDF level in pterygia may play a role in the formation
and progression of pterygia.20
Dushku and Reid13 reported that in pterygium, vimentin is expressed
by altered limbal stem cells, which give rise to the motile daughter
stem cells that form the leading edge of the pterygium. Furthermore,
they found abnormal p53 expression in the altered limbal cells of
pterygia, suggesting that a pterygium is found by proliferation rather
than degeneration.21
Immunohistochemical examination of pterygial tissue has disclosed
growth of the presumed pterygial cells outside the pterygial body,
20
which may account for the high rate of pterygium recurrence after
simple excision of the pterygial body.13 The vimentinexpressing
epitheloid cells were present not only over the ocular surface of
pterygium but also in the normal appearing conjunctiva adjacent to
the pterygium.22
Chiang et al23 noted the presence of cyclooxygenase -2 in pterygial
tissue and suggested its role in pterygium formation.
Adiguzel et al24 reported increased expression of cyclooxygenase -2
in recurrent pterygium and suggested its use a marker for prediction
of recurrence.
Although heredity is reported to play a role in pterygium it is not
crucial. The inheritance is dominant with a low penetrance, but it
would appear that the actual lesion is not transmitted but rather the
tendency of the eye to react in this way to environment stimuli.25
Coroneo et al
26
conceptualized a two stage hypothesis for
pterygium pathogenesis:
1) initial and progressive disruption of the limbal conealconjunctival epithelial barrier and
21
2) progressive active conjunctivalization of the cornea by

tissue characterized by extensive cellular proliferation,
inflammation,
connective
tissue
remodeling,
and
angiogenesis.
Microscopically histological section shows accumulation of
amorphous, eosinophilic, hyalinised or granular appearing material
resembling degenerated collagen interspersed with coiled or
fragmented
fibres
resembling
abnormal
elastic
tissue.
The
accumulated stromal material was thought to be elastic tissue

because it stained with elastic tissue stains. However, this has been
disputed as the tissue is resistant to the non proteolytic enzyme
elastase, hence the term elastoid and elastotic degeneration were
invoked.25 There is elastotic degeneration of the collagen tissue of
the stroma of the conjunctiva. The overlying epithelium may be
normal, atrophic or hyperplastic. According to Duke-Elders, a
pterygium can disrupt or destroy the underlying Bowman membrane
with replacement of only the superficial layers of the stroma with
fibroblasts. But Mootha V
10
concluded that long standing nasal
pterygium in elderly patients may rarely induce deep corneal

changes at the level of the endothelium and Descemet membrane.
22
Endothelial cell density may be lower in eyes with pterygia with

deep corneal changes.10
Corneo et al26 concluded in their study that pterygium can be
considered to be a proliferative, invasive lesion with focal limbal
failure associated with excessive UV exposure. It is characterized by
chronic inflammation and angiogenesis with resultant connective
tissue remodeling. This is in contrast to the traditional notion of
pterygium being considered as purely degenerative process.
The major complaint of the patient is cosmetic or dimness of vision.
Diminished vision is mostly due to astigmatism but may be due to
encroachment of the pupillary area of the cornea by the lesion. Some
patient may be conscious of some fleshy mass growing on to the
cornea.
Pterygia warrant treatment when they become cosmetically
bothersome, encroach upon the visual axis, induce significant
astigmatism, causes persistent irritation or causes diplopia due to
interference in ocular movement.
Surgical removal is the treatment of the choice. The simple excision
(bare sclera) method of pterygium removal has the advantage of
23
brevity. This technique, however, has an unacceptably high

recurrence rate of 60% to 80%. In addition, recurrences are
frequently very aggressive and often end up larger than the primary
pterygium. Because the results of this procedure are so poor,
surgeons have added a number of adjunctive therapies in an attempt
to reduce the recurrence rate.
Simple Excision Plus Mitomycin C has been shown to be effective
in preventing recurrence for primary and recurrent pterygium. While
many chemotherapeutic agents have been used in the past,
mitomycin C is currently the most popular.
Diaz, Lilliam et al27 reported a significant reduction in recurrence
rate with intraoperative use of Mitomycin C.
Rubinfeld and colleagues28 revealed reports of severe complications
such as scleritis, infectious sclerokeratitis, and scleromalacia after
pterygium excision with adjunctive Mitomycin C therapy.
Simple removal plus conjunctival reconstruction with sliding
conjunctival flap has also shown to lower the recurrence rates. This
method of reconstructing the defect after simple removal appears to
24
reduce the recurrence rate to about 10% and is only slightly more
time-consuming and difficult than simple excision.
Amniotic Membrane transplantation has gained increased popularity
over the past 10 years. When preserved amniotic membrane is used
to reconstruct the surface defect left after pterygium removal, it is
often combined with extensive removal of Tenons fascia and often
by local application of mitomycin. It is similar in complexity to
conjunctival autografts and uses an expensive and potentially
hazardous material derived from human tissue.
Prabhasawat P et al29 conducted a study and found that recurrence
rate were significantly higher in amniotic membrane graft in
comparison to conjunctivoautografts in patients with pterygia.
Lamellar Keratoplasty has been use to act as a barrier against
pterygium recurrence and to replace the thinned and scared corneal
tissue after pterygium excision30. The main limitations are the need
for donor corneal tissue with the risk of graft rejection and
transmission of infection, as well as the increased complexity of the
procedure.
25
Conjunctival autografting (CAG) has been considered the best and

most suitable approach that can lower the recurrence rate (2%-39%)
of pterygium .29, 31, 32
In 1985, Kenyon et al
33
proposed that a conjunctival autograft
(CAG) of the bare sclera could be used in treatment of recurrent and

advanced pterygium.
Limbal conjunctival autograft transplantation, a recent method, is
most commonly used to prevent recurrence after surgical excision of
pterygium, on the identification of the importance of limbal stem
cells in the pathogenesis of ocular surface disorders and pterygium.
Limbal stem cells act as a junctional barrier preventing conjunctival
epithelial invasion onto the healthy corneal epithelium.14, 26, 34-36
At present there are three techniques for attaching the CAG by the
help of sutures, glue and recently autoblood has been used instead of
fibrin glue. Each technique has its own advantages and
disadvantages.
Traditionally, the conjunctival autograft is attached with sutures, the
technique is easy but may be associated with suture related
complications
including
infection,
26
granuloma
formation,
complicated surgical technique, prolonged operative time, and

prolonged postoperative patient discomfort 37
Fibrin glue have been used as an alternative mean of attaching the
grafts. Some reports favours the use of fibrin glue
with
improved
comfort,
decreased
6, 37
surgical
above sutures
time,
reduced
complication and recurrence rate have been reported.

Fibrin glue is a blood derived product that is absorbable. Although
the use of fibrin as a biologic adhesive was first introduced in 1909,
it was not until 1944 that Tidric et al used fibrin for skin graft
fixation.38
The use of fibrin glue during pterygium surgery was first described
by Cohen at al in 1993.39
Fibrin tissue bioadhesives mimics the natural fibrinogen and
thrombin reaction are used on various ophthalmological surgeries for
tissue adhesion, blood coagulation and wound healing.5
Koranyi et al5 in their cut and paste study concluded that using glue
in attaching conjunctival autograft in pterygium surgery with fibrin
glue causes significantly less postoperative pain and shortens
surgery time significantly.
27
Fibrin glue has the potential risk of prion disease transmission and
anaphylaxis in susceptible individuals,
40
also, the cost of fibrin glue
is high.
If the synthetic glue can be prepared from elements of human blood,
then natural blood can also be used as a tissue adhesive. Sutureless
grafting without synthetic fibrin glue has been successfully used in
gingival grafts.41 Conjunctiva, representing a similar mucosal
surface, is fixated on the scleral bed by using the natural fibrin clot
derived from the oozing blood during the operation.42
Most recent approach of conjunctival autografting is without using
suture or glue and the graft is adhered because of patients own
blood coagulum acting as a bioadhesive. This technique apparently
appears free of suture and glue related problems.
The recurrence in most cases is seen within 6 months, but can
sometime occur late.43
Sebban and Hirst43 defined recurrence as the presence of
fibrovascular tissue regrowth extending beyond the surgical limbus
onto clear cornea.
Pterygium fleshiness was identified as a risk factor for recurrence.30
28
As there is little data available on the use of autoblood in pterygium

autografting, the purpose of this prospective study is to compare the
three different methods for pterygium excision and conjunctival
autografting (CAG) which are suturing, gluing and suturelessgluefree (SGF) technique (using oozing autoblood as tissue
adhesive) in view of
1
2
3
4
5
6
Graft stability,
Postoperative inflammation,
Postoperative patient discomfort,
Recurrence,
Cost, and
Surgical time.
29
Review
of
Literatur
e
30
Pterygium is a greek word. In India it is called Nakhoona due

to its resemblance to the nail in its shape. It is a fleshy, triangular
shaped growth of bulbar conjunctiva and hypertrophied
subconjunctival connective tissue encroaching onto the cornea.
Rohtagi S2 did a prospective observational study on patients
with pterygium to analyse its epidemiological trends like age, sex,
and incidence, effect of living conditions and occupation on the
occurrence of pterygium. The age incidence of the group showed
that the incidence of pterygium was 4% in the age group of less than
30 years. It rises to a maximum of 32% in the age of 30-39 years and
then gradually declines. There was a male preponderance of 60%,
the incidence being more in rural areas (72%). The incidence was
found to be maximum among farmers (40%) followed by labourers
(20%), office staff (10%), students (4%) and housewives (10%). He
concluded that people who work outdoors are subjected to
involuntary U.V. B exposure. The highest exposure will occur during
two hours on either side of noon.
Nakaishi H. et al44 reported pterygium to be associated with
corneal and conjunctival microtrauma from exposure to sunlight
31
(especially ultraviolet radiation). Particulate material such as smoke,

sand or dust particles is also speculated to be the possible pathogenic
factor for pterygium as well as pinguecula. Pterygium is more
frequent in areas with more ultraviolet radiation, in hot, dry, windy,
dusty and smoky environments.
Mackenzie FD et al6 conducted a case control study in which
278 patients treated for primary pterygium were compared with a
similar number of people without pterygium who were matched for
age, race and sex. Risk of pterygium was increased among patients
who, in their third decade of life, worked outdoor in an environment
with high surface reflectance of ultraviolet light compared with those
subjects who worked indoors. They concluded that there is a strong
causal relationship between ultraviolet light exposure and the
development of pterygia.
According to Corneo MT7 pterygium is perhaps the most
obvious of the ophthalmohelioses (sun related blindness) and can
blunt sight in several different ways.
There is a strong protective element in the wearing of regular
sunglasses or a hat, as suggested by Mackenzie et al 6. According to
32
Rim T.H.T. et al45 education to avoid excessive sun exposure would

be helpful in reducing disease risk.
Kwok LS and Corneo MT46 proposed that the initial biologic
event in pterygium pathogenesis is an alteration of limbal stem cells
due to chronic ultraviolet light exposure. The concomitant
breakdown of the limbal barrier and subsequent conjunctivalization
of the cornea explain the formation of a primary pterygium
In the past, the pathogenesis of pterygium was thought to be
related to disturbance of the tear film spread.
New theories include the possibility of damage to limbal stem
cells by ultraviolet light and by activation of matrix
metalloproteinases (MMP). Nick Di Girolamo et al11 demonstrated
active MMP species in pterygia immunohistochemically. They also
suggested that MMP-7 may play a significant role in the
angiogenesis that characterizes this lesion.
Tekelioglu et al17 noted the presence of increased levels of T
lymphocytes and inflammatory markers in pterygial tissue as
compared to normal conjunctiva, suggesting a possible role of
cellular immunity to its pathogenesis.
33
Jin J. et al20 compared expression levels of an angiogenic

inhibitor, pigment epithelium-derived factor (PEDF), in pterygia
with those in normal corneal and conjunctival tissues. They
concluded that pterygia exhibit significantly lower PEDF but higher
vascular endothelial growth factor levels than those in normal
corneas and conjunctivae.
Chiang et al23 noted the presence of cyclooxygenase-2 in
pterygial tissue and suggested its role in pterygium formation.
Adiguzel et al24 reported increased expression of cyclooxygenase-2
in recurrent pterygium and suggested its use as marker for prediction
of recurrence.
Solomon A. et al47 examined the expression patterns of
extracellular matrix degrading enzymes in cultured primary
pterygium body fibroblast (PBF) activated by cytokines and growth
factors potentially derived from ocular surface epithelial cells and
tears. They concluded that chronic inflammatory stimulation by IL-1
and TNF- , which potentially derived from the ocular surface and
tears, may be responsible for increased expression of MMPs in
cultured PBF. These data have clinical implications on progression
34
of pterygium and recurrence associated with incomplete excision of

primary PBF under the influence of ocular surface inflammation.
They suggested that suppression of intraoperative and postoperative
inflammation may be new strategy to prevent pterygium recurrence.
Corneo et al26 concluded in their study that pterygium can be
considered to be a proliferative, invasive lesion with focal limbal
failure associated with excessive UV exposure. It is characterized by
chronic inflammation and angiogenesis with resultant connective
tissue remodeling. This is in contrast to the traditional notion of
pterygium being considered as purely degenerative process.
Surgical removal is the treatment of the choice. The simple
excision (bare sclera) method of pterygium removal has the
advantage of brevity. This technique, however, has an unacceptably
high recurrence rate of 60% to 80%. Tan D.T. et al1 reported 61%
recurrence rate in cases of bare sclera excision.
Pterygium excision is often combined with various adjunctive
measures to prevent recurrence of the disease. Ang Leonard PK et
al32 classified adjunctive measures as medical method, betairradiation and surgical methods.
35
Mitomycin C remain the most commonly used medical

adjunctive method for the prevention of pterygium recurrence. Diaz,
Lilliam et al27 reported a significant reduction in recurrence rate
with intraoperative use of 0.04% mitomycin C. They conducted a
nonconcurrent prospective study of 68 patients with primary or
recurrent pterygium. They concluded that mitomycin C is efficacious
in preventing recurrences and a safe adjunct therapy during
pterygium surgery. They also suggested that intraoperative
mitomycin C application leads to few complications while providing
a significant reduction in the recurrence rate. Similarly Raiskup F et
al48 in their study on Mitomycin C for pterygium: long term
evaluation, evaluated 99 patients who underwent pterygium surgery
with mitomycin C between 1989 and 1994. 63% of patients had
pterygium surgery with intraoperative application of 0.02%
mitomycin C for 5 minutes and 37% of patients received mitomycin
C 1% or 2% drops four times daily for 2 weeks postoperatively. In
three patients, pterygium recurred within 18 months. They
concluded that the use of mitomycin C in pterygium surgery is safe,
but a long term follow up are required. However Rubinfeld and
colleagues28 revealed reports of severe complications such as corneal
36
edema, corneal perforation, iritis, sudden onset mature cataract,

secondary glaucoma, scleral calcification, and scleromalacia after
pterygium excision with adjunctive Mitomycin C therapy. They
suggested if mitomycin C is to be used, the lowest possible
concentration should be applied for the shortest time period.
Beta irradiation was a well accepted adjunctive treatment two
to three decades ago. Chayakul V. et al49 showed that beta
irradiation was associated with a significantly higher recurrence rate
than postoperative mitomycin C. Beta irradiation is a less popular
procedure because of the risk of serious sight threatening
complications, such as scleral necrosis, corneal perforation and
endophthalmitis, as reported by Moriarty A. P. et al50.
The surgical options available include the use of amniotic
membrane transplant, lamellar keratoplasty, conjunctival autograft,
limbal and limbal-conjunctival transplant, conjunctival rotation
autograft and use of fibrin glue.
Amniotic membrane transplant has been proposed as a
treatment option for pterygium. Solomon A et al51 did an
interventional case series on 54 eyes of 54 patients to evaluate the
37
outcome and recurrence rate after primary and recurrent pterygia

removal combined with amniotic membrane transplantation and
concluded that it is an effective and safe procedure for pterygium
surgery, with a relatively low recurrence rate for both primary and
recurrent pterygia. It can be a useful alternative to conjunctival
autograft when a large conjunctival defect has to be covered such as
in primary double head pterygia and in large recurrent pterygia.
Tananuvat N et al52 did a randomized trial to study the efficacy and
safety of amniotic membrane transplantation as an adjunctive
therapy after surgical excision of primary pterygium and to compare
the clinical outcome with that of conjunctival autograft. 86 eyes of
78 patients with primary pterygium were operated. The surgical
outcome of primary pterygium excision followed by amniotic
membrane
and
conjunctival
autograft
transplantation
were
compared. They found that amniotic membrane transplantation for

pterygium surgery has an unacceptably high recurrence rate.
Similarly, Prabhasawat P et al29 conducted a prospective study of
amniotic membrane graft and primary closure was compared
retrospectively with conjunctival autografts and found that
recurrence rate were significantly higher in amniotic membrane graft
38
in comparison to conjunctival autografts in patients with pterygia.

This result is also supported by Luanratanakorn et al53 who
conducted randomized controlled trial to determine whether
amniotic membrane graft can be used as an alternative to
conjunctival autograft after pterygium excision and found that
amniotic membrane graft had a higher recurrence rate than
conjunctival autograft.
Golchin B et al30 conducted a study to evaluate the efficacy
and safety lamellar keratoplasty in the treatment of recurrent
pterygium and of scleral necrosis induced by beta irradiation.
Lamellar keratoplasty was performed on 68 eyes in the recurrent
pterygium group and on 30 eyes in the scleral radionecrosis group.
The recurrence rate following lamellar keratoplasty was 5.9%. They
concluded that lamellar keratoplasty is a safe and effective treatment
option for both recurrent pterygium and beta irradiation induced
scleral necrosis. As such this is not a favored procedure for treating
primary pterygium.
Conjunctival autograft transplantation was first described as a
treatment for pterygium by Kenyon KR et al33in 1985. They
39
performed this technique on 57 eyes of 54 patients. The pterygia

were primary in 16 eyes and recurrent in 41. The mean follow up of
2 years detected three (5.3%) recurrences after autograft
transplantation.
Ang Leonard PK32 et al in their review of current concepts
and techniques in pterygium treatment, reviewed variations in
conjunctival autograft surgery, which include the use of narrow strip
conjunctival autograft, limbal conjunctival autografts, limbal
epithelial autograft, conjunctival flaps and conjunctival rotation
autografts.
Dupps WJ et al54 did a retrospective noncomparative
interventional case series to determine the efficacy of narrow strip
conjunctival autograft surgery in the treatment of pterygium and has
shown that narrow strip conjunctival autografting is an effective
surgical technique in preventing pterygium recurrence and creating
an intervening bare sclera area between the secured conjunctival
graft and the anterior margin of the conjunctival wound may be
important in preventing recurrence.
40
Sharma A et al55 demonstrated that there was no statistically

significant difference in the recurrence rates between conjunctival
autografting and mitomycin C use. They did a clinical trial to
evaluate and compare the long term safety and efficacy of low dose
intraoperative application of mitomycin C (0.02%) with conjunctival
autograft in primary pterygium surgery.
Frucht-Pery J et al56 did a prospective randomized
comparative study to compare the clinical outcome of pterygium
surgery combining intraoperative mitomycin C with a free
conjunctival autograft with three other methods of pterygium
surgery, including intraoperative mitomycin C alone, conjunctival
autograft alone, and bare sclera without adjunctive treatment. They
concluded that pterygium excision with a free conjunctival autograft
combined with intraoperative low-dose mitomycin C is a safe and
have a significantly lower recurrence rate compared to conjunctival
graft alone.
Du Z et al57 did a randomized clinical trial to observe the
therapeutic effects of limbal epithelial autograft transplantation and
pterygium excision in the treatment of pterygium and concluded
41
that, to provide a new stem cell source, limbal epithelial autograft

transplantation, for an injured limbus is a reasonable therapeutic
method for the treatment of pterygium.
Young et al58 prospectively compared mitomycin C and limbal
conjunctival autograft surgery in preventing pterygial recurrence,
and showed that the mitomycin C group was associated with a
higher recurrence rate (15.9%) compared with the limbal
conjunctival autograft group (1.9%).
But it is technically more
difficult and inapplicable in cases with previous limbal disturbance.

Jap A et al59 recommended conjunctival rotation autograft for
pterygium as an alternative to conjunctival autograft in which the
latter is contraindicated or difficult. Such cases included eyes with
scarred superior conjunctiva, limited availability of conjunctival
donor tissue for transplant as in double headed pterygia. There were
51 rotation autografts performed on 45 eyes of 43 patients. In this
procedure, the underlying fibrovascular pterygium tissue was
removed and the original epithelium replaced over the bare sclera
with a 180 degrees rotation. They concluded that conjunctival
rotation autograft is a useful technique in cases in which it is not
42
possible or desirable to use the superior conjunctiva as a donor

source.
McCoombes et al60 reported a recurrence rate of 3.2% by
using a sliding conjunctival flap after primary pterygium excision in
258 eyes with an 86% follow up rate.
There are various techniques for attaching the conjunctival
autograft to the bed. Traditionally, sutures were used before for the
emergence of commercially available fibrin glue. Many studies have
come, preferring the use of fibrin glue over sutures. However, the
most recent approach is attaching the conjunctival autograft with
patients own blood coagulum.
More surgical expertise, technical ability and surgical time are
needed to secure the graft with sutures. Sridhar MS et al61
demonstrated that sutures do not actively participate in wound
healing and may cause additional trauma to the injury site and
adjacent tissue. Also, infectious agent might enter along the suture
tract, or the sutures might act as the nidus of the inflammation itself.
Loose or broken sutures require removal and, hence, additional
working time.
43
Sutureless graft fixation with use of fibrin glue as tissue

adhesive in pterygium surgery has recently gained popularity since
the work of Koryani et al5 in 2004. It outweighs the suturing
technique with the advantages of faster surgical time, faster and
more comfortable recovery period, good cosmesis and lesser
recurrence rate. They used fibrin glue to achieve conjunctival graft
adhesion after surgical excision of the pterygium. They carried out a
prospective randomized clinical trial, 43 eyes were operated for
primary nasal pterygium. Autologous conjunctival graft taken at the
superotemporal limbus was attached to cover the sclera after
pterygium excision. After randomization, in 20 patients the
transplant was attached to the sclera with a fibrin tissue adhesive and
in 23 patients with absorbable sutures. They concluded that using
glue instead of sutures when attaching the conjunctival transplant in
pterygium surgery causes significantly less postoperative pain and
shortens surgery time significantly.
In a retrospective study comparing the long term outcomes of
the glue technique versus absorbable sutures, Koranyi et al62
reported significantly lower recurrence rate in the glue group as
compared to the suture group. The recurrence rate was 5.3% in the
44
glue group and 13.5% in the suture group (p = 0.001). The

reoperation rates were 1.2% and 3.3%, respectively (p = 0.31).
Complications, such as transient transplant edema, and persistent
corneal epithelial defects, occurred equally in both groups.
Bahar et al63 performed a comparative randomized clinical
trial in 65 eyes with primary nasal pterygium to compare the short
term results of conjunctival closure in pterygium surgery using fibrin
adhesive versus Vicryl sutures with respect to operative time,
postoperative ocular signs and symptoms. They concluded that use
of fibrin glue in pterygium surgery significantly reduces operative
time and patient symptoms, pain, and discomfort.
Karalezli et al64 did a study to compare the use of fibrin glue
versus sutures for fixating conjunctival autograft in patients
undergoing pterygium excision. Fifty eyes with primary pterygium
were randomized to undergo pterygium surgery using either fibrin
glue or 8-0 Vicryl sutures to attach the conjunctival autograft. The
patients were followed up for 12 months. In the fibrin glue group,
the mean operation time was 15.7 min and in the suture group it was
32.5 min. The intensity of postoperative pain, foreign body
45
sensation, irritation and epiphora were significantly lower in the

fibrin glue group than in the suture group. Two patients in the fibrin
glue group had partial graft dehiscence. The recurrence was
observed in one eye (4%) in the fibrin glue group and in three eyes
(12%) in the suture group. They concluded that the use of fibrin glue
in pterygium surgery with conjunctival autografting reduces surgery
time, improves postoperative patient comfort and results in a lower
recurrence rate compared with suturing.
Srinivasan S et al65 compared the degree of conjunctival
autograft inflammation, subconjunctival hemorrhage and graft
stability following the use of sutures or fibrin glue during pterygium
surgery. They conducted the prospective clinical trial on 40 eyes of
the 40 patients having primary pterygium. The degree of
inflammation was significantly less in fibrin glue than with sutures
at 1 month and 3 months postoperatively. No significant difference
was found for inflammation at 1 week postoperatively. Conjunctival
grafts secured with fibrin glue were as stable as those secured with
sutures. No significant difference was found in degree of
postoperative subconjunctival hemorrhage between the groups. They
concluded that conjunctival grafts secured with fibrin glue during
46
pterygium surgery not only are as stable as those secured with

sutures, but also produce significantly less inflammation.
Yuksul B et al66 performed a prospective randomized clinical
trial on 58 eyes to compare the efficiency and safety of fibrin glue to
suture technique in pterygium surgery performed with limbal
autograft. In 29 eyes, the transplant was attached to the sclera with a
fibrin tissue adhesive and in 29 eyes with 8-0 Virgin silk sutures.
Patients were followed up for six months. Subconjunctival
hemorrhage occurred under the graft in one patient in fibrin glue
group. Pterygium recurrence was seen in one case of fibrin group,
and two cases of suture group. Average cost was higher (p<0.05) and
surgery time was shorter (p<0.02) in fibrin group. They concluded
that using fibrin glue for graft fixation in pterygium surgery causes
significantly less postoperative pain and shortens surgery time
significantly.
Cha DM67 et al retrospectively reviewed the medical records
of 52 eyes from 46 patients who underwent pterygium excision and
conjunctival autografting to compare the effect of using fibrin glue
or 10-0 nylon sutures on the clinical outcome. The operation
47
duration was 27.71 (5.22) minutes in the fibrin glue group and
43.30(8.18) minutes in the suture group (p = 0.000). seven days after
the operation, the fibrin glue group showed milder conjunctival
inflammation that the suture group (p = 0.000). Postoperative
complications and corneal recurrence rates were not statistically
different between the two groups. They concluded that the use of
fibrin glue in pterygium excision with conjunctival autografting is
likely to be a more effective and safer procedure than suturing.
Ratnaligam V et al68 did a prospective, randomized clinical
trial to evaluate the recurrence rate, surgical time, and postoperative
pain between conjunctival autografting with sutures and with fibrin
glue in pterygium surgery. Sixty eight eyes were operated with fibrin
adhesive and sixty nine eyes with sutures. Patients were followed up
at 1 day, 1 week, 1 month, 6 months, and 1 year after surgery. There
were three recurrences in the fibrin adhesive group and 11
recurrences in the suture group. The mean duration required to
complete surgery in fibrin adhesive group was shorter than that of
the suture group. No major complications were observed in either
group. They concluded that the use of fibrin adhesive in primary
pterygium surgery with conjunctival autografts reduces the
48
recurrence rate, surgical time, and postoperative pain when

compared with sutures.
Nieuwendaal CP et al69 conducted a retrospective case series
to evaluate the rate of recurrence and to detect pre or postoperative
complications in pterygium surgery using fibrin glue to attach the
conjunctival autograft. In 1 patient with a primary pterygium, the
lesion recurred after 4 months (2.9%). One autograft was lost on the
first postoperative day. They concluded that the use of fibrin glue
seems to be a safe, easy, and effective technique for attaching the
conjunctival autograft in pterygium surgery.
Farid M et al70 compared the pterygium recurrence rate after
pterygium excision with conjunctival autograft, using fibrin glue
versus absorbable sutures. The recurrence rate in fibrin glue group
was 3.7% compared with 20% in the sutured group (p = 0.035).They
also found that there was a significant inverse relationship between
age and rate of recurrence overall (p = 0.025).
Ozdamar Y et al71 performed a comparative study fibrin glue
and Vicryl suture for closing limbal conjunctival autografts and
histologic evaluation after pterygium excision. Patients were
49
followed for 6 months. Histopathologic examination was performed

in both groups on postoperative days 1, 15, and 45. Foreign body
granulation tissue was not seen in any histopathologic studies in eyes
with fibrin glue, whereas it was observed in eyes with Vicryl sutures
from day 15 to day 45. They concluded that the use of fibrin glue
decreases patient symptoms during the postoperative period after
pterygium surgery. Compared with sutures, fibrin glue had no
adverse effects on ocular tissue.
Despite viral inactivation techniques in commercial fibrin
glue, transmission of infectious agents like Parvovirus B19 and
prions may take place. Cases of anaphylactic reaction have been
reported after use of fibrin sealant. Oswald AM et al72 reported three
cases of anaphylactic reaction after use of fibrin sealant. The
allergen was believed to be bovine protein aprotinin, which was
induced in the product as as antifibrinolytic to slow the dissolution
of the fibrin clot.
De Wit D et al40 described a simple method of achieving
conjunctival autograft adherence during pterygium surgery avoiding
potential complications associated with the use of fibrin glue or
50
sutures. A total of 15 eyes underwent sutureless and glue-free

autologous conjunctival graft post-pterygium excision. Mean follow
up time was 9.2 months. They concluded that sutureless and gluefree technique for pterygium surgery may prevent potential adverse
reaction encountered with the use of foreign materials.
Sharma and Moore et al 42 reported 4 cases using autologous
fibrin glue for pterygium surgery. In their study, they showed well
positioned grafts an all 4 cases after 6 week follow up.
Malik KPS et al73 did a prospective interventional case series
to study the efficacy of sutureless and glue free limbal conjunctival
autograft for primary pterygium surgery. They carried out study on
40 eyes with primary nasal pterygium requiring surgical excision.
Pterygium excision with limbal conjunctival autografting without
using glue or sutures was performed in all patients followed by
bandaging for 48 hours. The patients were followed up post
operatively on 2nd day, 1week, 6 weeks, 6 months and 12 months.
They were examined for hemorrhage, wound gape, graft shrinkage,
chemosis, graft dehiscence and recurrence. They concluded that
sutureless and glue free limbal conjunctival autografting following
51
primary pterygium excision is a safe, effective and economical

option for the management of primary pterygium.
Singh PK et al74 did a prospective randomized case control
study to compare the outcomes of conjunctival autograft with fibrin
glue and conjunctival autograft with patients own blood acting as a
bioadhesive in treating pterygium after surgical excision. Twenty
eyes with pterygium were randomly divided into 2 groups: group I
(10 eyes) underwent conjunctival autograft with fibrin glue and
group II (10 eyes) with patients own blood coagulum acting as a
fixative. The patients were followed up for 12 months for outcomes
of graft, recurrence rate, graft displacement, retraction, inflammatory
reaction, graft failure, or any other complications. The duration of
surgery was less in group I than group II. The rate of recurrences
were equal in both the groups. The complications regarding graft
displacement and graft retraction were more common in patients
with grafting with autologous blood (10%) than in those with the
glue. They concluded that autologous fibrin in blood is a useful
alternative method for graft fixation in pterygium surgery.
52
Foroutan A et al75 evaluated the efficiency and safety of using

autologous fibrin glue for attachment of a conjunctival autograft in
primary pterygium surgery. Thrombin and fibrinogen were prepared
from the patients own blood in two separate sealed tubes in the
blood transfusion center. Autologous fibrin glue was applied over the
bare sclera for attachment of the free conjunctival autograft to the
surrounding conjunctiva and sclera. Of the 13 patients, 3 developed
autograft retraction that resolved completely with continued eye
patching. Two eyes developed total graft dehiscence, and sutures
were used for reattachment of the graft in its correct position. Two
eyes developed recurrence of pterygium, one of them had already a
total graft dehiscence. They suggested that autologous fibrin glue is
a safe and useful alternative method for graft fixation in pterygium
surgery.
Mitra S et al76conducted a prospective interventional case
series of 19 primary and recurrent pterygium operated with
conjunctival autografts. Graft fixation was done using the oozing
blood clotted over the bare sclera as tissue adhesive. Commonest
complication seen was the sub graft hemorrhage that was observed
53
in 14 patients, graft edema occurred in 9 patients and medial edge

recession was observed in 2 cases. No recurrence was noticed.
Dulani N et al77 analysed the efficacy of blood oozed during
pterygium excision as tissue adhesive to secure conjunctival
autografts. 59 eyes from 59 patients with primary pterygium were
recruited. All eyes underwent pterygium excision followed by
conjunctival autografting. Blood oozed during pterygium excision
was used as adhesive. In the mena follow up period of 6 months,
symblepheron formation, motility restriction, conjunctival
hyperemia, graft edema were not observed in any of the patients.
Recurrence developed in 1 eye, graft loss in 2 eyes and subgraft
hemorrhage in two eyes. They concluded that blood oozed during
pterygium excision may provide novel approach for securing
conjunctival autograft.
54
Aims and
Objectiv
es
55
56
The present study have been designed with the following aims and
objectives-
1. To compare the effect of suturing, gluing and sutureless

gluefree (SGF) technique in patients undergoing pterygium
excision and conjunctival autografting on the basis of graft
stability.
2. To compare the three techniques employed for pterygium

surgery on the degree of sub-graft hemorrhage and
postoperative inflammation.

surgery on the degree of post-operative patient discomfort
which includes pain, itching, watering and foreign body
sensation.

surgery on the basis of recurrence of the pterygium.

surgery on the basis of cost and surgical time.
57
58
59
Material
and
Methods
60
This prospective Study was conducted at Dr. Mohan Lal Memorial

Gandhi Eye Hospital, Aligarh. Permission for this study was
obtained from the ethical committee of the hospital. Informed
consent was taken from the patients in their own language in a
prescribed bilingual format. 150 patients who fulfilled the inclusion
criteria were selected from all those attending out patient department
presented with primary pterygium in month of 29 th August 2013 to
28th August 2014.
INCLUSION CRITERIA:
Age (20 to 75 years)
Patients with primary pterygium
EXCLUSION CRITERIA:
Patients with history of any previous ocular surgery.
Patients with eyelid disease, or anterior segment pathology
like
conjunctivitis,
symblepheron,
keratitis,
degeneration, corneal dystrophy and anterior uveitis.

Patients with history of ocular trauma six months back.
61
corneal
Patients on aspirin or other anticoagulants.

Mentally retarded patients.
Highly uncooperative patient.
METHODS:
A detailed history of all patients was elicited and they were clinically
examined as per the proforma attached.
HISTORY
The following particulars were recorded name, age, sex, address and
family income. Detailed history was taken as per the attached study
proforma.
EXAMINATION OF EYE
Torch Light Examination
Patients both eye were examined. The examination started with
looking at head posture, eyelids, condition of lacrimal apparatus.
Special emphasis was done on examination of conjunctiva and
cornea.
Visual Acuity
62
Visual acuity of both the eyes was recorded and corrected by

Snellens Chart or Landolts C Chart.
63
Slit Lamp Examination

A Haag Streit 900 slit lamp was used for examination. Both the eyes
were examined under diffuse, focal and retro illumination on the day
of examination. The cornea was examined carefully for any
abnormality other than pterygium. The anterior chamber, lens and
pupillary reactions were examined to rule out any abnormality.
The size of the pterygium was estimated by slit-lamp examination.
The height of the slit was adjusted to the lesion and covered it from
limbus up to the corneal side of the pterygium. The size was
measured in millimeters.
Surgical Technique
All the procedures were performed by one surgeon to ensure
similarity in the procedure, thereby eliminating intersurgeon
variability.
Pterygium excision was performed after administration of peribulbar
anaesthesia. The local blocks consisted of a 6:4 mixture of 2%
lignocaine with 1:20,000 epinephrine and 0.5% bupivacaine. Under
aseptic precautions, after insertion of a lid speculum, the head of the
pterygium was separated from the cornea and dissected towards the
limbus. The body was trimmed up to 4 mm away from the limbus.
64
Subconjunctival fibrous tissue was removed as much as possible

taking care not to damage the underlying muscle sheath. Hemostasis
was achieved by pressure application at the bleeding site. Residual
fibrovascular tissue on the surface of the cornea was removed with a
toothed forceps.
The dimensions of the bare sclera were measured with vernier
caliper. A free conjunctival graft was harvested from supero-limbal
bulbar conjunctiva taking care not to include Tenon tissue under the
graft. The donor graft taken was 1mm larger in length and width in
comparison to the bare sclera. The entire graft was excised from its
limbal attachment with Vannas scissors, with care taken to maintain
the epithelium side up and the limbal edge toward the limbus. The
donor graft was placed on the top of cornea, it helps in unfurling the
donor graft and maintaining the proper orientation. The graft was
kept moist.
The patients were randomized into three groups. Group 1 involves
conjunctival
autografting
with
sutures,
Group
involves
conjunctival autografting with fibrin glue and group 3 involves

conjunctival autografting with autoblood.
Group 1: Conjunctival Autograft with Sutures
65
The graft was approximated to the recipient conjunctival edge with 4

or 5 interrupted 8-0 vicryl sutures (ethicon). Care was taken to
maintain proper orientation with the epithelial side up and the limbal
edge towards the limbus.
Group 2: Conjunctival Autograft with Fibrin Adhesive
Preparation of Fibrin Glue
Fibrin glue is a blood derived product that consists of two
components: fibrinogen and thrombin, both prepared by processing
plasma. When mixed and fibrinogen is activated by thrombin, an
adhesive fibrin network is formed.
It can be prepared at a blood transfusion center or from patients own
blood or obtained as a commercially available preparation.
Reliseal (Reliance Life Sciences Pvt. Ltd., Mumbai, India) is a
commercially available fibrin adhesive. The kit (0.5) contains the
following
Yellow bottle- Fibrinogen 35 mg (component 1)
Blue bottle- Thrombin 250 IU (component 2)
Red bottle- Aprotinin 1500 Kiu
1 ampoule of 5ml sterile water for injection (WFI)
66
4 X 2ml syringes for reconstitution and application

4 X 21G sterile needles for aspiration of the two
components
2 X 20G blunt application needles
Reliseal applicator with two mixing chambers and one
plunger guide.
It was prepared according to the manufacturers directions.
The two components of fibrin glue can either be applied
simultaneously with Reliseal applicator or sequentially.
In the glue group, 1 drop of fibrin glue was applied over the bare
sclera in the recipient bed and spread out with the cannula. The graft
was immediately placed in the correct orientation onto the bare
sclera and gently smoothed. Thereafter, the edges of the graft were
cautiously apposed to the edges of the recipient conjunctiva by
forceps for 30 seconds for firm adhesion.
Group 3: Conjunctival Autograft with Autoblood
In Sutureless-Gluefree group, the bare sclera was allowed to bleed, if
no blood was available to provide autologous fibrin, small
perforating veins and capillaries were purposely punctured to
67
encourage a thin layer of blood to cover the scleral bed. The

conjunctival autograft was then applied over the bare sclera and
allowed to adhere spontaneously over it. Care was taken to maintain
the orientation of the juxtalimbal border toward the cornea and to
prevent graft rollover. The free graft was held in position, until firm
setting of the autologous fibrin had occurred. Care was taken to
ensure that excessive and prolonged bleeding did not displace the
graft, and residual active hemorrhage visible under the surface were
tamponaded with direct compression using a blunt instrument like
the iris repositor.
Surgery time was monitored and noted from the insertion of the lid
speculum to the removal of lid speculum.
A simple pad and bandage was used. The bandage was opened on
the first postoperative day. Patients were advised not to rub their
eyes or indulge in contact sports for a few days.
Postoperative therapy included 1% prednisolone acetate eye drops
and 0.5% moxifloxacin eye drops every 4 hours in the first week,
tapered gradually over 1 month.
Patient Evaluation and follow up
68
All subjects were seen at 1 day, 2 day, 1 week, 1 month and 3

months postoperatively. During each postoperative visit, history
regarding pain, itching, watering and foreign body sensation was
taken and slit-lamp examination was performed. Patients were
graded on the degree of graft stability, subgraft hemorrhage, graft
inflammation and subjective symptoms using a 5 point scale. Table 1
shows the scoring of the variables.
Recurrence was defined as any regrowth of fibrovascular exceeding
1mm onto the cornea.
Other complications like diplopia, symblepheron, dellen formation,
granuloma formation were also looked for.
69
Table 1: Scoring of Outcome Variables

Outcome
Variables
Grade 1
Scoring
Grade 2
Grade 3
Grade 4
Gaping/displac
ement of one
side of the
graft bed
junction
Gaping/displac
ement of two
sides of the
graft bed
junction
Gaping/displac
ement of three
sides of the
graft bed
junction
Graft
complete
ly
displace
d from
the bed
< 25% of the

size of the
graft
< 50% of the

size of the
graft
< 75% of the

size of the
graft
No
dilated
corkscr
ew
vessel
in the
graft
1 dilated
corkscrew
vessel crossing
the graft bed
margin
2 dilated
corkscrew
vessels
crossing the
graft bed
margin
3 dilated
corkscrew
vessels
crossing the
graft bed
margin
Pain
None
Very mild, but

easily tolerated
Mild, causing
some
discomfort
Moderate, that
interferes with
usual activity
or sleep
Itching
None
Very mild, but

easily tolerated
Mild, causing
some
discomfort
Moderate, that
interferes with
usual activity
or sleep
Watering
None
Very mild, but

easily tolerated
Mild, causing
some
Moderate, that
interferes with
Hemorrh
age
.involvin
g the
entire
graft
3
dilated
corkscre
w
vessels
crossing
the graft
bed
margin
Severe,
that
complete
ly
interfere
s with
usual
activity
or sleep
Severe,
that
complete
ly
interfere
s with
usual
activity
or sleep
Severe,
that
Graft
stability
Subgraft
hemorrha
ge
Inflammati
on
Grade
0
All four
sides
of the
graft
margin
are
well
appose
d
None
70
FB
sensation
None
Very mild, but

easily tolerated
discomfort
usual activity
or sleep
Mild, causing
some
discomfort
Moderate, that
interferes with
usual activity
or sleep
STATISTICAL ANALYSIS
Data was tabulated and statistically analyzed.
Data was analyzed using Statistical Package for Social Sciences
(SPSS) version 15.0. Chi-square test was used for comparison of
categorical data, Kruskall-Wallis H and Mann Whitney U tests were
used to compare the ordinal data. Analysis of variance followed by
Independent samples t test was used to compare the continuous
data. The data has been represented as frequencies and percentages
and mean and standard deviation.
A p value less than 0.05 indicated a statistically significant
association.
71
complete
ly
interfere
s with
usual
activity
or sleep
Severe,
that
complete
ly
interfere
s with
usual
activity
or sleep
72
Results
73
The present study was carried out with an aim to compare the
efficacy of Sutures, Fibrin Glue and Sutureless-Gluefree Technique
for Conjunctival Autografting in Pterygium Excision Surgery. For
this purpose, a total of 150 patients fulfilling the inclusion criteria
were enrolled in the study and were randomly allocated to one of the
three groups as follows:
Table 2: Group wise distribution of cases
SN
1.
2.
3.
Group
I
II
III
Description
Suture
Glue
Sutureless-Gluefree
No. of cases
50
50
50
Percentage
33.3
33.3
33.3
Out of 150 patients enrolled in the study, a total of 50 (33.3%)

were managed using suture technique and comprised the Group I of
study, another 50 (33.3%) were managed using Glue technique and
comprised the Group II of study and remaining 50 (33.3%) were
managed using Sutureless-Gluefree technique and comprised the
Group III of study.
74
Table 3: Comparison of three study groups according to age and gender

SN
1.
2.
Characteristic
Overall
Group I Group II Group III

(n=50)
(n=50)
(n=50)
Mean Age SD 39.43
41.64
38.22
38.44
(Range in years) 12.71 (20- 14.30
10.81
12.74
72)
(20-72)
(21-65)
(21-70)
Gender
Male
72 (48%) 25 (50%) 28 (56%)
19 (38%)
Female
78 (52%) 25 (50%) 22 (44%)
31 (62%)
75
Statistical
significance
F=1.137;
p=0.324
2=3.365;
p=0.185
Age of patients ranged from 20 to 72 years. Overall mean age

was 39.4312.71 years.
Groupwise mean age of patients in Groups I, II and III was
41.6414.30, 38.2210.81 and 38.4412.74 years respectively.
Statistically, there was no significant difference in mean age of
patients in different groups (p=0.324).
With respect to gender, overall majority of patients were
females (n=78; 52%). There were 72 (48%) males.
On groupwise evaluation, majority of patients in Group II were male
(n=28; 56%) whereas majority of patients in Group III were females
(n=31; 62%). In contrast, in Group I, both the genders were evenly
76
distributed (n=25; 50%). Despite these proportional differences, the

difference among groups was not significant (p=0.185).
Table 4: Comparison of three study groups according to side where
procedure was carried out
SN
Characteristic
1.
2.
Left
Right
Group I
(n=50)
No.
%
23
46.0
27
54.0
Group II
(n=50)
No.
%
24
48.0
26
52.0
Group III
(n=50)
No.
%
26
52.0
24
48.0
2=0.374 (df=2); p=0.830 (NS)
Majority of cases in Groups I and II had right side as the

affected side whereas majority of cases in Group III had left side as
the affected side. However, there was no significant difference
among group with respect to side of involvement (p>0.05).
Table 5: Comparison of three study groups according to time taken for

procedure
77
Characteristic
Mean
TimeSD
(Range in min)
Group
I
(n=50)
19.12 3.47
(11-25)
Group
II
(n=50)
15.502.38
(10-21)
Group
III
(n=50)
14.682.27
(11-20)
Statistical
significance
F=36.53;
p<0.001
Between Group comparison of time taken for procedure (Independent

samples t-test)
I vs II
t
7.564
I vs III
p
<0.001
t
6.076
II vs III
p
<0.001
t
1.761
p
0.081
Mean Time (in minutes)

25
20
15
Mean Time (in minutes)
10
5
0
Group 1
Group 2
Group 3
Time taken for procedure ranged from 10 to 25 min. Mean

time taken was minimum in Group III (14.682.27 min) and
maximum in Group I (19.123.47 min). Mean time taken was
15.502.38 min in Group II. ANOVA revealed statistically
significant intergroup differences among groups (p<0.001).
On
evaluating the data further, it was observed that both Groups II and
78
III took significantly lesser time as compared to Group I (p<0.001),

however, the difference between Groups II and III was not
significant statistically (p=0.081).
79
Table 6: First Follow Up Evaluation (Day 1)

SN
Parameter
Group I
(n=50)
Mean
/ No.
1.
Graft stability score
2.
3.
Graft loss
Graft edema
SD/
%
0.2
4
-
Mean
/ No.
0.92
0
1.0
6
0.7
1
0.7
9
0.3
3
1.0
3
0.9
0
0.06
0
4.
5.
Subgraft
hemorrhage score
Inflammation score
0.94
2.84
6.
Pain score
7.
Itching score
8.
Watering score
9.
FB sensation score
0.50
0.12
0.58
10.
11.
12.
13.
14.
Symblepheron
formation
Motility restriction
Diplopia
Anaphylaxis
Recurrence
Group II
(n=50)
Group III
(n=50)
SD/
%
0.3
9
-
Mean
/ No.
0.44
8.0
0.5
7
0.9
0
0.7
5
0.3
3
0.6
4
0.5
8
0.18
-
0.40
2.04
0.74
0.12
0.58
0.28
-
SD/
%
0.4
5
-
0.34
0
0.8
9
0.9
9
0.6
5
0.0
0
0.4
8
0.5
2
1.10
1.70
0.52
0.00
0.24
Statistical
significance
(Kruskal
Wallis test/
Chi-square
test)
H/
P
2
8.41 0.015
1
8.21 0.016
9
16.1 <0.00
5
1
37.9 <0.00
6
1
4.20 0.122
6.48
0.039
8.03
0.018
14.8
1
-
0.001
For variables with suffix score values depicted are mean and sd and analyzed with Kruskal-Wallis H test.
For variables with no suffix, values depicted are No. & % and analyzed with chi-square test.
80
For variables analyzed with scoring system

In all the three groups, minimum scores were observed for
itching and maximum for inflammation. Statistically significant
81
differences among groups were observed for all the variables

(p<0.05) except pain (p=0.122).
For graft stability, mean scores were minimum in Group I
(0.060.18).
For inflammation and FB sensation, mean scores were
minimum in Group III and maximum in Group I.
For subgraft hemorrhage, mean scores were minimum in
Group II (0.400.57) and maximum in Group III (1.100.89).
For pain, mean scores were minimum in Group I (0.500.79)
and maximum in Group II (0.740.75).
For itching mean score in Group III was 0.000.00 and was
0.120.33 in both Groups I and II.
Fr watering too, both Groups I and II had same mean score
(0.581.03) whereas Group III had a mean score of 0.240.48.
For variables displayed categorically, except for 4(8%) cases
in Group II showing edema no other complication was observed.
82
Table 6a: Between Group comparison of Outcome at Day 1 (Mann

Whitney U test)
Parameter
I vs II

Graft loss
Graft edema
Subgraft hemorrhage
score
Inflammation score
Pain score
Itching score
Watering score
FB sensation score
Symblepheron
formation
Diplopia
Anaphylaxis
Recurrence
I vs III
p
z/
1.837
4.167
2.438
0.066
0.041
0.015
4.638
1.912
0
1.187
2.824
-
z/
II vs III
P
z/
2.914
1.023
0.004
0.306
1.182
4.167
4.237
0.237
0.041
<0.001
<0.001
0.056
1
0.235
0.005
-
5.694
0.637
2.514
1.440
3.573
-
<0.001
0.524
0.012
0.150
<0.001
-
1.689
1.467
2.514
2.945
0.872
-
0.091
0.142
0.012
0.003
0.383
-
For variables evaluated using scoring system

Between Groups I and II, statistically significant differences
were observed for subgraft hemorrhage, inflammation and FB
sensation only.
Between Groups I and III, significant differences were
observed for all the parameters except subgraft hemorrhage, pain
and watering.
Between Groups II and III, significant differences were
observed for subgraft hemorrhage, itching and watering respectively.
83
For categorical variables, evaluation could be done only for

edema which was found to be significantly higher in Group II as
compared to Groups I and III (p=0.016).
84
Table 7: Second Follow Up Evaluation (Day 2)

SN
1.
Parameter
Group I
(n=50)
Graft loss
Graft edema
4.
5.
Subgraft
hemorrhage score
Inflammation score
6.
Pain score
7.
Itching score
SD/
%
Mean
/ No.
SD/
%
Mean
/ No.
SD/
%
0.10
-
0.3
0
-
0.28
-
0.4
5
-
0.18
-
0.3
9
-
1.46
0
0.9
9
0.7
2
0.7
4
0.5
2
1.1
1
0.8
9
0.80
3.26
0.70
0.34
8.
Watering score
0.86
9.
10.
11.
12.
13.
14.
FB sensation score
Symblepheron
formation
Diplopia
Anaphylaxis
Recurrence
Group III
(n=50)
Mean
/ No.
2.
3.
Group II
(n=50)
0.60
8.0
0.5
3
0.8
1
0.7
5
0.3
9
0.7
2
0.6
4
0.36
1.96
0.66
0.18
0.88
0.52
0
0.8
6
0.9
3
0.5
4
0.0
0
0.5
3
0.5
4
1.04
1.60
0.44
0.00
0.36
Statistical
significance
(Kruskal
Wallis test/
Chi-square
test)
H/
P
2
5.32
1
0.070
8.21 0.016
9
16.4 <0.00
2
1
65.4 <0.00
2
1
3.12
6
0.210
18.5 <0.00
0
1
12.3
3
0.002
35.6 <0.00
8
1
-
85
86
For variables evaluated using scoring system,

In all the three groups, maximum scores were observed for
inflammation. In Group I minimum score was observed for graft
stability, whereas in Group II itching had minimum scores. In Group
III itching had the minimum score. Statistically significant
differences among groups were observed for all the variables
(p<0.05) except graft stability (p=0.070) and pain (p=0.122).
(0.100.30).
Group II (0.360.53).
For inflammation, mean scores were maximum in Group I
(3.260.72) and minimum in Group III (1.600.93)
For pain, mean scores were minimum in Group III (0.440.54)
and maximum in Group I (0.700.74).
For itching mean score in Group III was 0.000.00 and
maximum was in I (0.340.52).
87
For watering, minimum mean score was in Group III

(0.360.53) and maximum in Group II (0.880.72)
For FB sensation, minimum mean score was in Group III
(0.520.54) and maximum in Group I (1.460.89).
For variables displayed categorically, except for 4(8%) cases in
Group II showing edema no other complication was observed.
Whitney U test)
Parameter
I vs II

Graft loss
Graft edema
Subgraft hemorrhage
score
Inflammation score
Pain score
Itching score
Watering score
FB sensation score
Symblepheron
formation
Diplopia
Anaphylaxis
Recurrence
I vs III
p
z/
1.147
4.167
1.986
0.251
0.041
0.047
6.555
0.316
1.647
0.935
2.824
-
z/
II vs III
P
z/
2.283
1.010
1.547
0.022
0.315
0.122
1.182
1.895
4.340
0.237
0.169
<0.001
<0.001
0.752
0.100
0.350
0.005
-
7.183
1.700
4.339
2.046
3.573
-
<0.001
0.089
<0.001
0.041
<0.001
-
1.962
1.329
3.129
3.760
0.872
-
0.050
0.184
0.002
<0.001
0.383
-
88

sensation only.
observed for all the parameters except subgraft hemorrhage and
pain.
observed for subgraft hemorrhage, inflammation, itching and
watering respectively.
compared to Groups I and III (p=0.016).
89
Table 8: Third Follow Up Evaluation (Day 7)

SN
Parameter
Group I
(n=50)
Mean
/ No.
1.
2.
3.
4.
5.
Graft loss
Graft edema
Subgraft
hemorrhage score
Inflammation score
6.
Pain score
7.
Itching score
8.
Watering score
1.76
0.3
0
0
0.7
6
0.8
3
0.7
3
0.6
5
1.0
2
0.8
0
0.10
0
0.58
3.20
0.86
0.48
1.06
9.
10.
11.
12.
13.
14.
FB sensation score
Symblepheron
formation
Diplopia
Anaphylaxis
Recurrence
SD/
%
Group II
(n=50)
Mean
/ No.
SD/
%
0.60
0.3
7
8
0.2
7
1.0
5
0.5
2
0.5
9
0.7
0
0.5
7
0.26
4
0.08
1.60
0.34
0.32
1.00
Group III
(n=50)
Mean
/ No.
SD/
%
0.44
0.6
6
2
0.8
4
0.9
4
0.5
3
0.1
4
0.4
3
0.5
4
0.16
1
0.54
1.12
0.26
0.02
0.24
Statistical
significance
(Kruskal
Wallis test/
Chi-square
test)
H/
P
2
1.46 0.235
2
5.38 0.068
8.56 <0.00
1
1
65.4 <0.00
1
1
14.7 <0.00
6
1
10.4 <0.00
5
1
18.3 <0.00
0
1
62.0 <0.00
8
1
-
90
91

inflammation. In Groups I minimum mean score was observed for
graft stability, whereas in Group III itching had minimum scores.
Statistically significant differences among groups were observed for
all the variables (p<0.05) except graft stability (p=0.235).
(0.100.30).
Group II (0.080.27) and maximum in Group I (0.580.76).
For pain, mean scores were minimum in Group III (0.260.53)
For itching minimum mean score was in Group III (0.020.14)
For watering, minimum mean score was in Group III
92
For FB sensation, minimum mean score was in Group III

For variables displayed categorically, except for 4 (8%) cases in
Group II and 1 (2%) case in Group III showing edema no other
complication was observed.
Whitney U test)
Parameter
Graft loss
Graft edema
Subgraft hemorrhage
score
Inflammation score
Pain score
Itching score
Watering score
FB sensation score
Symblepheron
formation
Diplopia
Anaphylaxis
Recurrence
I vs II
z/ 2
1.147
4.167
1.986
I vs III
p
0.251
0.041
0.047
z/ 2
2.283
1.547
6.555
0.316
1.647
0.935
4.834
-
<0.001
0.752
0.100
0.350
<0.001
-
II vs III
P
0.022
0.122
z/ 2
1.182
4.167
4.340
0.237
0.041
<0.001
7.183
1.700
4.339
2.046
5.332
-
<0.001
0.089
<0.001
0.041
<0.001
-
1.962
1.329
3.129
3.760
0.482
-
0.050
0.184
0.002
<0.001
0.630
-

sensation only.
93

observed for all the parameters except subgraft hemorrhage and
pain.
observed for subgraft hemorrhage, inflammation, itching and
watering respectively.
compared to Group I (p=0.041). None of the other comparisons were
significant statistically (p>0.05).
94
Table 9: Fourth Follow Up Evaluation (1 month)

SN
Parameter
Group I
(n=49)
Mean
/ No.
1.
2.
3.
4.
5.

Graft loss
Graft edema
Subgraft
hemorrhage score
Inflammation score
0.24
0.0
0
0.2
8
0.6
6
0.4
2
0.3
7
0.5
2
0.4
3
0.00
0.08
0.76
6.
Pain score
7.
Itching score
8.
Watering score
9.
FB sensation score
10.
Symblepheron
formation
Diplopia
Anaphylaxis
Recurrence
0.22
0.16
0.35
11.
12.
13.
14.
SD/
%
Group II
(n=48)
Mean
/ No.
SD/
%
0.15
0.5
8
0.4
0
0.8
8
0.2
8
0.3
3
0.4
8
0.3
6
0.10
0.10
0.67
0.08
0.13
0.33
Group III
(n=50)
Mean
/ No.
SD/
%
0.14
0.1
4
0.6
1
0.7
4
0.4
0
0.2
0
0.4
3
0.4
0
0.02
0.14
0.48
0.14
0.04
0.17
Statistical
significance
(Kruskal
Wallis test/
Chi-square
test)
H/
P
2
2.02 0.364
1
4.07
3
0.130
5.62 0.060
6
4.12 0.127
7
4.04 0.133
1
5.15 0.076
4
2.85 0.240
0
8.21
0.676
95
A total of 2 patients in Group II and 1 patient in Group I was

lost to follow up at 1 month follow up.
inflammation and minimum for graft stability. Statistically no
significant difference was observed among different groups for any
of the outcome measures.
None of the categorical outcomes were positive in any case in
any of the three groups.
96
As none of the intergroup differences were significant

statistically, hence no between groups comparisons were done for
data at 1 month.
97
Table 10: Final Follow Up Evaluation (3 months)

SN
Parameter
Group I
(n=47)
Mean
/ No.
1.
2.
3.
4.
5.

Graft loss
Graft edema
Subgraft
hemorrhage score
Inflammation score
0.00
0.00
0.38
6.
Pain score
7.
Itching score
8.
Watering score
9.
FB sensation score
0.00
0.17
0.00
0.02
10.
11.
12.
13.
14.
Symblepheron
formation
Diplopia
Anaphylaxis
Recurrence
SD/
%
0.0
0
0.0
0
0.7
1
0.0
0
0.3
8
0.0
0
0.1
5
Group II
(n=48)
Mean
/ No.
0.02
0.00
0.23
0.06
0.00
0.15
0.04
2.0
SD/
%
0.1
4
0.0
0
0.4
7
0.2
4
0.0
0
0.3
6
0.2
0
2.0
Group III
(n=46)
Mean
/ No.
0.00
0.00
0.15
0.00
0.02
0.07
0.04
0
SD/
%
0.0
0
0.0
0
0.4
2
0.0
0
0.1
5
0.2
5
0.2
0
0
Statistical
significance
(Kruskal
Wallis test/
Chi-square
test)
H/
P
2
1.95 0.376
8
0
2.92
6
5.96
0
13.5
9
7.64
4
0.39
9
-
1.000
0.232
8.21
0.676
0.051
0.001
0.022
0.819
-
98
A total of 4 patients in Group III, 3 in Group I and 2 in Group

II were lost to follow up at 3 months.
inflammation and minimum for subgraft hemorrhage. Statistically
significant differences among groups were observed for itching and
watering only (p<0.05)
For graft stability, all the patients of Groups I and III had
scores of 0 whereas for Group II, mean score was 0.020.14.
For subgraft hemorrhage, all the patients in all the three groups
had score 0.
99

For pain, Groups I and III had all the patients with score 0
whereas in Group II, mean score was 0.060.24.
For itching minimum mean score was in Group II (0.000.02)
For watering, minimum mean score was in Group I
(0.000.00) and maximum in Group II (0.150.36).
For FB sensation, minimum mean score was in Group I
(0.020.15) and maximum in Groups II and III (0.200.04).
None of the categorical outcomes were positive.
Table 10a: Between Group comparison of Outcome at 3 months (Mann

Whitney U test)
Parameter
Graft stability
Subgraft
hemorrhage
I vs II
Z
0.990
0
I vs III
p
0.322
1.000
100
z
0
0
P
1.000
1.000
II vs III
z
0.990
0
P
0.322
1.000
Inflammation
Pain
Itching
Watering
FB sensation
0.779
1.732
2.971
2.706
0.565
0.436
0.083
0.003
0.007
0.572
1.688
0
2.441
1.770
0.584
0.091
1.000
0.015
0.077
0.559
1.020
1.732
1.011
1.260
0.021
0.308
0.083
0.312
0.208
0.983

were observed for itching and watering only.
observed only for itching.
Between Groups II and III, no significant differences were
observed for all the parameters.
101
Table 9: Cost
SN
1.
2.
3.
Method
Cost
740
3600
0
Suture
Glue
Sutureless-Gluefree
Cost (in Rupees)

4000
3500
3000
2500
Cost (in Rupees)
2000
1500
1000
500
0
Category 1
Category 2
Category 3
With respect to cost, for suture group it is Rs 740, for glue Rs 3600,
for sutureless gluefree group no additional cost is required
102
Table 10: Recurrence rate

SN
Method
1.
Suture
2.
Glue
3.
Sutureless-Gluefree
2
=2.041; p=0.360
No.
1
1
0
%
2
2
0
Recurrence
1.2
1
0.8
Recurrence
0.6
0.4
0.2
0
Group 1
Group 2
Group 3
A total of 1 (2%) cases in Group I and 1 (2%) in Group II had

recurrence. None of the patients in Group III had recurrence.
Statistically, the difference among groups was not significant.
103
Discussio
n
104
Pterygium is a degenerative condition of the subconjunctival tissues

which proliferate as a vascularized granulation tissue to invade the
cornea, destroying the superficial layers of the stroma and the
Bowmans membrane, the whole being covered by conjunctival
epithelium.
Pterygium is more frequent in areas with more ultraviolet radiation,
in hot, dry, dusty, windy, and smoky environments. There is also a
hereditary factor.
Pterygium occurs at highest prevalence and most severely in tropical
areas near the equator and to a lesser and milder degree in cooler
climates. Outdoor work in situations with high light reflectivity,
including from sand and water increases the chances of pterygium
development.
Damage to the limbal stem cells by UV light and by activation of
MMP are considered to play crucial role in the pathogenesis of
pterygium.
Due to the extremely high rate of recurrence, frequency of problems
relating to healing, and complications of adjunctive treatments that
105
attempt to lower the recurrence rate, current indications for surgery

for pterygium are understandably conservative.
The indications include interference with vision, either by
obstruction of the visual axis or induction of regular or irregular
astigmatism; threatened interference with vision, as evidenced by
documented growth approaching the visual axis; and recurrent or
chronic surface inflammation. If there would have been a surgical
procedure that had an extremely low rate of recurrence and other
surgical complications and provided a consistently excellent result,
the indications for surgery could be much more liberal.
There have been many attempts to optomise pterygium surgery, its
related complication and recurrence.
Conjunctival autografting is generally regarded as the procedure of
choice for the treatment of primary and recurrent pterygium. The use
of conjunctival autograft gained popularity in the 1980s following
the landmark study by Kenyon et al33 in 1985. It has the significant
benefit of reducing the recurrence rate to 5% to 15%; however, it is
significantly more difficult and time consuming than simple
excision.
106
The conjunctival autograft can be fixed by 3 techniques which are

suturing, fibrin gluing and using patients autoblood.
As there is little data available on the use of autoblood in pterygium
autografting, in the present study we compared these three
techniques of autograft fixation.
The most common method of autograft fixation is suturing, but it
requires more surgical expertise, technical ability and surgical time
to secure the graft with sutures. In our study, it was observed that
both Glue Group and SGF Group took significantly lesser time as
compared to Group I (p<0.001), however, the difference between
Groups II and III was not significant statistically (p=0.081). Time
taken for procedure ranged from 10 to 25 min. Mean time taken was
minimum in Group III (14.68 2.27 min) and maximum in Group I
(19.12 3.47 min). Mean time taken was 15.50 2.38 min in Group
II.
Sutures do not actively participate in wound healing and may cause
additional trauma to the injury site and adjacent tissue. Also,
infectious agent might enter along the suture tract, or the sutures
might act as the nidus of the inflammation itself. Loose or broken
107
sutures require removal and, hence, additional working time.

However, in our study no suture related problem were encountered.
Singh PK et al74 found graft displacement and graft retraction were
more common in patients with grafting with autologous blood than
in those with grafting with the glue. In our study, for graft stability
the differences in three groups were not significant (p=0.789).
Srinivasan S et al44found no significant difference in the subgraft
hemorrhage between suture and fibrin glue group. In our study, the
differences in three groups for subgraft hemorrhage were not
significant (p=0.668).
No grafts were lost in all the three groups.
Mitra S et al76 reported graft edema in 9 cases (47.3%) following
pterygium excision with conjunctival autografting with autoblood. In
our study, on day 1 and day 2, graft edema occured in 4 (8%) cases
of Group II only, thus showing a significant difference among
groups (p=0.016).
Srinivasan S et al44 reported greater degree of inflammation on
suture group than in glue group. Means scores for post-operative
inflammation were maximum in Group I (suture) at day 1 (p<0.001),
108
day 2 (p<0.001), day 7 (p<0.001) and 1 month (p<0.001) follow up

(p<0.001). At 3 month follow up visit inflammation were maximum
in Group I only, though it was not statistically significant (p=0.232).
In our study, Group III showed better cosmesis, faster and more
comfortable patient rehabilitation. Patient discomfort including pain,
irritation, watering and foreign body sensation were minimum in
Group III in comparison to Group I and Group II at day 1 to 1 month
follow up, which were statistically significant (p<0.001). After 1
month the difference among the group were not statistically
significant (p=0.678).
KPS Malik et al73 reported recurrence in 1 case (2.5%) at 6 months
after pterygium excision with conjunctival autografting with
autologous blood. Singh PK74 reported equal rate of recurrences in
grafting with fibrin glue (10%) and the grafting with autologous
blood (10%). De Wit D et at40 reported no recurrence in their study.
Foroutan A et al75 reported recurrence in 2 cases (13.33%) out of 13
who underwent pterygium excision with conjunctival autograft using
autologous fibrin glue. However, in our study none of the pterygium
recurred in SGF Group in comparison to 1 recurrence in Suture
109
Group (2%) and 1 in Fibrin Glue Group (2%) in our 3 month follow
up period, however the difference was not significant statistically
(p=0.761).
Singh PK et al74 reported in their study that none of the patient
developed corneal ulcer, scleral melting, dellen, hypersensitivity to
fibrin adhesive, and symblepheron formation. Similarly KPS Malik
et al 73 reported in their study that none of the patients developed
corneal ulcer, conjunctivitis, dellen, symblepheron formation, injury
to medial rectus, or corneal perforation. In our study, only one case
developed granuloma which was attributable to finger nail trauma. It
required intervention. No other complications like symblepheron
formation, motility restriction, dellen formation, infection or
anaphylaxis were noted.
Taking cost of suture used in Group I in our study was Rs 800.
Taking cost of glue in Group II was Rs 3600 whereas in Group 3 no
additional cost was there. The difference was statistically significant
(p<0.001).
In the light of our present study, the sutureless-gluefree procedure
for attaching conjunctival autograft following pterygium excision
110
was found to be simpler, cheaper and much more safer than suturing
and gluing procedures. The potential complication of suture and glue
such as inflammation, granuloma, infection, anaphylaxis can be
avoided, moreover the cost of glue, its preparation, risk of improper
sterilization, less availability, short life of few hours after
preparation, risk of transmission of infections, requirement of
pooling of multiple patients may be avoided by adoption of
autologous blood as a sealant in place of fibrin glue.
Conjunctival graft fixation with autoblood is superior over other
techniques in respect to better cosmesis, faster surgical and more
comfortable patient rehabilitation time, reduced post operative
inflammation which may be resulting in reduced recurrence rate.
The technique is cheap and also free of dependency of any
preparation, potential risk of anaphylactic reaction and transmission
of other diseases.
111
Conclusi
on
112
This Prospective study was conducted in Dr. Mohan Lal Memorial

Gandhi Eye Hospital, Aligarh. 150 patients who fulfilled the
inclusion criteria were selected from all those attending out patient
department presented with primary pterygium.
It was aimed to study the three techniques for pterygium excision
and conjunctival autografting which were suturing, gluing and
sutureless-gluefree technique on the basis of graft stability, subgraft
hemorrhage, post-operative inflammation, post-operative patient
discomfort, recurrence, cost and surgical time.
The salient findings of the study were:
(i) All the patients were between 20-72 years of age.
(ii) With respect to gender, majority of patients in Group II
were male (n=28; 56%) whereas majority of patients in
Group III were females (n=31; 62%). In contrast, in
Group I, both the genders were evenly distributed (n=25;
50%).
Despite
these
proportional
differences,
the
difference among groups was not significant (p=0.185).

(iii) Grafts were stable in the three techniques, the difference
in the three groups were not significant.
113
(iv) Post-operative inflammation was seen maximum in

suture group and minimum in SGF group at day 1
(p<0.001), day 2 (p<0.001), day 7 (p<0.001) and 1 month
(p<0.001) follow up (p<0.001). At 3 month follow up visit
also, inflammation was more in Group I only, though it
was not statistically significant (p=0.232).
(v)For subgraft hemorrhage, mean scores were minimum in
Fibrin glue Group and maximum in Suture Group.
(vi) Post-operative patient discomfort were minimum in
sutureless-gluefree technique. The differences among the
groups were significant upto 1 month follow up, thereafter
they were not statistically significant.
a. For pain, mean scores were minimum in SGF Group
and maximum in Suture Group.
b. For itching mean score in SGF Group was minimum
and maximum was in Suture Group.
c. For watering, minimum mean score was in SGF
Group and maximum in Fibrin Glue Group.
114
d. For FB sensation, minimum mean score was in SGF

Group and maximum in Suture Group.
(vii)The cost of suture used in Suture Group was Rs 800. The
cost for fibrin glue in Glue Group was Rs 3600. In
Sutureless-Gluefree group there was no additional cost.
(viii)
Time taken for procedure ranged from 10 to 25
min. Mean time taken was minimum in SuturelessGluefree group (14.682.27 min) and maximum in Suture
Group
(19.123.47
min).
Mean
time
taken
was
15.502.38 min in Glue Group.
Thus to conclude, sutureless and gluefree limbal conjunctival

autografting following pterygium excision has better cosmesis, faster
surgical and more comfortable patient rehabilitation time and is a
safe, and economical option for the management of primary
pterygium requiring surgical intervention.
Conflict of Interest: No financial or any other interest in any
material, or company described or mentioned in the study.
115
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131
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132
Annexur
e
133
134
STUDY PROFORMA
Name
Age
Sex
Address
Occupation
OPD Ticket No.
Mobile No.
Ophthalmic Complaints
1. Diminution of vision
Present /
Absent
2. Fleshy mass
Present / Absent
3. Itching
Present / Absent
4. Stinging
Present / Absent
5. Watering
Present /
Absent
6. Redness
Present /
Absent
135
7. Heaviness
Present / Absent
8. Foreign Body Sensation
Present / Absent
9. Pain
Present /
Absent
10. Photophobia
Present /
Absent
11. Colored Haloes
Present / Absent
12. Diplopia
Present /
Absent
13. Black Spots
Present / Absent
14. Others
Past History
Ocular Trauma
Previous Ocular Surgery
Eye Infection
Recurrence of pterygium
Prolonged intake of aspirin or other anticoagulants.
History of Systemic Disease
136
Diabetes mellitus
Hypertension
Any other chronic diseases
Ocular Examination
R/E
L/E
1.
Visual Acuity
2.
External Ocular Examination by Torchlight

Head posture
forehead
Eye brows
Eye lids and lashes
Punctual Area
Eye Ball Motility
Conjunctiva
Cornea
3.
Slit Lamp Examination

Conjunctiva
Cornea
pterygium :
size
type
137
site (nasal/ temporal)

probe test
Anterior Chamber
Iris
Pupil
Lens
Operative Notes
Date on which surgery performed:
Surgical technique used:
Time taken in Surgery:
138
Follow Up:
Day 1
Day 2
Graft
Stability
Subgraft
Hemorrhage
Inflammatio
n
Pain
Itching
Watering
Foreign
Body
Sensation
Recurrence
Any other
complication
139
Day 7
1 Month 3 Month
140
Informed Consent form to participate

Study Title & Design: Factors affecting visual prognosis in traumatic
cataract in 2 to 16 years of age
Study Number:
Subjects Initials:
Subjects Name:
Date of birth/ Age:

If you are willing to participate, please read carefully and fill the form.
i
I confirm that I understood the whole details of the above study and
have had the opportunity to ask questions. [ ]
ii I understand that my participation in the study is voluntary and that
I am free to withdraw at any time, without giving any reason,
without my medical care or legal rights being affected. [ ]
iii I understand that the sponsor of the study, others working on the
sponsors behalf, the Ethics Committee and the regulatory
authorities will not need my permission to look at my health records
both in respect of the current study and any further research that
may be conducted in relation to it, even if I withdraw from the study.
I agree to this access. However, I understand that my identity will
not be revealed in any information released to third parties or
published.[ ]
iv I agree not to restrict the use of any data or results that arise from
this study provided such a use is only for scientific purpose. [ ]
v I agree to take part in the above study. [ ]
Signature of the participant:

Date:
Signatorys Name:
Signature of data collector:
Date:
Study Investigators Name:
Signature of the Witness:
Date:
Name of the Witness:
141
142
Master
Chart
143

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A COMPARITIVE STUDY OF THE

EFFECT OF SUTURES, FIBRIN

This to certify that DR ADITYA AGGARWAL is a bona fide

DR. ARCHNA BHATNAGAR

DR. AJAY KUMAR

Senior Ophthalmic Surgeon

Dr. Mohan Lal Memorial

Dr. Mohan Lal Memorial

Gandhi Eye Hospital,

Gandhi Eye Hospital,

OPHTHALMOLOGY in this hospital from the period of 30 th MAY

Dr. RAZIA S. KHAN

Gandhi Eye Hospital,

DECLARATION BY THE CANDIDATE

I hereby declare that the subject matter of this thesis entitled A

DR. ADITYA AGGARWAL

approach and constructive criticisms have been a constant driving

I thank my brothers, Dr. Tarun and Dr. Varun, and my sister

Dr. Aditya Aggarwal

Pterygium is a Greek word meaning wing of a butterfly. Pterygium

devised a simple grading system which classifies the

appearance of pterygium into three grades.

1 GRADE 1- Atrophic pterygium, episcleral vessels under the

In India, it is called Nakhoona in Hindi, due to its

resemblance to a nail in its shape.

yellow-brown coloration. Pooling of tears in the region of

Tekelioglu and colleagues17 noted the presence of increased levels of

conceptualized a two stage hypothesis for

2) progressive active conjunctivalization of the cornea by

accumulated stromal material was thought to be elastic tissue

concluded that long standing nasal

pterygium in elderly patients may rarely induce deep corneal

Endothelial cell density may be lower in eyes with pterygia with

brevity. This technique, however, has an unacceptably high

Conjunctival autografting (CAG) has been considered the best and

proposed that a conjunctival autograft

(CAG) of the bare sclera could be used in treatment of recurrent and

complicated surgical technique, prolonged operative time, and

complication and recurrence rate have been reported.

also, the cost of fibrin glue

As there is little data available on the use of autoblood in pterygium

Pterygium is a greek word. In India it is called Nakhoona due

(especially ultraviolet radiation). Particulate material such as smoke,

Rim T.H.T. et al45 education to avoid excessive sun exposure would

Jin J. et al20 compared expression levels of an angiogenic

of pterygium and recurrence associated with incomplete excision of

Mitomycin C remain the most commonly used medical

edema, corneal perforation, iritis, sudden onset mature cataract,

outcome and recurrence rate after primary and recurrent pterygia

compared. They found that amniotic membrane transplantation for

in comparison to conjunctival autografts in patients with pterygia.

performed this technique on 57 eyes of 54 patients. The pterygia

Sharma A et al55 demonstrated that there was no statistically

that, to provide a new stem cell source, limbal epithelial autograft

But it is technically more

difficult and inapplicable in cases with previous limbal disturbance.

possible or desirable to use the superior conjunctiva as a donor

Sutureless graft fixation with use of fibrin glue as tissue

glue group and 13.5% in the suture group (p = 0.001). The