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Textbook of Pterygium

Management

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DVD Contents

1. Pterygium Excision with Conjunctival Autografting Using Glue (Chapter 3)Tushar Agarwal, Shikha Gupta, Namrata Sharma

2. Conjunctival Excision and Extended Tenectomy with Conjunctival Autograft for Primary Pterygium (Chapter 5)Chintan Malhotra, Arun K Jain, Vikash Rohilla

3. Pterygium Excision with Inferior Conjunctival Autografting (Chapter 6)Qi Chen, Fan Xu, Min Li, Li Jiang, Jiping Xu

4. Pterygium Excision with Narrow-strip Conjunctival Autograft (Chapter 7)Angelique Pillar, Bennie H Jeng, David M Meisler, William J Dupps

5. Conjunctival Excision with Autograft Using Sandwich Technique (Chapter 8)Ali Fadlallah, Marc Fava, Steve Robinson, Catherine Choi, Georges El Mollayess, Samir Melki

6. Pterygium Surgery with Autograft Affixation Using Blood (Chapter 9)Kanhaiya Mittal, Shikha Gupta, Tushar Agarwal

7. Pterygium Excision by Mini-flap Technique (Chapter 10)Kyoung Yul Seo, Sang Min Nam, Ji Won Jung

8. Minor Ipsilateral Simple Limbal Epithelial Transplantation (Chapter 12)Erick Hernandez-Bogantes, Enrique O Graue-Hernandez

9. Conjunctival Excision with Limbal Conjunctival Autograft or Amniotic Membrane Grafting, with or without Mitomycin-C in Recurrent Pterygium (Chapter 16)Tarun Arora, Shikha Gupta, Tushar Agarwal

10. Sealing the Gap for Managing Pterygium (Chapter 18)Anny MS Cheng, Wei-li Chen, Scheffer CG Tseng

11. Double-headed Pterygium: Split Conjunctival Grafts (Chapter 19)Neelima Aron, Shikha Gupta, Tushar Agarwal

12. Management of Pterygium with Coexisting Cataract (Chapter 20)Koray Gumus, Cynthia I Tung, Zaina Al-Mohtaseb

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Textbook of Pterygium

Management

EditorsTushar Agarwal MD

Professor Department of Ophthalmology

Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences

New Delhi, India

Shikha Gupta MD

Assistant Professor Dr Rajendra Prasad Centre for Ophthalmic Sciences

All India Institute of Medical Sciences New Delhi, India

Namrata Sharma MD

Professor Dr Rajendra Prasad Centre for Ophthalmic Sciences

All India Institute of Medical Sciences New Delhi, India

New Delhi | London | Panama

The Health Sciences Publisher

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Jaypee Brothers Medical Publishers (P) Ltd.

HeadquartersJaypee Brothers Medical Publishers (P) Ltd.4838/24, Ansari Road, DaryaganjNew Delhi 110 002, IndiaPhone: +91-11-43574357Fax: +91-11-43574314E-mail: [email protected]

Website: www.jaypeebrothers.comWebsite: www.jaypeedigital.com© 2017, Jaypee Brothers Medical PublishersThe views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.All rights reserved. No part of this publication and DVD-ROM may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.Inquiries for bulk sales may be solicited at: [email protected]

Textbook of Pterygium Management

First Edition : 2017

ISBN 978-93-86261-54-0Printed at

Overseas OfficesJ.P. Medical Ltd.83, Victoria Street, LondonSW1H 0HW (UK)Phone: +44-20 3170 8910Fax: +44(0) 20 3008 6180E-mail: [email protected]

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Dedicated toThe memory of my father, Dr SP Agarwal

—Tushar Agarwal

While You pen down, I enact to be the writer I bow to You millions of times forever

For people, assume me to be the Creator!! —Shikha Gupta

My parents, Dr Ramesh C Sharma and Maitreyi Pushpa,husband Subhash Chandra and daughter Vasavdatta

—Namrata Sharma

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ContributorsContributors

Ali Fadlallah MD Boston Eye Group Harvard Medical School Massachusetts Eye and Ear Infirmary Boston, Massachusetts, USA

Angelique Pillar MD Cole Eye Institute Cleveland Clinic Foundation Cleveland, Ohio, USA

Anny MS Cheng MD Ocular Surface Center Miami, Florida, USA

Anubha Rathi MD Senior Resident Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi, India

Arun K Jain MD DNB Professor Cornea, Cataract and Refractive Surgery Advanced Eye Centre Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh, India

Bennie H Jeng MD Department of Ophthalmology and Visual Sciences University of Maryland School of Medicine Baltimore, Maryland, USA

Berthold Seitz MD Department of Ophthalmology Saarland University Medical Center UKS Homburg/Saarland, Germany

Catherine Choi MD Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, Massachusetts, USA

Chintan Malhotra MS Associate Professor Cornea, Cataract and Refractive Surgery Advanced Eye Centre Postgraduate Institute of Medical Education and Research Chandigarh, India

Cord RH Huchzermeyer MD

Department of Ophthalmology Friedrich-Alexander University Erlangen-Nürnberg Erlangen, Germany

Cynthia I Tung MD Assistant Professor Department of Ophthalmology The University of Texas MD Anderson Cancer Center Houston, Texas, USA

David M Meisler MD Cole Eye Institute Cleveland Clinic Foundation Cleveland, Ohio, USA

Elsie Chan Royal Victorian Eye and Ear Hospital Melbourne, Australia

Enrique O Graue-Hernández MD MSc Head Department of Cornea and Refractive Surgery Instituto de Oftalmología FundaciÓn Conde de Valenciana Mexico City, Mexico

Erick Hernandez-Bogantes MD Cornea and Refractive Surgery Instituto de Oftalmología Fundación Conde de Valenciana Universidad Nacional Autónoma de México Mexico City, Mexico

Fan Xu Department of Ophthalmology People’s Hospital of Guangxi Zhuang Autonomous Region Nanning, Guangxi, People’s Republic of China

Georges El Mollayess MD American University of Beirut Medical Center Beirut, Lebanon Harvard Medical School Boston, Massachusetts, USA

Ji Won Jung MD Department of Ophthalmology and Inha Vision Science Laboratory Inha University School of Medicine Incheon, South Korea

Jiping Xu Department of Ophthalmology People’s Hospital of Guangxi Zhuang Autonomous Region Nanning, Guangxi, People’s Republic of China

Jong-Soo Lee MD Professor Department of Ophthalmology College of Medicine, Pusan National University Pusan (Busan), South Korea

Kanhaiya Mittal MD Senior Resident Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi, India

Koray Gumus MD, FEBOphth

Associate Professor Department of Ophthalmology Erciyes University School of Medicine Kayseri, Turkey

Kyoung Yul Seo MD Department of Ophthalmology Severance Hospital Yonsei University College of Medicine Seoul, South Korea

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Textbook of Pterygium Managementviii

Li Jiang Department of Ophthalmology People’s Hospital of Guangxi Zhuang Autonomous Region Nanning, Guangxi, People’s Republic of China

Manpreet Kaur MD Senior Resident Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi, India

Marc Fava MD Massachusetts Eye and Ear Infirmary Harvard Medical School Beth Israel Deaconess Medical Center Harvard Medical School Boston Eye Group Boston, Massachusetts, USA

Min Li

Department of Ophthalmology People’s Hospital of Guangxi Zhuang Autonomous Region Nanning, Guangxi, People’s Republic of China

Mohit Khattri MS Glaucoma and Cornea Services Department of Ophthalmology Ganesh Shankar Vidyarthi Memorial Medical College Kanpur, Uttar Pradesh, India

Namrata Sharma MD

Professor Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi, India

Neelima Aron MD Senior Resident Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi, India

Pooja Bandivadekar MD Consultant Cornea, Cataract and Refractive Surgery Services Doctor Eye Institute Mumbai, Maharashtra, India

Prafulla Kumar Maharana MD Assistant Professor Cornea, Cataract and Refractive Surgery Services Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi, India

Puneet Jain MD Fellow, Oculoplasty and Ocular Oncology Center for Sight Superspecialty Eye Hospital Hyderabad, Telangana, India

Qi Chen

Department of Ophthalmology People’s Hospital of Guangxi Zhuang Autonomous Region Nanning, Guangxi, People’s Republic of China

Samir Melki MD Massachusetts Eye and Ear Infirmary Beth Israel Deaconess Medical Center Harvard Medical School Boston, Massachusetts, USA Boston Eye Group Boston, Massachusetts, USA

Sang Min Nam MD Department of Ophthalmology CHA Bundang Medical Center CHA University Seongnam, South Korea

Scheffer CG Tseng MD PhD Medical Director Ocular Surface Center PA Ocular Surface Research and Education Foundation 7000 SW 97th Avenue, Suite 213, Miami, Florida 33173, USA

Shalini Mohan MS Associate Professor Chief Glaucoma and Cornea Services Department of Ophthalmology Ganesh Shankar Vidyarthi Memorial Medical College Kanpur, Uttar Pradesh, India

Shikha Gupta MD Assistant Professor Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi, India

Steve Robinson MS Boston Eye Group Boston, Massachusetts, USA

Surendra Kumar Sachan MS Glaucoma and Cornea Services Department of Ophthalmology Ganesh Shankar Vidyarthi Memorial Medical College Kanpur, Uttar Pradesh, India

Tarun Arora MD Associate Consultant Cornea, Lens and Refractive Surgery Services Medanta—The Medicity Gurugram, Haryana, India

Tushar Agarwal MD Professor Department of Ophthalmology Dr Rajendra Prasad Centre for Ophthalmic Sciences All India Institute of Medical Sciences New Delhi, India

Vikash Rohilla MS

Cornea, Cataract and Refractive Surgery Advanced Eye Centre Postgraduate Institute of Medical Education and Research Chandigarh, India

Wei-li Chen MD PhD

Department of Ophthalmology National Taiwan University Hospital Taipei, Taiwan

William J Dupps MD PhD Cole Eye Institute Cleveland Clinic Foundation Cleveland, Ohio, USA

Zaina Al-Mohtaseb MD Assistant Professor Department of Ophthalmology Cullen Eye Institute Baylor College of Medicine Houston, Texas, USA

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Preface

Pterygium, by definition, is a fleshy ocular mass, most often, on the nasal conjunctiva that may cross the limbus to invade the cornea. In spite of the innocuous description, it has been a resilient adversary for the ophthalmic surgeons. The entity is known to exist since 1000 BC when Susruta, the first recorded ophthalmic surgeon and the father of Indian surgery, mentioned about it in Susruta Samhita in great details. He described the removal of inflamed and fleshy pterygium by means of hook and a thread with forceps and mentioned about the high probability of recurrence if not excised properly. This disease has been recognized the world over throughout the centuries. Various medical treatments have been described by Chinese, which inhibit blood vessel formation such as rehmannia, akebia, licorice and ginseng. Dioscorides described the use of gum of acacia, sepia shell power, sweet wood, vinegar and aloe extract and salt to inhibit the recurrence. With the advent of modern ophthalmic surgery, the surgery for pterygium has been under constant refinement. Though the excision of the lesion is relatively simple, its high predilection for recurrence is what makes it a challenging condition. It continues to be a cause of significant ocular morbidity in various regions of the world. Hence, there are continuously evolving trends in the management of pterygium, both in the terms of experimental drugs and surgeries. Surgical therapies described in the past used materials such as thread or horse hair, which were used to hook the pterygium to aid its removal. Modern-day surgical therapy involves age old conventions such as simple excision leaving bare sclera underneath, to surgical options such as conjunctival autografts, conjunctival flaps, amniotic membrane grafting, use of chemoadjuvants such as mitomycin C, anti-VEGF molecules like bevacizumab and ranibizumab, and use of B irradiation. Recurrence after primary lesion is a surgical failure as management of recurrent pterygium is challenging. Despite the abundance of literature on the treatment of pterygium, the sore point remained an unacceptable high recurrence rate of the order of 70–80%, specifically with the technique of bare sclera which was left after the pterygium excision. The paradigm shift in the management of pterygium was heralded by Kenyon et al. who described the use of conjunctival autograft (CAG) for covering the bare sclera. The conjunctival autograft offered much lower recurrence rates compared with the previous surgical techniques. This development was further strengthened by the introduction of fibrin glue to attach the CAG instead of sutures in 2004 when Koranyi et al. described the modified ‘cut and paste’ technique of pterygium excision with sutureless graft fixation. With the singular step of removal of sutures from the surgery, recurrence rates dropped dramatically. Over the next decade, this technique was further modified and refined. In the present day, pterygium excision with some form of tissue grafting with the help of fibrin glue appears to have become the gold standard for the treatment of primary pterygium. This technique and its modifications have been described in great detail in the textbook to enable the surgeons to replicate the same. You will also have the opportunity to view and learn techniques such as extensive tenectomy, narrow strip conjunctival autograft, sandwich technique, autologous blood, mini-flap technique and minor ipsilateral simple limbal epithelial transplantation (mini-SLET). Despite the advances, challenges still persist in the management of recurrent pterygium. The techniques described in this book for the management of the recurrent pterygium include conjunctival excision with limbal conjunctival autograft with or without mitomycin C/amniotic membrane graft, combined ipsilateral autologous limbus and homologous amniotic membrane transplantation for recurrent symblepharopterygium and ‘sealing the gap’. Pterygium may be complicated by other coexisting ocular pathologies that may warrant a surgeon’s attention while excising the lesion. These special situations include double-headed pterygium, pterygium complicated with co-existing cataract, corneal opacity, ocular surface squamous neoplasia and glaucoma with operated filtering surgery. The steps to manage these variations, have been included in separate chapters. Despite the best efforts of the surgeons, one might still encounter serious sight-threatening complications such as scleral melt after any form of pterygium surgery and other postsurgical complications with their respective management have been dealt with in the later chapters. We have deliberately provided minute details of the surgical steps in each chapter. This will ensure that the readers can go on to replicate these techniques in their clinical practice. And that is the ultimate goal of creating the book.

Tushar AgarwalShikha Gupta

Namrata Sharma

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Acknowledgments

We thank our contributing authors from all over the world. They worked very hard to provide the chapters and videos contained in this book. It is because of their long-term commitments towards teaching and research that this work has been made possible. We would like to thank Professor (Dr) Atul Kumar, Professor, Head and Chief, Dr Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences (AIIMS), New Delhi, India, who has provided us a fertile ground for conducting clinical work and research. We acknowledge Professor (Dr) JS Titiyal, Head, Cornea, Cataract and Refractive Surgery Services, Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, who has provided us with constant support. We acknowledge the mentorship provided by Professor (Dr) Rasik B Vajpayee (Vision Eye Institute, Royal Victorian Eye and Ear Hospital, North West Academic Centre, University of Melbourne, Melbourne, Australia). He has inspired us to work on the areas of clinical research that are pertinent to the neediest patients. The junior and senior residents of Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, deserve a special thanks for their hard work without which the surgical developments described in the book would not have been possible. We acknowledge the work of the technicians and nurses of Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, whose diligent work makes such projects possible. We thank Shri Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, whose professionalism, speed of execution and skills in medical publishing can outrival the best in the business. We would like to thank our families who have sacrificed their precious family time to allow us to spend that time to work on the book. At the end, we would like to convey our deep sense of gratitude towards our patients, who inspire us everyday with their faith in us, to work better and harder.

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Contents

SeCTiON i PTeRyGiuM: WhAT, Why AND WheN?

1. Etiopathogenesis of Pterygium 3Shikha Gupta, Tushar Agarwal

Ultraviolet Radiations 3 Angiogenesis and Inflammation 4 Lymphangiogenesis 4 Tumorigenesis 4 Genetics 5

2. Workup of a Case of Pterygium 9Shikha Gupta, Tushar Agarwal

Clinical History Taking in a Case of Pterygium 9 Counseling Patient Regarding Expectations from Pterygium Excision 13

SeCTiON ii SuRGiCAl MANAGeMeNT Of PTeRyGiuM

3. Pterygium Excision with Conjunctival Autografting Using Glue 17Tushar Agarwal, Shikha Gupta, Namrata Sharma

Indications 17 Advantages and Disadvantages 17 Surgical Procedure 18

4. Pterygium Excision with Conjunctival Autograft (Suture Technique) 27Elsie Chan

Technique 27 Results 28 Complications 29

5. Conjunctival Excision and Extended Tenectomy with Conjunctival Autograft for Primary Pterygium 31Chintan Malhotra, Arun K Jain, Vikash Rohilla

Indications 31 Current Role 31 Surgical Steps for Crater Technique 32

6. Pterygium Excision with Inferior Conjunctival Autografting 37Qi Chen, Fan Xu, Min Li, Li Jiang, Jiping Xu

Indications 37 Current Role 37 Outcomes 37 Surgical Technique 37

7. Pterygium Excision with Narrow-strip Conjunctival Autograft 42Angelique Pillar, Bennie H Jeng, David M Meisler, William J Dupps

Indications 42 Outcomes 42 Surgical Technique 43

8. Conjunctival Excision with Autograft Using Sandwich Technique 45Ali Fadlallah, Marc Fava, Steve Robinson, Catherine Choi, Georges El Mollayess, Samir Melki


9. Pterygium Surgery with Autograft Affixation Using Blood 48Kanhaiya Mittal, Shikha Gupta, Tushar Agarwal


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Textbook of Pterygium Managementxiv

10. Pterygium Excision by Mini-flap Technique 53Kyoung Yul Seo, Sang Min Nam, Ji Won Jung


11. Conjunctival Excision with Amniotic Membrane Grafting with or without Sutures 58Prafulla Kumar Maharana, Namrata Sharma

Rationale for Use 58 Indications 58 Surgical Technique 59 Complications 60 Outcomes 61

12. Minor Ipsilateral Simple Limbal Epithelial Transplantation 64Erick Hernandez-Bogantes, Enrique O Graue-Hernandez

Principle of Mini-SLET 64 Indications 64 Surgical Technique 64

13. Antimetabolites in Pterygium Management 67Puneet Jain, Shikha Gupta, Tushar Agarwal

Mitomycin C 67 Indications 67 Contraindications 67 Advantages and Disadvantages 67 Outcomes 68 Preparation and Uses 685-Fluorouracil 71 Indications 71 Contraindications 71 Advantages and Disadvantages 71 Outcomes 71 Preparation and Uses 71

14. Antivascular Endothelial Growth Factor Agents 74Shikha Gupta, Puneet Jain, Tushar Agarwal

Indications 74 Contraindications 74 Advantages and Disadvantages 74 Outcomes 75 Preparation and Uses 77

15. Adjunctive Therapy in Pterygium Management 79Puneet Jain, Shikha Gupta, Tushar Agarwal 79

Beta Irradiation 79 Interferon Alpha-2b (IFN a-2b) 81 OLOGEN® 82

SeCTiON iii MANAGeMeNT Of ReCuRReNT PTeRyGiuM

16. Conjunctival Excision with Limbal Conjunctival Autograft or Amniotic Membrane Grafting, with or without Mitomycin-C in Recurrent Pterygium 85Tarun Arora, Shikha Gupta, Tushar Agarwal


17. Combined Ipsilateral Autologous Limbus and Homologous Amniotic Membrane Transplantation for Recurrent Symblepharopterygium 89Berthold Seitz, Cord RH Huchzermeyer

Indications 90 Advantages and Disadvantages 90 Surgical Techniques 90 Outcomes 91

18. Sealing the Gap for Managing Pterygium 94Anny MS Cheng, Wei-li Chen, Scheffer CG Tseng

Principle Behind the Technique 95 Advantages of Using Amniotic Membrane Transplant 96 Surgical Technique 97 Postoperative Care 103

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Contents xv

SeCTiON iV ChAlleNGiNG SiTuATiONS iN PTeRyGiuM MANAGeMeNT

19. Double-headed Pterygium: Split Conjunctival Grafts 107Neelima Aron, Shikha Gupta, Tushar Agarwal

Indications of Split Conjunctival Grafting 107 Advantages of Split Conjunctival Grafting 107 Disadvantages of Split Conjunctival Grafting 107 Surgical Technique 107 Outcomes 111

20. Management of Pterygium with Coexisting Cataract 112Koray Gumus, Cynthia I Tung, Zaina Al-Mohtaseb

The Impact of Pterygium on Visual Parameters 112 Simultaneous Pterygium and Cataract Surgery 113 Timing of the Cataract Surgery: Before or After the Pterygium Excision 113 Surgical Technique for Pterygium Surgery 114

21. Management of Corneal Opacity after Pterygium Surgery 117Manpreet Kaur, Anubha Rathi, Tushar Agarwal

Predisposing Factors 117 Prevention 117 Preoperative Considerations 118 Management 118

22. Management of Pterygium with other Coexisting Ocular Surface Conditions 121Pooja Bandivadekar, Tushar Agarwal, Shikha Gupta

Pterygium and Ocular Surface Squamous Neoplasia 121 Indications 121 Investigations 121 Management 121Corneal Opacity and Pterygium 123 Management 123

23. Pterygium and Glaucoma 125Shalini Mohan, Mohit Khattri, Surendra Kumar Sachan

Timing of Surgery 125 Preoperative Considerations and Evaluation 125

24. Complications after Pterygium Surgery 128Manpreet Kaur, Shikha Gupta, Namrata Sharma

Graft-related Complications 128 Host and Donor Site Complications 132 Generalized Ocular Side Effects 134

25. Autologous Advanced Tenon Grafting Combined with Conjunctival Flap for Scleromalacia 136Jong-Soo Lee

Materials for Ocular Surface Reconstruction 136 Indications 137 Advantages and Disadvantages 137 Surgical Technique 137 Postoperative Care 138 Outcomes 139

26. Tectonic Lamellar Graft in Post Pterygium Surgery Corneoscleral Melt 142Anubha Rathi, Manpreet Kaur, Shikha Gupta

Clinical Presentation 142 Pathophysiology 142 Approach to Management 142 Surgical Technique 143 Outcomes 144

Index 147

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Tushar Agarwal, Shikha Gupta, Namrata Sharma

Chapter 3Pterygium Excision with Conjunctival

Autografting Using Glue

Pterygium surgery by means of excision followed by conjunctival autografting with the help of fibrin glue was first described by Koranyi and colleagues in 2004. The inventors named it as “Cut and Paste Pterygium Surgery”. The advent of this technique was a paradigm shift in the surgical management of pterygium. A single innovation of replacing sutures with fibrin glue as a method of attaching the autograft to the host bed was responsible for changing the entire outlook of this surgery. All the problems associated with the use of sutures including, graft inflammation, patient discomfort and a relatively large learning curve were taken out in a single sweep.

Since it is introduction, this technique has been evaluated thoroughly by means of several clinical trials. It has been shown that glue assisted conjunctival closure has lower recurrence rates, enhanced patient comfort with decreased pain, decreased graft inflammation and lower operative time. The use of glue instead of sutures dramatically eased the surgery thereby bringing it into the ambit of many more surgeons than previously. It also had a significant impact on bringing down the recurrence rate of pterygium, down to 5% or less.

Fibrin tissue adhesive (Tisseel Duo Quick, Baxter, Vienna, Austria) which is being used to adhere the conjunctival autograft onto the host bed is a biological adhesive which mimics the natural fibrin clot formation that occurs in vivo. Its use in ophthalmology is very safe and is used widely in other medical fields as a hemostatic and adhesive agent with minimal side effects. It helps achieve graft adhesion by simulating the final stage of the coagulation cascade. It contains two syringes, 1 containing a solution comprised of factor XIII, plaminogen, plasma fibronectin, and fibrinogen (to be reconstituted with the aprotinin solvent which is an inhibitor of fibrinolysis) and a second syringe containing human thrombin solution (to be reconstituted with calcium chloride solution). Both syringes are available as dual injection system (Duploject) in order to mix their contents in appropriate proportions. Thrombin enables the splitting of fibrinopeptides to form fibrin monomers, which cross link to form fibrin clot.

However, in pterygium surgery it is preferred to use the two components separately. The usual practice is to apply the fibrin part on the underside of the autograft and the thrombin part on the scleral bed. This prevents immediate polymerization of

the glue, thereby allowing some more time for the surgeon to position the graft in the desired position.

INdICatIoNSAt present, pterygium excision and conjunctival autograft affixation using fibrin glue remains the most suitable procedure for primary pterygium of varying severity. In addition, it is also the most commonly performed procedure for recurrent pterygium with or without the use of an adjuvant.

The primary requirement for determining suitability of a patient for this surgery is the presence of adequate amount of healthy bulbar conjunctiva, especially in the superior half of the globe.

Patients who had undergone prior filtration surgery or those requiring the surgery in near future, those who have undergone corneal transplant, scleral buckling surgery, those with pre-existing superior conjunctival scarring (due to previous ocular surgery or trachoma) or a history of ocular trauma/chemical exposure are not suitable for this surgery.

advaNtaGeS aNd dISadvaNtaGeSAt present, conjunctival autografting with fibrin glue is considered the standard method for the surgical correction of pterygium. After the advent of this technique, recurrence rates have dropped from more than 50% with bare sclera pterygial excision to less than 5%. Koranyi and colleagues who first described this technique did a 10-year retrospective chart review of 325 eyes which underwent this proceudre. They found that in their series, fibrin glue use resulted in a recurrence rate of 5.3% of all cases operated, compared to a recurrence rate of 13.5% with use of 8’0 vicryl sutures. The intraoperative use of fibrin glue during pterygium surgery also requires significantly shorter surgical time by approximately 13 minutes compared to use of sutures. Moreover, in terms of surgical efficiency, not only it is shorter, but also easier to learn and perform than use of sutures for beginners and experts alike. Furthermore, its use is associated with less graft inflammation when compared to use of sutures. Patient comfort is also higher with the use of glue due to less pain perceived. Sutures act as chronic irritants till

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Section II: Surgical Management of Pterygium18

the time they get absorbed (2–3 weeks) or are removed (non-absorbable). Use of glue also helps attain better cosmesis due to less intense graft hyperemia when compared to sutures.

In terms of outcomes, there is a marginally higher incidence of partial graft dehiscence, graft slippage and loss of grafts with use of fibrin versus use of sutures. These complications can be minimized by keeping the tension on the autograft as minimal as possible, slightly oversizing the graft in relation to the host site defect, not including tenon in donor conjunctiva, carefully removing the wire speculum at the completion of surgery, applying the bandage cautiously, staying taped for at least 24 hours, instructing the patient to avoid eye rubbing and ocular friction in any form.

In developing countries, prohibitive cost of the glue is another important deterrent in its use. It is priced at approximately 110$ in India whereas cost of vicryl suture is nearly 10$ making its use almost ten times costlier to sutures. Further, due to its short shelf life, it has to be used within 4 hours of preparation and hence cases cannot be clubbed at an interval greater than 4 hours. One method is to devise an operating list in such a manner so as to combine all cases requiring glue listed together within an interval of 4 hours in order to cut the running cost. In this way, 3–4 patients can pool together and pay the cost of one kit only.

Other rare complication can occur in the unfortunate event of any hypersensitivity reaction to the use of glue since it is prepared from pooled human plasma. The incidence of allergic reactions has been reported to be 0.5/100,000 (all reactions) and 0.3/100,000 (serious reactions). Observed symptoms may include bradycardia, tachycardia, hypotension, flushing, bronchospasm, wheezing, dyspnea, nausea, urticaria, angioedema, pruritus, erythema and paresthesia. Though these reactions are seen more commonly in those who have had prior exposure within 3 years to the fibrin sealant containing aprotinin, they can also occur in those receiving glue for the first time. In such cases, use of glue should be discontinued with immediate effect along with removal of any remnant sealant from the ocular surface. In cases of mild reactions, administration of antihistamines may suffice. However, shock therapy may be necessary for severe hypotensive reactions.

SUrGICaL proCedUre

anesthesiaThe surgery can be done either under peribulbar or topical anesthesia. There are relative advantages and disadvantages of both types specific to pterygium surgery. With topical anesthesia, the patient can be instructed to move his eyes in a particular direction during the surgery. This can be helpful while dissecting the pterygium and in harvesting the graft. It is also better cosmetically than peribulbar anesthesia in which there are chances of occurrence of subconjunctival bleeds and subcutaneous ecchymosis which can take a long while

to clear up. Peribulbar anesthesia on the other hand is better suited for cases with more extensive pterygia and those whose involvement may extend into the fornices or beyond. It may also be a better choice when the surgeon is still early in the learning curve. However, this type of anesthesia requires the assistant to position the globe during surgery to aid in the dissection. This can hamper the surgical field. It is best to do the initial cases under peribulbar anesthesia. Once the surgeon is comfortable with the procedure then one can progress to operating under topical anesthesia.

Topical anesthesia is administered by installation of proparacaine drops, 1% a couple of times in the eye, 5 minutes before the start of the surgery. It may be supplemented during the surgery.

Peribulbar block is administered as per the standard technique for such blocks. Care should be taken that the conjunctiva is not damaged during the injection of the anesthetic.

The eye to be operated is cleaned with diluted betadine and a surgical drape is applied. A wire speculum is applied to keeps the lids pulled apart during the surgery. It is important to obtain a good exposure of the eyeball for the procedure. One should be able to visualize at least a couple of millimeters, both above and below the cornea after the speculum is applied (Fig. 3.1).

The first step is to demarcate the area that needs to be excised. It is not required that to cut away the entire visible pterygium it may lead to a very large tissue defect, that may be unmanageable with an autograft. One can identify the landmark till which the dissection needs to be done, by looking at the counjunctival vessels on the pterygium. Look at the conjunctival vessels in the leading edge of the pterygium. In comparison to normal conjunctival vessels, they are more prominent and also form an irregular pattern. Trace these vessels backwards where the pterygium merges into the normal conjunctiva. The point where these abnormal vessels end is the landmark for to determine the amount of tissue to be excised (Fig. 3.2). This point is demarcated with a surgical marking pen or a tip of a Sinskey hook dipped in Gentian violet paint. Ensure that there is a thick demarcation line. Inject a combination of lignocaine and epinephrine 1:100,000 below the head of the pterygium. This serves multiple functions. It supplements the anesthesia, hydrodissects the pterygium away from the underlying cornea and reduces bleeding. The firmly adherent pterygium fibrovascular tissue is then grasped using Lim’s forceps and excised using angled Vannas scissors (Fig. 3.3). The tissue is excised till the area that has been demarcated. Care should be taken to avoid damaging the medial rectus muscle during dissection. The bleeding vessels on the exposed corneoscleral pterygium bed are cauterized (Fig. 3.4). One should avoid excessive use of cautery as this can lead to corneal melting later on.

The removal of pterygium is followed by polishing of the corneoscleral bed to remove any attached remnants of the tissue and to smoothen the irregular surface, which is usually

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Chapter 3: Pterygium Excision with Conjunctival Autografting Using Glue 19

Fig. 3.1 Left eye of a patient with a vascular wing-shaped pterygium covering approximately 4 mm of nasal corneal surface

Fig. 3.3 The head of the pterygium is grasped with Lim’s forceps and excised using angled Vannas scissors at the neck where demarcation line is drawn

Fig. 3.4 The actively bleeding vessels on the exposed corneoscleral pterygium bed are cauterized using bipolar cautery

Fig. 3.2 A Sinskey hook dipped in Gentian violet paint is used to demarcate with broad lines the area of pterygium from normal conjunctiva that needs to be excised

done differently by the surgeons using a crescent blade, diamond burr, Westcott scissors, iris spatula or No. 64 Beaver blade (Fig. 3.5). We prefer to smoothen the corneal surface with the aid of a combination of crescent knife and a motorized diamond burr [Alger brush 2000 (Rumex International Corp, Florida, USA) with a 3.5-mm round, fine diamond burr]. The remnants of the pterygium are scrapped off using a crescent knife. When the crescent knife is applied vertically to the corneoscleral plane, it scrapes more superficially than if it is held at a more acute angle. Following the gross dissection with the knife, a motorized diamond to clear any remaining fibrovascular tissue and smoothen the corneoscleral bed (Fig. 3.6). Polishing with should be performed under continuous irrigation, with avoidance of prolonged motion at a single place, to prevent creation of an irregularly deep corneal surface. One of the main goals of pterygium surgery is to restore the smoothness of the limbus. Hence, one should be

patient in polishing the corneoscleral bed. This restoration of corneal smoothness aids reepithelialization, enhances corneal clarity in the postoperative period, and might influence the final corneal topography.

Graft preparationOnce the corneoscleral bed is prepared, the next step is to create the conjunctival autograft. The conjunctival defect is measured with calipers and equivalent sized conjunctival graft is harvested from the superolateral quadrant of the same eye. First mark the two points on the superior limbus that will define the width of the graft. This is width is equal to the width of the tissue defect (Fig. 3.7). Then, the vertical extent of the graft is marked out by a surgical marking pen or sinskey hook dipped in GV paint. Ensure that bold lines are created on the conjunctiva. A mixture of xylocaine and adrenaline is injected sub-conjunctivally to

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Fig. 3.7 Conjunctival graft sized equal to the conjunctival defect created at pterygium site is harvested from the superolateral quadrant by marking it using bold demarcation lines using sinskey hook dipped in GV paint

Fig. 3.8 The conjunctival graft is being cut with angled Vannas scissors initially on two of its edges

Fig. 3.5 The remnants of the pterygium are scrapped off the corneal surface using a crescent knife with the blade held vertically to aid in superficial dissection

Fig. 3.6 A motorized diamond burr helps achieve the final polished corneal surface by removing the irregularities by remaining fibrovascular tissue

lift up the conjunctiva to be harvested. Similar to the injection under the pterygium this injection serves the same, multiple functions. The graft (consisting of conjunctiva only, and not Tenon’s) is then cut using angled Vannas scissors initially on two of its edges (Fig. 3.8). By obtaining conjunctiva alone, the graft can be made to stretch more easily at the host site defect, help with faster healing and will minimize the risk of postoperative graft edema. This leaves the graft attached on two of the four sides. This allows you to dissect the Tenon’s tissue from underneath the conjunctiva as tautness is provided by the 2 attached edges. This dissection is done using an angled Vannas’s scissors. The end point of this dissection is reached once the graft is thin enough to visualize the blades of the scissors through the graft (Fig. 3.9). Having completed this, cut the third conjunctival edge, taking care to cut just outside the demarcation lines. These lines on the graft help to identify the three edges of the free graft. Finally, the conjunctiva is cut at

the juxtalimbal edge and the graft is rendered free (Fig. 3.10). At all time points, the graft should be handled very gently, with non toothed forceps like Pierce-Hoskins conjunctival forceps. It is laid inverted on the cornea.

Graft attachmentBefore moving the graft to the site of the conjunctival defect, the corneoscleral bed is dried. Now the graft is moved next to the site of the conjunctival defect. This is done by sliding the graft in the inverted position, on the cornea to align it next to the defect (Fig. 3.11). One should never attempt to lift the graft as it will lead to its crumpling. It is advisable to not to irrigate the ocular surface once the autograft is lying free lest it should get washed away or get disoriented.

A couple of drops of thrombin (Fig. 3.12) (first part of the glue) are applied onto the host bed while fibrin (second part

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Fig. 3.9 The underlying Tenon’s tissue is being dissected from underneath the conjunctiva using an angled Vannas’s scissors as tautness is provided by the attached edges till the graft is thin enough to visualize the blades of the scissors through the graft

Fig. 3.11 The graft is slided into position juxtaposed to the conjunctival defect at host site

Fig. 3.10 Finally, the conjunctival graft is cut at the juxtalimbal edge by holding it inverted onto the cornea. Note that the graft is thin enough to allow visibility of underlying cornea through it

Fig. 3.12 Few drops of thrombin (first part of the glue) are being applied onto the host bed

of the glue) is applied on the inverted surface of the autograft (Fig. 3.13). The separate application of the two components of fibrin glue allows some extra time for the surgeon to oppose the graft with the conjunctiva. Now lift the two distal edges of the graft and flip it over onto the corneoscleral bed (flipover maneuver) (Fig. 3.14). The surgeon has about 20–30 seconds to get the graft into position before the two components of the glue combine to stick the two surfaces together.

The first priority is to position the limbal edge of the graft. Ensure that this edge is fully opposed to the underlying surface and is taut. This is followed by the apposition of the two edges perpendicular to the limbus followed lastly by the distal edge (Fig. 3.15). These are apposed by small pinching movements of the Lim’s forceps taking small bites of the two opposing conjunctival surfaces. Finally, a lens hook is then used to iron out the autograft and to express any fluid from beneath the graft surface (Fig. 3.16). Excessive dried glue is trimmed off with a scissors. During the entire surgery, the surgeon should be wary

of handling the tissues gently, and use of non-toothed forceps for conjunctival autograft handling to minimize postoperative inflammation and pterygial recurrence. The wire speculum is removed and the stability of the graft is checked before taping the eye closed.

postoperative adviceThe operated eye is bandaged for at least 6 hours. Typical postoperative medication includes topical moxifloxacin 1% t.i.d. for 2 weeks prednisolone acetate 2% quid for 2 weeks followed by tapering over 2 weeks 0.5% carboxymethylcellulose drops quid for up to 3 months.

The patient is instructed to avoid eye rubbing as the graft can get dislodged. Activities such as swimming and contact sports should be avoided till at least 6 weeks postoperatively.

In a large majority of cases, the surgery is done to improve the cosmetic appearance. Hence, the patients

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Fig. 3.13 Fibrin (second part of the glue) is being applied with an applicator on the inverted surface of the autograft

Fig. 3.15 The two edges perpendicular to the limbus are being apposed by small pinching movements of the Lim’s forceps taking small bites of the two opposing conjunctival surfaces

Fig. 3.14 The graft is immediately flipped over the corneoscleral bed by holding the two distal edges by the forceps, with priority given to appose the limbal edge of the graft first

Fig. 3.16 Finally, a lens hook is used to iron out the autograft in order to express any fluid from the underside of graft

should be counseled that it can take up to 4–6 weeks for the eye to return to normal appearance. If there is a prominent subconjunctival hemorrhage, it may take 2–4 weeks to clear. A yellowish transplant edema was sometimes observed and was slightly more common in the glue group. Topical phenylephrine drops may be prescribed to help subside the conjunctival redness from subconjunctival hemorrhage at the site of autograft.

outcomesA brief synopsis of major clinical studies with major outcomes that have been done in the past concerning the use of fibrin glue for conjunctival autograft affixation is listed in (Table 3.1).

CoNCLUSIoNThe method of graft fixation has mostly been superseded by the use of fibrin glue whenever available instead of the conventional use of absorbable/nonabsorbable sutures as initially described. This is because fibrin glue is superior in terms of conferring a significantly lower recurrence rate over the past techniques, requires less surgical time, causes less pain, discomfort and inflammation and offers better cosmesis. The technique is easy to learn, perform and master with high surgeon-surgeon repeatability. With the high cost as its single most important disadvantage, it is being performed as the standard technique world over for the management of both primary and recurrent pterygia.

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table 3.1 Various trials involving excision of pterygium with autograft with use of fibrin glue

Authors Study design Study groups Sample size Observations/ complications

Recurrence Follow-up

Pan HW, et al. Meta-analysis Fibrin glue vs sutures 342 subjects (366 eyes) in 7 studies

Decreased operating time (mean difference -17.61 minutes, 95% CI -26.03 to -9.18, p<0.0001) Same rate of complica-tions (Peto OR 1.82, 95% CI, 0.63-5.27, p = 0.27)

Decreased recurrence rate (Peto odds ratio [OR] 0.33, 95% CI, 0.15-0.71, p = 0.004)

Uyes Hs RCT Fibrin glue beriplast P 11 eyes Shorter operative time (p < 0.001)1 patient = subconjunctival hemorrhage

None (short follow-up)

2 months

10’0 MFN sutures 11 eyes Lesser postoperative comfort (p < 0.05).1 patient = partial graft dehiscence

Srinivasan S Prospective, observer masked, clinical trial

Fibrin glue (Tisseel) 20 eyes Less graft inflammation 1 month (p = 0.019) and 3 months (p = 0.001)No difference in graft stability and subconjunctival hemorrhage

Not assessed 3

Sutures 20 eyes

Bahar I RCT after bare sclera with 0.02% mitomycin C

Fibrin tissue adhesive (Quixil)

N = 42 Shorter operative time (p < 0.05); greater patient satisfaction (p = 0.04)

Five (11.9%) 12

8-0 Vicryl sutures N = 39 Greater ocular discomfort (p < 0.05)1 patient corneal dellen

3 eyes (7.7%) (p < 0.05)

Hall RC RCT Fibrin tissue adhesive (Tisseel)

25 eyes Shorter operative time (p < 0.001); less pain till day 2 (p = 0.05)1 patient = absent graft

0 12

Vicryl sutures 25 eyes Greater ocular discomfort (p < 0.05)

2

Ratnalingam, et al.

Double-blind RCT

Fibrin glue 68 eyes Shorter operative time (p < 0.001); less pain till 1 week (p=0.05) in group I11 (15.9%)

3 (4.41%) 12

Sutures 69 eyes

Rubin MR, et al.

RCT Fibrin glue (Quixil™) 22 eyes Mean surgical time less in group I (p < 0.001). Ocular discomfort scale analysis less in group I till 3 weeks (p < 0.001); ocular hyperemia less intense in group 1 till 3 weeks (p < 0.001).

1 6 months

Sutures 26 eyes 2

(Contd...)

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(Contd...)

(Contd...)



Karalezli A, et al.

RCT Fibrin glue 25 eyes Shorter operative time (p < 0.001); less pain (p = 0.001); less foreign body sensation (p <0.05); partial graft dehiscence (2 patients)

One eye (4%) 12 months

8’0 Vicryl sutures 25 eyes Three eyes (12%) (p < 0.05).

Koranyi G RCT Fibrin glue: Tisseel Duo Quick

20 eyes Shorter operative time (p < 0.001); less pain (p = 0.05)

2 (4%) 6 months

Absorbable sutures (7-0 Vicryl rapid)

23 eyes 4 (20%)

Anbari AA, et al.

Prospective interventional comparative study

Autologous cryoprecipitate

47 eyes Shorter operative Time (P < 0.05)

0% 12

8’0 Vicryl sutures 43 eyes 12%

Miranda-Rollón MD, et al.

Comparative interventional case series

Sutures affixed CAG (7’0 silk)

9 eyes 33.3% experienced pain after surgery compared to none in group II; 44.4% had inflammation after surgery compared to none in group II

0 NA

Fibrin glue affixed CAG

8 eyes 1 graft lost 1

Jiang J, et al. Comparative Interventional case series

Fibrin glue 20 eyes Shorter operative time (p < 0.001)

5% 12 months

10’0 MFN Suture 20 eyes Same complications 10%

Koranyi G, et al.

10-year retrospective chart review

Fibrin glue 325 eyes Transient transplant edema

5.3% 17 +/-12 month

8’0 Vicryl sutures 136 eyes Same rate of persistent corneal epithelial defects

13.5% (p = 0.01) 35 +/- 26 month

Cha DM, et al. Retrospective comparative case series

CAG with fibrin glue 22 eyes Milder conjunctival inflammation (p = 0.000)Lesser surgical time (p = 0.000)

Similar recurrence rates

3 months

10’0 MFN 30 eyes

Farid M, et al. Retrospective comparative case series

Fibrin glue 27 eyes Decreased recurrence with increasing age (p = 0.025)

3.7%20% (p = 0.035)

22–36 months

8’0 Vicryl sutures 20 eyes

Huerva V, et al. Retrospective noncomparative case series

CAG with nylon 10/0 sutures (29.45%) or glue (70.55%)

112 eyes No difference in recurrence rate between primary and recurrent pterygium, and between sutures and fibrin; recurrences seen in Hispanics

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(Contd...)



Coral-Ghanem R, et al.

Prospective series Fibrin glue 106 eyes Transitory granuloma (3), partial graft slippage (3), dellen (1)

12 (11.3%) 5 months

Retrospective case series

Sutures 58 eyes 15 eyes (25.9%)

Glue only

Por YM, et al. Prospective noncomparative case series

Fibrin glue: Tisseel 29 eyes One spontaneous subgraft hemorrhage

One pterygium recurrence

6 months

Sandra S, et al. Prospective case series

Fibrin glue 51 eyes (38 primary, 7 recurrent)

Graft edema (n = 4; 7.8%), graft hyperemia (n = 2; 3.8%), and transient graft dislocation (n = 3; 5.9%);

1 graft dehi-scence (2%)

n = 5; 9.8 % 24 months

Ayala M, et al. Prospective case series

CAG with glue 88 eyes Average operation time: 11.8 +/- 2 (SD) minutes

4.54% 12 months

Marticorena J, et al.

Case series Tissucol Duo, Baxter 20 eyes No dehiscence No graft loss,mild graft retraction (2)mild foreign body sensation (25%)

26.05 +/- 3.15 weeks

Nuiewendaal, et al

Retrospective case series

Tissucol Duo 500 human fibrin glue

35 eyes 1 Graft = Lost 2.9% recurrence Between 14 and 36 months

Sarnicola V, et al.

Retrospective case series of primary pterygium

CAG with fibrin glue 111 eyes Graft pseudoedema (n = 45; 40.54%), graft retraction (n = 3; 2.70%), and donor site granuloma (n = 1; 0.9%)

Mean recurrence rate 4.5% (5 eyes)

24 months

Kandavel, et al.

Retrospective case control study

CAG with fibrin glue in primary pterygium

15 hispanic 1 dellen, 1 pyogenic granuloma

6 of 15 (40%) 9.3 +/- 9.8 months

11 white patients 1 dellen, 1 pyogenic granuloma

0 of 11 (0%) (p = 0.02)

13.0 +/- 10.7 months

BIBLIoGraphy 1. Al Fayez MF. Limbal-conjunctival vs conjunctival autograft

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2. Anbari AA. Autologous cryoprecipitate for attaching conjunctival autografts after pterygium excision. Middle East Afr J Ophthalmol. 2013;20(3):239-43.

3. Ayala M. Results of pterygium surgery using a biologic adhesive. Cornea. 2008;27(6):663-7.

4. Cha DM, Kim KH, Choi HJ, et al. A comparative study of the effect of fibrin glue versus sutures on clinical outcome in patients undergoing pterygium excision and conjunctival autografts. Korean J Ophthalmol. 2012;26(6):407-13.

5. Coral-Ghanem R, Oliveira RF, Furlanetto E, et al. Conjunctival autologous transplantation using fibrin glue in primary pterygium. Arq Bras Oftalmol. 2010;73(4):350-3.

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15. Miranda-Rol lón MD, Pérez-G onzález L E , S entier i-Omarrementería A, et al. Pterygium surgery: comparative study of conjunctival autograft with suture versus fibrin adhesive. Arch Soc Esp Oftalmol. 2009;84(4):179-84.

16. Nieuwendaal CP, van der Meulen IJ et al. Long-term follow-up of pterygium surgery using a conjunctival autograft and Tissucol. Cornea. 2011;30(1):34-6.

17. Pan HW, Zhong JX, Jing CX. Comparison of fibrin glue versus suture for conjunctival autografting in pterygium surgery: a meta-analysis. Ophthalmology. 2011;118(6):1049-54.

18. Por YM, Tan DT. Assessment of fibrin glue in pterygium surgery. Cornea. 2010;29(1):1-4.

19. Ratnalingam V, Eu AL, Ng GL, et al. Fibrin adhesive is better than sutures in pterygium surgery. Cornea. 2010;29(5):485-9.

20. Rubin MR, Dantas PE, Nishiwaki-Dantas MC, Felberg S. Efficacy of fibrin tissue adhesive in the attachment of autogenous conjunctival graft on primary pterygium surgery. Arq Bras Oftalmol. 2011;74(2):123-6.

21. Sandra S, Zeljka J, Zeljka VA, et al. The influence of pterygium morphology on fibrin glue conjunctival autografting pterygium surgery. Int Ophthalmol. 2014;34(1):75-9.

22. Sarnicola V, Vannozzi L, Motolese PA. Recurrence rate using fibrin glue-assisted ipsilateral conjunctival autograft in pterygium surgery: 2-year follow-up. Cornea. 2010;29(11):1211-4.

23. Srinivasan S, Dollin M, McAllum P, et al. Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observer masked clinical trial. Br J Ophthalmol. 2009;93(2):215-8.

24. Uy HS, Reyes JM, Flores JD, Lim-Bon-Siong R. Comparison of fibrin glue and sutures for attaching conjunctival autografts after pterygium excision. Ophthalmology. 2005;112(4):667-71.

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