Pterygium is a degenerative disease of conjunctiva,

Transcription

1 Original Article A new technique of sutureless and glueless conjunctival autografting in pterygium surgery by thermocautery Arunava Kundu 1, Krishna Kanta Roy 1, Nazneen Nazm 1, Sampurna Mukherjee 1, Biplab Biswas 1, Avirupa K. Banik 1, Sandeep Shankar 2 Abstract Purpose: To compare the efficacy and safety of thermocautery with vicryl 8-0 sutures in conjunctival autografting for the treatment of primary pterygium. Methods: A prospective, clinical trial was conducted in 80 eyes of 80 patients with primary pterygium. Patients underwent pterygium surgery using either by thermo cautery (40 eyes) or by vicryl 8-0 sutures (40 eyes) to attach the conjunctival autograft. Postoperatively all the patients were evaluated on postoperative days 1, 3, and 7 and then at months 1, 3 and 12. Outcome measures were surgery time, postoperative patient symptoms, complications and recurrence rate. Result: In cautery group mean surgical time(22.4±1.9) was which was significantly shorter (p=0.0005) than suture group(25.3 ± 2.1). At day 7 and 30 there is statistically significant difference present. Whereas at 3 and 12 month after surgery all symptoms decrease both in suture group and cautery group. 2 patient developed conjunctival recurrence (grade 3) in the cautery group and 3 patient in suture group. Corneal recurrence(grade 4) was noted 1 in each group. But there is no statistically significant difference(p= 0.644) in overall recurrence rate. In cautery group 02 patient developed graft dehiscence. Conclution: Conjunctival autografting with thermocautery in pterygium surgery is safer, faster, techniqually easier, economical and have less post operative discomfort than conventional surgery. Key-words : Pterygium, Conjunctival autograft, Thermo cautery. Pterygium is a degenerative disease of conjunctiva, probably due to alteration of limbal stem cell by chronic UV ray exposure 1. It is managed by surgical excision which is first described by Susruta in Since then multiple surgical procedure was reported however recurrence ( %) remains a big problem in pterygium management 3-4. In last few decade Conjunctival autograft and antimetabolite was use to prevent recurrence. Though it was proposed that anti metabolite reduce the recurrence rate but multiple complication such as sclera thinning, scleral melting, globe perforation, cataract and endothelial damage restrict its use in pterygium surgery Recently better understanding the role of limbal stem cell in pterygium recurrence leads to development of limbal conjunctival autografting technique alternative to suture to attach the conjunctival auto graft. Though it is faster and don t have any suture related complication but plasma derived fibrin is costly, it can transmit infectious agent (Hepatitis B, HIV and Parvo virus B19 and may cause anaphylactic reaction in susceptible individual Currently there is no safer, faster, easier and cost effective technique by which conjunctival autograft can be attached with sclera bed. In current study we described a new technique of suture less and glue less conjunctival autografting by using thermo cautery. The purpose of this study is to compare outcome of pterygium surgery by conjunctival autografting with thermo cautery and with nylon 10-0 for the treatment of primary pterygium. Traditionally suture was used to fixed the conjunctival autograft sclera bed. But it is time consuming and in postoperative period patient developed irritation and suture related complication 14. Fibrin glue also used as an Material and Method This prospective experimental study was conducted at a referral centre of Eastern India from August 2016 to 1 ESI-PGMSR, Joka, Kolkata, India, 2 AFMC, Pune,India. Corresponding Author : Dr. Krishna Kanta Roy, kkroy2020@gmail.com Received on : 03/03/2017, Revision accepted on : 23/11/2017 Conflict of Interest : None, Financial Disclosure : None Current Indian Eye Research. Current Indian Eye Research 65

2 September All the procedures were performed in accordance to the tenets of the Declaration of Helsinki, and the study protocol was approved by the institutional Ethics Committee. Informed consent was obtained from all the participants after explaining the nature of study. All the patients were evaluated by anindividual observer and graded according to the grading system developed by Ten et al wheregrade 1 (atrophic) described as clearly distinguishableepiscleral vessels under the body of the pterygium; grade 3 (fleshy), episcleral vessels totally obscured and all other pterygia not falling in to grade 1 or 3 described as grade 2 (intermediate). In current study we include Grade 2 and 3 pterygia 19. Patient with any active eye disease like ocular surface disease, pseudopterygium, glaucoma or previous surgery were excluded from the study. Sample size was calculated by following assumption: level of significance 5%, power 80%. A minimum 37 patient required in each group. A total 80 eyes of 80 patients with primary pterygium were included in that time period. Patient with odd serial number were underwent conjunctival autografting fixed with thermo cautery and even serial number were underwent conjunctival autografting fixed with 10-0 nylon. Pre Operatively all patient underwent detailed ophthalmic examination including best corrected visual acuity (BCVA), slit lamp biomicrosccopy, fundus examination, applanation tonometry. All the surgery done by a single surgeon under local anaesthesia by lignocain and bupivacain. After dressing and draping head of pterygium was separated from the cornea by blunt dissection. If scar tissue is present they are removed by polishing. Then the body of pterygium was separated by blunt dissection and cut 01 mm away from lacrimal curuncle. Minimal cautery was used to control bleeding. After removal of pterygium a trapezoid shaped bare sclera created and measured by calliper. Additional 01 mm in length and width relative to bare sclera conjunctival auto graft was harvested from superior bulber conjunctiva after injecting normal saline subconjunctivally. Dissection was done carefully to exclude Tenon s capsule under the graft and a thin rim of corneal epithelium was included in limbal side with help of Crescent blade. Then graft placed over the bare sclera with epithelial side up and limbal edge towards limbus. In cautery group minimal cautery were applied to the adjoining graft and recipient edge just to make it stiky. The adjoining stiky margins were pinched together to ensure firm adhesion at multiple points to ensure proper adhesion. In suture group conjunctival graft secured with surrounding conjunctiva by 8-0 vicryl suture. After removing the speculum pad bandage applied over that eye with 0.3% Tobramycin and 0.1% Dexamethasone ointment. Surgical time monitored and noted from incision to the removal of speculum. 01 day after surgery pad and bandage removed and slitlamp examination done. Topical Moxifloxacine, Difluprednet and artificial tear prescribed to all patients. Patients were followed up 01, 03,07 days, 1 month, 3 month and 12 month after surgery. At each visit BCVA, slit lamp biomicroscopy, fundus examination, applanation tonometry and assessment of any complication including recurrence was done in each patient. The rcecurrence was graded by the grading system developed by Prabhasawat et al 20. The postoperative symptom was evaluated at each post operative visit and graded by a 5 point scale proposed by Lim-Bon-Siong et al 21. Result We included a total 80 eyes with primary pterygium, of them 40 eyes underwent pterygium excision and conjunctival autografting with suture and rest 40 eyes underwent pterygium excision and conjunctival autografting with thermo cautery. All the patients followed up for 12 months. In suture group there is 23 males and 17 females with a mean age of 52.4±10.4 (Table1). In cautery group there is 24 males and 16 females with a mean age of 56.2±10.2. The demographic characterestic of the study population are summarized in the table no 1. There were no statistically significant difference both in age in between two groups (p=0.15). In preoperative assessment there were no statistically significant difference in pterygium grade in between two groups(p= 0.63). In cautery group mean surgical time(22.4±1.9) was which was significantly shorter (p=0.0005) than suture group(25.3 ± 2.1). In postoprerative day 1 and 3 there is no statistically significant difference in symptom score (Irritation, foreign body sensation, Epiphora and Pain) in between two groups. But at day 7 and 30 there is 66 Current Indian Eye Research

3 Table1: Comparative data of study groups Cautery Group Suture Group p Value Mean Age 56.2 ± ± Sex Male Female Pterygium Grade(%) Grade Grade Surgery Time 22.4 ± ± statistically significant difference present. Whereas at 3 and 12 month after surgery all symptoms decrease both in suture group and cautery group (Figure1). In that 12 month follow up period 2 patient developed Figure -1 Five-point scale assessmen of postoperative irritation (1a), foreign body sensation (1b), epiphora (1c), and pain (1d) at 1, 3, 7days, 1month, 3month and 12month after pterygium surgery. Current Indian Eye Research 67

4 conjunctival recurrence (grade 3) in the cautery group and 3 patient in suture group. Corneal recurrence(grade 4) was noted 1 in each group. But there is no statistically significant difference (p=0.644) in overall recurrence rate. In cautery group 02 patients developed graft dehiscence Discussion The idealsurgical procedure for pterygium which has low recurrence rate, low complication rate, less post operative symptom and satisfactory cosmetic appearance after surgery. Recently pterygium excision and conjunctival autografting with help of suture or fibrin glue reduced the recurrence rate significantly The current study described the new technique thermal cautery which was an attempt to decrease postoperative symptom, surgical time and cost of surgery. This study shows cautery required significantly shorter surgical duration(p=0.0005) than suture group, which makes this technique more convenient for the patients and surgeons. Besides this is more beneficial for the hospital also, and more number of surgeries can be done in a single day, which is more suitable for developing country like India. After pterygium surgery, initial few postoperative days patients are usually more symptomatic. In the current study 01 and 03 day after surgery symptom score has no significant difference between the two groups. This is probably due to presence of corneal epithelial defect. However the cautery group has significantly lesser symptom score both at posterative day 7 and day 30 than suture group especially foreign body sensation. According to Biedner et al suture themselves or inflammation caused by the suture causes more foreign body sensation in suture group though in all cases knot were buried 27. Whereas at postoperative month 3 and 12 there is no significant difference in symptom score in between two groups, this is probably due to absorption of all suture after 01 month. Another advantage of thermocautery is that it is more cost effective. 01 pack of 8-0 Vicryl (Johnson and Johnson, Intl, Brussels,Belgium) is INR 500, where as 01 thermo cautery cost about INR 300 and it is reusable. The thermo cautery eliminate the tedious suturing process and makes the surgery easier, faster and ensures more consistent result irrespective of experience of the surgeon. In terms of recurrence rate in current study there is no statistically significant difference in recurrence rate in between two groups 12 month after surgery(p=0.644). 68 Current Indian Eye Research In conclutionconjunctival autografting with thermocautery in pterygium surgery is safer, faster, techniqually easier, economical and have less post operative discomfort than conventional surgery. The recurrence rate seems to be comparable to conventional surgery. In recurrent pterygia further randomized trial required to confirm these findings. Reference 1. Chui J, Coroneo MT, Tat LT, et al. Ophthalmic pterygium: a stem cell disorder with premalignant features. Am J Pathol 2011;178: Rosenthal JW. Chronology of pterygium therapy. Am J Ophthalmol1953;36: Anduze AL, Burnett JM. Indications for and complications of mitomycin-c in pterygium surgery. Ophthalmic Surg Lasers 1996;27: Singh G, Wilson MR, Foster CS. Mitomycin eye drops as treatment for pterygium. Ophthalmology 1988;95: Martins TG, Costa AL, Alves MR, Chammas R, Schor P. Mitomycin C in pterygium treatment. Int J Ophthalmol 2016:9: Dunn JP, Seamone CD, Ostler HB, Nickel BL, Beallo A. Development of scleral ulceration and calcification after pterygium excision and mitomycin therapy. Am J Ophthalmol 1991;112: Tsai YY, Lin JM, Shy JD. Acute scleral thinning after pterygium excision with intraoperative mitomycin C: a case report of scleral dellen after bare sclera technique and review of the literature. Cornea 2002;21: Safianik B, Ben-Zion I, Garzozi HJ. Serious corneoscleral complications after pterygium excision with mitomycin C. Br J Ophthalmol 2002;86: Lindquist TP, Lee WB. Mitomycin C-associated scleral stromalysis after pterygium surgery. Cornea 2015;3 4: Rubinfeld RS, Pfister RR, Stein RM, Foster CS, Martin NF, Stoleru S, et al. Serious complications of topical mitomycin-c after pterygium surgery. Ophthalmology 1992;99: Avisar R, Avisar I, Bahar I, Weinberger D. Effect of mitomycin C in pterygium surgery on cornea endothelium. Cornea 2008;27: Coroneo MT, Girolamo ND, Wakefield D. The pathogenesis of pterygia. Curr Opin Ophthalmol 1999;10: Sridhar MS, Vemuganti GK, Bansal AK, et al. Impression cytologyproven corneal stem cell

5 deficiency in patients after surgeries involving the limbus. Cornea 2001;20: Starck T, Kenyon KR, Serrano F. Conjunctival autograft for primary and recurrent pterygia: surgical technique and problem management. Cornea 1991;10: Por YM, Tan DT. Assessment of fibrin glue in pterygium surgery. Cornea 2010;29: Bahar I, Weinberger D, Dan G, et al. Pterygium surgery: fibrin glue versus Vicryl sutures for conjunctival closure. Cornea 2006;25: Hino M, Ishiko O, Honda KI, et al. Transmission of symptomatic parvovirus B19 infection by fibrin sealant used during surgery. Br J Haematol 2000;108: Oswald AM, Joly LM, Gury C, et al. Fatal intraoperative anaphylaxis related to aprotinin after local application of fibrin glue. Anesthesiology 2003;99: Tan DT, Chee SP, Dear KB, et al. Effect of pterygium morphology on pterygium recurrence in a controlled trial comparing conjunctival autografting with bare sclera excision. Arch Ophthalmol 1997;115: Prabhasawat P, Barton K, Burkett G, et al. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology 1997;104: Lim-Bon-Siong R, Valluri S, Gordon ME, et al. Efficacy and safety of the ProTek (Vifilcon A) therapeutic soft contact lens after photorefractive keratectomy. Am J Ophthalmol 1998;125: Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985; 92: Chen PP, Ariyasu RG, Kaza V, et al. A randomized trial comparing mitomycin C and conjunctival autograft after excision of primary pterygium. Am J Ophthalmol 1995;120: Prabhasawat P, Barton K, Burkett G, et al. Comparison of conjunctival autografts, amniotic membrane grafts, and primary closure for pterygium excision. Ophthalmology1997;104: Hirst LW. The treatment of pterygium. Surv Ophthalmol 2003;48: Ang LP, Chua JL, Tan DT. Current concepts and techniques in pterygium treatment. Curr Opin Ophthalmol 2007;18: Biedner B, Rosenthal G. Conjunctival closure in strabismus surgery: Vicryl versus fibrin glue. Ophthalmic Surg Lasers 1996;27:967. Cite this article as: Kundu A, Roy KK, Nazm N, Mukherjee S, Biswas B, Banik AK, Shankar S. A new technique of sutureless and glueless conjunctival autografting in pterygium surgery by thermocautery. Current Indian Eye Research 2017; 4: Disclaimer Current Indian Eye Research (CIER) is the journal of Ophthalmic Research Group, which gives editorial freedom to the editor of CIER. CIER follows guidelines of editorial independence proposed by World Association of Medical Editors and code of good publication practice of the Committee of Publication Ethics. CIER is intended for professionals associated with medical research and practice, without warranty, express or implied. Statements in the journal are responsibilities of the authors and advertisers and not the author s Current Indian Eye Research 69