European Journal of Cardiovascular Medicine

Pterygium is a benign fibrovascular proliferation of the subconjunctival tissue, typically extending onto the cornea in a triangular fashion from the bulbar conjunctiva, often involving the limbus-a region rich in stem cells crucial for corneal integrity.^[1,2] Its prevalence varies widely, with higher rates observed in populations residing within the "pterygium belt," between 30° north and south latitude.^[3] In rural Indian populations over 40 years of age, the prevalence is approximately 13.2%, with the highest rates seen in coastal regions.^[4]

The etiology is multifactorial, with chronic UV (Ultra-Violet) radiation-especially UVB-as the primary risk factor.^[5,6] Other contributing elements include environmental irritants (dust, wind), genetic predisposition, and inflammatory mediators.^[7-9] Clinically, patients may present with irritation, foreign body sensation, and visual disturbances due to induced astigmatism or obstruction of the visual axis.^[10-12]

While medical management with lubricants and anti-inflammatory agents offers symptomatic relief, surgical excision remains the definitive treatment for progressive or symptomatic pterygia.^[13,14] However, recurrence remains a key challenge, particularly with simple excision techniques.^[15,16] CAG (Conjunctival Auto-Grafting) has become the preferred method due to its lower recurrence rates rates,^[17] especially when limbal tissue is included in the graft.^[18,19]

Traditionally, sutures have been used for graft fixation, but sutureless options like fibrin glue and autologous blood are gaining popularity for their potential to reduce operative time, inflammation, and discomfort.^[20,21] However, consensus on the optimal fixation method remains unclear, highlighting the need for comparative studies like the present one.

Aims and Objectives

The aim of this study was to compare the surgical outcomes of pterygium excision with conjunctival autograft using autologous blood and fibrin glue in the management of primary pterygium. The objectives include evaluating the socio-demographic profile of the patients, assessing the grade of pterygium, and determining the efficacy of autologous blood and fibrin glue individually in postoperative outcomes following pterygium excision. Furthermore, the study aims to compare the overall efficacy of autologous blood versus fibrin glue in terms of surgical success, recurrence rates, and associated complications.

This interventional study was conducted over a period of 18 months in the Department of Ophthalmology at People’s College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh. The study aimed to compare the surgical outcomes of pterygium excision with conjunctival autograft using autologous blood and fibrin glue in patients with primary pterygium. A total of 150 patients were enrolled from the ophthalmology outpatient department, and data were collected using a structured case data sheet. The study design was interventional in nature, with independent variables including name, gender, occupation, and education, while the grade of pterygium was considered the dependent variable.

Inclusion and Exclusion Criteria

The study included patients aged 40 to 60 years of both sexes diagnosed with primary pterygium of varying grades who provided informed consent. Patients who did not give consent were excluded, along with those having ocular surface diseases, dry eyes, autoimmune conditions, a history of ocular trauma, secondary pterygium due to chemical burns, pseudo-pterygium, recurrent pterygium, or temporal pterygium.

Data Collection Procedure

Demographic data, including age, gender, occupation, and religion, were collected from all enrolled subjects. Clinical examination was conducted using slit lamp biomicroscopy to assess the affected eye(s), and pterygium was graded preoperatively using the Johnston grading system based on hyperemia, translucency, and vascular network, and classified morphologically as per Maheshwari’s grading.[22] Patients were then randomly assigned into two groups: Group A underwent pterygium excision with conjunctival autograft using autologous blood, and Group B with fibrin glue. Preoperative assessments included visual acuity (Snellen chart), intraocular pressure, fundus examination, and refraction when necessary, with photographic documentation of pterygium size. All surgeries were performed by a single surgeon under local anesthesia, and the grafts were harvested from the superior conjunctiva and fixated either with fibrin glue or autologous blood. Patients were followed up on postoperative day 1, day 7, at 1 month, and at 6 months. Graft stability was assessed using fluorescein staining and graded from 1 to 4 as per Nadarajah et al.,[23] where grade 4 indicated total graft dislodgement. Recurrence, defined as fibrovascular regrowth onto the cornea, was assessed at each follow-up with a slit lamp.

Statistical analysis

All collected data were recorded using a preformed pro forma and compiled into a master chart in Microsoft Excel 2007. Descriptive statistics were presented as numbers and percentages, with visual representations such as bar diagrams and pie charts used where appropriate. Statistical analysis was performed using SPSS software, applying the chi-square or Fisher’s exact test for categorical variables. A p-value of <0.05 was considered statistically significant.

In Table 1 majority of participants in both groups were males, aged 56–60 years, and worked as labourers. There were no significant differences between groups in terms of age, gender, occupation, or religion.

In Table 2, most patients had progressive pterygium, with grade 2 severity being the most common in both groups. No statistically significant differences were noted.

In Table 3, subconjunctival hemorrhage and partial graft retraction were significantly more common in Group A (autologous blood). Other complications showed no significant differences.

In Table 4, recurrences were observed in both groups with no statistically significant difference, suggesting similar long-term efficacy.

Graft edema and hemorrhage were highest on day 1 and declined by one month. Group A had consistently higher values in Table 5.

According to Table 6, retraction remained more common in Group A throughout follow-up. Graft loss remained stable after day 7. Only one granuloma case occurred in Group A.

In Table 7, recurrence was first noted at 6 months postoperatively in both groups, with no statistically significant difference.

The age group most commonly affected by pterygium in this study was 56–60 years (61.3%), followed by 51–55 years (27.3%), consistent with findings by Malladi et al.[24] and others.[17,25-28] This supports the established theory that pterygium is related to cumulative exposure to ultraviolet radiation, which increases with age.[29] The study also observed a male predominance (60.7%), with a male-to-female ratio of 1.54:1, a trend reported in several studies,[27,28] likely due to greater UV exposure among men.[1] Most patients (80%) were labourers, reflecting higher exposure to environmental irritants such as dust, heat, and UV radiation. This is in agreement with Kumar et al,[30] who identified increased conjunctival damage from sun exposure as a key factor in pterygium prevalence.

Regarding clinical presentation, 60.7% had unilateral and 39.3% had bilateral pterygium, similar to results from Chavan et al.[31] and Rathinakumar et al.[32] Progressive pterygium was the most common type (69.3%), aligning with studies by Manhas et al.[33] and Rathinakumar et al.[32] though Banerjee et al.[34] reported a higher incidence of atrophic pterygium. The majority of patients had grade 2 pterygium (71.3%), which was also the predominant grade observed by Nadarajah et al.[23] Among postoperative complications, graft edema was more frequent in the autologous blood group (52%) compared to the fibrin glue group (40%), although not statistically significant. Similar trends were reported by Kodavoor et al.[27] while Garg et al.[25] observed higher edema rates in the fibrin group. Subconjunctival hemorrhage was significantly more common in Group A (77.3%) than in Group B (10.7%) (p < 0.001), consistent with findings from Kodavoor et al.[27] Mittal et al.[28] and Garg et al.[25]

Donor site hemorrhage occurred in 36% of patients in Group A versus 22.7% in Group B, without significant difference. Granuloma formation was rare, seen in one patient from the autologous blood group, similar to reports by Kodavoor et al.[27] and Nadarajah et al.[23] but not observed in the study by Garg et al.[25] The higher incidence in Group A may be due to the pro-inflammatory nature of blood components, potentially increasing fibrovascular reactions. Partial graft retraction was significantly more common in the autologous blood group (38.7%) compared to the fibrin glue group (5.3%) (p < 0.001), aligning with  Nadarajah et al.[23] and Malladi et al.[24] This could be attributed to the variability in clot formation with autologous blood, making it less predictable and stable than the uniform adhesion provided by fibrin glue. Complete graft loss was slightly higher in Group A (4%) than in Group B (2.7%), although not statistically significant. These findings are comparable to those of Malladi et al.[24] Kodavoor et al.[27] and Nadarajah et al.[23] though Garg et al.[25] reported no graft loss. The variability in outcomes suggests a need for better control over graft adherence with autologous methods.

Recurrence was observed in 5.3% of Group A and 2.7% of Group B patients. While this difference was not significant, most studies support lower recurrence rates with fibrin glue.[24,27] However, contrasting results were seen in the studies by Garg et al.[25] which reported higher recurrence with fibrin glue. Lower postoperative inflammation associated with fibrin glue may contribute to reduced recurrence risk. Follow-up data indicated that graft edema and hemorrhage were most common on day 1 and decreased steadily. By day 30, no patients had graft edema in either group. Subconjunctival hemorrhage persisted in 5.3% of Group A at one month and resolved in Group B. Similar postoperative trends were noted by Garg et al.[25] and Mittal et al.[28]

Partial graft dislodgement in Group A was 38.7% on day 1, dropping to 8% by day 7 and remaining stable. In Group B, it remained 5.3% throughout. Garg et al.[25] reported higher retraction rates initially, but both groups improved by day 21. Granuloma appeared only in Group A, both at one month and six months, consistent with Nadarajah et al.[23] Donor site hemorrhage followed a similar pattern, with early high incidence in Group A and resolution by day 7. Complete graft loss occurred in 5.3% of Group A by day 1 and persisted at 4% through six months. In Group B, loss was 2.7% and remained unchanged. Recurrence appeared at six months in both groups, though other studies have noted recurrence as early as one to three months.[25,23]

Limitations

This study has several limitations. Being a single-center study, the findings may not be generalizable to broader populations. The follow-up period was limited to six months, potentially missing late-onset complications or recurrences. As the study was not blinded, observer bias in postoperative assessments cannot be ruled out. The sample size may have been insufficient to accurately assess the incidence of rare complications like granuloma. Additionally, the study population consisted exclusively of rural patients, limiting the analysis of risk factors compared to urban populations. Lastly, the absence of intermediate-type pterygium precluded evaluation of its specific postoperative outcomes.

This interventional study comparing conjunctival autograft fixation using autologous blood versus fibrin glue in primary pterygium surgery found the condition to be more prevalent in older males engaged in outdoor activities, with unilateral, progressive, and grade 2 pterygium being most common. While most postoperative complications such as graft edema, donor site hemorrhage, granuloma, graft loss, and recurrence were slightly higher in the autologous blood group, only subconjunctival hemorrhage and partial graft retraction showed statistically significant differences. Although autologous blood is a cost-effective, sutureless option, fibrin glue demonstrated superior outcomes with fewer complications and better graft stability.

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