European Journal of Cardiovascular Medicine

Pterygium is a common degenerative ocular condition characterized by a fibrovascular proliferation of the conjunctiva that invades the corneal surface, typically from the nasal side. It is prevalent in individuals exposed to chronic ultraviolet (UV) light, dust, wind, and dry environmental conditions, earning the label “surfer’s eye” in certain populations. While often benign, pterygium can lead to irritation, dryness, redness, and progressive encroachment into the visual axis, resulting in visual impairment. One of the significant visual consequences of pterygium is induced astigmatism, caused by tractional changes on the corneal curvature, disruption of the tear film, and irregular anterior corneal surface. This is particularly evident in larger pterygia, often exceeding 2 mm onto the cornea, where increased astigmatism correlates with reduced best-corrected visual acuity. Therefore, pterygium removal not only addresses cosmetic and irritative symptoms but also aims to improve visual function by reducing induced astigmatism. [1,2]

Among surgical techniques, conjunctival autografting has become the preferred method due to its effectiveness in reducing recurrence rates when compared to older techniques like bare sclera excision. Traditionally, graft fixation has been achieved using sutures, which are effective but often associated with longer operative time, more postoperative discomfort, inflammation, and potential suture-related complications such as granuloma formation or infection. In contrast, fibrin glue is a biological adhesive derived from plasma fibrinogen and thrombinhas emerged as a sutureless alternative that provides rapid graft fixation with less inflammation, shorter surgery time, and improved patient comfort. Additionally, by minimizing surgical manipulation and preserving ocular surface integrity, fibrin glue may lead to more stable and favorable refractive outcomes.[3,4]

While numerous studies have compared recurrence rates and complications between suture and fibrin glue techniques, limited research has focused specifically on the refractive changes, particularly corneal astigmatism, following these two methods of graft fixation. Since pterygium-induced astigmatism significantly affects visual quality, understanding whether the choice of fixation technique influences postoperative refractive stability is of clinical importance.

There is a growing emphasis on not only reducing recurrence but also optimizing visual rehabilitation. Hence, this study addresses a critical gap in literature by evaluating and comparing the refractive outcomes, particularly astigmatic changes, in patients undergoing conjunctival autografting with sutures versus fibrin glue following primary pterygium excision. This can guide ophthalmic surgeons in selecting the most appropriate surgical technique to enhance both anatomical and functional outcomes for patients.

The present study was carried out in the department of Ophthalmology at Sarojinidevi Eye Hospital, Hyderabad.

Type of study: The present study was a prospective comparative study.

Duration of study: The study was carried out for a period of 18 months.

Sample Size: The study was conducted on 60 patients.

Inclusion Criteria: Patients having primary nasal pterygium covering 2mm or more cornea.

Exclusion Criteria: Pterygium that had recurred, double pterygium both nasal and temporal, dry eye, severe ocular surface disorders, patients of glaucoma with prolonged medication and post-trabeculectomy, posterior segment pathology, history of ocular trauma, and pseudopterygium.

All the patients fulfilling selection criteria were explained about the details of the disease process, options of treatment, ultimate outcome, possible effects, complications and chances of recurrence in both procedure and a written informed consent was obtained before enrolment. They were informed of their right to withdraw from the study at any stage.

Data Collection

 A detailed clinical history was taken, including demographic data, chief ocular complaints, and history of HTN, DM, ocular surgeries, and medications. Personal history was noted. Preoperative evaluation included visual acuity (uncorrected and best corrected), auto-refractometry, slit lamp biomicroscopy, keratometry, intraocular pressure, nasolacrimal passage assessment, and fundoscopy. Basic investigations such as Hb, BT, CT, RBS, and BP were also performed.

 A total of 60 eyes diagnosed with primary pterygium and meeting the inclusion criteria were included in the study.

Patients were randomly allocated into two equal groups, comprising 30 eyes each:

GROUP A (n = 30): Underwent pterygium excision followed by conjunctival autograft (CAG) fixation with 8-0 vicryl sutures.

GROUP B (n = 30): Underwent pterygium excision followed by CAG fixation using fibrin glue.

Postoperative evaluation was conducted, including assessment of uncorrected and best corrected visual acuity, refraction using an auto- refractometer, and slit lamp biomicroscopy of the anterior segment. The necessary data was recorded and noted down in the master charts. All the data was documented and analyzed by subjecting to statistical

analysis.

Statistical Analysis

The collected data was entered into Microsoft Excel Worksheet-2010 and data was taken into IBM SPSS Statistic for windows, version 24 (IBM Corp., Armonk, N.Y., USA) software for calculation of frequency, percentage, mean, standard deviation and probability value.
Qualitative data was represented in the form of frequency and percentage.  Association between qualitative variables was assessed by Chi Square test with continuity correction for 2 x 2 tables and Fisher’s exact test for all 2 x 2 tables, where P value of chi square test was not valid due to small counts.

Quantitative data was represented using mean and standard deviation. Analysis of quantitative data within the groups was done using paired t test if

data passes ‘Normality test’.
One Way Analysis (ANOVA) was used to compare more than two groups.

A ‘P’ value of > 0.05 was considered not significant

.A ‘P’ value of <0.05 was considered statistically significant

.A ‘P’ value of< 0.001 is highly significant

Group-1-Suturing of CAG with 8.0 vicryl sutures. Group-2-Fixing of CAG with fibrin glue.

Table-1: Demographic distribution of patients.

In Group 1, the majority of patients were in the 51 to 60 years age group (11 patients, 36.7%), In Group 2, the highest proportion was also seen in the 51 to 60 years age group (12 patients, 40%), In Group 1, there were 9 male patients (30%) and 21 female patients (70%). In Group 2, there were 8 male patients (26.66%) and 22 female patients (73.33%).

 In Group 1, 18 patients (60%) had right eye involvement, while 12 patients (40%) had left eye involvement. In Group 2, right eye involvement was seen in 20 patients (66.7%), and left eye in 10 patients (33.3%). The p-value suggesting no statistically significant difference in age, gender and laterality distribution between the two groups.

Table-2: Comparison of mean refractive status (Sphere D) before and after surgery.

The spherical equivalent was compared at three time points. Pre-operatively, the mean sphere in Group 1 was +0.75 ± 1.10 D, and in Group 2 was +0.77 ± 1.08 D. At 1 week post-op, it was +0.70 ± 1.00 D in Group 1 and +0.72 ± 0.98 D in Group 2. At 1 month post-op, values were +0.68 ± 0.95 D and +0.70 ± 0.93 D for Groups 1 and 2, respectively. P-values at each time point (0.91, 0.89, 0.87) indicated no statistically significant difference between the groups.

Table-3: Comparison of mean refractive status (Cylinder D) before and after surgery.

Cylinder values showed similar trends in both groups. Pre-operative mean cylinder was -2.00 ± 0.90 D in Group 1 and -2.05 ± 0.92 D in Group 2. At 1 week post-op, values were -1.50 ± 0.75 D and -1.48 ± 0.72 D respectively. At 1 month post-op, Group 1 had -1.35 ± 0.65 D while Group 2 had -1.30 ± 0.60 D. No significant difference was noted at any point (p-values: 0.83, 0.88, 0.76).

Table-4: Comparison of mean Uncorrected and corrected Visual Acuity (UCVA) improvement

Pre-operatively, the mean UCVA was 0.20 ± 0.18 in Group 1 and 0.22 ± 0.19 in Group 2. At 1 week post-op, Group 1 showed 0.23 ± 0.19 and Group 2 showed 0.25 ± 0.19. At 1 month, both groups reported 0.25 ± 0.19 and 0.25 ± 0.18 respectively. The p-values (0.61, 0.73, 0.83) revealed no statistically significant difference in UCVA between the groups.

BCVA was assessed at the same intervals. Pre-operative BCVA was 0.40 ± 0.35 in Group 1 and 0.39 ± 0.33 in Group 2. At 1 week post-op, values were 0.41 ± 0.34 (Group 1) and 0.40 ± 0.33 (Group 2). At 1 month post-op, Group 1 had 0.45 ± 0.33 and Group 2 had 0.42 ± 0.31. P-values (0.84, 0.77, 0.69) showed no significant difference in BCVA improvement between the groups.

Table-5: Comparison of post-operative complications between the groups.

Graft edema was reported in 4 patients (13.3%) in Group 1 and 3 patients (10%) in Group 2. Graft displacement occurred in 1 patient in each group (3.3%). Recurrence at 6 months was also reported equally in both groups (2 patients, 6.7%).

However, post-operative discomfort was significantly higher in Group 1 (16 patients, 53.3%) compared to Group 2 (6 patients, 20%). The p-value for post-op discomfort was 0.004, indicating a statistically significant difference favoring the fibrin glue group in terms of patient comfort

The present study observed that the majority of patients in both groups fell within the 51 to 60 years age bracket. This age-related trend in pterygium cases has been consistently reported in literature, reflecting the cumulative effect of environmental exposure, particularly UV radiation, over time. The higher prevalence in older age groups may be attributed to prolonged exposure to risk factors such as outdoor work, dry climates, and dust, all of which are more impactful with advancing age.[5] The lack of statistically significant difference in age distribution between the suture and fibrin glue groups (p = 0.41) suggests that both techniques were applied uniformly across different age groups. Similar age-related distributions were reported by Panda et al[6] and Gazzard et al[7] both of whom identified pterygium as more prevalent among middle-aged to older individuals in high sunlight exposure areas.

            In both groups, females constituted the majority of patients. Though some studies have reported a higher prevalence in males, often attributed to increased outdoor activity and occupational exposure, our findings may reflect localized demographic or healthcare seeking behavior trends. Women might be more likely to seek surgical correction for cosmetic reasons or ocular irritation, as suggested by Maheshwari et al. and Al-Bdour et al[8,9]. The lack of statistical significance in gender distribution between groups (p = 0.06) indicates that gender did not influence the choice of graft fixation method. This was in line with the findings of Srinivas et al[10], who reported similar gender distribution patterns in South Indian populations undergoing pterygium surgery.

             Both groups showed higher involvement of the right eye, though the difference was not statistically significant (p = 0.59). This right-sided predominance has been noted in earlier studies and is often attributed to lateralized sun exposure, especially in individuals who frequently drive or work with one side exposed to sunlight[11]. The predominance may also be incidental due to small sample size.

          There was no significant difference between the two groups in terms of spherical refractive error, both pre- and post-operatively (p > 0.05 at all time points). This suggested that neither method of graft fixation, suturing nor fibrin glue, had a differential effect on the spherical component of refraction. These findings were consistent with previous studies by Koranyi et al[12] and Bahar et al[13] who observed minimal impact on spherical values after conjunctival autografting, regardless of the fixation technique used. The slight post-operative reductions in spherical values in both groups likely reflect corneal surface regularization after removal of the pterygium mass.

            A gradual improvement in cylindrical error was seen in both groups postoperatively, with no statistically significant difference between them (p > 0.05). This aligned with studies by Tomidokoro et al[14]. and Avisar et al[15] who observed that pterygium excision leads to a decrease in astigmatism by alleviating the mechanical traction on the cornea. The similar outcomes across both groups suggested that the method of fixation does not significantly influence postoperative astigmatism correction. Both fibrin glue and sutures allow adequate graft stability and positioning necessary to support corneal remodeling.

            Both groups exhibited slight improvement in UCVA postoperatively, but the difference was statistically insignificant (p > 0.05). UCVA gains are typically associated with removal of visual axis-encroaching tissue and improved ocular surface integrity. These results correlated with studies by Koranyi et al[12] and Ratnalingam et al[15], who found that conjunctival autograft techniques provide functional visual recovery irrespective of the fixation method used.

                  BCVA improvements followed a similar trend, with marginal gains in both groups that were not statistically different. This indicated that the primary benefit of surgery lies in visual function stabilization rather than drastic improvements, particularly in early-stage pterygium. Comparable outcomes have been reported by Tseng et al.[16] and Bhandari et al.[17], who noted that post-operative BCVA improvements are usually modest and largely dependent on pre-existing corneal damage or irregularity.

                 Both groups demonstrated low complication rates for graft edema, displacement, and recurrence. However, post-operative discomfort was significantly more common in the suture group compared to the fibrin glue group (p = 0.004). This supported the widely documented advantage of fibrin glue in enhancing patient comfort by eliminating the foreign body sensation associated with sutures.  Studies by Koranyi et al.[12] and Uy et al[18] also concluded that fibrin glue significantly reduces inflammation, postoperative discomfort, and surgical time. Additionally, Srinivasan et al. found that patient reported comfort was a key deciding factor in favoring fibrin glue over sutures in similar settings.

Pterygium is a prevalent ocular surface condition in tropical countries like India, and its surgical management has evolved significantly over the years to minimize recurrence and improve patient comfort and visual outcomes. Among the various surgical techniques, conjunctival autologous grafting (CAG) following primary pterygium excision has emerged as a widely accepted method due to its low recurrence rates and favorable safety profile. However, the method of graft fixation, either with sutures or fibrin glue, plays a crucial role in influencing post-operative healing, patient experience, and refractive outcomes.

This prospective comparative study was undertaken to evaluate the refractive status, visual acuity changes, and complication rates in patients undergoing conjunctival autografting with either sutures or fibrin glue following primary pterygium excision at a tertiary care center. The findings demonstrated that both techniques were comparable in terms of refractive outcomes, with no statistically significant differences in postoperative spherical and cylindrical values at one month. Likewise, improvements in uncorrected and best corrected visual acuity were observed in both groups, again with no meaningful difference between them.

Despite the similar visual and refractive outcomes, fibrin glue showed notable advantages in terms of patient comfort. Patients who underwent graft fixation with fibrin glue reported significantly less postoperative discomfort compared to those who received sutures. Furthermore, while both techniques exhibited low rates of complications such as graft edema, displacement, and recurrence, the fibrin glue group had a slightly more favorable complication profile overall.

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From a surgical perspective, the use of fibrin glue offered a quicker and smoother operative experience, reducing surgical time and minimizing tissue trauma, which may contribute to better immediate postoperative recovery. However, cost and availability of fibrin glue can be limiting factors in resource-constrained settings, where suturing remains a reliable and effective option.

In conclusion, both suturing and fibrin glue techniques for conjunctival autograft fixation after pterygium excision are effective in achieving comparable refractive and visual outcomes. While sutures continue to be a valid and accessible approach, fibrin glue offers superior postoperative comfort and ease of surgery, making it a preferable choice when resources permit. The choice of technique should therefore be guided by patient-specific considerations, surgeon expertise, and institutional availability, balancing efficacy, comfort, and economic feasibility.

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