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   Table of Contents      
ORIGINAL ARTICLE
Year : 2020  |  Volume : 68  |  Issue : 10  |  Page : 2084-2087

Comparison of inferior conjunctival autografting and conjunctival tissue grafting from pterygium itself in the cases of filtering blebs and glaucoma suspects-A retrospective analysis


1 Cornea Services, The Eye Foundation, Coimbatore, Tamil Nadu, India
2 Cornea, Refractive and Cataract Surgery, The Eye Foundation, Coimbatore, Tamil Nadu, India
3 The Eye Foundation, Coimbatore, Tamil Nadu, India

Date of Submission22-Nov-2019
Date of Acceptance04-Apr-2020
Date of Web Publication23-Sep-2020

Correspondence Address:
Dr. Shreesha Kumar Kodavoor
Cornea and Refractive Services, The Eye Foundation, Coimbatore, Tamil Nadu; The Eye Foundation, 582, Diwan Bahadur Rd, R.S. Puram, Coimbatore - 641 002, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2164_19

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  Abstract 


Purpose: This study aims at comparing the effectiveness of inferior conjunctival autografting (CAG) and conjunctival tissue grafting from pterygium itself (CTG) in the cases of filtering blebs/glaucoma suspects. Methods: One hundered and five eyes of 97 patients who underwent pterygium excision with conjunctival autografting (CAG) in the period from 2010 to 2016 were included. Fifty one eyes had filtering blebs and 54 were glaucoma suspects. Fifty two eyes of 49 patients (Group 1) had undergone pterygium excision with inferior conjunctival autograft (CAG) and 53 eyes of 48 patients (Group 2) had undergone pterygium excision with conjunctival tissue graft (CTG) from the pterygium itself. The minimum follow up period was 6 months. Results: Both groups had 2 eyes with recurrence, which was not statistically significant. Among other complications, graft retraction was seen with a higher incidence in Group 2, which was statistically significant. Conclusion: In situations where sparing of the superior conjunctiva is mandatory, both the techniques of inferior conjunctival autografting and conjunctival tissue graft from the pterygium itself are excellent alternate options with comparable outcomes and no additional risk of significant complications.

Keywords: Conjunctival tissue graft, filtering blebs, glaucoma suspects, inferior conjunctival autograft, pterygium


How to cite this article:
Kodavoor SK, Soundarya B, Dandapani R. Comparison of inferior conjunctival autografting and conjunctival tissue grafting from pterygium itself in the cases of filtering blebs and glaucoma suspects-A retrospective analysis. Indian J Ophthalmol 2020;68:2084-7

How to cite this URL:
Kodavoor SK, Soundarya B, Dandapani R. Comparison of inferior conjunctival autografting and conjunctival tissue grafting from pterygium itself in the cases of filtering blebs and glaucoma suspects-A retrospective analysis. Indian J Ophthalmol [serial online] 2020 [cited 2020 Oct 31];68:2084-7. Available from: https://www.ijo.in/text.asp?2020/68/10/2084/295704



Pterygium is a disorder of the ocular surface characterized by the growth of fibrovascular tissue leading to the destruction of Bowman's membrane. Ultraviolet light exposure has been shown to be one of the most important pre disposing factors for this degenerative condition.[1] Conjunctival autografting, which is the mainstay in the management of pterygium, has been shown to have a lower recurrence rate when compared to other surgical options.[2],[3],[4],[5],[6],[7],[8] The conjunctival graft is most commonly harvested superiorly. However, superior bulbar conjunctiva may not be available for harvesting a graft in all cases, for example, in the cases of conjunctival scarring due to surgery or trauma. Similarly, grafting from the superior site may also not be possible in the eyes with filtering blebs and it would affect the outcome and functioning of a future filtration surgery.[9] Thus, options that can be used in such cases include inferior bulbar conjunctival grafting, conjunctival tissue graft from the overlying pterygium itself, amniotic membrane grafting, and bare sclera technique. This study aims at comparing the efficacy of the first two methods, as there have been no previous comparative studies on the same.


  Methods Top


105 eyes of 97 patients who underwent pterygium excision with conjunctival autografting (CAG) in the period from 2010 to 2016 were retrospectively analyzed. The study was approved by the Ethics committee and adhered to the tenets of Declaration of Helsinki. Among the 105 eyes, 51 eyes had filtering blebs and 54 were glaucoma suspects. 52 eyes of 49 patients (Group 1) had undergone pterygium excision with conjunctival autograft (CAG) from the inferior conjunctiva and 53 eyes of 48 patients (Group 2) had undergone pterygium excision with conjunctival tissue graft (CTG) from the pterygium itself. The choice of procedure was based on the grade of the pterygium. Eyes with Grade 2 pterygia underwent conjunctival tissue grafts and those with Grade 3 and 4 underwent inferior conjunctival graft in the view of larger defects and the need for larger grafts. Pre operative evaluation was done in the form of history, visual acuity, slit lamp examination, grading of pterygium, and fundus examination.

Surgical procedure

Patients in both the groups underwent the procedure under 0.5% proparacaine HCl (Aurocaine, Aurolab, Tamil Nadu, India) topical anesthesia and subconjunctival injection of 2% xylocaine (AstraZeneca, UK). In the eyes belonging to Group 1, the avulsion of the pterygium head was done first and followed by the excision of fibrovascular tissue. Hemostasis was achieved using gentle wet field cautery. Adequate sized conjunctival graft was harvested from the inferior bulbar conjunctiva by dissecting the conjunctiva from the Tenon's capsule [Figure 1]. The grafts were secured using fibrin glue, Tisseel (Baxter AG, Vienna, Austria).
Figure 1: Inferior CAG; (a) Pre operative on-table image; (b) Dissection of pterygium tissue; (c) Harvesting graft from inferior conjunctiva; (d) Application of tissue glue over bed; (e) Secured graft; (f) Post operative follow-up at 6 months

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In the Group 2 eyes, the surgical procedure was carried out akin to a technique described by Jap et al. and a previous study conducted by us.[10],[11] Subconjunctival injection of 2% xylocaine into the pterygium tissue was done. The overlying conjunctiva was meticulously dissected and separated from the pterygium tissue, which was then excised and placed on the corneal surface. Adequate hemostasis was achieved using cautery. The thin conjunctival layer dissected was then placed without rotation on the bare sclera with epithelial side up [Figure 2]. The graft was then secured using fibrin glue, Tisseel (Baxter AG, Vienna, Austria) as in Group 1.
Figure 2: Conjunctival tissue graft; (a) Pre operative on-table image; (b) Injection of subconjunctival 2% xylocaine (c) Dissection of conjunctiva from pterygium tissue; (d) Dissected thin conjunctival graft; (e) Graft secured without rotation using tissue glue; (f) Post operative follow-up at 6 months

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Patients were started post operatively on topical antibiotics (0.5% moxifloxacin) 4 times a day for 2 weeks, topical steroids (0.5% loteprednol) for 4 weeks, and preservative free tear substitutes (0.5% carboxy methyl cellulose) for 6 weeks. Post operative evaluation, which included clinical examination and refraction, was done on multiple follow ups, which included visits on post operative day 1, 2 weeks, 6 weeks, and 6 months,

Statistical analysis was done using the t-test. Statistical significance was defined as P < 0.05.


  Results Top


The demographic data is elaborated in [Table 1]. The mean age of the patients in Group 1 and Group 2 was 46.6 ± 8.9 years and 46.8 ± 9.9 years and male:female ratio was 19:33 and 26:27 respectively. The number of eyes with filtering blebs in the Group 1 and Group 2 were 28 and 23 and number of glaucoma suspect eyes were 24 and 30 respectively. Mean follow up of the patients in Group 1 and Group 2 was 18.1 ± 6.9 and 16.6 ± 8.1 months, respectively.
Table 1: Demographic data

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Recurrence was the primary complication compared between the two groups. It was seen in 2 eyes in each group, which was not statistically significant. Other complications are listed in [Table 2] and [Figure 3]. Graft retraction in Group 2 was statistically significant when compared with group 1. This can be explained by the fact that obtaining a larger sized graft from the pterygium or oversizing the graft becomes difficult in this conjunctival tissue grafting technique, thus resulting in a graft that is just adequate to cover the bare sclera, which can lead to graft retraction.
Table 2: Comparison of complications among the two groups

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Figure 3: Complications; (a) Graft retraction; (b) Graft edema; (c) Subconjunctival hemorrhage

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  Discussion Top


Harvesting grafts from the inferior conjunctiva or from the pterygium tissue itself aims to preserve the superior conjunctiva in the cases of planned or already performed glaucoma filtration surgeries.

The Group 1 patients in our study underwent inferior conjunctival autografting and the recurrence rate was found to be 3.84%, with the occurrence of donor site fibrosis in 11.53% of the cases. The recurrence rate following inferior conjunctival autografting has not been found to be different from superior conjunctival grafts, thus this procedure does not require any additional adjunctive agents like mitomycin C. Irritation on blinking is also seen less frequently in inferior grafts when compared to graft taken superiorly.[12] However, the drawbacks of this method include technical challenges in obtaining a large thin graft and risk of symblepharon formation.[12]

PP Syam et al.[13] did a retrospective analysis of 30 eyes that underwent pterygium excision with inferior CAG and found the technique to be effective especially in eyes, which are not suitable for the harvesting of superior conjunctiva as a donor. They reported a recurrence rate of 3.3% and the most common complication seen in their study was conjunctival scarring at the donor site, which was seen in 36.6% of the cases, whereas another study conducted by Shrestha A et al.[1] which included 50 eyes undergoing the same technique with a 6 months follow up, reported a recurrence in 4% of the eyes and conjunctival scarring in 8% of the eyes. Both studies reported no symblepharon formation and the results were comparable to our present study.

In a study conducted by Kim et al.[12] inferior conjunctival transpositional flap was done in 54 eyes of 50 patients with primary pterygium and a recurrence of 5.6% was reported. However, this technique may be associated with partial wound disruption, difficulty in obtaining complete donor site coverage, and flap encroachment on to limbus.

It has been shown that there is no significant difference in the rate of recurrence between autografting from superior and inferior conjunctiva in eyes with primary pterygium, however, there can be a significantly higher likelihood of recurrence in the cases of recurrent pterygia in eyes that undergo autografting from the inferior site.[14] Wong et al. reported a higher incidence of recurrence (18.2%)[15] while using inferior limbal-conjunctival autograft in 11 cases of recurrent pterygia with a follow up 10 to 19 months. They also reported a non progressive pseudopterygium formation at the donor site in 45.5% of the eyes. A comparative study between superior and inferior CAG in 36 eyes with primary pterygia conducted by Ashraf Bor'i et al. compared the clinical and histopathological results. The authors reported 1 recurrence in each group and found no difference in stem cell density between the 2 groups.[16] An alternative choice in such patients where superior conjunctiva needs to be spared, is amniotic membrane transplantation. Recurrence rates with amniotic membrane grafting were found to be as low as 3.8% to 5.6%.[17],[18]

In the Group 2 eyes of our study, we harvested a thin layer of conjunctival graft from the surface of pterygium tissue and positioned it on the bare sclera without any rotation. Jap et al.[10] conducted a study with conjunctival tissue graft, but with 180° rotation of the conjunctiva and reported a recurrence rate of 4%. The graft rotation was done to shift the epithelium at the limbal end away from it, to prevent recurrence, for which there is no solid scientific evidence. A previous study conducted by us on 98 eyes with primary pterygia, where conjunctival tissue from the pterygium tissue itself, without rotation, was used in eyes with glaucoma filtering bleb/glaucoma suspects, and in the cases of double-head pterygia. A similar method had been used as described in our methodology and a recurrence rate of 4.08% was seen, which is comparable to our present study.[11]

It has to be noted that the harvested conjunctival tissue tends to be more fragile and the risk of tears are more common even with minimal manipulation. Also, the inclusion of subepithelial tissue in the graft could potentially lead to graft retraction. Thus, a meticulous dissection of the underlying pterygium tissue becomes necessary.[19] Another cause for graft retraction in this technique results from the difficulty in obtaining a larger sized graft from the pterygium, thus leading to a graft, which is just adequate to cover the bare sclera. Histopathologically, it has been seen that a section of the normal conjunctiva had 2-4 cell layered epithelium with no dysplasia or malignancy, whereas, the conjunctiva overlying the pterygium was found to be uniformly thick with 8–12 layers of epithelial cells, few goblet cells and capillary networks, but with a similar absence of granuloma or dysplasia, thus making it a good source for grafting in selected cases.[11]


  Conclusion Top


Thus, it can be seen that in situations where sparing of the superior conjunctiva is mandatory, both the techniques of inferior conjunctival autografting as well as conjunctival tissue graft from the pterygium itself are excellent alternate options with comparable outcomes and no additional risk of significant complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shrestha A, Shrestha A, Bhandari S, Maharjan N, Khadka D, Pant SR, et al. Inferior conjunctival autografting for pterygium surgery: An alternative way of preserving the glaucoma filtration site in far western Nepal. Clin Ophthalmol 2012;6:315-9.  Back to cited text no. 1
    
2.
Kenyon KR, Wagoner MD, Hettinger ME. Conjunctival autograft transplantation for advanced and recurrent pterygium. Ophthalmology 1985;92:1461-70.  Back to cited text no. 2
    
3.
Ti SE, Chee SP, Dear KBG, Tan DTH. Analysis of variation in success rates in conjunctival autograft for primary and recurrent pterygium. Br J Ophthalmol 2000;84:385-9.  Back to cited text no. 3
    
4.
Allan BD, Short P, Crawford GJ, Barrett GD, Constable IJ. Pterygium excision with conjunctival autografting: An effective and safe technique. Br J Ophthalmol 1993;77:698-701.  Back to cited text no. 4
    
5.
Figueiredo RS, Cohen EJ, Gomes JA, Rapuano CJ, Laibson PR. Conjunctival autograft for pterygium surgery: How well does it prevent recurrence? Ophthalmic Surg Lasers 1997;28:99-104.  Back to cited text no. 5
    
6.
Sharma A, Gupta A, Ram J, Gupta A. Low dose intra-operative mitomycin-C versus conjunctival autograft in primary pterygium surgery: Long-term follow-up. Ophthalmic Surg Lasers 2000;31:301-7.  Back to cited text no. 6
    
7.
Lewallen S. A randomised trial of conjunctival autografting for pterygium in the tropics. Ophthalmology 1989;96:1613-4.  Back to cited text no. 7
    
8.
Riordan-Eva P, Kielhorn I, Ficker LA, Steele AD, Kirkness CM. Conjunctival autografting in the surgical management of pterygium. Eye 1993;7:634-8.  Back to cited text no. 8
    
9.
Broadway DC, Grierson I, Hitchings RA. Local effects of previous conjunctival incisional surgery and the subsequent outcome of filtration surgery. Am J Ophthalmol 1998;125:805-18.  Back to cited text no. 9
    
10.
Jap A, Chan C, Lim L, Tan DT. Conjunctival rotation autograft for pterygium. An alternative to conjunctival autografting. Ophthalmology 1999;106:67-71.  Back to cited text no. 10
    
11.
Kodavoor SK, Tiwari NN, Ramamurthy D. Concomitant use of conjunctival tissue graft from the pterygium itself without rotation in pterygium surgery: A full circle in conjunctival autografting. Indian J Ophthalmol 2018;66:506-10.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Kim S, Yang Y, Kim J. Primary pterygium surgery using the inferior conjunctival transposition flap. Ophthalmic Surg Lasers 1998;29:608-11.  Back to cited text no. 12
    
13.
Syam PP, Eleftheriadis H, Liu CS. Inferior conjunctival autograft for primary pterygia. Ophthalmology 2003;110:806-10.  Back to cited text no. 13
    
14.
Koc F, Demirbay P, Teke MY. Primary and recurrent pterygium conjunctival autografting. T Oft Gaz 2002;32:583-8.  Back to cited text no. 14
    
15.
Wong AK, Rao SK, Leung AT, Poon AS, Lam DS. Inferior limbalconjunctival autograft transplantation for recurrent pterygium. Indian J Ophthalmol 2000;48:21-4.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Bor'I A, Elmarakby MA, Saleh ME, Khairy M. Superior versus inferior conjunctival autograft using fibrin glue in management of primary pterygium: Clinical and histopathological results. J Clin Exp Ophthalmol 2016;7:1-6.  Back to cited text no. 16
    
17.
Ma DHK, See LC, Liau SB, Tsai RJF. Amniotic membrane graft for primary pterygium: Comparison with conjunctival autograft and topical mitomycin C drops. Br J Ophthalmol 2000;84:973-8.  Back to cited text no. 17
    
18.
Solomon A, Pires RTF, Tseng SCG. Amniotic membrane transplantation after extensive removal of primary and recurrent pterygia. Ophthalmology 2001;108:449-60.  Back to cited text no. 18
    
19.
Tan D. Conjunctival grafting for ocular surface disease. Curr Opin Ophthalmol 1999;10:277-81.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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