Conjunctival autografting with sutures versus without sutures in pterygium surgery: a prospective comparative study

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Some favored the use of free graft. Some favored the use of bulbar conjunctiva to cover the defect from the same or opposite eyes [10,11,12]. The bare sclera technique described by D' Ombrain [13] has been practiced worldwide as the most basic and simple technique for pterygium removal. Pterygium surgery is marred by its high recurrence rate.
The various other adjuncts have been used to reduce the recurrence rate. Kunitomo and Mori [20] reported the effect of postoperative use of mitomycin -0.04 % as eyedrops to prevent pterygium recurrence after excision but it was associated with the serious sight-threatening complication. It has been reported to cause superficial punctate keratitis [21], scleral ulceration and calcification, corneoscleral, ciliary body and vitreoretinal toxicity and uveitis and secondary glaucoma [22].  [24]. Therefore this study was undertaken to compare the conjunctival autograft with and without sutures in terms of operating time, postoperative symptoms and graft success.

Aims and objectives
The outcome measures were studied in both groups   Statistically, no significant difference was found in preoperative characteristics of pterygium between two groups and was found to be statistically significant (Table-2). The overall success rate in both groups was similar (Table-3).
Postoperative symptoms -Subjective symptoms of pain, foreign body sensation, watering, and discomfort were fewer and disappeared rapidly in Group -II as compared to Group -I. The intensity of these symptoms was significantly lower in Group -II as compared to Group -I on all follow up days. All patients treated were asymptomatic by 2 weeks in Group -II and by 4 weeks in Group -I. In Group -II 20 patients had Grade -II discomfort and 5 patients had Grade-III discomfort. (Table 4 and 5).

Discussion
The high rate of recurrence after pterygium excision has been the main obstacle in its successful Although conjunctival autografting is an effective method for the prevention of recurrence after pterygium surgery, suturing needs surgical experience and technical skills.  [26].
In the present study, postoperative symptoms were less severe with conjunctival autograft without sutures than with sutures similar to Uy et al study [28]. Malik K P et al and Wit D et al, also reported that postoperative symptoms were more with suture group than with sutureless group [23,24].
In the present study, the graft was attached in both groups with three out of twenty-five in the suture group and two out of twenty-five in the suture-free group had graft edema which resolved over 1st post-operative week. Corneal defects were observed in five out of twenty-five in the suture group and four out of twenty-five in the suture-free group. One patient had conjunctival granuloma and one patient had a recurrence in the suture group. Chi-square was non-significant. In a study conducted by Elvan S [29], postoperative conjunctival edema occurred in eight eyes, recurrence in 3 eyes and none had granuloma formation. The follow-up period was six months and recurrence occurred at four months. A study by Malik K P et al [23] reported a recurrence rate of 2.5 % and no granuloma formation at 6 months of follow up in case of sutureless conjunctival autografting.
Hall R C et al [30] reported no recurrence in conjunctival autografting with glue and two cases of recurrences in the suture group. Wit D et al [24] reported no recurrence in 15 [28,33]. The graft was successfully attached in both groups in the present study. Similarly, grafts were successfully attached in both groups and intact after 2 months in UY et al study [28].

Conclusion
The present study concluded that both are effective methods of conjunctival autograft but autograft without sutures associated with less operating time, less learning curve and less post-operative discomfort in terms of severity and duration.
What does the study add to the existing knowledge?
This study was conducted to compare methods of conjunctival autografting with and without sutures, There are other methods of attaching conjunctival autograft without sutures like fibrin glue. But fibrin glue is costly and the risk of infection transmission is there.
The surgical treatment of pterygium with conjunctival autograft without sutures i.e. sutureless and glueless, is a very effective and easy technique with minimum surgical time, better postoperative comfort to the patient and very low recurrence rate. It is also cost-effective as compared to sutures and other sutureless techniques like fibrin glue. In recent times hope it becomes the gold standard treatment of pterygium excision with conjunctival autograft. As still conventional methods of pterygium excision are practiced widely.