Pterygium is a triangular wing-shaped, fibro-vascular tissue derived from conjunctiva encroaching the cornea[1],which lead to cosmetic and visual deterioration secondary to induced astigmatism and visual axis involvement. Although several theories have been associated with etiology, its pathology remains controversial [2]. It is more common in the countries with relatively high exposure to ultraviolet radiation, the hot and dusty climates, and those living in rural areas and some occupational groups like agriculture workers, labourers, drivers, welders and carpenters. In recent studies, tropical residence and ultraviolet radiation exposure have been implicated as risk factors in the etiopathogenesis of pterygium formation. [3,4]. There are various surgical techniques for pterygium excision like simple excision, pterygium excision with conjunctival free autograft or rotational flap, having their own sets of advantages and disadvantages. Simple surgical excision (the bare sclera) is a simple and common procedure used to remove a pterygium. However, the bare sclera is associated with a rate of recurrence as high as 80%.(5).To reduce the recurrence, Mitomycin C (MMC), amniotic membrane and conjunctival transplantation are used after simple surgical excision. [6,7].

The use of Mitomycin C is associated with many side effects such as congestion, corneal epithelial defect, corneal perforation and sclera thinning. [8,9]. Conjunctival tissue is used either as a free autograft or rotation flap after simple pterygium excision to reduce surgical recurrence and to avoid the side effects of MMC.[10]. Of the two transplant procedures, the free conjunctival autograft procedure has lesser recurrence and complication rates but requires training by qualified surgeons and has a longer surgical time. [11]. In this procedure, the graft is obtained from supero-temporal/nasal bulbar conjunctiva, leaving behind a bare scleral area of higher dimension which heals in a longer time, which leads to post-operative irritation and discomfort to the patient. Conjunctival rotation flap surgery, on the other hand, is a relatively simple procedure to master and surgical time is also short.[12]. The objectives of this study were to compare symptomatic comfort, visual outcome, recurrence and complications in free conjunctival autograft and rotation flap techniques following primary pterygium surgery.

The pterygium was cut near the limbus by Wescott’s scissors, the head of the pterygium was dissected from the surface of the cornea and subconjunctival fibrous tissue was removed completely. Any residual fibrous tissue was removed with the use of a 15 number blade. Cautery was used minimally in case of abnormal bleeders in the bare scleral area.

For the free conjunctival auto-grafting procedure, the graft tissue was harvested from supero-temporal/nasal bulbar conjunctiva, approximately 1 mm larger than the area of the bare sclera. The flap was dissected, completely freed from the underlying Tenon's tissue and transposed over the bare area. For conjunctival rotational flap procedure, the flap was created from the superior bulbar conjunctiva, rotated to the bare area aligning the limbal to limbal end of the flap with the scleral bed. In both the procedures uniform pressure was applied on the graft using 2 iris repositors, so that the graft gets adhered to the underlying sclera with the help of the blood coagulum.

After the application of a 0.5% Moxifloxacin with 0.1% Dexamethasone eye ointment, the eye was closed with a sterile pad. Surgical time was noted in both procedures. Postoperatively antibiotic steroid combination (Moxiloxacin+Loteprednol) eye drops in tapering doses (starting with four times a day for 4 weeks) and tears substitutes were prescribed to all patients (4 times/day) for 4 weeks on discharge. Postoperative follow up was done on the first postoperative day then at one week, one month and three months after surgery for symptomatic comfort, visual outcome, recurrence and complications.

Symptomatic comfort, graft stability, corneal clarity and any complication were noted postoperative day 1 and at day 7, whereas visual acuity, auto-refracto keratometer measurements and biomicroscopic examinations were performed at 1 month and 3 months follow up. At each follow-up visit, a questionnaire was filled by the patients, for grading pain, redness, foreign body (F.B) sensation and lacrimation into four grades.

The questionnaire was scored from (0 to 3) 0 - nothing; 1 -mild; 2 - moderate; 3 -severe. Additionally, in the 3^rd month, the overall satisfaction with the procedure was recorded as four grades 0 -unsatisfied; 1 - low satisfaction, 2 -moderate satisfaction and 3 - highly satisfied. Both the groups were compared for ocular signs and symptoms and overall satisfaction.

The displaced graft was reported on postoperative day 1 in two patients of group A and one patient of group B. reposition was done under topical anaesthesia with the help of iris repositors. persistent epithelial defect occurred in one patient with a rotational flap which was managed conservatively. Conjunctival granuloma formation was observed in one patient with free autograft, and was treated conservatively. The recurrence rate was 6.7% (n=2) in group A and 3.4% (n=1) in group B at the 3 months follow up. There were no major complications like graft necrosis, corneal thinning, scleral thinning or necrosis.

Table-2: Comparison of Surgical time, Complications and Recurrence.

Table 3: Presents the pre and post-operative visual acuity and astigmatism. The pre and postoperative mean BCVA (Log MAR) were compared at 1 month and 3 months. In group A preoperative mean BCVA of 0.48 ± 0.42 was significantly improved to 0.36 ± 0.44 (P < 0.001) at 1 month and 0.36 ± 0.44 (P < 0.001) at 3months after surgery. In group B preoperative mean BCVA of 0.46 ± 0.39 was significantly improved to 0.37 ± 0.41 (P < 0.001) and 0.34 ± 0.41 (P < 0.001) at 1 month and 3months postoperative, respectively.

The preoperative mean astigmatism (Refractive cylinder) was 1.38 ± 1.56 D in group A and 1.41 ± 1.63D in group B. In group A, postoperative mean astigmatism reduced to 0.87 ±0.92 D and 0.84±0.75D at 1month and 3 months respectively. In group B postoperative mean astigmatism reduced to 0.92 ±0.86 D at 1month and 0.87±0.79D at 3 months.

The changes in corneal astigmatism were statistically significant at 1 month and 3^rd month. The preoperative mean corneal astigmatism was 2.33 ± 1.62 D and 2.41 ± 1.71D in group A and group B respectively. In group A postoperative mean corneal astigmatism reduced to 1.38±0.92 D at 1month and 1.12±0.81 D at 3^rd-month post-surgery.

Figure 2: Postoperative symptoms and signs at 1month in both groups.

There was a statistically significant difference in the scores of the postoperative pain, redness, foreign body sensation and lacrimation (p<0.05) in the two groups.

Usually the pterygium is an asymptomatic wing-shaped fleshy mass, but it can present as symptomatic discomfort including redness, inflammation, foreign body sensation and in progressive cases, it can deteriorate vision as it encroaches the cornea with obscuring the visual axis of the cornea and inducing astigmatism. The Indications for pterygium surgery include patient discomfort and irritation, chronic inflammation, visual disability or cosmetic disfigurement.

Primary pterygium surgery aims to improve symptomatology, preserve or improve visual acuity and maintain ocular surface regularity and prevent a recurrence. The pterygium surgery is a minor surgical procedure, but if not done properly, it may lead to recurrence. Cases who underwent rotational flap surgery had better symptomatic comforts and overall satisfaction than Group A (p<0.05) whereas graft stability was comparable in both the groups. In both groups autologous blood coagulum was used for conjunctival grafting in pterygium surgeries. It has fewer postoperative discomforts, easy to use and avoid suture related complications.

In our study we found that visual acuity improved after pterygium excision surgery followed by conjunctival grafting in both groups. BCVA significantly improved from 0.48 ± 0.42 and 0.46±0.39 preoperatively to 0.36 ± 0.44 and 0.34 ± 0.41 postoperatively in group A and B respectively (at 3 months; P <0.0001). Maheshwari S [13]. concluded that visual acuity significantly improves in all grades of pterygium after pterygium excision surgery (P <0.05). The reason for the improvement in visual acuity after pterygium surgery was lesser induced astigmatism and clearance of visual axis, previously obscured by pterygium.[8].

Several previous researchers have found that pterygium excision surgery significantly reduces pterygium induced corneal astigmatism. Mohite et al [14]. found a significant reduction in mean corneal astigmatism after pterygium surgery from 3.046 ± 1.20 D to 1.486 ± 0.63D (P<0.001).