Evaluation of Autograft Characteristics After Pterygium Excision Surgery: Autologous Blood Coagulum Versus Fibrin Glue

The effect of different pterygium surgery techniques on the ocular surface parameters in different durations: a systematic review and meta-analysis

PURPOSE

To evaluate the effects of different pterygium surgery techniques on ocular surface (OS) in different follow-up periods.

METHODS

PubMed, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wan Fang, and China Biology Medicine disc were searched for studies reporting pre- and post-operative OS parameters in pterygium.

RESULTS

A total of 33 articles were finally included. Three OS parameters showed relatively consistent changing trends after surgery including ocular surface disease index (OSDI), tear film break-up time (BUT), and score of corneal fluorescein staining (SCFS). They worsened significantly at 1w post-operation and then gradually improved: OSDI and BUT showed obvious improvement in 1 m post-operation (SMD =  - 0.58, 95%CI = [- 1.04, - 0.13]; SMD = 0.42, 95%CI = [0.06, 0.78]); SCFS was restored to preoperative levels in 3 m after surgery (SMD =  - 0.54, 95%CI = [- 1.16, 0.07]). Another parameter, Schirmer test without anesthesia (SIT), presented transient increase at 1w post-operation (SMD = 0.87, 95%CI = [0.27, 1.47]) and presented a relatively stable improvement after 1 m post-operation (SMD = 0.52, 95%CI = [0.16, 0.89]). All parameters in amniotic membrane graft (AMT) showed better improvement in early stage and they showed non-inferior improvements in the long term compared with conjunctival autograft (CAG). Limbal-conjunctival autograft (LCAG) made excellent improvement to OS in the long term while pterygium excision (PE) showed the worst OS. The type of pterygium (primary and secondary), diabetes mellitus (DM) status, and fixation method had certain effects on the results.

CONCLUSIONS

OS of pterygium is deteriorated at 1w post-operation then gradually improved to preoperative levels after 1 m post-operation. Among various surgery techniques, LCAG had the best improvement to OS which especially displayed in the long-term outcomes.

TFOS Lifestyle: Impact of elective medications and procedures on the ocular surface

The word "elective" refers to medications and procedures undertaken by choice or with a lower grade of prioritization. Patients usually use elective medications or undergo elective procedures to treat pathologic conditions or for cosmetic enhancement, impacting their lifestyle positively and, thus, improving their quality of life. However, those interventions can affect the homeostasis of the tear film and ocular surface. Consequently, they generate signs and symptoms that could impair the patient's quality of life. This report describes the impact of elective topical and systemic medications and procedures on the ocular surface and the underlying mechanisms. Moreover, elective procedures performed for ocular diseases, cosmetic enhancement, and non-ophthalmic interventions, such as radiotherapy and bariatric surgery, are discussed. The report also evaluates significant anatomical and biological consequences of non-urgent interventions to the ocular surface, such as neuropathic and neurotrophic keratopathies. Besides that, it provides an overview of the prophylaxis and management of pathological conditions resulting from the studied interventions and suggests areas for future research. The report also contains a systematic review investigating the quality of life among people who have undergone small incision lenticule extraction (SMILE). Overall, SMILE refractive surgery seems to cause more vision disturbances than LASIK in the first month post-surgery, but less dry eye symptoms in long-term follow up.

Spontaneous attachment of complex Descemet's membrane detachment following multiple failed interventions

We describe a case with complex Descemet membrane detachment (DMD) which persisted despite initial two failed surgical attempts to appose the ocular tissues. However, over time, tissue alignment was obtained spontaneously. A 60-year-old woman, operated trabeculectomy, had a total DMD intraoperatively during a complicated cataract surgery. Initial attempt to DM repositioning with intracameral air injection failed. Anterior Segment Optical Coherence Tomography (ASOCT) showed detachment of both DM and pre-Descemet's layer (PDL). After consultation with a corneal surgeon, patient was again attempted for Intra-operative Optical Coherence Tomography (iOCT)-guided settlement of DMD with intracameral air which again failed. So, the patient was registered for lamellar corneal transplant, but at 3 months follow-up, DM had spontaneously attached, confirmed on ASOCT. This case shows for the first time that even complex DMDs involving PDL, can spontaneously appose despite failed surgical interventions.

Systematic Review: Effects of Pterygium and Pingueculum on the Ocular Surface and Efficacy of Surgical Excision

PURPOSE

This systematic review examines the specific effects of pingueculum and pterygium on the ocular surface and evaluates the efficacy of surgical excision in reversing those effects.

METHODS

A systematic review was performed according to the Preferred Reporting Items for the Systematic Review and Meta-Analyses statement and included 59 articles studying the effects of pterygium and pingueculum on the ocular surface as measured by tear break-up time (TBUT), Schirmer testing, tear osmolarity, Ocular Surface Disease Index (OSDI), and the effects of surgical removal on these ocular surface parameters.

RESULTS

In most studies, eyes with pterygium or pingueculum when compared with control eyes had a statistically significantly lower TBUT (average 3.72 s), lower Schirmer I without anesthesia (average 3.01 mm), lower Schirmer II (average 4.10 mm), higher tear osmolarity (average 12.33 mOsm/L), and higher OSDI (average 6.82 points). Moreover, excision of pterygium and pingueculum led to a statistically significantly higher TBUT (average 3.15 s higher at 1 mo postexcision), lower tear osmolarity (average 3.10 mOsm/L lower at 3 mo postexcision), and lower OSDI score (average 2.86 points lower 1 mo postexcision) in most of the studies. The effect of excision on Schirmer test scores was equivocal because most studies did not reach significance.

CONCLUSIONS

Our data confirm the relationship between pterygium and pingueculum and abnormal tear function and symptoms of dry eye disease. Furthermore, the data suggest that tear film parameters might improve after surgical removal of pterygium or pingueculum. Future studies would be helpful in exploring the potential role of pterygium and pingueculum excision in the management of dry eye disease.

A novel antimicrobial coating to prevent periprosthetic joint infection

Aims

Periprosthetic joint infection (PJI) is a debilitating condition with a substantial socioeconomic burden. A novel autologous blood glue (ABG) has been developed, which can be prepared during surgery and sprayed onto prostheses at the time of implantation. The ABG can potentially provide an antimicrobial coating which will be effective in preventing PJI, not only by providing a physical barrier but also by eluting a well-known antibiotic. Hence, this study aimed to assess the antimicrobial effectiveness of ABG when impregnated with gentamicin and stem cells.

Methods

Gentamicin elution from the ABG matrix was analyzed and quantified in a time-dependent manner. The combined efficiency of gentamicin and ABG as an anti-biofilm coating was investigated on titanium disks.

Results

ABG-gentamicin was bactericidal from 10 μg/ml and could release bactericidal concentrations over seven days, preventing biofilm formation. A concentration of 75 μg/ml of gentamicin in ABG showed the highest bactericidal effect up to day 7. On titanium disks, a significant bacterial reduction on ABG-gentamicin coated disks was observed when compared to both uncoated (mean 2-log reduction) and ABG-coated (mean 3-log reduction) disks, at days 3 and 7. ABG alone exhibited no antimicrobial or anti-biofilm properties. However, a concentration of 75 μg/ml gentamicin in ABG sustains release over seven days and significantly reduced biofilm formation. Its use as an implant coating in patients with a high risk of infection may prevent bacterial adhesion perioperatively and in the early postoperative period.

Conclusion

ABG’s use as a carrier for stem cells was effective, as it supported cell growth. It has the potential to co-deliver compatible cells, drugs, and growth factors. However, ABG-gentamicin’s potential needs to be further justified using in vivo studies.

Cite this article: Bone Joint Res 2020;9(12):848–856.

Modified Sutureless and Glue-Free Method Versus Conventional Sutures for Conjunctival Autograft Fixation in Primary Pterygium Surgery: A Randomized Controlled Trial

PURPOSE

To compare the advantages and disadvantages of a modified sutureless and glue-free method with those of conventional sutures for conjunctival autograft fixation in pterygium surgery.

METHODS

A prospective randomized controlled study was performed on 73 eyes with primary nasal pterygium. After pterygium excision, the bare sclera was covered with a limbal conjunctival autograft, which was fixed using a modified sutureless and glue-free method in group 1 (39 eyes) and sutures in group 2 (34 eyes). The main outcome measures were operative time, autograft stability, postoperative discomfort, autograft thickness, pterygium recurrence, and complications.

RESULTS

The mean operative time was significantly shorter in group 1 (11.9 ± 1.3 minutes) than in group 2 (24.3 ± 6.1 minutes, P < 0.0001). On day 2 postsurgery, the average conjunctival autograft thickness was significantly higher in group 1 (861 ± 340 μm) than in group 2 (577 ± 287 μm, P = 0.034). Subsequently, conjunctival autograft thickness gradually decreased, with no significant difference between groups after 1 week. There were no significant differences in postoperative discomfort between groups, except for a greater foreign body sensation on day 2 and an itching sensation in 1 week in group 2 compared with group 1. Autograft side displacement occurred in 4 patients (10.3%) in group 1; 2 of these 4 developed a granuloma. There was 1 recurrence (2.9%) in group 2.

CONCLUSIONS

The modified sutureless and glue-free limbal conjunctival autograft fixation method might be effective and efficient for primary pterygium surgery, with potentially decreased recurrence and postoperative discomfort.

Evaluation of Autologous Blood in Pterygium Surgery With Conjunctival Autograft

PURPOSE

Autologous blood has been used exploratively with conjunctival autograft in pterygium surgery. However, it is controversial whether autologous blood performed better than other fixation methods, including fibrin glue and sutures. This meta-analysis was conducted to evaluate the effectiveness of using autologous blood in pterygium surgery with conjunctival autograft.

METHODS

The study was conducted according to the PRISMA guidelines. The MEDLINE, Cochrane library, and Embase databases were systematically searched from their establishment until April 1, 2018. Randomized controlled trials comparing autologous blood with fibrin glue/suture in pterygium surgery with conjunctival autograft were included. The methodological quality of the included studies was assessed using the Cochrane risk of bias tool. Outcome measurements were recurrence, graft displacement, graft retraction, and surgical duration. Review Manager 5.3 (Cochrane Community, Cochrane Collaboration, London, UK) was used to perform the statistical analysis. When I < 50%, statistical heterogeneity was considered acceptable, and a fixed-effects model was adopted; alternatively, the random-effects model was used.

RESULTS

Seven randomized controlled trials including 516 patients were finally included in the meta-analysis. Four studies with 379 patients compared autologous blood and fibrin glue. Autologous blood was inferior to fibrin glue with respect to surgical duration, graft retraction, and graft displacement. However, there was no statistical difference between the 2 groups in terms of the recurrence rate. Four studies with 152 patients compared autologous blood and traditional suturing. Autologous blood was superior to sutures in terms of surgical duration and inferior to sutures in terms of graft retraction. No difference was detected in terms of graft displacement and recurrence rate.

CONCLUSIONS

In conclusion, autologous blood is an appropriate method for graft fixation in pterygium surgery. Current research suggests that autologous blood derivatives may be a promising approach after pterygium excision. However, this requires further confirmation.

Cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery (CAGE CUP): study protocol of a randomised controlled trial

INTRODUCTION

Pterygium is a non-cancerous growth of the conjunctival tissue over the cornea that may lead to visual impairment in advanced stages, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence of pterygium is a frequent problem. It has been previously shown that fibrin glue may result in less recurrence and may take less time than sutures for fixing the conjunctival graft in place during pterygium surgery. However, fibrin glue is a biological material and it carries the risk of transmitting infectious agents from pooled and single-donor blood donors and anaphylaxis in susceptible individuals. Cauterisation is another surgical option, and it would be advantageous to know whether cauterisation may be superior surgical option compared with fibrin glue. This protocol describes the rationale and design of the randomised controlled trial (RCT) in which we will compare cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery.

METHODS AND ANALYSES

This will be a parallel group RCT comparing cauterisation versus fibrin glue for conjunctival autografting in primary pterygium surgery. Computer-generated randomisation will be used, and allocation concealment will be conducted using sequentially numbered opaque sealed envelopes. Surgeons will not be blinded to the procedures, but participants, other investigators and outcome assessors will be blinded. Adult participants with primary pterygium operated in a tertiary hospital in Split, Croatia, will be included. Primary outcome will be recurrence of pterygium, defined as any regrowth of tissue from the area of excision across the limbus onto the cornea after 180 days.

ETHICS AND DISSEMINATION

The trial was approved by the ethics review board of the University Hospital Split (500-03/17-01/68). Results will be disseminated at conferences and through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT03321201; Pre-results.

In Situ Blood Coagulum versus Sutures for Autograft Fixation after Pterygium Excision

PURPOSE

To compare the outcomes of autograft fixation using patient's own blood coagulum and using sutures after pterygium excision.

METHODS

In this prospective clinical study, 30 eyes of 30 patients with primary pterygium were randomly assigned into two groups: Group 1 (15 eyes) underwent autograft fixation with 10/0 nylon sutures and Group 2 (15 eyes) underwent autograft fixation by using in situ blood coagulum following pterygium excision. Primary outcome measure of this study was graft failure and displacement. Recurrence, the duration of surgery and patient discomfort were also evaluated. The patients were examined at day 1, day 7, month 1, month 6, and month 12.

RESULTS

Mean duration of surgery was significantly less in Group 2 (mean duration 14 ± 2 minutes) compared with Group 1 (mean duration 48 ± 2 minutes). Graft failure and displacement were more common in Group 2 (13.3%) compared with Group 1 (6.7%). Recurrence was reported equally in both groups. Patient discomfort was found significantly more in Group 1 (foreign body sensation due to sutures.) Conclusions: Autograft fixation by using in situ blood coagulum after pterygium excision is an effective technique with less patient discomfort and shorter operation time.