Comparing residual astigmatism after pterygium surgery using fibrin glue vs sutures

A DISSERTATION ON
“COMPARISION OF RESIDUAL ASTIGMATISM
FOLLOWING
CONJUNCTIVAL AUTOGRAFT
AFTER
PTERYGIUM EXCISION,
SUTURE VERSUS FIBRIN GLUE”
BY
ANKIT .S. VARSHNEY
(4th
YEAR, B. OPTOMETRY)
HARI JYOT COLLEGE OF OPTOMETRY,
ROTARY EYE INSTITUTE,
NAVSARI, GUJARAT.
2010-2011.

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“COMPARISION OF RESIDUAL ASTIGMATISM
FOLLOWING
CONJUNCTIVAL AUTOGRAFT
AFTER
PTERYGIUM EXCISION,
SUTURE VERSUS FIBRIN GLUE”
A DISSERTION SUBMITTED TO THE
VEER NARMAD SOUTH GUJARAT UNIVERSITY, SURAT.
In partial fulfillment of the regulations for the award of
THE DEGREE OF BACHELOR IN OPTOMETRY
BY
ANKIT .S. VARSHNEY
(4th
YEAR, B. OPTOMETRY)
Under the guidance of
DR. RASMITA KUKADIA
M.S. (OPHTHALMOLOGY)
HARI JYOT COLLEGE OF OPTOMETRY,
ROTARY EYE INSTITUTE,
NAVSARI, GUJARAT.

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CERTIFICATE
This is to certify that the enclosed work on the subject
“COMPARISION OF RESIDUAL ASTIGMATISM FOLLOWING
CONJUNCTIVAL AUTOGRAFT AFTER PTERYGIUM
EXCISION, SUTURE VERSUS FIBRIN GLUE” was carried
out by Ankit .S. Varshney (4t h year, B. Optometry) himself
under my supervision and guidance towards the fulfillment
of requirements of the degree of “Bachelor in Optometry”
of Veer Narmad South Gujarat University, Surat.
---------------------- -----------------
---------
MR. Viral Purohit Dr. Rashmita Kukadia
Chairman I/C Principal
Hari Jyot College of Optometry Hari Jyot College of Optometry
Dt. Dt.

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ACKNOWLEDGEMENT
There are a number of people to whom I would like to express my heartfelt
gratitude for helping me with this thesis.
I am highly indebted to Hon. Principal Dr. RASMITA KUKADIA (M.S
Ophthalmology), and Professor Mr. NIRAV MEHTA (M.Optom) Rotary Eye
Institute, Navsari without whose, constant support, guidance and constructive
criticism this study would not have been possible.
I am very thankful to Dr. Jigisha Randeri, Dr. Gautam Kukadia, Dr.
Saurabh Kapoor, Dr. Vanraj Rathwa, Dr. Saurin Shroff, Sanjay Ahir Sir for
their guidance throughout the duration of the study and during complication.
My hearted thanks to my dearest friend Keyur N Sharma (B. Optom).
My whole hearted thanks to MY C0LLEGUES and Optometry student of
Hari Jyot college of Optometry, who helped me at some or other stage during
this study.
I also express my thanks to the nursing staff of Rotary Eye Institute, the
office staff for helping me.
A special thank to Sir Mr. VIRAL PUROHIT.
I am thankful to MY PARENTS & SISTERS.
Who have been constant sources of inspiration and support throughout my
academic career.
Last, but not the least I am thankful to all my patients who have co-operated
with me and without them, this study would not have been possible.
ANKIT .S.VARSHNEY

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ABSTRACT
TITLE: “Comparision of residual astigmatism following conjunctival
autograft after pterygium excision, suture versus fibrin glue”
Aim and Objectives: To compare the residual astigmatism with Auto and
Manual keratometer and to evaluate the safety and efficacy by using Fibrin glue
and Vicryl sutures for conjunctival autograft after pterygium excision .
Material and Methods: A Prospective randomized study was done in 50 eyes
of 50 patients diagnosed to have primary pterygium. In 25 patients, auto graft
was attached to sclera with fibrin glue [Reliseal, India] and in 25 patients with
7-0 Vicryl suture. Keratometry was done with Auto-K model labeled as ARK-30
(NIDEK) and another with Manual (Bausch & Lomb) keratometer, to find out
corneal or residual astigmatism pre and post operatively.
RESULTS: Out of 50 patients, 18 were female and 32 were male. In Vicryl
group, 100% patients had foreign body sensation, graft edema, and inflammation
on day 1, which was reduced to greater extent in fibrin glue patients on day 1 .
Mean improvement in astigmatism was 0.866 ± 0.812 in fibrin glue group and
0.846 ± 0.806 in Vicryl group.
CONCLUSION: Using fibrin glue instead of using 7-0 Vicryl suture when
attaching the conjunctival auto graft in pterygium surgery can significantly
obviates suture-related complications and discomfort and decreased
postoperative astigmatism. In addition, the added advantage of decreased
postoperative morbidity and reduced hospital stay.
KEY WORDS:
Reliseal fibrin glue, 7-0 Vicryl suture, Keratometer, Corneal Astigmatism.

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INDEX
No. TITLE Page No.
1. INTRODUCTION 6
2. AIM AND OBJECTIVES 8
3. GENERAL CONSIDERATION 9
4. REVIEW OF LITERATURE 19
5. MATERIAL & METHODS 21
6. PROFORMA 28
7. STATISTICAL ANALYSIS 29
8. OBSERVATIONS 33
9. DISCUSSION 43
10. SUMMARY & CONCLUSION 47
11. BIBILOGRAPHY 49
12. MASTER CHART 51-52

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INTRODUCTION
Pterygium was recognized 3000 years ago, it was described by
Susrutha way back in 1000 B.C. in India. It was also noted by great
physicians of ancient times like Hippocrates, Galen, Celsus, etc.
A pterygium is a wing shaped growth of fibro vascular conjunctiva
encroaches onto the cornea generally situated on the nasal side. It
sometimes occurs both nasally and temporally, and rarely only on the
temporal side, its incidence varies across geographical locations.
Several hypotheses have been described to its etiology; currently it is
believed that the incidence of pterygium increases with age and this
suggests that it is more likely to affect those who have been longer
exposed to the climatic or occupational conditions, which favour its
development.
Many theories have been advanced as to the causation of pterygium
including chronic conjunctivitis due to infection, chronic irritation due to
Wind and Dust, Ultraviolet radiation and Infrared radiation. One of the
most difficult problems has been to isolate these environmental factors for
study when they are so often associated with each other.
Pterygium causes functional problems such as reduced visual acuity,
diplopia, and problem in fitting contact lenses. Reduced vision is either by
direct obscuration of the visual axis or, more commonly, through irregular
astigmatism - induced either by distortion of the cornea or pooling of the
tear film at the leading edge of pterygium.
This abnormality has been measured by keratometry and refraction.
In this study, an attempt was made to assess the role of pterygium excision
in pterygium-induced astigmatism.

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Anti-inflammatory drugs and lubricants have an important role in
minimizing the patients’ discomfort but do not cure the disease.
The optimum mode of treatment for symptomatic Pterygia would
combine efficacy (a low recurrence rate) with safety (freedom from sight
threatening complications), and would not affect visual acuity adversely.
The efficacy of pterygium excision with conjunctival auto grafting in a
sun-exposed population in which Pterygia are prevalent has previously
been questioned. High recurrence rates are weighted against eye
threatening postoperative complications. Autologous conjunctival grafting
seems to be the best method, giving both low recurrence rate and high
safety.
Need for the study:
 Pterygium has a moderate to high prevalence 30° above and below
the equator. Pterygium surgery is fairly common in our country,
which is located within the tropics.
 Navsari city and its surrounding places have dry, windy, dusty, and
hot climate.
 The main occupation of people in this place is agriculture, labours
etc., which is outdoor occupation. They are exposed to such a dry and
dusty climate, which increase the occurrence of pterygium.
 Hence, we have decided to determine outcome of conjunctival
autograft in primary pterygium with Fibrin glue and Vicryl suture.
 Our objective was to lessen patient discomfort by using glue
rather than sutures when securing the graft.

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AIM AND OBJECTIVES
AIM:
To compare the residual astigmatism with Auto and Manual
keratometer by using Fibrin glue and Vicryl sutures for
conjunctival autograft after pterygium excision.
OBJECTIVES:
1. Comparision of amount of astigmatism after pterygium excision
with autograft in nasal/temporal pterygium.
2. To evaluate the safety and efficacy of fibrin glue/suture in
pterygium excision with autograft.
3. Comparision of technique; fibrin glue versus sutures in
pterygium surgery with autograft.
4. To evaluate the comfort level of patients after postoperative
surgeries with fibrin glue and Vicryl suture.

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GENERAL CONSIDERATION
Pterygium is a wing shaped encroachment of conjunctiva over the
cornea. Pterygium is a Greek word-meaning wing (of butterfly). As
pterygium grows, it may become red and cause irritation. Eventually, it
may lead to visual disturbances by disrupting the normal smooth surface of
the cornea or astigmatism. It occurs most commonly on nasal aspect of
interpalpebral exposure zone. Despite being recognized for many years and
being very common in some parts of the world, very little is known about
the pathogenesis of this condition. This ignorance is reflected in the poor
results of intervention and the wide range of treatments advocated.
In mild cases, redness and discomfort can be controlled with
lubricant eye drops. Surgical intervention is generally considered when
symptoms of redness, irritation or blurred vision are resistant to
conservative treatment, when vision is affected by progressive growth of
pterygium, breakup of the precorneal tear film, restricted ocular motility,
and progressive growth toward the visual axis, difficulty with contact lens
wear, refractive surgery and cosmetic deformity.
In early days, surgical management of pterygium included bare sclera
technique but was associated with high recurrence rate. To avoid this,
adjunctive treatment such as β radiation, thiotepa, mitomycin C, 5-
fluorouracil, cyclosporine A or daunorubicin is used. Newer techniques
include conjunctival auto grafting with or without limbal stem cell
transplantation, or using other tissue sources such as buccal mucous
membrane grafts, amniotic membrane grafting, lamellar keratoplasty,
penetrating keratoplasty, or sclerokeratoplasty. The other techniques

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include Yttrium-Aluminium-Garnet (YAG) laser treatment and a polishing
technique as advocated by Barraquer.
Of all these newer methods, conjunctival auto grafting is most
commonly performed and is associated with low rates of recurrence. The
autograft is attached to bare sclera with the help of 7-0 Vicryl suture; this
is associated with increased surgical time, more postoperative pain,
discomfort, and watering, prolonged healing time.
In recent times, the universal trend toward simpler, quicker, and
more comfortable surgical procedures have fostered the development of
suture less techniques and hence, use of tissue adhesives for attaching
conjunctival autograft. This technique reduces the surgical time, causes
significantly less post operative pain, irritation, watering, induces less
inflammation, reduces healing time and recurrence. Fibrin glue is the most
recent among all adhesive and is gaining acceptance world over for use in
treatment of various ocular conditions.
Various explanation have put forward for greater prediction on nasal side:
1. Excess of sub conjunctival tissue nasally.
2. Greater bowing of lateral 2/3rd
of upper lid and consequent protection
by longer lashes. (Cameron2, 1965).
3. Greater exposure of the interpalpebral conjunctiva to ultra violet
radiation. (Cameron2, 1965).
4. Greater curvature of nasal fibres of orbicularis occuli, causing a
greater squeezing effect upon nasal subconjunctival tissue.
5. The normal flow of the tears is from temporal to nasal side towards
punta and carries dust particles of conjunctival sac and accumulates
it on sulcus lacrimals. This, probably, leads to more irritation of the
nasal conjunctiva.

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INCIDENCE AND PRIVELANCE:
Pterygium is prevalent in all parts of world, but prevalence increase with
proximity to the equator.
A study of prevalence of pterygium in Gujarat (1997) is 2.59%. In India,
its prevalence is high in Maharashtra, Assam and Andhra Pradesh.
Cameron2 has mapped pterygium belt as 37° north and south of the
equator. Prevalence is as high as 22% in equatorial area and <2% in
latitudes above 40°.
Prevalence of lesion increase with age, the highest incidence occurs
between the ages 20-49 years3
. Patient younger than the age of 15 years
rarely acquire a pterygium.
It is twice as common in men as women are. This may be attributable to
more hours spent outdoor by men as compare to women.
ETIOLOGICAL FACTORS:
It has been accepted that environmental factors are responsible for the
development of pterygium4
. More recently, it has become clear that
ultraviolet light exposure is the most important environmental influence.
When UV rays continuously assault eye, the conjunctiva may thicken in a
process similar to callus formation on the skin. The sensitive structures of
the outer eye often cannot tolerate the degenerative process, and irritation,
redness, foreign body sensation, and ocular fatigue can result. High

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exposure in the second or third decade of life is particularly relevant to
causation5
. Most Pterygia develop on the nasal limbus6
and it has been
proposed that this is attributable to reflected sunlight being preferentially
focused at this point. The way in which ultraviolet light interacts with the
limbus and cornea to produce a pterygium is unknown. Tseng et al7
suggested that pterygium is a manifestation of localized, interpalpebral
limbal stem cell dysfunction or deficiency, perhaps as a consequence of
UV-light-related stem cell destruction. Moran & Hollows4
in 1984
deduced, occurrence of pterygium is strongly correlated with UV exposure
although dryness, inflammation, and exposure to wind and dust or other
irritants may also be factors. UV-B is mutagenic for the p 53 tumour
suppressor gene in limbal basal cells. Without apoptosis, transforming
growth factor – β is overproduced and leads to collagenase up-regulation,
cellular migration, and angiogenesis. Genetic factors are also important. In
particular, environments, some racial groups are affected more than
others are and there is a tendency for Pterygia to occur in families8
.
Barrquer9
has proposed that the limbal elevation produced by the
conjunctival lesion, like pinguecula, produces tear film discontinuity,
peripheral corneal drying, and micro ulceration, which ultimately lead to
fibro vascular invasion.
HISTOPATHOLOGY:
Pterygium formation is mainly characterized by elastotic degeneration,
fragmentation, and breakdown of stromal collagen followed by destruction
of Bowman’s layer by advancing fibro vascular tissue resulting in corneal
scarring. The histopathology is non-specific. Hyaline degeneration and a

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low-grade inflammatory reaction are usually present. Histopathologic study
of pterygium shows a fibrous tissue base adjacent to the cornea, with
degenerated elastic tissue resting on this vascularized, fibrous base. Blood
vessels are prominent, usually located just beneath epithelium, which
appears conjunctival in nature. Electron microscopic study of lesions by
Cameron et al2
showed active fibroblast in the region of Bowman’s layer
at the level of pterygium.
Recurrent pterygia shows lack elastotic degeneration and are more
accurately classified as an exuberant granulation tissue response.
Stocker’s line – A corneal epithelial iron line may from axial to and
circumscribing the head of the pterygium more often older and stat ic
lesions3
.
BIOCHEMICAL AND IMMUNOLOGICAL CHANGES3
:
The non-goblet epithelial cells of the pterygium synthesize anomalous
mucus glycoprotein of normal conjunctival epithelium.
The glycosaminoglycans in Pterygia contain much more sugar that is
neutral and sialic acid than the glycosaminoglycans from normal
conjunctiva.
In one study, immunofluorescence staining of Pterygia revealed Ig G and
Ig E in all samples tested and not in control conjunctiva, raising the
possibility of a Gell-Coombs hypersensitivity reaction in which antigen,
such as dust or pollen, may contribute to pterygium formation.

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PARTS OF PTERYGIUM:
HEAD: First 1 to 2 mm of apex.
NECK: Lies between head and the body.
BODY: Extends from neck to the conjunctival fornix. Fleshy, vascularized
tissue that is delineated from normal conjunctiva both superior and
inferiorly by sharp folds. Vessels are straight and appear to be under
tension.
CAP: Gray subepithelial fibrous tissue at the leading edge of head.
Sometimes round grey corn like extensions of the cap, precede the head –
the island of Fuchs – seen in progressive Pterygia very commonly.3
CLINICAL GRADING OF PTERYGIUM:
Donald Tan et al10
developed a simple clinical slit lamp grading scale,
based on relative translucency of the body of the pterygium, which was
predictive of recurrence.
BODY
HEAD

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Grade T1- (Atrophic) pterygium in which episcleral vessels
underlying the body of the pterygium were unobscured and clearly
distinguished.
Grade T2- (Intermediate) all Pterygia that do not fall into grade T1
and grade T3 categories (i.e. episcleral vessels details were
indistinctly seen or partially obscured).
Grade T3- (Fleshy) thick pterygium in which episcleral vessels
underlying the body of the pterygium are totally obscured by fibro
vascular tissue.
The growth of pterygium across the cornea is slow one and it usually takes
several years to reach the visual axis.
Progressive pterygium or an active lesion is characterized by:
 Fleshy and congested appearance
 Punctuate staining over the body
 Presence of cap with or without islands of Fuchs.
Regressive or inactive pterygium is characterized by:
 Absence of episodic congestion,
 Disappearance of punctuate staining over the body and
shrinkage of cap gradually.
 The lesion may remain stationary for several years and finally
involution occurs.
 Head gets flattened and thinned out leaving behind a scar that
blends with adjacent cornea.
 The body gets changes into a membrane like structure with few
fine blood vessels.

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Recurrent pterygium is defined as a secondary fibro vascular growth,
across the limbus, on the cornea from the corneoscleral defect of a
previously excised pterygium. Formation is often rapid and more
aggressive. Recurrent pterygia are more common in:
 Younger patients
 Patients with an aggressive post-operative inflammation.
 Patients re-exposed to an endemic area high in pterygium
etiologic factors.
 Large size primary pterygium
 Inadequate surgery.
Donald Tan et al10
showed that recurrence was clearly related to the
degree of fibro vascular tissue in the pterygium, with fleshy pterygium
having highest capacity for recurrence, while atrophic pterygium had the
lowest.
CLINICAL FEATURES: Pterygium are usually asymptomatic most
patients essentially present for cosmetic reasons intermittent episodes of
inflammation during which pterygium becomes hyperemic and patient
presents with complains of:
 Redness
 Photophobia
 Tearing
 Foreign body sensation
 Decrease in visual acuity
 Extra ocular movement limitation e.g. diplopia

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MANAGEMENT
MEDICAL MANAGEMENT:
A small pterygium with mild symptoms of photophobia and redness can be
managed by:
 Avoiding dust and some filled environments.
 Topical preservative free lubricants with artificial tear drops.
 If hyperemia is bothersome, then topical vasoconstrictors like
Naphazoline or Oxymetazoline may be prescribed.
 Mild non-penetrating corticosteroid such as Medrysone 1% can
relieve symptoms when used judiciously.
 Antihistamines to aid in reduction of histamine associated
edema and itching.
 To prevent progression some authors advocate the use of
ultraviolet blocking spectacles.
SURGICAL MANAGEMENT:
INDICATIONS:
 Visual impairment – via two mechanisms - Lesions encroaching
onto the visual axis and/or induced astigmatism.
 Cosmetic blemish.
 Recurrent inflammation.
 Mobility restriction causing diplopia.
 Interference with contact lens wear.
 Suspicious changes which may indicate a malignant
transformation.
 Recurrent pterygium.

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CURRENT SURGICAL TECHNIQUES
The first report of a surgical treatment of pterygium is more than 3000
years old.
1. Human amniotic membrane transplantation: Many authors have
reported that amniotic membrane grafts are a viable alternative to
Conjunctival autografts in reducing recurrences after pterygium excision11
.
2. Conjunctival autograft: The transplantation of free conjunctival
autografts of superotemporal bulbar conjunctiva from the same eye to close
wound after the excision of advanced or recurrent pterygium. This
technique has become popular over the last 15 years; resected conjunctiva
from the superior limbus (where it is protected from solar damage by the
upper lid of same eye) is transplanted to the area of the pterygium
excision. Autologous conjunctival autografting seems to be the best
method, giving both a low recurrence rate and fewer side effects11
.
3. Limbal Conjunctival Autograft: Prolong destruction of the limbal
tissue by UV rays and other injuries, results in the invasion of
Subconjunctival cells into the cornea. Based on this concept several
authors have reported the inclusion of limbal stem cells in conjunctival
autograft in management of both primary and recurrent pterygia. The stem
cells generate new corneal epithelial cells in addition to inhibiting
conjunctival epithelial invasion of cornea.
Materials for attaching the graft:
1. The conjunctival autograft is secured in place with 10-0/7-0 Vicryl,
8-0 virgin-silk, and 10-0 nylon interrupted sutures most commonly.
2. Conjunctival autograft with fibrin glue: Koranyi12
first popularized
it in pterygium surgery in 2004.

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REVIEW OF LITERATURE
Pterygium is the wing-shaped fleshy growths on the corneal limbus. The
word pterygium was introduced to the English language in 1875 by
Walton1
. It has been known to physicians for thousands of years.
Pterygium significantly affects the ocular surface.
PREVIOUS STUDIES
1. Koranyi G; Seregard S; Kopp ED; Sweden, [Br J Ophthalmol. 2004;
88(7):9114]12
conducted a prospective randomized clinical trial in 43
patients to evaluate the benefits of a no suture, small incision like
approach to pterygium surgery, Cut and paste with a fibrin tissue adhesive
with respect to postoperative pain and surgery time. They concluded that
using glue instead of sutures when attaching the conjunctival transplant in
pterygium surgery causes significantly less postoperative pain and shortens
surgery time significantly.
2. Koranyi G; Seregard S; Kopp ED; Sweden, between 1994 and 2003;
[Acta Ophthalmol Scand. 2005; 83(3):298-301]13
conducted a
Retrospective study, included 461 eyes of 381 patients operated for
primary nasal pterygium to evaluate the recurrence rate, re-operation rate
and side-effects after attaching the transplant to the sclera with a fibrin
tissue adhesive compared to the outcome after graft attachment using
absorbable sutures and concluded that using a fibrin tissue adhesive
instead of sutures when attaching the conjunctival transplant in primary
pterygium surgery results in a significantly lower recurrence rate (5.3% in
the glue group and 13.5% in the suture group).

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3. Uy HS; Reyes JM; Flores JD; Lim-Bon-Siong Ophthalmology, 2005;
112(4):667-71 R, of Philippines14
, concluded a Prospective, randomized,
interventional case series study on 22 patients. Comparing fibrin glue and
sutures for attaching conjunctival autograft after pterygium excision and
concluded that Fibrin glue is a safe and effective method for attaching
conjunctival autografts, use a fibrin glue results in shorter operating times
and less postoperative discomfort.
4. Dr. Rajendra Kumar Bisen, Dr. Rupam Janak Desai, Dr. Falguni
Mehta, Dr. O.P. Billore, Dr. Jigisha Kiran Randeri, Dr. Pravin Jain, Dr.
Kapil Khurana (External Diseases Sessions; IJO, 2009, Pg 215)15
conducted a Prospective, randomized, hospital based, comparative study, to
evaluate the effectiveness and safety of fibrin glue as compared to Vicryl
sutures for attaching conjunctival autograft after pterygium excision, on 47
eyes of 46 patients and concluded that Using fibrin glue instead of Vicryl
suture when attaching the conjunctival autograft in pterygium excision
causes significantly less pain, discomfort, postoperative graft oedema,
inflammation, and also reduces the astigmatism and surgical time and
hence is more patient friendly.
5. Dr. Ankur Midha, Dr. Poonam Jain, Dr. Mukesh Sharma (AIOC 2009
PROCEEDINGS) conducted a Prospective, randomized study on Pterygium
Excision and Limbal Conjunctival Autografting–Astigmatism and
Cosmetism on 100 eyes of 100 patients verifies that as the size of
pterygium increases, the amount of induced astigmatism increases in direct
proportion. Successful pterygium surgery reduces the pterygium-induced
refractive astigmatism and improves the visual acuity. In terms of
cosmesis, fibrin glue has a definite advantage over suturing at least in the
early post operative period.

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MATERIAL AND METHODS
A prospective, randomized, hospital based, comparative study was done, to
evaluate the amount of astigmatism / residual astigmatism / effectiveness
and safety of fibrin glue as compared to Vicryl sutures for attaching
conjunctival autograft after pterygium excision, in 50 eyes of 50 patients
diagnosed to have primary pterygium.
Inclusion Criteria
 Clinically significant primary pterygium requiring excision (more
than 3mm over the cornea, horizontally from the limbus),
 Pterygium induced corneal astigmatism.
 Cosmetically blemish due to pterygium.
 Willingness to participate in research project and to attend research
clinic.
 Minimum follow up of 1 month.
Exclusion Criteria
 Age <18 years
 Previous surgery in the affected eye.
 Signs of significant pathology or active disease or other concurrent
corneal pathology.
 Poor general health.
 Poor visual acuity due to other ocular pathology.
 Known hypersensitivity to human blood products.
 Connective tissue disease that could influence wound healing.

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Patients’ details were recorded as follows
1. Demographic details:
For identification of patients and statistical analysis, if necessary,
history regarding name, age, sex, residence, occupation, case register
no. were noted.
2. Patient’s complaints and relevant history:
The onset, duration and progress of complaints in the form of growth,
grittiness, foreign body sensation, tearing, blurred vision, redness,
contact lens intolerance, symptoms “often” or “constant”, aggravating /
relieving factor of symptoms.
 H/o exposure to UV rays (outdoor working hours).
 H/o occupation e.g. Agriculture, dry and hot climate, were also noted.
3. Antecedent treatment history:
Details of treatment taken in form of artificial tears, oral medications or
surgical treatment were inquired.
4. Examination findings
Preliminarily all patients were examined thoroughly with torchlight as
well as with slit lamp biomicroscopy, then uncorrected Visual acuity on
standard Snellen chart is taken.
After that, subjective and objective refraction was done to find out the
Best Spectacles Corrected Visual Acuity (BSCVA) and the total amount
of astigmatism, pre operatively.
Detailed anterior segment examination, Documentation of pterygium
location, primary or recurrent status, and Pterygium Grading were also
noted.

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Slit lamp photography, pre and post surgery were taken. Pre-operative
measurement of pterygium extent over the cornea and width at limbus
were also measured with callipers under microscope.
Grade Extent (mm) on to cornea
 Grade 1- 0-2 mm from limbus
 Grade 2 - 2-4 mm from limbus
 Grade 3 - more than 4 mm from limbus
Intraocular pressure was measured with Schiotz tonometer and detailed
fundus examination was done to rule out any pathology in posterior
segment.
Keratometry was done with two different instruments, one with Auto-K
model labeled as ARK-30 (NIDEK) and another with Manual (Bausch &
Lomb) keratometer, to find out corneal or residual astigmatism pre and
post operatively.
After obtaining informed consent, the patients underwent pterygium
excision.
All patients were informed in their 1st
visit about the study and method of
treatment they had to undergo and the date of their next visit usually
decided according to their convenience.
Out of 57 patients, 7 patients did not turn up due to some reasons.
Bausch and Lomb keratometer

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FIBRIN SEALANT KIT:
 Preparation of fibrin glue sealant: The fibrin sealant kit contains two
major components in separate vials:
1. Freeze Dried Human Fibrinogen
2. Freeze Dried Human Thrombin
No antimicrobial preservative is added in any components.
 Aprotinin solution (bovine) as a sterile solution containing Aprotinin
B.P., 1500 kallikrein inhibitor units (kiu)/ml in 0.5ml kit.
 1×5 ml ampoule of sterile water for injection.
 4×2 ml syringes for reconstitution and application; 4×21G sterile
needles for aspiration of the two components; 2×20G blunt
application needles.
 Applicator with two mixing chambers and one plunger guide.
Kit Fibrinogen: Thrombin Aprotinin
0.5ml 20mg 250IU 1500kiu
 Preparation of fibrinogen solution:
 Aspirated the entire content of Aprotinin solution from the vial using
the above 2ml syringe.
 Aspirated Aprotinin solution injected into vial containing fibrinogen-
dried powder.
 Reconstituted fibrinogen solution, aspirated into a fresh graduated
2ml sterile syringe.

25 | P a g e
 Preparation of thrombin solution:
 0.5ml sterile water for injection aspirated from 5ml ampoule into 2ml
syringe.
 This aspirated water for injection, injected into the vial containing
Thrombin dried powder.
 Reconstituted Thrombin solution 0.5ml aspirated into a fresh graduated
2ml sterile syringe.
 Both the syringes mounted on applicator, barrel locked into the
applicator housing with a click.
 Nozzles of both syringes engaged with mixing chamber.
 Mixing chamber connected to blunt application needle.
 Plunger guide pushed while applied Reliseal solution, liquid sealant
solution ejects out, which was applied to pre-dried wound surface.
Surgical steps of pterygium excision with conjunctival autograft using
Fibrin glue.
 The surgeries were performed under peribulbar block.
 The eye was painted with Betadine solution and then draped with
autoclaved towels with full aseptic precaution.
 Wire speculum was applied to separate the lids.
 The pterygium head was separated from the cornea by blunt dissection
with reverse stripping technique.
 The pterygium tissue was sufficiently dissected sub conjunctively with
precaution taken not to damage the horizontal recti.
 The conjunctiva was separated from underlying Tenon’s capsule and
dissected pterygium. Moreover, dissected pterygium was excised.
 The wound bed was scraped to bare sclera and homeostasis achieved.

26 | P a g e
 The size of the defect was measured with Castroveizo callipers.
 A free conjunctival graft of a similar size as the conjunctival defect
was prepared at the superotemporal limbus of the same eye. Care was
taken to include as little as possible of Tenon’s tissue in the graft. The
limbal edge of the graft contained a thin rim of corneal epithelium but
no attempt was made to include the corneal stroma.
 Graft bed area dried prior to application of fibrin glue.
 Glue applied by applicator blunt needle to the bare sclera.
 The graft then after moved to the nasal area and attached to the sclera
with glue.
 Proper orientation was maintained, with the epithelial side facing
upwards and the limbal edge towards the limbus.
 Muscles hook was used to stretch the graft and squeeze out the excess
fibrin glue.
 The adhesion strength at the edge of the graft was checked using 0.12
forceps. In the cases, where graft detaches while checking the strength,
“touch up” was done by applying fibrin glue to the unsecured areas.
 Surgical time was noted from first cut of conjunctiva to removal of lid
speculum.
 Antibiotic-Steroid eye ointment was then applied.
 Pad and Patch was done to prevent discomfort and then removed on next
morning.
Surgical steps of pterygium excision with conjunctival autograft using
Vicryl sutures: All the surgical steps were same except, instead of using
fibrin glue, conjunctival auto graft was attached to bare sclera with the
help of 7-0 Vicryl suture.

27 | P a g e
Post-operatively following eye drops were prescribed:
 Antibiotic-Steroid combination and Lubricant eye drops with a dose six
times daily for a week and tapered out over 6 weeks.
 Antibiotic ointment applied twice daily for 1 week.
Patients were examined on 1st
postoperative day, at 1 week, at 1 month for
follow-up examination.
 Postoperatively, on all follow up, complete ocular examination was
done including UCVA, BSCVA subjectively and objectively,
Keratometry with two different instruments to determine any diminution
of vision for change in astigmatism, IOP, examination of graft, donor
area, and cornea.
 On each follow up graft was evaluated for:
Position of the graft, graft host junction for any gaping or detachment,
Graft edema, Subgraft hemorrhage, Inflammation, and infection,
Recurrence, Pain, foreign body sensation, epiphora were assessed and
then graded by scale 0 to 3 by asking questionnaires:
Absent -No symptom
Mild -Patient had tolerable symptom and present Occasionally.
Moderate -Tolerable symptom present throughout the day or
Intolerable symptom present occasionally.
Severe -Intolerable symptom present throughout the day.
 Subjective assessment was also done to find out postoperative
discomfort in both types of surgeries.
 Practical benefits anticipated from successfully completed project.

28 | P a g e
PROFORMA
Pt. Name: O.P.D No.
Age/Sex: Occupation:
Presenting complain:
UCVA: BSCVA:
Ant. Seg. Examination:
Type of Pterygium: Nasal/Temporal
Progressive/Non-Progressive
Duration of Pterygium
Keratometry: Auto K Manual K
Type of Operation: Fibrin glue/Vicryl suture
Post-operative Day 1: Post-operative 1month:
Position of Graft- Position of Graft-
Foreign body sensation- Foreign body sensation-
Inflammation- Inflammation-
Graft edema- Graft edema-
Subjective Test- Subjective Test-
Keratometry-(Auto K)(Manual K) Keratometry-(Auto K)(Manual K)

29 | P a g e
STATISTICAL ANALYSIS
1. t- test for testing the significance of difference between two
means17
In this test two independent random reading of 25 patients in both the
techniques have been selected. Auto Keratometry reading for change in
corneal astigmatism after postoperative surgeries at the interval of 1 month
with Fibrin glue and Vicryl suture have been taken.
We are interested in testing the hypothesis that there is no significant
difference in the post op astigmatism between the two surgeries:
Ho : µ1 = µ2 against H1 : µ1 ≠ µ2
Where µ1 and µ2 are mean of the postoperative astigmatism.
We use the following test statistic.
……. Formula 1
Where, = mean of post op astigmatism of Fibrin glue after 1 month
= mean of post op astigmatism of Vicryl suture after 1 month
n1 = no. of patients in fibrin glue (25)
n2 = no. of patients in Vicryl suture (25)
S = Combined standard deviation
The value of S can be calculated by the following formula.
   
221
2
22
2
11



 
nn
S

21
2121
nn
nn
S
t





1
2

30 | P a g e
Thus S = 0.56289504
Putting this value in formula 1
Therefore t = 2.6129563
The degrees of freedom = n1 + n2 - 2 = 48
From the table of t- distribution, we find the value t48, 0.05 = 2.012
t (cal) = 2.6129563 > t (tab) = 2.012
Thus, Hypotheses Ho is not accepted, there is a significant difference in
the post op astigmatism between the two surgeries, at 5% level of
significance.
However, to know whether which surgery is better for postoperative
residual astigmatism we need to test the Co-efficient of Variation.
Where
&
Where,
C.V1 = Co-efficient of Variation for Fibrin glue
C.V2 = Co-efficient of Variation for Vicryl suture
C.V1 = 89.082497 and C.V2 = 97.36995
Therefore, Co-efficient of Variation of Fibrin glue < Vicryl suture which
means fibrin glue surgery is better than Vicryl suture surgery.
100.
1
1
1 


VC 100.
2
2
2 


VC
100. 


VC  
n
 

2



31 | P a g e
2. Paired t –test17
In this test two dependent random reading of 25 patients in both type of
keratometry have been taken. In fact, the two reading from Auto and
Manual keratometry were consisting of pairs of observations made on the
same individual patients. Keratometry readings for difference in corneal
astigmatism between two different instruments postoperatively have been
taken.
We are interested in testing the hypotheses that there is no significant
difference in corneal astigmatism when testing with two different
keratometer:
Suppose the variances of two different keratometry reading are equal to 𝜎2
.
Define ∆ = µ1 - µ2. We want to test the hypothesis
Ho: ∆ = 0 against H1: ∆ ≠ 0
Where µ1 and µ2 are mean of the corneal astigmatism, taken with two
different instruments.
We use the following test statistic.
……. Formula 1
Where, , d = X-Y (difference in reading between two instruments).
n = no of patients (25)
S = Standard deviation of differences
The value of S can be calculated by the following formula.
S
dn
t 
n
d
d

 
1
22




n
dnd
S

32 | P a g e
Where,
= 4.5809 & = -0.3076 putting these value in S.
Thus S = 0.30382671
Putting the value of S in equation 1
Therefore t = 5.0620961
The degrees of freedom = n – 1 = 24
From the table of t- distribution, we find the value t24, 0.05 = 2.06
t (cal) = 5.0620961 > t (tab) = 2.06
Thus, Hypotheses Ho is not accepted, there is a significant difference in
corneal astigmatism when testing with two different keratometer, at 5%
level of significance.
However, to know whether which type of keratometer is better for
measuring corneal astigmatism we need to test the Co-efficient of
Variation.
&
Where,
C.V1 = Co-efficient of Variation of Auto keratometer
C.V2 = Co-efficient of Variation of Manual keratometer
C.V1 = 75.264992 and C.V2 = 75.828157
Therefore, Co-efficient of Variation of Auto keratometer < Manual
keratometer which means Auto keratometry is better option in finding
corneal astigmatism than Manual keratometry.
 2
d n
d
d

100.
1
1
1 


VC 100.
2
2
2 


VC

33 | P a g e
OBSERVATIONS
Pterygium is a common disease entity found in several parts of the
world. The frequency of pterygium occurrences in different groups of
people has been studied and the results of modalities of treatment, which
were employed, are discussed.
In the present study, Conjunctival autograft with fibrin glue was
performed in 25 eyes in 25 patients and Conjunctival autograft with Vicryl
suture was performed in 25 eyes in 25 patients who were evaluated in
detail and compared. The results of various observations were documented
and charted.
TABLE 1- SEX DISTRIBUTION
SEX / TYPE
OF Sx
FIBRIN GLUE VICRYL
No. % No. %
MALE 18 72 14 56
FEMALE 7 28 11 44
TOTAL 25 100 25 100
In our study, males and females were included randomly. The study
comprised of 72% male and 28% female in fibrin glue group as compared
to this Vicryl group male were 56% and female 44%.
0
5
10
15
20
FIBRIN GLUE VICRYL
18
14
7
11
No.ofPatients
GRAPH-1 : SEX DISTRIBUTION
MALE
FEMALE

34 | P a g e
TABLE 2 –AGE DISTRIBUTION
AGE / TYPE
OF Sx
FIBRIN GLUE VICRYL
No. % No. %
21-30 YRS 06 24 03 12
31-40 YRS 09 36 11 44
41-50 YRS 06 24 07 28
51- 60 YRS 02 08 03 12
61-70 YRS 02 08 01 04
In the present study, patients’ age ranged from 21 to 70 years. Maximum
numbers of patients were between 21 to 60 years (92% in fibrin group and
96% in Vicryl group). Pterygium excision was performed considering its
necessity in ocular surface reconstructive surgeries in all age groups.
0
2
4
6
8
10
12
21-30 31-40 41-50 51- 60 61-70
6
9
6
2 2
3
11
7
3
1
No.ofpatients
AGE
GRAPH-2 : AGE DISTRIBUTION
FIBRIN GLUE
VICRYL

35 | P a g e
TABLE 3 - EYE AFFECTED
RE / LE-
TYPE OF Sx
FIBRIN GLUE VICRYL
No. % No. %
RIGHT 10 40 12 48
LEFT 15 60 13 52
In our study, patients were selected randomly. Right eye was affected in
40% in fibrin group and 48% in Vicryl group while left eye was affected
60% in fibrin group and 52% in Vicryl group.
TABLE 4 – LATERALITY OF EYE AFFECTED
LATERALITY/ TYPE
OF Sx
FIBRIN GLUE VICRYL
No. % No. %
NASAL 20 80 16 64
TEMPORAL 02 08 03 12
NASAL + TEMPORAL 03 12 06 24
0
5
10
15
RIGHT LEFT
10
15
12
13
No.ofPatients
EYES
GRAPH-3: EYE AFFECTED
FIBRIN GLUE
VICRYL

36 | P a g e
In fibrin group 80% eyes were nasal, 08% with temporal and 12% with
nasal + temporal pterygium while in Vicryl group 64% were nasal, 12%
temporal and 24% with nasal + temporal pterygium.
TABLE 5 – COMPARISION OF PRE OP AND POST OP BEST
SPECTACLE CORRECTED VISUAL ACUITY
BSCVA/TYPE
OF Sx
FIBRIN GLUE VICRYL
PRE OP POST OP PRE OP POST OP
No. % No. % No. % No. %
6/6 16 64 20 80 15 60 16 64
6/9 03 12 03 12 01 4 05 20
6/12 02 8 02 8 02 8 03 12
6/18 04 16 - - 03 12 - -
6/24 - - - - 01 4 01 4
6/36 - - - - 02 8 - -
6/60 - - - - 01 4 - -
0
5
10
15
20
25
FIBRIN GLUE VICRYL
20
16
2
3
3
6
No.ofPatients
LATERALITY
GRAPH-4: LATERALITY OF PTERYGIUM
NASAL + TEMPORAL
TEMPORAL
NASAL

37 | P a g e
In our study, out of 25 eyes only 07 eyes in Vicryl group had preoperative
best spectacle corrected visual acuity <6/12 which remained only in 4%
post operatively, while in all other eyes BSCVA is ≥6/12 post operatively.
In fibrin group, out of 25 eyes only 04 eyes had BSCVA <6/12 pre
operatively which improved to ≥6/12 with BSCVA post operatively, while
in all other eyes BSCVA increase post operatively.
The improvement in BSCVA was due to reduction in astigmatism and the
residual loss of visual acuity might be attributed to age related changes.
TABLE-6 FOREIGN BODY SENSATION
ABSENT MILD MODERATE SEVERE
FIBRIN
N (%)
VICRYL
N (%)
FIBRIN
N (%)
VICRYL
N (%)
FIBRIN
N (%)
VICRYL
N (%)
FIBRIN
N (%)
VICRYL
N (%)
DAY 1 01(4) - 17(68) - 07(28) - - 25(100)
1 MONTH 21(84) 02(8) 04(16) 23(92) - - - -
0
2
4
6
8
10
12
14
16
18
20
PRE OP FIBRIN GLUE POST OP FIBRIN
GLUE
PRE OP VICRYL POST OP VICRYL
16
20
15
16
3 3
1
5
2 2 2
3
4
0
3
00 0
1 1
0 0
2
00 0
1
0
No.ofPatients
GRAPH-5: PRE AND POST OPERATIVE BEST
SPECTACLE CORRECTED VISUAL ACUITY
6 ⁄6
6 ⁄9
6 ⁄12
6 ⁄18
6 ⁄24
6 ⁄36
6 ⁄60

38 | P a g e
On 1st
postoperative day, as compared to all the eyes in Vicryl group, none
in fibrin glue group had severe foreign body sensation, while 68% and 28%
of eyes had mild and moderate grade of foreign body sensation in fibrin
glue group. At 1 month, 84% patients had no foreign body sensation and
16% had mild sensation in fibrin group while in Vicryl group, only 8%
patients had absent and 92% had mild foreign body sensation.
TABLE-7: POST OPERATIVE INFLAMMATION
FIBRIN
N (%)
VICRYL
N (%)
FIBRIN
N (%)
VICRYL
N (%)
FIBRIN
N (%)
VICRYL
N (%)
FIBRIN
N (%)
VICRYL
N (%)
DAY 1 - - 20(80) - 05(20) 11(44) - 14(66)
1 MONTH 21(84) 06(24) 04(16) 19(76) - - - -
On 1st
postoperative day all the cases from both the groups had
inflammation. In fibrin group, 80% cases had mild and 20 % moderate
0
5
10
15
20
25
FIBRIN VICRYL FIBRIN VICRYL FIBRIN VICRYL FIBRIN VICRYL
1 0
17
0
7
0 0
2521
2
4
23
0
0 0
0
No.ofPatients
GRAPH-6: FOREIGN BODY SENSATION
MONTH 1
DAY 1
Followup Period

39 | P a g e
inflammation. While in Vicryl group, 44% had moderate and 66% cases
had severe inflammation. Inflammation subsided in 84% cases in 1 month
in fibrin group while in remaining cases it persisted upto 6 weeks, compare
to Vicryl group in which only 24% cases were free from inflammation at
the 1 month; 76% cases still persisted with mild inflammation. This can be
attributed to the fact that sutures cause more tissue reaction while
degrading as compare to this fibrin glue causes less inflammation.
TABLE 8: POST OPERATIVE GRAFT ODEMA
FIBRIN GLUE VICRYL SUTURE
ABSENT
N %
PRESENT
N %
ABSENT
N %
PRESENT
N %
1 DAY 04(16) 21(84) - 25(100)
1 MONTH 25(100) - 20(80) 05(20)
0
5
10
15
20
25
FIBRIN VICRYL FIBRIN VICRYL FIBRIN VICRYL FIBRIN VICRYL
0 0
20
0
5
11
0
14
21
6
4
19
0
0
0
0
No.ofPatients
GRAPH-7: POST OP INFLAMMATION
MONTH 1
DAY 1

40 | P a g e
On 1st
post operative day, in fibrin glue group 16% cases had no graft
edema and 84% had present, at 1 month none of fibrin glue patient had
graft edema. While in Vicryl group, all the cases had graft edema on day 1,
which resolved in 80% cases at 1 month while remaining resolved within 6
weeks.
TABLE-9: PRE OP AND POST OP ASTIGMATISM
ASTIGMATISM FIBRIN GLUE VICRYL SUTURE
PRE OP POST OP PRE OP POST OP
(N %) 1Mth (N %) (N %) 1Mth (N %)
Upto 0.50D 08 (32) 15 (60) 06 (24) 15 (60)
>0.50 to 1.0D 04 (16) 07 (28) 07 (28) 03 (12)
>1.0 to 2.0D 07 (28) 03 (12) 04 (16) 06 (24)
>2.0 to 3.0D 04 (16) - 03 (12) 01 (4)
>3.0 02 (8) - 05 (20) -
In our study, Fibrin glue group had >3.0D astigmatism in 8%, >2-3.0D in
16%, >1-2.0D in 28% and 48% had upto 1.0D astigmatism that reduced
0%
20%
40%
60%
80%
100%
120%
ABSENT PRESENT ABSENT PRESENT
16%
84%
0%
100%
100%
0%
80%
20%
PercentageofPatients
GRAPH-8: POST OP GRAFT EDEMA
MONTH 1
DAY 1

41 | P a g e
postoperatively at 1 month upto 88% and only 12% had >1-2.0D
astigmatism postoperatively. While in Vicryl group 20% had >3.0D, 12%
had >2-3.0D, 16% had >1-2.0D and 52% had upto 1.0D of astigmatism
which was reduced to 72% upto 1.0D, 24% upto >1-2.0D and 4% upto >2-
3.0D astigmatism postoperatively after 1 month. Pterygium significantly
affects the corneal astigmatism.
0%
10%
20%
30%
40%
50%
60%
70%
PRE OP POST OP
FIBRIN GLUE
32%
60%
16%
28%28%
12%
16%
0%
8%
0%
PercentageofPatients
GRAPH-9A: CHANGE IN ASTIGMATISM (FIBRIN)
Upto 0.50
>0.50 to 1.0D
>1.0 to 2.0D
>2.0 to 3.0D
>3.0
0%
10%
20%
30%
40%
50%
60%
70%
PRE OP POST OP
VICRYL SUTURE
24%
60%
28%
12%
16%
24%
12%
4%
20%
0%
Percentageofpatients
GRAPH 9B: CHANGE IN ASTIGMATISM (VICRYL)
Upto 0.50
>0.50 to 1.0D
>1.0 to 2.0D
>2.0 to 3.0D
>3.0

42 | P a g e
TABLE-10: MEAN CHANGE IN ASTIGMATISM
Follow up
Period
Mean astigmatism Mean astigmatism
Pre op 1.326 ± 1.177 1.562 ± 1.21
1month 0.460 ± 0.448 0.716 ± 0.631
The mean preoperative astigmatism in fibrin glue group was 1.326 ±
1.177D that reduced postoperatively to 0.460 ± 0.448D (p value <0.001)
whereas Vicryl group had preoperatively astigmatism 1.562 ± 1.21 D that
reduced postoperatively to 0.716 ± 0.631D (p value <0.001). Mean
improvement in astigmatism was 0.866 ± 0.812 in fibrin glue group and
0.846 ± 0.806 in Vicryl group.
1.326
0.46
1.562
0.716
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Pre op 1 month
Meanastigmatism
Followup period
GRAPH-10: Mean change in Astigmatism in both
group
FIBRIN GLUE
VICRYL

43 | P a g e
DISCUSSION
There have been many attempts to optimize Pterygium surgery. Today wide
varieties of techniques are in use. The aim is to excise the Pterygium and
prevent its recurrence.
Age/Sex incidence:
The patients included in our study aged between 20 to 70 years. Mean age
of the patients were 40.48 and 41.24 in fibrin glue group and Vicryl suture
group respectively. The disease affects preferentially adults over middle
age; the highest incidence is in fourth decade. (Table 2)
Pterygium is more frequently seen in men than in women. This is attributed
to the fact that males are exposed to dust and environmental initiates more
than the women. The male/female distribution was 18/7 in fibrin group and
14/11 in Vicryl group (Table 1); compared to this, Koranyi et al12, 13
noted
the male/female distribution as 108/150 in the glue group and 65/59 in the
suture group. The mean age at the time of the surgery was 50 years (range:
24-90 years) in the glue group and 40 years (range: 18-56 years) in the
suture group. Irit Bahar, Dov Weinberger et al18
in their study examined
35 men and 30 women, 25 to 74 years of age (mean, 49 ±12 years).
Pterygium laterality:
In the present study, 72% patients had Pterygium nasally and 18% had
bilateral Pterygium (Table 4). The nasal affinity of the pterygium was
attributed to the following factors. Sparseness of the subconjuntival tissue
in the temporal region. The temporal region is exposed to lesser extent to
UV radiation due to greater amount of bowing of outer 2/3 of t he upper lid.
In the study conducted by Dr. Gnana Murthy and H. Shahul25
it was

44 | P a g e
found 97.2% had nasal Pterygium compared to temporal Pterygium and in
the study by Fernandes, M., Sangwan, V.S., Bansal, A. K., et al.26
, 20%
had bilateral Pterygium.
Postoperative foreign body sensation:
In our study, both the groups were evaluated for postoperative foreign
body sensation; which was graded on scale 0-3 (no, mild, moderate,
severe). On day one, in fibrin glue group more patients (68%) had mild
foreign body sensation as compared to moderate foreign body sensation
(28%) while (4%) had no pain or foreign body sensation while in Vicryl
group all patients (100%) had severe foreign body sensation. At 1 month,
(84%) cases of fibrin glue group had no foreign body sensation while only
(16%) cases had mild symptoms; in Vicryl group, (92%) cases had mild
and only (8%) cases had no foreign body sensation (Table 6).
Similar results were reported by Irit Bahar, Dov Weinberger et al18
who
observed foreign body sensation in 20% fibrin glue patients while in Vicryl
group 60% patients felt foreign body sensation on 1st
post operative day
(p<0.001). On 21st
day, in fibrin glue group all patients were free from
foreign body sensation while in Vicryl group 20% cases still had foreign
body sensation.
None of the patients in fibrin glue group complained of pain while all
Vicryl group patients had complained of pain on first postoperative day.
Koranyi et al12, 13
reported that in contrast to glue, the presence of sutures
causes significantly more postoperative pain (p<0.001). This may be
caused by an up-regulated inflammatory process around the sutures during
degradation.

45 | P a g e
Uma Sridhar et al19
reported in their study that none of the patients
complained of watering. Discomfort and foreign body sensation was
present to a limited extent in all patients and resolved by one week in all
patients.
A. Jain, J. Sukhija et al21
observed that the average pain was significantly
lower when glue had been used (p<0.05).
Postoperative inflammation:
In our study, postoperative inflammation on day one in fibrin glue group
was mild in 80%; 20% had moderate inflammation as compared to 44%
with moderate and 66% with severe inflammation in Vicryl group. There is
always some reparative inflammation following surgery, the glue
components from pure human fibrin does not give rise to additional
inflammation. Both silk and nylon sutures placed in the conjunctiva can
cause inflammation, and migration of Langerhans’ cells to the cornea
(Suzuki et al. 2000)23
. More severe inflammation may cause higher
recurrence rates (Ti & Tseng 2002)24
. (Table 7).
Postoperative Graft edema:
In our study, we observed graft edema in 84% cases with fibrin glue while
in Vicryl group all of the patients were having edema on first post-
operative day. In fibrin glue group, edema resolved in 100% cases at upto
1 month. In Vicryl group, edema resolved in 80% cases at 1 month. (Table
8). Results are comparable with study of Jaspreet Sukhija et al21
who
reported 33.33% in fibrin group and 60% in Vicryl group of patients with
graft edema.
Uma Sridhar et al19
in their study of 20 eyes showed evidence of mild
graft edema which resolved by the second postoperative week.

46 | P a g e
Mean corneal astigmatism:
In our study, the mean preoperative and postoperative corneal astigmatism
was 1.326 ± 1.177D and 0.460 ± 0.448D in fibrin glue group, 1.562 ±
1.21D, and 0.716 ± 0.631D in Vicryl group. The mean absolute change in
corneal astigmatism (difference in the magnitude of astigmatism between
preoperative and postoperative measurement at 1 month) was 0.866 ± 0.812
in fibrin glue group and 0.846 ± 0.806 in Vicryl group. (Table 9-10)
Compared to this, Maheshwari et al22
reported mean absolute change in
corneal astigmatism of 2.85 ± 2.68D with mean preoperative and
postoperative corneal astigmatism to be 4.40 ± 3.64D and 1.55 ± 1.63D
respectively: conjunctival autograft was sutured with 7-0 Vicryl.
Uma Sridhar et al19
in their study, there was significant decreased in
astigmatism after pterygium excision.
Results also correlate with the study of Stern and Lin20
where the mean
preoperative astigmatism was 5.93 ± 2.46D and the mean postoperative
pterygium excision astigmatism was 1.92 ± 1.68D.
From the above statistical analysis17
, we can say that there is a significant
variation in residual astigmatism between two types of surgeries, and fibrin
glue surgery is better option than Vicryl suture surgery.
Again, we can say that there is a significant variation in the power of
corneal astigmatism between Auto and Manual keratometer. Auto
keratometry is better and accurate option for measuring pre and
postoperative corneal astigmatism rather than with Manual keratometry.

47 | P a g e
SUMMARY AND CONCLUSION
A prospective comparative randomized study was carried out on 50 eyes of
50 patients attending the OPD in Rotary Eye Institute, Navsari.
Out of 50 patients, 18 were female and 32 were male.
Higher prevalence rate was observed between the age group of 21 to 60
years. The mean age was 40.48 ± 12.11 and 41.24 ± 9.49 years in fibrin
and Vicryl group respectively.
In fibrin glue patients, post-operative foreign body sensation of mild and
moderate grade was seen in 68% and 28% of eyes respectively. At the end
of 1 month, 84% patients had no foreign body sensation and 16% had mild
sensation. In Vicryl group, 100% patients had foreign body sensation on
day 1.
In fibrin glue group, 80% cases had mild, and 20% had moderate
inflammation. While in Vicryl group, 44% cases had moderate, and 66%
cases had severe inflammation.
In fibrin glue group, 84% cases had graft edema on immediate
postoperative day and all patients were free of graft edema at 1-month
follow-up. In Vicryl group, all patients had graft edema on day 1, which
resolved in 80% cases at 1 month.
The mean preoperative and postoperative corneal astigmatism was 1.326 ±
1.177D and 0.460 ± 0.448D (p value<0.001) in fibrin glue group, 1.562 ±
1.21D, and 0.716 ± 0.631D (p value<0.001) in Vicryl group.
Mean improvement in astigmatism was 0.866 ± 0.812 in fibrin glue group
and 0.846 ± 0.806 in Vicryl group.

48 | P a g e
From the above discussion, we can conclude the following:
There is a significant variation in residual astigmatism between two
types of surgeries, and fibrin glue is better option than using Vicryl
suture in pterygium surgery.
 Use of fibrin glue can be a useful adjunct in attaching Conjunctival
autograft for pterygium excision, as it significantly obviates suture-
related complications and discomfort. Normal anatomical appearance
of the ocular surface was restored in less than a month.
 It has excellent haemostatic properties, which cause less bleeding
during operation and significantly lessens conjunctival inflammation
and graft edema after surgery. In addition, the added advantage of
decreased postoperative morbidity and reduced hospital stay is highly
beneficial which is an important consideration in this day and age.
 However, the cost-benefit ratio needs to be consideration, but full-
paying patients who can afford it, may be offered fibrin glue in
pterygium surgery as a surgical option. The cost of 1 double syringe
of Reliseal is equal to about 5 Vicryl sutures. Up to 3 consecutive
cases can be performed with one Reliseal unit. If we consider the
shorter operative time with the glue, we may conclude that its
material cost approximates that of sutures.
 Long-term studies are needed to determine whether the rate of
pterygium recurrence is affected by the use of fibrin glue instead of
suture material.
 Again, from statistical analysis it can be concluded that Auto
keratometry is better option in measuring pre and postoperative
corneal astigmatism than with manual keratometry, as least patient’s
cooperation and examiners skill is being required.

49 | P a g e
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