Comparison of Fibrin Glue and Sutures for

Attaching Conjunctival Autografts after
Pterygium Excision
Harvey S. Uy, MD,1,2 Johann Michael G. Reyes, MD,1 John D. G. Flores, MD,1 Ruben Lim-Bon-Siong, MD1

Purpose: To compare the efficacy and safety of fibrin glue and suturing for attaching conjunctival autografts
among patients undergoing pterygium excision.
Design: Prospective, randomized, interventional case series.
Participants: Twenty-two patients undergoing excision of primary pterygium.
Methods: A superior conjunctival autograft was harvested and transferred onto bare sclera after pterygium
excision. Fibrin glue (Beriplast P) was used to attach the autograft in 11 eyes and nylon 10-0 suture was used to
attach the autograft in 11 eyes. The patients were followed up for 2 months.
Main Outcome Measures: Graft success, recurrence rate, operating time, patient comfort.
Results: All conjunctival autografts in both groups were successfully attached and were intact after 2
months. The average operating time for the fibrin glue group was significantly shorter (P⬍0.001). Postoperative
symptoms were fewer for the fibrin glue group than the suture group. One patient (9%) from the fibrin group
experienced subconjunctival hemorrhage, and 1 patient (9%) from the suture group experienced partial graft
Conclusions: Fibrin glue is a safe and effective method for attaching conjunctival autografts. The use of fibrin
glue results in shorter operating times and less postoperative discomfort. Ophthalmology 2005;112:667– 671 © 2005
by the American Academy of Ophthalmology.

The main challenge of pterygium surgery is prevention of such as buttonholes, suture abscesses, granuloma formation,
recurrence. High recurrence rates have prompted ophthal- tissue necrosis, and giant papillary conjunctivitis.8 –15
mologists to develop different adjunctive measures for re- Tissue adhesives are alternative means for attaching con-
currence prevention. Beta-radiation, excimer laser, and junctival grafts and may shorten operating time, improve
antineoplastic–antimetabolite drugs are some techniques postoperative comfort, and avoid suture-related complica-
currently used to prevent return of the pterygium, but these tions.16,17 This purpose of this study is to compare the
may sometimes be associated with serious complications.1–7 efficacy and safety of a preparation of fibrin glue (FG;
Conjunctival autografting after pterygium excision is Beriplast P, Aventis Behring, King of Prussia, PA) with
associated with lower recurrence rates (2%–9%) and rela- nylon sutures for attaching conjunctival autografts during
tively few sight-threatening complications.8 –10 pterygium surgery.
The current method of attaching conjunctival autografts is
by means of suturing. The use of suture materials requires a
high degree of surgical skill and is associated with several
disadvantages, including prolonged operating time, postopera- Patients and Methods
tive discomfort, and potential for suture-related complications
Twenty-two consecutive patients with primary pterygia undergo-
ing primary pterygium excision at the Philippine General Hospital
from June to August 2001 were prospectively enrolled. A com-
Originally received: August 30, 2004. prehensive medical and ocular history was obtained, including
Accepted: November 12, 2004. Manuscript no. 2004-62. patient age, gender, family, medical and ocular history. Snellen
Department of Ophthalmology and Visual Sciences, University of the visual acuity measurement, funduscopy, applanation tonometry,
Philippines, Philippine General Hospital, Manila, Philippines. slit-lamp examination, and anterior segment photography were
Asian Eye Institute, Makati, Philippines. performed preoperatively. Patients with ocular pathology other
Presented in part at: Association of Researchers in Vision and Ophthal- than error of refraction, with a history of previous ocular surgery
mology Annual Meeting, May, 2002; Fort Lauderdale, Florida. or trauma, narrow occludable angles, ocular hypertension, physi-
The authors have no financial interest in any of the products or devices ologic or glaucomatous optic disc cupping, a family history of
mentioned in the article. glaucoma, or known hypersensitivity to any component of FG
Correspondence to Harvey S. Uy, MD, Asian Eye Institute, 9F Phinma were excluded. Informed consent was obtained from all patients.
Plaza Building, Rockwell Center, Makati, Philippines 1200. E-mail: The institutional review board approved the protocol and informed consent form.

© 2005 by the American Academy of Ophthalmology ISSN 0161-6420/05/$–see front matter 667
Published by Elsevier Inc. doi:10.1016/j.ophtha.2004.08.028

fibrin sealant to prevent rapid fibrinolysis. grade 3 ensure that the spatial orientation was maintained and that the sides (fleshy). the conjunctiva was carefully The mean surgical duration was 67. technique described by Starck et al. 2. Care was taken to maintain the spatial orientation of the Pterygium graft in relation to the limbus. All pterygia were nasally located. Fort Worth. Only 1 eye per patient was entered and the sutured group. All patients completed the 2-month area of the graft and separate it from the underlying Tenon’s follow-up period. containing thrombin (human) and calcium chloride. factor drops were applied 6 times daily for 1 month after the surgery. and contact dermatitis. The mean prevent buttonholes and graft rollover. Astra.9 The conjunctival donor graft site was marked on all sides with gentian violet to outline an oversized graft with an additional 1. factor XIII. tonometry were tested during each visit. severe. and grade 2 (interme. Dissection was carried to the Siong et al:18 (0) none. we followed the postoperative symptoms. XIII (human). It is a 2-component system patch applied for 24 hours. tion of pterygium grading was similar for both groups (Table 1). The distribu- capsule. Table 1. The mean age was 45⫾20 lution was injected into the donor conjunctiva to balloon out the years (range. 13 were male (59%). was used to determine differences in pain intensity and other For harvesting the free conjunctival autograft. Sweden) was then injected into the pterygium head to erate. fibrinogen. The sides of the graft were then attached to the surrounding conjunctiva 1 (atrophic) 0 (0) 0 (0) 2 (intermediate) 6 (55) 7 (64) at intervals of 1 to 1.8⫾1. After instillation the fourth week. 2. the graft was placed onto the bare sclera. Data Analysis tival edges were then excised with Wescott scissors.0 mm of length and width Results relative to the dimensions of the graft bed. the lid retractors were removed. After a drying period of 5 minutes. tearing. n ⫽ 11 eyes). The limbal side of the graft was Grade Suture Group (%) Fibrin Glue Group (%) affixed to the limbal area with horizontal mattress sutures. Tobramycin– dexamethasone ointment (TobraDex. Worth. foreign body sensation. The graft was then et al:13 grade 1 (atrophic). By use of minimal manipulation and atraumatic conjunc. 668 . and clinical virus safety measures. no pain. episcleral vessels under the body of the immediately transferred onto the bare sclera. pain causing some discomfort. Because the major The patients were followed up on the first day after surgery and components of FG. 23– 67 years). (3) mod- Zeneca. The 3 (fleshy) 5 (45) 4 (36) sutures were removed 1 month postoperatively. n ⫽ 11 eyes) or FG difference between the mean operating room time of the FG group (treatment group. development of complications such as corneal defects. sterile preparation and draping. Alcon Laboratories. Aprotinin from bovine lungs is present in the retractors to its removal at the end of surgery. and the patient was asked to blink several times to test graft Fibrin Glue adherence and mobility. 15) taking care to follow the on weeks 1. a drop of fibrinogen solution was placed on the bare sclera and spread out with a needle cannula. The pterygium head and surrounding atrophic conjunc. A lidocaine– epinephrine solution (Xylocaine 2%. (2) mild. Fort junctiva into the cornea. (4) balloon out the conjunctiva and delineate the underlying fibrovas. and thrombin. 4. cular tissue. Treatment Group and its 4 corners were anchored to the episclera with nylon 10-0 sutures. Of the 22 patients. presence of pain but limbus. and 8. The lidocaine– epinephrine so. and 4 using a 5-point scale adapted from Lim-Bon- surgical plane of the pterygium. A slit-lamp examination nants is prevented by screening of plasma donors and donated was performed at every visit to monitor autograft integrity and plasma. potential transmission of contami. The epithelial side was marked to prevent graft inversion. tival forceps and Vannas scissors. pain that partially interferes with usual activity or sleep. Thrombin The pterygia were graded according to the system used by Tan solution was applied to activate the sealant. of the graft were apposed to the edges of the recipient conjunctiva. Tobramycin and dexamethasone eye- composed of Combiset-1. Fibrinogen is converted into fibrin on a tissue surface by the action of thrombin. granuloma forma- tion. virus removal or inactivation by the manufacturing pro. episcleral vessels totally obscured. are then on weeks 1. Fibrin is Study Procedures then cross-linked by factor XIII to create a firm. April 2005 Pterygium Grading In the FG group. giant papillary conjunctivitis. Care was taken to suture group and 27. and aprotinin (bovine). TX) was placed in all eyes and a pressure stage of the coagulation process.0 minutes for the FG group. Distribution of Pterygium According to Grading and For the suture group. Snellen visual acuity testing and isolated from human plasma. Number 4. The patient was then randomly assigned by coin toss to receive Analysis of covariance was used to determine whether there is a either nylon 10-0 sutures (control group. aron formation.6 minutes for the dissected away from the Tenon’s capsule. and Combiset-2. mechanically Operating time was measured starting from placement of the lid stable fibrin network. all other pterygia not falling into these 2 grades. Ophthalmology Volume 112. Recurrence was defined as any growth of con- of topical proparacaine HCl (Alcaine. containing fibrinogen (human). symbleph- cess and pasteurization. The pterygia were dissected from and discomfort were evaluated on the first postoperative day and the apex using a surgical blade (No. Care was taken to pterygium are not obscured and clearly distinguished. diate). Blunt and sharp dissection was performed to separate the pterygium from the underlying sclera and surrounding con- junctiva. TX). The Friedman test for K-related samples in the study. Surgical Technique Graft success was defined as an intact graft by the fourth week after surgery.0⫾3. pain that completely interferes with usual activity or sleep. Alcon Lab- Fibrin glue (Beriplast P) is a fibrin sealant that imitates the final oratories. easily tolerated.5 mm with simple interrupted sutures. the involved eye underwent standard ophthalmologic Subjective sensations of pain. graft failure was defined as absence of the graft by A single surgeon (JGR) performed all surgeries. (1) very mild. The free graft then was placed on top of the cornea and kept moist using sterile normal saline solution irrigating solution.

some amount of graft edema and hemorrhage was present in all eyes. 669 . Fluorescein staining shows epithelial defect corresponding to pterygium site. One patient in the suture group had partial graft dehiscence develop inferiorly and a conjunctival defect that resolved after 2 weeks. The same eye 1 day after pterygium excision with intact conjunctival autograft attached with fibrin glue. which spontaneously resolved after 3 weeks. foreign body sensation. One patient in the FG group had extensive subconjunctival hemorrhage develop un- der the graft. Five-point scale assessment of postoperative foreign body sen- Subjective symptoms of pain. operating time was significantly shorter when FG was used instead of nylon sutures (P⬍0. Postoperatively. A. and discomfort were fewer and disappeared more rapidly in the FG group than the suture group. Uy et al 䡠 Fibrin Glue 4 3 Degree of pain Fibrin glue group 2 Suture group 1 0 1 7 14 28 Days after surgery Figure 2. Figure 1. B. The intensity of these symptoms was significantly lower in the FG group than the suture group on all follow-up days (P⬍0. Figure 3. tearing.001). Five-point scale assessment of postoperative pain after conjunc- tival autografting. The same eye 1 month after surgery showing complete corneal reepithelializa- tion and a successful conjunctival autograft with markedly less conjunc- tival congestion and hemorrhage. There were no cases of pterygium recurrence at the end of the follow-up period (Fig 1). and it gradually subsided over time. Anterior segment photograph showing preoperative fleshy grade 3 nasal pterygium. sation after conjunctival autografting. All grafts were successfully attached and were intact by the end of the follow-up period. None of the patients lost vision or had symblepharon develop at the donor site. One patient (9%) in the suture group with a large pterygium blocking the visual axis noted an improvement in Snellen visual acuity from 20/200 to 20/25. C.001). without graft dehiscence. All patients treated with FG were asymptomatic after 2 weeks (Figs 2–5).

15 Degree of Tearing Glue 2 Group Although conjunctival autografting is safer and clearly more Sutured effective than bare sclera resection in preventing pterygium 1 Group recurrence.14 Because the use of fibrin glue 2 S u tu re d G ro u p removes the need for the tedious suturing process. Number 4. All autografts were suc- pterygium removal.3. lamellar keratoplasty. used and 25 times higher odds of recurrence if MMC was This study compared the use of a different preparation of not used. No recurrences occurred by the end of the 2-month 0 observation period in both treatment groups. and. the learning curve can be shortened.17 Vicryl 7-0 sutures were compared with FG. However. Koranyi et al17 recently completed a junctival autografting. The advantages of using FG include ease of use.12. and this case responded to steroid treatment. In the study by MMC is more effective than ␤-irradiation for prevention Koranyi et al. the use of MMC can be asso. uveitis. repair of leaking glaucoma filtering Discussion blebs. a greater amount of surgical expertise and tech- nical ability is needed to attach autografts using sutures.12 Conjunctival autografting is also associated with fewer 3 Fibrin complications. more recently. Because the graft survival rate is similar Figure 5. Five-point scale assessment of postoperative tearing after con. cataract surgery. and attachment of an amniotic membrane patch. Vienna. Baxter. Moreover. con. A recent study reported that the success rate of sutured conjunctival au- 3 tograft can vary widely among different surgeons (range. No sight-threatening complications developed.5 operative symptoms were still reported when FG was used Conjunctival autografting results in lower pterygium re. and postoperative comfort. and graft dehiscence. in pterygium surgery.2 However. Austria) to reduce the patients and surgeons.19 A recent meta-analysis of pterygium alone can be used to attach conjunctival autografts and at recurrence after surgery concluded that simple bare sclera the same time reduce operating time and postoperative resection alone is associated with 6 times higher odds of discomfort. because the use of FG produces significantly less symptoms. The authors recommended that simple bare sclera FG (Beriplast P) with the use of nylon 10-0 sutures for excision should not be encouraged as a method of primary securing conjunctival autografts. pterygium recurrence if a conjunctival autograft was not and none of the eyes lost vision in both series. conjunctival autografting will be better accepted by the patients.1. amniotic mem. although intraoperative cessfully attached using this preparation. such as FG. randomized clinical trial that demonstrated that FG (Tisseel) brane grafting. It is clear from these results that grafts attached with FG are better tolerated than 4 grafts attached with suture material. The short follow-up period is a 670 . cataract. Even ciated with sight-threatening complications such as cor. Only 1 case of necrotizing scleritis has been reported. for both groups. Fi- junctival autografting. and better results may be more consistently achieved despite differences in surgical 1 expertise. for attaching conjunctival autografts.14 Furthermore. sym- 1 7 14 28 blepharon. number of sutures needed for attaching conjunctival grafts rence prevention include use of mitomycin C (MMC). oculoplastic and orbital surgery. fewer complications and less postoperative discomfort. The current major methods of recur. Five-point scale assessment of subjective postoperative discom. April 2005 4 currence rates compared with bare sclera excision with primary closure and use of amniotic membrane grafts. offer an alternative Days after surgery method of conjunctival graft attachment that may produce Figure 4. though nylon 10-0 is a finer material and should produce neoscleral melt. This variability was attributed to significant F ib rin G lu e learning curves and different surgical skill levels among G ro u p different ophthalmologists. This study compared FG with nylon 10-0 sutures. fewer post- and symblepharon. would be similar as well. Ophthalmology Volume 112. suture use is associated with patient discom- 0 fort and minor complications such as dellen ulcer. brin glue has previously been used in ophthalmology for conjunctival wound closure. it is expected that the recurrence rates fort after conjunctival autografting. Degree of Discomfort 5%– 82%). secondary glaucoma. no 1 7 14 28 conclusions can be made from our data regarding long-term D a ys a fte r s u rg e ry recurrence rates.20 –26 Pterygium recurrence is the most common complication of Cohen and MacDonald16 have used an organic tissue pterygium surgery and is a frequent source of frustration for adhesive (Tisseel.17 Biologic adhesives. of pterygium recurrence. less suture-related discomfort than Vicryl 7-0.11. shorter operating times.

containing the lyophilized components. Tseng SC. Kajiwara K. Closure of blepharoplasty incisions with autol- 661–5. Br J Ophthalmol 1993. Kaza V. Stein RM. See LC. Arch Ophthalmol 1990. Sakla HF. Kaufman HE. 13.84:385–9. Kamlesh. safety of the ProTek (Vifilcon A) therapeutic soft contact lens after photorefractive keratectomy. 8. Comparative study of and biological bioadhesives in scleral tunnel phacoemulsifi- intraoperative mitomycin C and beta irradiation in pterygium cation in eyes with high myopia. Lim-Bon-Siong R. Sanchez-Thorin JC. Cornea planned to determine the recurrence rates and long-term 2003. 20. Br J Ophthalmol 2000. et al. J Cataract Refract Surg surgery. Kenyon KR. comparing conjunctival autografting with bare sclera excision. Dadeya S. Koranyi G. Allan BD.115:1235– 40. Liau SB. Barton K.109: primary pterygium.84:973– 8. volume. By use of sterile techniques.24:983– 8. success rates in conjunctival autografting for primary and several 0. Cornea 1991. Serious complica. Dear KB. Kaufman daunorubicin versus conjunctival autograft in primary ptery.0-ml total volume among 15. Chen PP.109:599 – 601.84:618 –21. The surgical assistant can primary closure for pterygium excision. Comte PR. Pfister RR. Effect of pterygium or conjunctival autograft. Hayasaka S. Surgically induced necro- several patients. comparing mitomycin C and conjunctival autograft after ex- age. Setogawa T. Talu H. The direct cost of FG was approximately $100 for a 1-ml Arch Ophthalmol 1997. Oph. 25. Yildiz TF. Br J Ophthal- Long-term studies are needed to determine whether the rate mol 2004. including potential for anaphylactic reaction and Ophthalmology 1985. Gordon M. By dividing the 1. 9. Efficacy and of suture material. Conjunctival autograft for disease transmission. ogous fibrin glue. 24. Cornea 2002. J Cataract Ophthalmol 1990. Analysis of variation in patients on the same day. Cryoprecipitated fibrinogen (fi- tive instillation of low-dose mitomycin C in the treatment of brin glue) in orbital surgery. Tsai RJ. Yelin JB.120. Tasindi E. Arch Oph- The use of FG can significantly shorten operating times and thalmol 1993. surgery for primary pterygium. Refract Surg 1998. Burkett G. Cohen RA.88:911– 4. Uy et al 䡠 Fibrin Glue limitation of this study.99:1647–54. Chee SP. Chee SP. None of the patients in this study had primary and recurrent pterygia: surgical technique and prob- anaphylactic reactions. Amniotic membrane graft for primary pterygium: comparison with conjunctival autograft and 1. Lagoutte FM. Am J Ophthalmol 1998. Gobbi F. tions of topical mitomycin-C after pterygium surgery. Br J Ophthalmol 2000. Conjunctival au- There are some concerns regarding the safety of fibrin tograft transplantation for advanced and recurrent pterygium.82: 22. Mandel MA. Hemo I. the cost can be reduced to $10 to $20 per tizing scleritis after pterygium excision and conjunctival au- eye. small incision approach to pterygium surgery. et al. of conjunctival autografts. Am J Ophthalmol 1995. 11. Am J Ophthalmol 1998. tograft. Zauberman H. Intraoperative 26. 4. Akarsu C. Excimer laser photo. Lim AS. Rubinfeld RS. Tan DT. Ariyasu RG. Ma DH. 23. Human fibrin tissue adhesive for sutureless lamellar ker- gium surgery. Meta-analysis on the 21. Efficacy of synthetic 5. Prabhasawat P. Hettinger ME.1-ml doses of FG can be readied without cross. Fatima S. 671 . Adherence to good manufacturing lem management.111:1167– 8. 125:169 –76. recurrent pterygium. Starck T. Our practice was to schedule 5 to 10 pterygium 14. Postopera. processes can help avoid transmission of pathogens. tografts with an organic tissue adhesive [letter]. Am J therapeutic keratectomy for recurrent pterygium. et al. Am J Ophthalmol 1990. Serrano F. Ibrahim-Elzembely HA. Rao GN. et al. References 19.21:305–7. A fibrin sealant for recurrence rates after bare sclera resection with and without perforated and preperforated corneal ulcers. An. McDonald MB. Noda S. glue use. In summary. Yamamoto Y. Use of fibrin glue in ocular surgery. The diluent is injected into the corresponding vial cision of primary pterygium. Pterygium excision other drawback is the lack of a cost-effectiveness analysis.22:522– 6. Ti SE. Br J Ophthalmol mitomycin C use and conjunctival autograft placement in 1989. We estimate the prepara. Oshika T. of pterygium recurrence is affected by the use of FG instead 18.19:132–3. Tan DT. Ciftci F. 2. effects of FG in securing conjunctival autografts.108:842– 4. A randomized trial Fibrin glue (Beriplast-P) comes in a ready-to-use pack.73:757– 61. 3.92:1461–70. Br J Ophthalmol 2000. Cornea 2002. Amano S. Kenyon KR. Cut and paste: a no suture. The desired amount 151– 60. Ophthalmic Surg 1988. Repair of a leaking bleb with fibrin glue. so that there is no addition to the morphology on pterygium recurrence in a controlled trial total operating time. Rocha G. et al. Khurana C.106:715– 8. Comparison needle and is ready for injection. 1998. Seregard S. with conjunctival autografting: an effective and safe tech- It would be interesting to investigate whether FG can be nique. Ergin A. 6. McCaffrey TV. Br J Ophthalmol 1998.77:698 –701.24:1326 –32. Wagoner MD. Valluri S. Ophthalmology 1997: prepare the FG while the surgeon is excising the pterygium 104:974 – 85. FG is an effective and safe method for 16. and tion time to be 5 minutes or less. Dear KB. SC. 17. topical mitomycin C treatment. of FG component is then drawn off with a sterile syringe 12. Taner P. atoplasty and scleral patch adhesion: a pilot study. 10. 5-Fluorouracil as chemoadjuvant mology 2003. Bansal AK. Alio JL. Motoyama Y. thalmology 1992. Sridhar MS. used to secure amniotic membrane grafts as well.21:766 –9. amniotic membrane grafts. 227– 8.10:196 –202. Short P. Crawford CJ. Mulet E. produce less postoperative symptoms and discomfort. Fixation of conjunctival au- attaching conjunctival autografts during pterygium surgery. Ophthal- 7. Gauthier L. Insler MS. Kopp ED.110:2168 –72. and a long-term study is being for primary pterygium surgery: preliminary report. contamination. Bartley GB.