Biological Glue in Pterygium Surgery Rotational Flap or Sliding Flaps

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Biological Glue in Pterygium Surgery Rotational
Flap or Sliding Flaps?

• David Zadok, Aron Zavaro, Morris Hartstein,
  Liat Attas, Isaac Avni, Oren G Benyamini
• Assaf Harofeh Medical Center
• Zerifin, Israel

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Introduction

• Autologous conjunctival grafting seems to be the
  best method for surgical removal of pterygium
• Low recurrence rate.
• High safety.
• Time consuming.
• Prolonged patient discomfort.

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Aim

• To compare two surgical techniques of
  conjunctival flap placement during pterygium
  surgery using a commercially available FDA
  approved, tissue adhesive Tisseel (Baxter,
  Vienna, Austria). One technique is the single
  rotational flap, and the other is the double
  sliding flaps.

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Tisseel

• Two component tissue adhesive which mimics the
  natural fibrin formation.
• Fibrinogen mixed with factor XIII and aprotinin.
• Thrombin-CaCl2 solution.
• The two components are mixed and applied on the
  flap and sclera simultaneously.

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• Through the action of thrombine the
  fibrinopeptides are split to fibrin monomers.
  These monomers aggregate by cross linking
  resulting in a fibrin clot. Thrombin
  concentration can be varied to regulate the speed
  of coagulation

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Methods

• A consecutive case series.
• 33 patients, 34 eyes with nasal pterygium.
• Group A Pterygium excision with a rotational
  flap.
• Group B Pterygium excision with sliding flaps.
• In both groups the flaps were pasted into place
  with fibrin glue Tisseel.
• Operating time was evaluated.
• Flap location and status was examined 1 day, 1
  week, 2,4 and 12 weeks post operatively.

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Rotational flap

• A conjunctival flap of the same size as the
  nasal conjunctival defect was prepared at the
  superior limbus of the same eye. The flap was
  moved to the nasal area and attached to the
  sclera with glue

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Double sliding flaps

• The body of the pterygium was dissected from the
  sclera and the surrounding macroscopically
  healthy Tenons capsule. Next the superior and
  inferior conjunctiva flaps were prepared. The
  inferior and superior flaps were pasted into
  their final position by placing a drop of Tisseel
  on the sclera and a second drop on the
  conjunctiva underside. Finally the nasal
  conjunctiva stump was pasted to the flaps edges.

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Results

• Day 1 Group A, all flaps (100) were found to
  be in place. Group B, 2 eyes (13) the superior
  and inferior flaps disengaged one from the other
  and a 2-3 mm gap between them was found. In 1 eye
  (6.5) the inferior flap disengaged completely
  and retracted to the lower fornix, and in 1 eye
  (6.5) both flaps disengaged from each other and
  from the sclera and completely retracted, leaving
  an area of bare sclera.

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Results Cont

• On the final follow-up visit (week 12) the flaps
  in both groups retained their previous position
  and were well integrated into the surrounding
  tissues. No evidence of recurrence was found,
  including the cases with the bare sclera.

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Discussion

• Tisseel has been used in medicine for over a
  decade.
• In ophthalmology it has been proven useful for
• Treating conjunctival wounds and fistulas.
• Adapting free skin grafts in eyelid surgery.
• Repairing injured canaliculi.
• Sealing wounds in cataract surgery.
• Pterygium surgery.

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Cut and Paste A no suture, small incision
approach to pterygium surgery. Koranyi G,
Seregard S, Kopp ED. BJO 200488911-914.

• A prospective randomized clinical trial comparing
  pasting conjunctival grafts vs suturing. (n43)
• Using glue instead of sutures causes
  significantly less post-operative pain and
  shortens surgery time significantly.
• Pre-published promising reports on hundreds of
  cases on the internet.

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Conclusion

• Pasting a rotational flap in pterygium surgery is
  a promising technique, insuring an excellent
  immediate post operative result with the
  advantages of biological glue over sutures
  shorter operating time and higher patient comfort
  and satisfaction. However its long term benefits
  are still to be determined.
• Pasting sliding flaps is not recommended by the
  results of this study and should be abandoned.

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Thank You