Biological Glue in Pterygium Surgery Rotational Flap or Sliding Flaps

1. 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

2. 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.

3. 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.

4. 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.

5. 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

6. 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.

7. 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

8. Double sliding flaps The body of the pterygium was dissected from the sclera and the surrounding macroscopically healthy Tenon�s 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.

9. 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.

10. 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.

11. 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.

12. Cut and Paste: A no suture, small incision approach to pterygium surgery. Koranyi G, Seregard S, Kopp ED. BJO 2004;88:911-914. A prospective randomized clinical trial comparing pasting conjunctival grafts vs suturing. (n=43) 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.

13. 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.

14. Thank You