Fibrin glue versus sutures for conjunctival autografting in primary pterygium surgery

What is the aim of this review?
The aim of this Cochrane Review was to find out if it is better to use fibrin glue or sutures (stitches) when operating on a pterygium (unwanted growth of tissue on the front of the eye). The operation involves replacing the pterygium with a piece of tissue from another part of the eye (autograft). Cochrane researchers collected and analysed all relevant studies to answer this question and found 14 studies.

Key messages
Using fibrin glue when doing the graft may result in a lower chance of recurrence of the pterygium. The operation may take less time as well. Fibrin glue may be associated with more complications such as a rupture of the graft, the graft shrinking and the development of an area of inflammation (granuloma).

What was studied in the review?
Sometimes a piece of tissue can grow on the front of the eye, and if it grows large enough it can affect vision. This tissue is known as a pterygium. People who live in hot, dusty places with high sunlight are more likely to get a pterygium. A pterygium can be uncomfortable and itchy, and may affect the appearance of the eye.

Doctors can remove this tissue and replace it with tissue from another part of the body, usually from another part of the conjunctiva (which covers the white part of the eye). This is known as a graft or autograft.

Cochrane researchers looked at two different methods of attaching this graft during pterygium surgery, either with fibrin glue or with stitches.

What are the main results of the review?
The review authors found 14 relevant studies. The studies were from Brazil, China, Egypt, India, Malaysia, New Zealand, Philippines, Saudi Arabia, Sweden and Turkey. These studies compared fibrin glue to stitches in people having their pterygium removed and a graft of tissue from the conjunctiva.

Using fibrin glue during pterygium surgery may result in fewer cases of recurrence of pterygium compared with using stitches (low-certainty evidence). It may take less time to do a pterygium operation and graft with fibrin glue (low-certainty evidence). There may be a higher chance of some complications with fibrin glue, such as a rupture of the graft, the graft shrinking or development of an area of inflammation (granuloma).

How up-to-date is this review?
The Cochrane researchers searched for studies that had been published up to 14 October 2016.

Authors' conclusions: 

The meta-analyses, conducted on people with pterygium in a hospital or outpatient setting, show fibrin glue may result in less recurrence and may take less time than sutures for fixing the conjunctival graft in place during pterygium surgery. There was low-certainty evidence to suggest a higher proportion of complications in the fibrin glue group.

Read the full abstract...
Background: 

Pterygium, a growth of the conjunctiva over the cornea, is a progressive disease leading in advanced stages to visual impairment, restriction of ocular motility, chronic inflammation and cosmetic concerns. Surgical removal is the treatment of choice, but recurrence can be a problem. Currently the best surgical option in terms of recurrence is conjunctival autograft. To date the most common surgical methods of attaching conjunctival autografts to the sclera are through suturing or fibrin glue. Each method presents its own advantages and disadvantages. Sutures require considerable skill from the surgeon and can be associated with a prolonged operation time, postoperative discomfort and suture-related complications, whereas fibrin glue may give a decreased operation time, improve postoperative comfort and avoid suture-related problems.

Objectives: 

To assess the effectiveness of fibrin glue compared to sutures in conjunctival autografting for the surgical treatment of pterygium.

Search strategy: 

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 9), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to October 2016), Embase (January 1980 to October 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 14 October 2016.

Selection criteria: 

We included randomised controlled trials (RCTs) in any setting where fibrin glue was compared with sutures to treat people with pterygium.

Data collection and analysis: 

Two review authors independently screened the search results, assessed trial quality, and extracted data using standard methodological procedures expected by Cochrane. Our primary outcome was recurrence of pterygium defined as any re-growth of tissue from the area of excision across the limbus onto the cornea. The secondary outcomes were surgical time and complication rate. We graded the certainty of the evidence using GRADE.

Main results: 

We included 14 RCTs conducted in Brazil, China, Egypt, India, Malaysia, New Zealand, Philippines, Saudi Arabia, Sweden and Turkey. The trials were published between 2004 and 2016, and were assessed as a mixture of unclear and low risk of bias with three studies at high risk of attrition bias. Only adults were enrolled in these studies.

Using fibrin glue for the conjunctival autograft may result in less recurrence of pterygium compared with using sutures (risk ratio (RR) 0.47, 95% CI 0.27 to 0.82, 762 eyes, 12 RCTs; low-certainty evidence). If pterygium recurs after approximately 10 in every 100 surgeries with sutures, then using fibrin glue may result in approximately 5 fewer cases of recurrence in every 100 surgeries (95% CI 2 fewer to 7 fewer cases). Using fibrin glue may lead to more complications compared with sutures (RR 1.92; 95% CI 1.22 to 3.02, 11 RCTs, 673 eyes, low-certainty evidence). The most common complications reported were: graft dehiscence, graft retraction and granuloma. On average using fibrin glue may mean that surgery is quicker compared with suturing (mean difference (MD) -17.01 minutes 95% CI -20.56 to -13.46), 9 RCTs, 614 eyes, low-certainty evidence).

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