The cut and paste technique fibrin tissue adhesive in pterygium surgery

Introduction: Pterygium has been a problematic disease throughout human history, owing its major tendency to recur after surgical removal. The factors causing primary pterygium and also those causing recurrence have been greatly investigated over the centuries. Many theories have been proposed along with countless surgical procedures aimed at preventing recurrence.

Material and Methods: In the 1990s simple excision and use of Mitomycin C (MMC) or free sutured conjunctival autografts were advocated as the best approach to managing pterygia. We compared these two methods in a randomized fashion at the St. Eriks Eye Hospital (Paper 1). All patients were operated on by a single surgeon (GK) and followed up in a regular, standardized manner. We followed our patients for four years in order to determine the method of choice for the future. Autografting turned out to be the best method and was chosen for use during the following years.

To shorten the surgery time, Tisseel Duo Quick, a fibrin-based tissue adhesive was tried instead of sutures to secure the autograft. We discovered that apart from the time for the procedure, postoperative patient discomfort had also been diminished. Therefore, a randomized controlled study was designed to compare suturing to gluing the conjunctival transplant (Paper 2). During the following years, the number and severity of recurrences also seemed to decrease. A retrospective study with long-term follow up was designed and performed, and we were able to confirm our discovery (Paper 3).

The Cut and Paste method has gained popularity in Sweden and elsewhere, and several ophthalmologists were guided by the inventor (GK). At the St. Eriks Eye Hospital two other ophthalmologists were also trained in the technique. In order to evaluate the learning curve, the rates of recurrence and complications when other ophthalmologists use the Cut and Paste method, the first 120 cases operated on by these surgeons were studied and compared with the results of GK (Paper 4).

Results: Autografting turned out to have the lowest recurrence rate and fewest complications. It was therefore chosen as the preferred procedure (Paper 1). We demonstrated that gluing the transplant was fast, safe and caused significantly less postoperative pain than sutures (Paper 2). In a long-term comparative study, we showed that recurrence rate and complications were lower when the autograft was glued rather than sutured (Paper 3). After other ophthalmologists were trained, there were only slight differences in recurrence rates and complications, and no significant learning curve was seen (Paper 4).

Conclusions: This thesis investigates the development and other aspects of the Cut and Paste method for surgery of primary pterygium. Conjunctival autografting was first shown to be superior to the technique of bare sclera with peroperative use of MMC. Then, the Cut and Paste method was shown to be even better, with less patient discomfort, shorter surgery time, and lower recurrence rate. Furthermore, we found it easy to teach and learn. This approach has also gained popularity and appreciation in Sweden and all over the world. Hence, we propose Cut and Paste as the method of choice when operating on primary pterygium.

List of scientific papers

I. Koranyi G, Artzén D, Seregard S, Kopp ED. (2010). "Intraoperative mitomycin C versus autologous conjunctival autograft in surgery of primary pterygium with four-year follow-up." Acta Ophthalmol [Epub ahead of print]:
https://pubmed.ncbi.nlm.nih.gov/20528781

II. Koranyi G, Seregard S, Kopp ED. (2004). "Cut and paste: a no suture, small incision approach to pterygium surgery." Br J Ophthalmol 88(7): 911-4
https://pubmed.ncbi.nlm.nih.gov/15205236

III. Koranyi G, Seregard S, Kopp ED. (2005). "The cut-and-paste method for primary pterygium surgery: long-term follow-up." Acta Ophthalmol Scand 83(3): 298-301
https://pubmed.ncbi.nlm.nih.gov/15948780

IV. Gabor Koranyi MD, Ditte Artzén MD, Tomas Wijk MD. (1970). "Learning curve in the Cut and Paste method for surgery of primary pterygium" (Submitted)