American Journal of Medicine and Medical Sciences

p-ISSN: 2165-901X    e-ISSN: 2165-9036

2023;  13(11): 1760-1777

doi:10.5923/j.ajmms.20231311.36

Received: Oct. 23, 2023; Accepted: Nov. 15, 2023; Published: Nov. 21, 2023

 

Excision of the Pterygium with Conjunctival Autograft and Autologous Blood to Prevent Recurrence

Mohammed Selim Reza 1, Md Rahimullah Miah 2, Nizam Jamil Hussain 1, Farhana Tasnim Chowdhury 1, Azima Aktar Jhuma 3, Md Altaf Hossain 4

1Department of Ophthalmology, North East Medical College Hospital, Affiliated to Sylhet Medical University, Sylhet, Bangladesh

2Department of IT in Health, North East Medical College Hospital, Affiliated to Sylhet Medical University, Sylhet, Bangladesh

3Department of Microbiology, Sylhet MAG Osmani Medical College Hospital, Affiliated to Sylhet Medical University, Sylhet, Bangladesh

4Department of Ophthalmology, Sylhet Women’s Medical College Hospital, Affiliated to Sylhet Medical University, Sylhet, Bangladesh

Correspondence to: Mohammed Selim Reza , Department of Ophthalmology, North East Medical College Hospital, Affiliated to Sylhet Medical University, Sylhet, Bangladesh.

Email:

Copyright © 2023 The Author(s). Published by Scientific & Academic Publishing.

This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/

Abstract

Background: The recurrence rate of primary pterygium has been decreased by the use of conjunctival autograft following surgical removal. This study describes the use of autologous blood for conjunctival autograft placement in order to reduce operative time, operative discomfort, and recurrence during follow-up. Materials and Methods: Fifty patients with primary pterygium were included in the study and divided into three groups. 7 patients aged 25–35 years in group I, 15 patients aged 36–45 years in group II and 28 patients aged 46–55 years in group III. The conjunctival autograft was grafted with autologous blood in all groups. Operative time, postoperative discomfort and recurrence were demonstrated in the three groups of patients. Results: Studies have shown that 80% of patients with pterygium excision are men, aged between 46 and 60 years. The study showed nasal 35 in male and 7 in female patients, while temporal 5 in male and 3 in female patients. The minimum surgical interval time with conjunctival autograft using autologous blood was 21 minutes and the maximum time was 45 minutes. After excision, the conjunctival limbal autograft has the lowest recurrence rate. The study represents at the end of the final follow-up at 3 months, the incidence of recurrence was observed in both male and female patients. Patients should be advised to wear sunglasses to reduce UV exposure and growth stimulation. Conclusion: The study concluded that without fibrin glue is the most effective method for conjunctival autograft attachment with autologous blood in pterygium surgery with minimal operative time and operative discomfort. Autologous blood instead of fibrin glue is an effective alternative way that is readily available, cost-effective, with less surgical time and operative discomfort. Using sutures is an old technique that involves maximum operation time and operative discomfort. Recurrence is reduced by using autologous blood without fibrin glue.

Keywords: Excision, Conjunctival autograft, Autologous blood, Interval time, Pterygium

Cite this paper: Mohammed Selim Reza , Md Rahimullah Miah , Nizam Jamil Hussain , Farhana Tasnim Chowdhury , Azima Aktar Jhuma , Md Altaf Hossain , Excision of the Pterygium with Conjunctival Autograft and Autologous Blood to Prevent Recurrence, American Journal of Medicine and Medical Sciences, Vol. 13 No. 11, 2023, pp. 1760-1777. doi: 10.5923/j.ajmms.20231311.36.

Article Outline

1. Introduction
2. Materials and Methods
    2.1. Data
    2.2. Techniques
    2.3. Interpretation
    2.4. Postoperative management
3. Results
    3.1. Gender Status
    3.2. Age Gradation
    3.3. Laterality of Pterygium on Gender
    3.4. Presentation Status of Pterygium
    3.5. Presentation Interval Time
    3.6. Risk Factors
    3.7. Complications
4. Discussion
    4.1. Treatment
    4.2. Recurrence
    4.3. Precautions
    4.4. Myths about Pterygium
    4.5. Risks
    4.6. One Health Policy Implication
5. Conclusions
Declaration
ACKNOWLEDGEMENTS

1. Introduction

Eye is the most important organ among the five senses, without which all human and animal life is dark. But in this beautiful enlightened life of all, suddenly various diseases spread to the eyes, which make everyone sick, many are deeply worried and don't want to see the dark world for the blind anymore [236]. Many people ask the question - why does the person suddenly have pain in the eyes [174]? Suddenly his eyes spread a lot of light why? Suddenly the person's vision became blurred? [9], why does his eye itch? What is the reason for his eyes suddenly turning red? Why suddenly double vision in his eyes? Why after a few days the triangular wings like fleshy hypertrophy [43,44,45] and decreased vision? [15,65,168]. Studies have shown that they cause pterygium and other eye diseases [1,6,7]. Pterygium, a term derived from "pterygion" (ancient Greek for wing), is a wing-shaped, fibrovascular overgrowth arising from subconjunctival tissue [74,213] that extends across the limbus of eyes [1,17,70,176]. Eyes are sensory organs that help all organisms see the world like bio-cameras [107]. Sudden overexposure to harmful rays of the eye causes abnormal triangular fin-like growths on the conjunctiva, resulting in reduced vision [235,236]. A pterygium is a membrane-like growth from the conjunctiva to the cornea [216], caused by the inner flesh of the eyelid, which is a worsening condition of the conjunctiva or subconjunctiva. It gradually grows from the canthus of the eye towards the cornea and many veins and arteries converge, resulting in a red appearance. The pterygium is also a degenerative condition of the subconjunctival tissue [213,215] that expands as vascularized granulation tissue to invade the cornea, destroying the superficial layers of the stroma and Bowman's membrane, the entire entity is covered by conjunctival epithelium [1,2]. This problem may recur after general surgery [36,37,48]. The prevalence of primary pterygium varies from 0.7% to 31% in different populations around the world [38]. Working outdoors increases the risk by 1.5 times [38]. Although the exact etiology is unknown, risk factors include genetic predisposition [180], chronic environmental irritants [108,110,111,141] such as dust, dryness, heat, and UV rays [5,19].
A pterygium is usually managed conservatively unless it has progressed to the pupillary area causing excessive astigmatism [76], resulting in vision loss [1,24]. Reported rate of recurrence [77], after simple excision of primary pterygium is 25%-45% [187,195]. High rates of recurrence are explained by the theory of corneal limbal stem cell deficiency [16,23,164,194]. A study by Spaeth et al [204] described a change in surgical technique using conjunctival autograft to cover the bare sclera after pterygium excision [12,13], resulting in reduced recurrence rates [3,29,33,50,55,69,73,161]. After pterygium surgery [177], the conjunctival autograft is secured with absorbable or non-absorbable sutures [1,25,94]. The presence of stitches is associated with various complications [39,154], viz. discomfort, increased lacrimation and occasionally suture-related granuloma or abscess [1,31,85]. With the discovery of new alternatives such as fibrin glue [80] and autologous blood [151], suture-related complications have ceased [25,28]. The use of fibrin glue during pterygium surgery was first described by Cohen and McDonald in 1993 [32]. Since then, several studies have been published on the safety and efficacy of fibrin glue in ophthalmic surgery [88,89,91,166]. This study presents innovative ideas compared to other studies, which will be exceptional and realistic to many researchers [40]. Because fibrin glue is a blood-derived product [175], its use is associated with an increased risk of blood-related disease transmission [185,188]. In addition, fibrin glue is expensive and rare in adjacent areas [217,230]. In this case, autologous blood is a good option as it is easily available- the only exceptions are patients who regularly take aspirin or other blood thinners or who suffer from coagulation factor deficiencies.
This study illustrates innovative research on autologous blood and advanced technology compared to the traditional use of sutures in attaching conjunctival autografts. To the best of the researcher's knowledge, very few studies have demonstrated improved health techniques for pterygium retrieval to avoid complications.

2. Materials and Methods

2.1. Data

50 patients reported with primary pterygium were recruited into the study after obtaining informed consent. A comprehensive evaluation was performed, which included the patient's biophysical profile, relevant medical and eye history, and a thorough eye ocular examination. Patients with recurrent pterygium or a history suggestive of hypersensitivity to human blood products were excluded from the study. Patients were divided into three groups of 20 each. In all three groups of patients, pterygium was excised with conjunctival autografting.

2.2. Techniques

The technique of securing the autograft was different in all three groups. Among the 50 patients, there were 7 patients aged 25-35 years in the first group, 15 patients aged 36-45 years in the second group and 28 patients in the third group aged 46-60 years. Autologous blood was used during surgery to secure the autograft for all patients. All surgeries were performed under local anesthesia [88] using a combination of 2% lignocaine and 0.5% bupivacaine [1]. The peribulbar block was followed by cleaning and sterile draping [84]. Tus bridle sutures were applied using Superior Rec 3-0 silk. Pterygium is excised using corneal scissors and sometimes a crescent blade is also used. Bleeding is controlled by applying pressure from a cotton bud. No cauterization was done. The area of the conjunctival defect was measured with (i) a caliper and (ii) a conjunctival limbal autograft obtained from the bulbar conjunctiva pretemporal quadrant measuring the same size, which as shown in Figure 1.
Figure 1. Representative images (A, B, C & D) of the conjunctival autograft using autologous blood of a patient in pterygium (male, age 57)

2.3. Interpretation

The graft was inverted over the cornea and brought close to the area of bare sclera formed by the incision of the pterygium. had the correct orientation maintenance is performed during graft placement. Depending on the group to which patients were assigned, the conjunctiva-limbal autograft was secured in place.

2.4. Postoperative management

All patients were given eye drops at regular intervals as advised by the ophthalmologist. Male and female patients were followed up at week 1 and then at weeks 2, 4 and 8, respectively. All patients were followed up with regular feedback for up to 3 months postoperatively.

3. Results

3.1. Gender Status

The study on excision of pterygium showed the gender status including male and female in Figure 2. The study also reveals that male patients were maximum (80%) in this study.
Figure 2. Male and Female status in the study of Excision of Pterygium

3.2. Age Gradation

The study showed the age status of excision of pterygium, which as shown in Figure 3. The study revealed that maximum patients were 28 (both male and female) within the age of 46-60 years.
Figure 3. Age Gradation

3.3. Laterality of Pterygium on Gender

The study showed the laterality of pterygium on male and female, which as shown in Figure 4. The study revealed that nasal 35 in male and 7 in female patients, while temporal 5 in male and 3 in female patients.
Figure 4. Laterality of pterygium on gender

3.4. Presentation Status of Pterygium

The study included the different presentation on excision of pterygium, which as shown in Figure 5. A 57-year-old landowner, Suranjan Das lives in Sunamganj district of Bangladesh. He came to the Department of Ophthalmology at North East Medical College Hospital with complaints of overgrowth of pink fleshy membrane in the right eye for the past 3 months, associated with foreign body sensation and visual loss, which had been the same for the past 1 month. Both near and far vision and there was no diurnal variation. On examination, a wing-shaped fleshy fold of the conjunctiva is seen on the cornea. An expert ophthalmologist performed the surgery successfully on time. The patient was followed closely, and the pterygium recovered smoothly. Presentations are shown in various ways, namely:
i. Examination of head, face and eyes:
(a) Head posture: straight and erect.
(b) Eye symmetry: symmetrical, right eye.
(c) Facial Symmetry: Symmetry.
ii. ROPLAS test: negative.
iii. Confirmation: Pterygium surgery with approval.
iv. Set up the preoperative environment
v. Surgery with conjunctival autograft using autologous blood.
vi. Follow dressing and postoperative period
vii. Wear anti-radiation sunglasses
viii. Recovery: Pterygium free postoperative eye.
Figure 5. Showing Presentation status with different steps of Pterygium Excision at the Department of Ophthalmology, North East Medical College Hospital, Sylhet, Bangladesh. Patient Mr. Suranjan Das, male, 57 years, right eye, resident: Sunamganj

3.5. Presentation Interval Time

The study showed the presentation interval time between male and female in different ages, which as shown in Table 1. The study also showed that the average interval time in Group-I (age 20-35) was 29 minutes, which was the lowest interval, but 45 minutes in Group-III (age 55+), which expressed as the maximum interval. Study represents interval time followed by age significance.
Table 1. Presentation Interval Time between male and female
     

3.6. Risk Factors

The study identified the top ten risk factors during presentation of excision of pterygium in the study area. These include, (i) hot climate, (ii) sun exposure, (iii) ultraviolet exposure, (iv) dry heat, (v) high winds, (vi) prolonged dryness, (vii) heavy dust and (viii) certain misuse of GPS sensor devices in the area, (ix) post-operative, risk of patient travels due to lack of ambulance area network control devices, and (x) follow-up problems due to lack of patient residential area network control units.

3.7. Complications

The study found the complications including (a) cystic degeneration, (b) infection, (c) neoplastic change to epithelioma, (d) fibrosarcoma or malignant melanoma, (e) diplopia, (f) symblepharon, and (g) dimness of vision due to astigmatism.

4. Discussion

Research shows that Pterygium is a common eye condition that is mostly observed in populated, dry, hot, dusty areas [1]. Initially the disease is treated with alternative and readily available surgical options to manage its current condition with prevention of recurrence [1]. Although this is the "ideal" Pterygium surgery known to all, there is controversy regarding it in some cases [221]. The exact cause of this disease is not known, but recent studies have shown that it is caused by wireless sensor tracking [130]. The disease is more common in the elderly, but studies have shown that people with GPS tracking in their eyes develop the ophthalmic diseases [130]. Again, there is a foreign body sensation in the eye, but sometimes the eye twitches. Many say that people who work in the sun or in dusty conditions are more prone to this disease, hot weather, smoky environment and dry eye problems increase this veil. If this membrane grows too much to penetrate the cornea, surgery is required [97]. This problem may recur after general surgery [96]. Surgical use of a conjunctival graft to cover the bare sclera after pterygium excision is easily the most effective [12,13,53], as shown in this study—with an average recurrence rate of 5% and scientifically active methods to reduce complications in a short period of time [73,92,210,204]. On the other hand, conjunctival-limbal autograft transplantation helps to compensate for limbal stem cell deficiency in a short period of time [34-35,54,56]. Studies also show that care must be taken when harvesting the graft to include the organ component, which includes the stem cells [92].
The study shows that scientific excision of pterygium with conjunctival autograft by using autologous blood to prevent recurrence can be done very easily and at low cost [28]. Autologous blood is a good alternative to sutures for conjunctival autograft attachment in pterygium surgery [155,175,185]. Sutures have inherent disadvantages of post-operative complications—comfort, eye opening, and other complications, whereas autologous blood is safer [185,217]. The use of autologous blood simplifies surgical procedures, shortens operating time, improves patient comfort, and sometimes produces less operative discomfort. Connecting the conjunctival autograft with autologous blood is technically difficult but can be learned with practice and is an excellent scientific method that avoids the need for sutures and glues, making it cost effective. Diabetic microvascular damage and differentiation of conjunctival tissue may be a major cause of pterygium [17,47,196,156,169]. Moreover, pterygium is caused by multiple diseases through wireless sensor tracking, especially coronavirus [107,112,113,120,121,123,127,130,143,145,146,148], cardiac arrest [106], stroke, tracheal disorder [147], diabetes [110,126], chronic kidney disease (CKD) [68], numbness [147], cancer [150], ARDS (acute respiratory distress syndrome) [138], liver cirrhosis [130,212], dengue [142], stomach cancer [150], obesity [127], numbness [147], and digital dermal disease [125, 237]. Pterygium is also caused in child [130,139,144] and wildlife due to GPS sensor tracking [122,124,131,133,134,135,136,140,141,149]. Moreover, pterygium is also spread as pandemic due to GPS tracking at active open eyes and voice with ultra-violet sensors [129,137]. Several observations are comparable to other studies on the priority application of advanced sensor technology [217].

4.1. Treatment

Pterygium needs to be treated at an early stage [51,152,207], which has not yet reached the stage of operation. Therefore, sometimes the use of beta-radiation or cryotherapy after surgery can be beneficial [199]. First line treatment- treatment of symptomatic patients involves tear substitutes, and topical steroids for inflammation [99,181-184,208]. Patient should also be advised to wear sunglasses to reduce ultraviolet exposure and decrease the growth stimulus [86]. Antibiotic treatment- has no role of antibiotic, but more adjuvant therapies can be applied [20,26,57,192].
PRAST Treatment Model [130]: PRAST implies Pterygium Recovery through Advanced Sensor Technology, a complementary model of DRAST (Disease Recovery through Advanced Sensor Technology). PRAST is a complementary procedure, which is simple, easy and acceptable and has a lower recurrence rate of ophthalmic diseases.
This PRAST model is newly in ophthalmic diseases treatment and less costly but taking more time. The patient must follow the principles of PRAST, which as shown in Figure 6, namely:
Figure 6. PRAST Treatment Model to recover pterygium
i. When a person experiences a sudden vision or a blurred vision, he must quickly move from his existing position to another place.
ii. The person with pterygium should immediately close the eyes tightly and keep the anti-radiation sunglasses on for 5 to 25 minutes or depending on the eye's good feeling.
iii. The sick person must remain quiet in the bedroom and when he feels sneezing, yawning, coughing and hiccups, he must quickly change his GPS position.
iv. A sick person must wear sunglasses while walking or being outside in sunlight.
v. When a healthy person is infected with Pterygium at an early stage, he must be in a network isolation zone,
vi. The person must remain in a silent mood as per mental health principles without switching-on the mobile phone till the time of recovery.
vii. Persons shall use PANCU (Personal Area Network Control Unit) devices for recovery of pterygium and other diseases.
viii. In case of sudden flatulence, nausea or polyphagia immediately close your eyes tightly and change your position quickly to recover.
ix. If the affected person uses a wireless sensor network isolator or residential area network control unit (RANCU) where he lives or works, he will recover.
x. When the person goes to sleep, if there are sudden itchy eyes, hiccups, sneezing, coughing or flatulence while awake on the pillow, move immediately and do it in another place, then he will sleep on the previous pillow soundly.
xi. Cybercriminals track the device with GPS sensor that makes the person sick, detect it with cloud network detector and disconnect the said connection, he will get well immediately.
xii. If the growth of pterygium is unexpected, he must follow the advice of an ophthalmologist.
This PRAST model recovers early-stage pterygium within 5-21 days depending on the principles followed accordingly. Post-operative pain was lower when anti-radiation glass was held over the eye compared to other methods. Because the anti-radiation glass disconnects the body cloud network at a specific GPS location.

4.2. Recurrence

After excision the recurrence rate is lowest in conjunctival limbal autograft, which follow the other studies [14,33,50,55,64,66,93,94,157,158,160,167,171,179,186,187,190,200,201,203,205,209,210,225,226,241].

4.3. Precautions

Precautions to prevent recurrence of pterygium- after excision the bare sclera is treated with-
a) Beta radiation (by strontium-90) not more than 2000 rads during the 1st week of surgery [83].
b) Thio-TEPA solution as drop (1 in 2000) 4 times daily for 6 weeks [162,206].
c) Mitomycin-C (0.02%) solution locally during operation [10,18,49,61,62,71,81,82,95,98,100,191,193].
d) Conjunctival limbal Autograft or amniotic membrane graft [4,12,21,27,30,52,57,69,72,75,78,79,87,90,98,153,159,163,165,173,186,189,197,198,202,211,214].
e) Surgical excision with lamellar keratectomy or lamellar keratoplasty [8,13,22,60,157,160,239].
f) old methods to prevent recurrence (not preferred now)- included transplantation of pterygium in lower fornix (McReynolds’s operation) and postoperative use of beta radiation [3,12,21,30,52,72,73,75,83,87,165,170,172,189,197,202,211,214].

4.4. Myths about Pterygium

Many doctors still have lies about pterygium. Some of them say that pterygium is due to diabetic [46] and heredity [11,58,59], some say that pterygium is due to ultraviolet radiation, some say that the patient is suffering from various diseases, some doctors say that pterygium is caused by virus/ bacteria like human papilloma virus [41,42,178]. Research shows that the above reasons are all myths. Pterygium is through GPS sensor tracking. Although advanced sensor technology was not invented before, when sensor devices were invented, natural pterygium was converted to disease simulation code and converted to ophthalmic disease (pterygium) code [130]. If the code is tracked by the GPS sensor, the pterygium occurs. When a person sits or lies down with eyes open at a specific GPS location, tracking the eyes with the GPS sensor device is affected by too much light and immediately blurs the person's vision. A flash of sensor light falls into the eye, causing a layer called a pterygium. The ISNAH (Impact of Sensor Network towards Animals and Humans) [112] effect suggests that the root cause of pterygium is wireless sensor tracking [130]. As the range of radiofrequency increases, so does the degree of ocular involvement, i.e., the prevalence of various ophthalmic diseases. Ophthalmic diseases can become pandemic due to this sensor tracking [130].

4.5. Risks

The human eye is a bio-camera, which receives all images through photoreceptors [107]. Cybercriminals convert sensor cells into images, and those images have digital tracking, digital poisoning, burning, collapsing, fracturing, damaging, blocking, swelling, shrinking and disturbing effects built-in to the device. By tracking these sensor cells with a wireless device, pterygium and other diseases in the eye are infected. Research has shown that humans and animals instantly become ill with CASSID (Common Acute Sudden Sensorineural Infection and Disorder) by tracking a GPS sensor to a specific location [112]. Light sensor tracking exposes the eye to intense light, causing the person to see a sudden blur at a specific GPS location. Failure to move quickly results in the formation of a triangular-shaped covering at one corner of the eye, called a pterygium. This pterygium increases due to repeated wireless sensor tracking through cloud networks. Pterygium is one type of ophthalmic diseases. So, individuals are in risks in pterygium with CASSID in the following top-ten ways [130], (Figure 7) namely:
Figure 7. Individuals infect in ophthalmic diseases due to GPS sensor tracking [130]

4.6. One Health Policy Implication

The number of patients with pterygium is increasing unexpectedly. Studies have shown that the misuse of wireless sensor technology is increasing the impact of disease in humans and animals, which is a cause for concern. Hence one health policy is needed to address this. Global crises require dynamic solutions and integrated responses linked to one health system [240]. Research findings reveal that the impact of one health policy is essential for advanced generations, including HELPTAP: (i) Human health [112,113,125,126,127], (ii) Environmental health [108,109,103,111,115,116,117,118,119,122,124,129], (iii) Legal health [128,130,131,132,133,135,238], (iv) Political health [136,243], (v) Technological health [101,102,104,105,114,134,150], (vi) Animal health [119,242], and (vii) Plant health [114,242,244]. As wireless sensor technology improves, its misuse due to lack of security is increasing. These abuses pose a threat to public health, which is difficult and time-consuming to address within a single sector. The One Health Approach facilitates new programs, policies, legislation, technology use, research and implementation across multiple sectors to communicate and work together to achieve improved public health outcomes. It promotes mutual cooperation between sectors, stakeholders and countries in the use of advanced technologies for protection, disease control and health care eco-technology-linked prevention. One health system can play an important role in getting comprehensive solutions to public health threats arising at the human-environment-legal-political-technological-animal-plant (HELPTAP) interface in the present era, especially in treating ophthalmic diseases and avoiding unforeseen risks.

5. Conclusions

Conjunctival autografting and autologous blood represent an exceptional concept in the health world in the treatment of pterygium. Studies show that autografting without sutures greatly reduces recurrence rates and effective surgical time. Furthermore, adequate management of the patient's ocular surface and reduction of postoperative inflammation without medication are crucial for low recurrence rates and good cosmesis. New methods on the subject of scientific research are currently being developed to standardize pterygium treatment in less time and less cost without surgery. A better understanding of the PRAST process by medical stakeholders can bring future treatments within reach by improving health science and ensuring the use of safe technologies to create a pterygium-free world.

Declaration

Funding
This research work has no financial support from any doners. So, the funders had no role in the design of the research, in data collection, analyses or final interpretation of data, in the writings of the manuscript, or in the decision to publish the findings.
Data Availability
The data being used to support the findings of this research work are available from the corresponding author upon request.
Competing Interests
The authors declare no potential conflict of interests in this research work.

ACKNOWLEDGEMENTS

The authors acknowledged the authority of North East Medical College Hospital (NEMCH), affiliated to Sylhet Medical University at Sylhet in Bangladesh for kind support.

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