ABSTRACT

A 50-year-old man with recurrent pterygium and a 46-year-old woman with primary pterygium underwent surgery using a novel autograft transfer technique that facilitates autograft suturing and ensures correct graft orientation. After removing the pterygium, three edges of the autograft were cut. The autograft was flipped first over the uncut edge and secured to the superior margin of the recipient bed with two sutures. Afterward, the fourth side of the graft was cut and the second flip was done over the sutured edge. Thus, the autograft was in correct surface and side orientation and was sutured to the recipient bed. This simple technique provides both easy transfer and correct orientation of the graft in autograft pterygium surgery.

Introduction

Pterygium is a wing-shaped fibrovascular conjunctival extension onto the cornea.¹ As pterygium is a common disorder, pterygium surgery is one of the most frequently performed eye surgeries.² Ideally, pterygium surgery should prevent recurrence, because postoperative recurrence is an annoying problem for both patients and surgeons.³ Currently, the preferred method of pterygium surgery is conjunctival autografting because of its lower recurrence rates after pterygium removal.^1,4 However, several complications such as graft edema, corneoscleral dellen, conjunctival inclusion cyst, and graft necrosis are observed in conjunctival autografting.^5,6 Conjunctival autografting also involves challenges such as suturing difficulties due to shrinkage and inverse implantation of the graft.⁵ When all edges of a conjunctival autograft are cut, graft orientation can easily be lost during transfer and after suture or sponge contact.⁶ Free conjunctival graft inversion may reduce surgical success by causing graft necrosis. It has also been reported that limbal-fornix disorientation of the graft may cause conjunctival graft edema.⁵

In our patients, we developed a novel graft transfer technique that facilitates graft suturing and ensures proper limbal-fornix and epithelial side up orientation.

Discussion

Numerous methods have been used for the treatment of pterygium and the prevention of pterygium recurrence. The bare sclera technique allows re-epithelialization of the scleral bed after simple excision of the pterygium. This approach is appealing due to its short surgical time and easy application, but it is rarely used today due to the high risk of recurrence (24-89%).⁷ Conjunctival autografting involves covering the exposed scleral bed after pterygium excision with a free autograft from the conjunctiva. Conjunctival autografting is widely used because it effectively prevents pterygium recurrence, but it requires technical expertise and a prolonged operative time.⁸ Furthermore, amniotic membrane is used to cover the exposed scleral bed after pterygium excision. Studies show that while amniotic membrane is associated with less recurrence compared to the bare sclera technique, the recurrence rate is higher than with conjunctival autograft.^9,10

Pterygium is believed to occur due to a local limbal deficiency, probably caused by chronic ultraviolet-related damage to limbal stem cells.¹¹ Healthy limbal tissue serves as a barrier that inhibits subconjunctival tissue invasion onto the cornea. LCAT is used in pterygium surgery to reduce pterygium recurrence by restoring limbal function.⁴ In a meta-analysis, LCAT was found to have a lower recurrence rate (0-17%) than all other surgical techniques and practices, including bulbar conjunctival autograft.¹² This result also supports the importance of limbal cells. Therefore, it is crucial to keep the correct (limbal and surface epithelial) directional and surface orientation of the graft while moving it to the recipient bed to increase surgical success and reduce complications.¹³

Various methods are described to prevent graft inversion and limbal-fornix disorientation: marking or cauterizing the graft edge, marking the graft with the letter “G”, and the fibrin glue method.^6,13 In these methods, a free graft is obtained by cutting all four sides of the graft. Other than with the “G” marking technique, limbal or surface disorientation of the autograft may occur while transferring and suturing the free graft. Our technique ensures proper limbal-fornix and epithelial side up orientation of the graft onto the recipient bed. Unlike the methods described above, it provides easier transfer and suturing because at least one graft edge is always fixed (which is superior to the “G” marking technique). Other advantages of our technique are that the first two sutures become embedded after the second flip and can be easily used in different graft fixation methods (e.g., suturing, fibrin glue, autologous fibrin in blood, electrocautery pen).

The double flip technique may reduce complications and increase surgical success as it ensures both easy transfer and correct orientation of the graft.