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• W2178869321 abstract "Purpose: To compare the use of polyglactin sutures versus nylon sutures for conjunctival autograft suturing in pterygium surgery. Methods: A prospective, randomized, controlled, clinical trial was conducted, in which 32 eyes of 32 patients with primary nasal pterygium were randomized to undergo pterygium surgery with the use of nylon sutures or polyglactin sutures for conjunctival autograft suturing. Patients were followed up for 3 months. Outcome measures included postoperative discomfort according to a visual analogue scale (VAS), graft hyperaemia, graft oedema and tarsal conjunctival papillary reaction. Results: There was no significant difference in the postoperative discomfort as assessed by VAS in both groups at all follow-up visits. Patients who had polyglactin sutures for suturing conjunctival autograft were noted to have more tarsal conjunctival papillary reaction at day 1 (p = 0.01) and more graft hyperaemia at week 1 (p = 0.019) after the operation. At 4 weeks postoperatively, significantly more nylon sutures remained on the autograft (p = 0.021), some of which were buried and could not be removed. Conclusions: Both polyglactin and nylon are effective suture materials for autograft suturing in pterygium surgery and cause comparable postoperative discomfort. Polyglactin sutures resulted in slightly more conjunctival reaction in the early postoperative period compared with nylon sutures. Pterygium excision followed by conjunctival autograft has been shown to be a safe and effective procedure for pterygium, with recurrence rates ranging from 2% to 39% (Kenyon et al. 1985; Lewallen 1989; Chen et al. 1995; Prabhasawat et al. 1997; Tan et al. 1997). Suture materials commonly used for conjunctival autograft suturing include polyglactin and nylon. Polyglactin is a copolymer of glycolide and lactide with high initial tensile strength (Ethicon Products Division, Johnson & Johnson, Gateway, New Brunswick, NJ, USA; http://www.jnjgateway.com) (Salthouse et al. 1977). The material has the advantage of being absorbed within 60 days, thus eliminating the need for suture removal. However, many surgeons often remove absorbable sutures 10–14 days after pterygium surgery to minimize irritation. Nylon, on the other hand, is a non-absorbable monofilament suture composed of polyamides, with minimal cellular response and prolonged tensile strength retention (Salthouse et al. 1977). Ophthalmological studies have compared polyglactin and nylon sutures for scleral flap suturing in trabeculectomy, corneal incision closure in phacoemulsification and various oculoplastic surgeries (Linberg et al. 1991; Bainbridge et al. 1998; Raina et al. 1999). Although some studies have demonstrated nylon and polyglactin sutures to be equally effective in terms of anatomical success and complications, others have reported otherwise. The aim of our study was to compare polyglactin versus nylon sutures for suturing conjunctival autograft in pterygium surgery with reference to postoperative discomfort and conjunctival reactions. Patients with primary pterygium were prospectively recruited in Hong Kong Eye Hospital during March−June 2005. Inclusion criteria included patients with primary nasal pterygium, aged 18 years or older, and able to co-operate in surgery under local anaesthesia. Patients with recurrent pterygium, scarred superior conjunctiva, previous surgery involving the superior bulbar conjunctiva, history of glaucoma, and/or cicatricial ocular surface disease were excluded. The study protocol and informed consent procedure were approved by an ethics committee and informed consent was obtained from all patients. The study was conducted in accordance with the tenets of the Declaration of Helsinki. Simple randomization with a computer-generated randomization table was used to allocate patients to the polyglactin or nylon suture groups. Patients were unaware of the suture material used but the surgeon and postoperative assessor were not masked to the assignment. All operations were performed by a single surgeon (VWYW) under topical anaesthesia with 0.4% oxybuprocaine hydrochloride drops given three times at 5-min intervals 15 mins before the surgery, supplemented with a subconjunctival injection of 0.2–0.5 ml 2% lignocaine with 1 : 100 000 epinephrine beneath the pterygium body at the commencement of the surgery. The pterygium head was grasped with forceps and lifted off the cornea. Subconjunctival fibrovascular pterygium tissue was dissected with scissors, after which the scleral bed was cauterized. The bare scleral defect was covered with autograft harvested from the superior bulbar conjunctiva and sized to overlap the edges of the defect by 1 mm horizontally and vertically. The autograft was transferred to the scleral defect with the limbal side opposing the limbus of the recipient. Interrupted 8–0 polyglactin sutures (Polyglactin 910; Johnson & Johnson, Gateway) or 10–0 nylon sutures (Ethilon nylon; Johnson & Johnson, Gateway) were placed with the four cardinal sutures anchored into the episclera. All knots remained unburied. Postoperatively, patients received a tapering course of dexamethasone, neomycin and polymyxin B eyedrops (Maxitrol; Alcon Laboratories, Inc., Fort Worth, TX, USA) for 6 weeks. Patients were reviewed at 1 day, 1 week, 4 weeks and 3 months postoperatively. At each postoperative visit, patients were asked to rate their discomfort using a 10-cm visual analogue scale (VAS) with one end labelled ‘no discomfort’ and the other labelled ‘worst possible discomfort’. Slit-lamp examination was performed to assess the amount of graft hyperaemia, oedema and tarsal conjunctival papillary hypertrophy using a 4-point scale (0 = absent, 1 = mild, 2 = moderate, 3 = severe). All remaining sutures were removed 4 weeks postoperatively. The primary outcome was the difference in VAS score between the two groups. Secondary outcomes included graft hyperaemia, oedema and tarsal conjunctival papillary hypertrophy. Complications such as stitch granuloma, graft dehiscence, epithelial defect and pterygium recurrence were also noted. Pterygium recurrence was defined as the presence of any corneal fibrovascular encroachment. For detecting a 20% difference in VAS score with a standard deviation of 10, α = 0.05 and power = 80%, the calculated sample size was 16 eyes in each group. All data were entered into spss Version 11.5 (SPSS Inc., Chicago, IL, USA). The differences in VAS score, graft hyperaemia, oedema and tarsal conjunctival papillary hypertrophy between the two groups were analysed using the non-parametric Mann–Whitney U-test. Fisher's exact test was performed to analyse the recurrence between the two groups. Serial comparisons of VAS score were performed using the Wilcoxon signed rank test. A p-value of ≤ 0.05 was considered statistically significant. A total of 32 eyes of 32 patients were recruited, of which 17 were randomized to the nylon group and 15 to the polyglactin group. One patient in the nylon group defaulted follow-up after week 1. The subsequent analysis was performed by ‘intention-to-treat’(Fig. 1). The baseline demographics of the two groups were comparable (Table 1). The mean number of nylon and polyglactin sutures placed was 9.4 (range 7–11) and 9.7 (range 8–13), respectively (p = 0.52). No intraoperative complications were encountered. Flow of participants in the study. Postoperatively, there was a significant decrease in the mean VAS discomfort score from day 1 to month 1 in both groups (p = 0.001). There was a trend for patients in the polyglactin group to report more postoperative discomfort than patients in the nylon group, especially at week 1, but the difference did not reach statistical significance (Fig. 2). Visual analogue scale score of postoperative patient discomfort in the nylon and polyglactin groups. Patients in whom polyglactin sutures had been used for suturing conjunctival autograft were noted to have more tarsal conjunctival papillary reaction at day 1 and more graft hyperaemia at week 1 after the operation compared with patients in the nylon group (p = 0.01 and p = 0.019, respectively). No significant difference in graft oedema was noted between the two groups postoperatively (Table 2). At 4 weeks postoperatively, significantly more nylon sutures (mean 2.6, range 0–7) remained on the autograft compared with polyglactin sutures (mean 0.9, range 0–4) (p = 0.021). Some of the nylon sutures were buried and could not be removed at week 4 and three patients had one or two residual buried nylon sutures at 3 months. All polyglactin sutures were successfully removed at week 4. Two patients in the nylon group and one in the polyglactin group were noted to have pterygium recurrence < 0.5 mm at month 3 (p = 0.59, Fisher's exact test). Fine superficial corneal vessels without concurrent fibrosis developed in two eyes in each group. In all, 18 patients continued in follow-up beyond the study period, seven in the nylon group and 11 in the vicryl group. The mean lengths of follow-up in the nylon and vicryl groups were 13.7 months (range 6–18 months) and 12.1 months (range 6–20 months), respectively. No new recurrences were seen. Of the three patients who had pterygium recurrence of < 0.5 mm, two continued in follow-up beyond the study period and no increase in the size of the pterygium recurrence was noted. The aim of conjunctival autograft after pterygium excision is to reduce recurrence; it is essential that the autograft is well anchored in the postoperative period. Various suture materials and techniques are employed to secure the autograft, including absorbable and non-absorbable sutures of different diameters. Sutures are placed either interrupted or continuously, with knots left exposed or buried. Although many reports have assessed the technical modifications and recurrence rates of conjunctival autograft for pterygium surgery, few have compared the use of different suture materials in terms of postoperative patient discomfort. In this randomized, controlled trial, we found that polyglactin sutures resulted in more tarsal conjunctival papillary reaction at day 1 and more graft hyperaemia at week 1 postoperatively. In a randomized, controlled study comparing polyglactin and nylon sutures for closing temporal corneal incisions after phacoemulsification, it was found that mild localized corneal haze developed in 18% of cases, which may be associated with absorption of the polyglactin sutures (Bainbridge et al. 1998). Menovsky et al. (2004) reported a higher incidence of infections and suture granulomas with the use of polyglactin compared with nylon sutures for skin closure in carpal tunnel surgery. Other studies found the two suture materials to perform similarly (Linberg et al. 1991; Raina et al. 1999; Gabel et al. 2000). Varssano et al. (2002) evaluated the efficacy of pterygium excision and conjunctival autograft using either 10–0 nylon or 8−0 to 10−0 polyglactin sutures for conjunctival autograft suturing. It was noted that superficial corneal vessels without concurrent fibrosis developed in 58.8% of eyes sutured with nylon, whereas none were seen in the polyglactin group. Our results did not show any such association, with only two eyes in each group showing fine superficial corneal vessels. Despite similar levels of postoperative discomfort and conjunctival reaction in the two groups after the first postoperative week, each suture material confers its own advantages. In the surgeon's experience, nylon sutures allowed for easier intraoperative handling and knotting. However, the removal of nylon stitches, especially those that are buried, is more difficult. Our results showed that significantly more nylon sutures remained on the autograft at week 4 compared with polyglactin sutures and removal may be more time-consuming and cause greater discomfort to the patient. Stitches that were buried and could not be removed may eventually become exposed and patients would require additional visits for suture removal. The short follow-up represents a limitation of our study. As the main outcomes were postoperative discomfort and conjunctival and autograft reactions, patients were only followed for 3 months. A longer follow-up duration would be required to assess the incidence of recurrence. Nevertheless, we retrieved our patients' medical records more than a year after the completion of the study and found no new recurrences or increases in the size of pterygium recurrence in patients who underwent subsequent follow-up. The use of a 10-cm VAS in the assessment of pain is advantageous in that it is a continuous scale, is easy to use and has been used in pain assessment in pterygium surgery (Oksuz & Tamer 2005). We identified a trend for patients in the polyglactin group to report more postoperative discomfort than patients in the nylon group, but the results did not reach statistical significance. A larger study in the future may be warranted to explore the association further. In summary, both polyglactin and nylon sutures are effective for conjunctival autograft suturing in pterygium surgery, and cause comparable levels of postoperative discomfort. The choice of suture material would depend on the surgeon's preference, availability, cost and the patient's co-operation in suture removal. As the use of fibrin tissue adhesive for conjunctival autograft anchoring is becoming more popular (Koranyi et al. 2005), the results of this study may provide useful information for comparing the use of sutures and tissue glue in pterygium surgery." @default.
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• W2178869321 title "Polyglactin sutures versus nylon sutures for suturing of conjunctival autograft in pterygium surgery: a randomized, controlled trial" @default.
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