Modified sutureless and glue-free method versus conventional sutures for conjunctival autograft fixation in primary pterygium surgery: a systematic review and meta-analysis.

BACKGROUND: Pterygium is a common ocular surface disorder that requires surgical intervention for treatment. Conjunctival autografts are preferred over simple excision due to lower recurrence rates. This systematic review and meta-analysis compared the modified sutureless glue-free (MSGF) method with conventional sutures (CS) for conjunctival autograft fixation in primary pterygium surgery. METHODS: A comprehensive search was conducted in MEDLINE, Embase, CENTRAL, Google Scholar and ClinicalTrials.gov for randomised controlled trials (RCTs) comparing MSGF and CS conjunctival autografts. Outcome measures included operation time, recurrence and postoperative complications. Standardised mean difference (SMD) and risk ratio (RR) were used for continuous and dichotomous outcomes, respectively. RESULTS: 11 RCTs involving 833 participants were included. The analysis revealed that MSGF had a significantly shorter operation time compared with CS (SMD -3.704, 95% CI -5.122 to -2.287, p<0.001). CS was associated with a higher risk of foreign body sensation (RR 0.22, 95% CI 0.06 to 0.74, p=0.01). MSGF was associated with a higher risk of graft dehiscence (RR 9.01, 95% CI 2.74 to 29.68, p=0.000) and graft retraction (RR 2.37, 95% CI 1.17 to 4.77, p=0.02). No significant differences were found in recurrence, graft haemorrhage, granuloma, Dellen and conjunctival oedema. CONCLUSION: Using the MSGF technique in conjunctival autograft fixation for pterygium surgery reduces operation time by relying solely on the patient's blood for fixation. However, it increases the risk of graft dehiscence and retraction. However, CS is linked to a higher likelihood of experiencing foreign body sensations. Understanding the learning curve and surgeon familiarity with novel techniques is crucial for optimising patient care and surgical outcomes, while individualised decision-making is necessary considering the advantages and disadvantages of each approach. Further research is warranted to minimise complications and optimise surgical outcomes.

Digital analysis of unilateral ptosis repair: external levator advancement vs. Müller's muscle conjunctival resection.

PURPOSE: Evaluation of lid contour and marginal peak point changes to compare outcomes of external levator advancement and Miiller's muscle conjunctival resection surgery in unilateral ptosis. METHODS: We reviewed the charts of unilateral ptosis patients who underwent external levator advancement or Miiller's muscle conjunctival resection. Eyelid contour analysis was conducted on preoperative and 6-month postoperative digital images. This was performed with the multiple margin reflex distances technique, measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. The marginal peak point changes were analyzed digitally using the coordinates of the peak point according to the pupil center. Each position's mean distance was compared preoperatively, postoperatively, and with the fellow eyelid. RESULTS: Sixteen patients underwent external levator advancement and 16 patients had Miiller's muscle conjunctival resection. The mean margin reflex distance was improved by both techniques (1.46 vs. 2.43 mm and 1.12 vs. 2.25 mm, p=0.008 and p=0.0001 respectively) and approached that of the fellow eyelid (2.43 vs. 2.88 and 2.25 vs. 2.58 mm, p=0.23 and p=0.19, respectively). However, statistically significant lid margin elevation was limited to between the N6 and T6 points in the external levator advancement group. Whereas, significant elevation was achieved along the whole lid margin in the Miiller's muscle conjunctival resection group. The marginal peak point was shifted slightly laterally in the external levator advancement group (p=0.11). CONCLUSIONS: Both techniques provide effective lid elevation, however, the external levator advancement's effect lessens toward the canthi while Müller's muscle conjunctival resection provides more uniform elevation across the lid margin. The margin reflex distance alone is not sufficient to reflect contour changes.

Complicated trabeculectomy converted into ab externo cyclodialysis.

The creation of a scleral flap during trabeculectomy can be complicated by a buttonhole, partial amputation at the limbus, and extensive thinning. In some cases, the procedure must be aborted to prevent more serious postoperative complications. This report describes a technique of converting complicated trabeculectomy into ab externo cyclodialysis. A 41-year-old patient with congenital glaucoma presented with a perforated scleral wall with the choroidal tissue exposed during the dissection of the partial-thickness scleral flap. By using a Barraquer cyclodialysis spatula through the scleral perforation, the choroid was separated from the sclera up to the scleral spur over 30° into the anterior chamber. The sclera and conjunctiva/Tenon were sutured with 10-0 nylon single sutures. Two months later, the intraocular pressure was reduced to 16 mmHg with no hypotensive topical medications. This case illustrates an alternative approach to managing a flap-related perioperative complication in trabeculectomy, which yielded good early results.

Key Roles of Conjunctiva Fornix-Bulbar Conjunctiva-Tenon Capsule in Conjoint Fascial Sheath Suspension.

BACKGROUND: Bulbar conjunctival prolapse is one of the complications of conjoint fascial sheath (CFS) suspension and has a negative impact on surgical results. To explore the prevention methods of this complication, the authors compared the incidence of it between the below-conjunctiva fornix-bulbar conjunctiva-Tenon capsule (CBT) approach and the above-CBT approach to dissecting CFS in CFS suspension and shared their experience in the treatment of bulbar conjunctival prolapse. METHODS: From January of 2020 to August of 2021, 81 patients with severe congenital ptosis who underwent CFS suspension were enrolled and divided into two groups. Forty-five patients' (group A) CFS was dissected by means of the below-CBT approach and 36 patients' (group B) CFS was dissected by means of the above-CBT approach. Data regarding the incidence and outcomes of bulbar conjunctival prolapse and the postoperative condition were collected and analyzed. RESULTS: The incidence of bulbar conjunctival prolapse was 24.44% in group A and 2.78% in group B. Of the 12 bulbar conjunctival prolapse patients, seven patients' conditions improved after conservative treatment, and five did not. All of them underwent bulbar conjunctiva resection within 1 year and were cured. No recurrent prolapse was observed within 3 months postoperatively. At the last follow-up, the mean marginal reflex distance 1 and palpebral fissure height were 4.09 ± 0.19 mm and 9.85 ± 0.62 mm, respectively. There were no complications except lagophthalmos (16 eyelids), asymmetric eyelid contour (one patient), and trichiasis (two eyelids). CONCLUSIONS: The incidence of bulbar conjunctival prolapse decreased significantly by dissecting CFS by means of the above-CBT approach. For patients with bulbar conjunctival prolapse after CFS suspension, bulbar conjunctiva resection could provide satisfactory results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Late-Onset Traumatic Corneal Conjunctival Epithelial Disorders due to Granular Formation After Cosmetic Suture Blepharoplasty.

PURPOSE: The purpose of this study was to report conjunctival granular formation as one of the causative factors of a traumatic corneal conjunctival epithelial disorder after plastic suture blepharoplasty. METHODS: Clinical charts of 7 patients who had visited Ohshima Eye Hospital with a symptomatic corneal epithelial disorder and history of suture blepharoplasty were reviewed. Clinical evidence of conjunctival granular formations was observed in all patients at the tarsal conjunctiva facing to corneal conjunctival traumatic epithelial disorders. The desired outcome was to alleviate the disorder. The assessment included tabulating results after the placement of a soft contact lens bandage and subsequent partial tarsal plate resection of the granular formation. RESULT: Seven women (mean age 45.0 ± 10.9 years) enrolled in this study had previously undergone suture blepharoplasty (mean 18.3 ± 6.9 years before). Soft contact lens bandages relieved all of the patients' complaints immediately. After resecting the granular formation, the traumatic corneal conjunctival epithelial disorder disappeared, and no recurrence was observed after surgery. CONCLUSIONS: The conjunctival granular formation within the tarsal conjunctiva after suture blepharoplasty caused the late-onset traumatic corneal conjunctival epithelial disorder. A complete cure was obtained after resection of the granular formation at the tarsal conjunctiva. To the best of our knowledge, this is the first report to identify the removal of granular formations in 7 patients with late-onset traumatic corneal conjunctival disorders many years after blepharoplasty. The resection of these lesions is a promising procedure to treat late-onset ocular epithelial disorder after suture blepharoplasty.

Comparing Outcomes of 45 µm Gelatin Stent Placed ab Externo with Open Conjunctiva to ab Externo with Closed Conjunctiva.

PURPOSE: Compare outcomes of a gelatin stent (XEN45 Gel Stent [XGS]) placed either ab externo with open conjunctiva (AEO) or ab externo with closed conjunctiva (AEC) with or without cataract surgery in patients with glaucoma. DESIGN: Retrospective nonrandomized comparative study. PARTICIPANTS: A total of 86 eyes from 86 glaucoma patients who received XGS placed either AEO (N = 49) or AEC (N = 37) with or without cataract surgery between May 2019 and April 2022 at Massachusetts Eye and Ear. METHODS: Reviewed and analyzed 809 visits from patient charts from a level 3 triage center. MAIN OUTCOME MEASURES: Intraocular pressure (IOP), medication burden, Kaplan-Meier (KM) success rates, 5-fluorouracil (5-FU) impact, and complications. RESULTS: Baseline demographics were similar between both groups, except for baseline IOP and glaucoma type. Both AEO and AEC procedures resulted in significant patterns of IOP and medication reduction from baseline up to 1 year. The AEO procedure had significantly higher KM qualified success (QS) rates than the AEC procedure, but similar complete success (CS) rates. Under QS, the cumulative probability of survival was 73% in the AEO group and 51% in the AEC group at month 6 and 62% in the AEO group and 20% in the AEC group at year 1. Under CS, the cumulative probability of survival was 41% in the AEO group and 37% in the AEC group at month 6 and 29% in the AEO group and 14% in the AEC group at year 1. The AEO procedure had significantly more IOP reduction than the AEC procedure at all postoperative time points beyond week 2, but similar medication burden reduction. At postoperative year 1 (POY1), the mean IOP was reduced to 10.72 ± 5.71 mmHg on 1.16 ± 1.68 medications after AEO and 17.03 ± 2.37 mmHg on 1.59 ± 1.21 medications after AEC. Phacoemulsification (phaco) was not a significant factor while 5-FU usage trended toward significance. Procedure time was longer for standalone XGS AEO. CONCLUSIONS: We demonstrate that both placements reduce medication and IOP from baseline, with AEO placement having more favorable XGS success rates and IOP control at the expense of longer procedure time and greater 5-FU usage. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Alternative Approach for the Treatment of Conjunctivochalasis: Plasma-Based Conjunctivoplasty.

PURPOSE: The aim of this study was to evaluate the efficacy of plasma-based conjunctivoplasty as a new surgical approach for conjunctivochalasis. METHODS: This prospective, noncomparative, interventional study included research on 42 eyes of 33 patients who underwent plasma therapy because of conjunctivochalasis between February 2020 and December 2021. Maintaining a 2-mm distance from the limbus, at least 3 lines (approximately 2 mm deep) of plasma therapy were applied to the conjunctiva from the temporal quadrant to the nasal quadrant. Patient symptoms, the fluorescein clearance test, ocular surface integrity with fluorescein staining, the Ocular Surface Disease Index questionnaire, tear breakup time (TBUT), tear meniscus height, and complications were evaluated. RESULTS: The mean patient age at the time of surgery was 67.3 ± 7.2 (range: 54-81) years. After surgery, the grades of conjunctivochalasis decreased in all patients. Although epiphora was present in 28 eyes (66.6%) preoperatively, none of the cases had epiphora during the follow-up period. The Ocular Surface Disease Index score improved significantly from 34.7 ± 10.3 preoperatively to 5.0 ± 4.2 3 months postoperatively ( P <0.001). Although the preoperative TBUT was 5.1 ± 2.2 seconds, the TBUT increased to 10.0 ± 2.3 seconds 3 months postoperatively ( P <0.001). Chemosis developed in only 1 eye (2.3%) and completely regressed with topical steroid treatment in the first postoperative week. CONCLUSIONS: Plasma-based conjunctivoplasty is a minimally invasive and simple surgery with less intraoperative and postoperative discomfort, a fast recovery, and can be suggested as an alternative approach to other treatment methods.

A novel bleb revision technique: lining with tenon's patch graft for treatment of large, ischemic, leaking blebs with severe conjunctival scarring after trabeculectomy.

PURPOSE: We report a new bleb lining technique with Tenon's patch graft for late-onset leakage from large ischemic bleb with severe conjunctival scarring and impractical conjunctival mobilization after trabeculectomy. STUDY DESIGN: Retrospective case series. METHODS: This study includes six cases with late-onset leakage from large ischemic blebs. Small Tenon's tissue is dissected from the incisional site or a previously made inferior incision for Tenon's anesthesia. A passage is created from the small incision to the leaking area of the bleb using a bleb knife or micro scissors. The Tenon's tissue, stained with indocyanine green, is inserted under the ischemic bleb's conjunctiva. A transconjunctival compression suture is placed across the leaking point to fix the Tenon patch graft positionally. RESULTS: In all cases, bleb leakage was completely sealed immediately after surgery. In 4 cases, the closure of the bleb leakage was maintained after surgery during the follow-up period (6-17 months). In two cases, bleb leakage recurred from different leaking points 7 or 9.5 months after the surgery; however, repeated tenon's patch lining revisions successfully closed these leakages. The intraocular pressure at the final visit was 5-13 mmHg (median, 10 mmHg) without glaucoma medication or additional glaucoma surgery. CONCLUSION: Tenon's patch-lining technique is a promising method for bleb leakage with large ischemic bleb and impractical conjunctival mobilization.

Subconjunctival dexamethasone-assisted conjunctival autograft harvesting versus normal saline during pterygium surgery - A randomized clinical trial.

PURPOSE: To evaluate the effect of subconjunctival dexamethasone compared to normal saline on conjunctival autograft harvesting in patients undergoing pterygium surgery. METHODS: Fifty-two eyes of 52 patients who underwent pterygium excision combined with autologous conjunctival graft (CAG) using releasable suture were included in this prospective interventional study. The patients were randomized into two groups of 26 patients each. Group A consisted of patients in whom CAG was harvested using subconjunctival 0.5 ml of 0.4% dexamethasone sodium phosphate and in group B patients, normal saline was used. The patients were assessed for postoperative pain, foreign body sensation, and watering as the subjective signs of inflammation and conjunctival inflammation and lid edema as the objective signs of inflammation at 12 and 24 h postsurgery. RESULTS: The mean age of group A and B patients was 47.69 + 13.09 and 46.00 + 10.76 years, respectively. The male:female ratio was 1.6:1 in group A and 1.1:1 in group B. The mean surgical time in group A was 243.96 ± 52.13 s and in group B was 258.08 ± 43.99 s. Postoperative pain, foreign body sensation, and watering were significantly lower in group A patients than in group B patients at both 12 and 24 h postoperatively (group A: 4.65 ± 1.33, 4.88 ± 1.73, and 3.85 ± 1.43, respectively, at 12 h; 1.89 ± 1.03, 1.69 ± 1.09, and 1.69 ± 0.97, respectively, at 24 h and group B: 6.42 ± 0.95, 6.65 ± 0.98, and 6.27 ± 1.40, respectively, at 12 h; 3.27 ± 1.43, 3.12 ± 1.25, 2.58 ± 1.14, respectively, at 24 h) ( P < 0.001). Conjunctival inflammation was significantly lower in group A at 12 h ( P < 0.05) and 24 h ( P < 0.05) after surgery compared to group B. Lid edema failed to show any significant ( P = 0.17) difference with respect to severity in both the groups at 12 and 24 h ( P = 0.699). CONCLUSION: Subconjunctival dexamethasone decreased patient discomfort following pterygium surgery. The dexamethasone group had reduced conjunctival inflammatory signs without any notable complications.

Conjunctiva in strabismus surgery - to stitch or to stick? - A randomized clinical trial.

PURPOSE: To evaluate the clinical outcomes with fibrin glue in comparison with vicryl sutures for limbal conjunctival wound closure in strabismus surgery. METHODS: In this prospective interventional study, patients undergoing horizontal muscle strabismus surgery were randomized into two groups: the vicryl suture group and the fibrin glue group. The limbal conjunctival incisions were closed with 8-0 vicryl in the suture group and with fibrin glue in the other group. The outcomes measured were post-operative conjunctival inflammation and wound apposition, patient comfort with the help of a questionnaire, and conjunctival thickness using anterior segment optical coherence tomography (AS-OCT) for both groups at 6 weeks. RESULTS: The study included 64 eyes of 64 patients (32 eyes in each group). The fibrin glue group performed better than the vicryl suture group for most of the symptoms like redness, irritation, watering, and foreign body sensation till 2 weeks post-operatively ( P < 0.001), after which both the groups performed similarly. As for clinical signs, no significant difference was noted between the two groups, except for conjunctival hyperemia, which was significantly lesser in the fibrin glue group at 2 weeks post-operatively ( P < 0.001). The conjunctival thickness measured at 6 weeks using AS-OCT revealed that the thickness increased significantly in the suture group compared to that in the glue group ( P < 0.001 medial site, P = 0.004 lateral site). CONCLUSION: Because of greater patient comfort and reduced inflammation associated with fibrin glue, it may be considered as a procedure of choice for conjunctival wound closure in strabismus surgery in the absence of the cost constraints.

Glaucoma surgical procedures under development.

PURPOSE OF REVIEW: Rapid innovation in glaucoma surgery is expanding surgical options in the angle, subconjunctival space, and supraciliary space. RECENT FINDINGS: Advancements in glaucoma surgery make it possible for surgeons to provide treatments with less risk. In particular, new devices and lasers are available for minimally invasive glaucoma surgeries. There are also new implants and techniques for bleb-forming glaucoma surgery. SUMMARY: As glaucoma surgeons have access to an increasing number of procedures, devices, and treatments, it is important for evidence to drive decision-making.

Iridodialysis Repair With Intrascleral Fixation of Flattened Flanged Polypropylene Suture.

PURPOSE: To present the flattened flanged polypropylene suture technique developed to obtain round and stable pupils in patients with iridodialysis. METHODS: After performing a fornix-based conjunctival peritomy, a flange was created at the tip of a 6.0 polypropylene suture by cautery. In the quadrant of iridodialysis, an ultrathin 30-gauge needle was inserted into the sclera at a distance of 2 mm from the limbus and advanced 1.5 mm intrasclerally, parallel to the limbus. The needle was directed radially into the eye and easily passed through the edge of the peripheral iris. The polypropylene suture was pushed into the lumen of the needle with the help of forceps. After the needle was externalized, the tip of the suture was flanged by cautery, and the flange was immediately flattened using a needle holder. RESULTS: Six eyes of six patients with iridodialysis were enrolled in this study. Postoperatively, the irises remained well positioned and the pupils became round in all eyes. None of the patients developed suture erosion, suture loosening or rupture, hyphema, hypotony, chronic iridocyclitis, and angle closure. CONCLUSION: The present technique provides a minimally invasive surgery and robust iris fixation without the need to create a scleral flap, groove, or pocket.

Sliding limbus-conjunctival flaps for minimizing the pterygium recurrence: a prospective tertiary care institute study.

Objective: To describe the surgical technique and long-term outcomes of sliding limbus-conjunctival flaps to treat primary pterygium. Methods: Our single-center, single-surgeon-based, prospective study (part of the postgraduate thesis) included primary pterygium patients. We included the larger pterygium in bilateral cases for our research. All patients underwent pterygium excision and reconstruction by sliding limbus-conjunctival flaps technique to minimize the recurrence rates. Similar surgical steps and drugs were used for all the enrolled patients. Two ophthalmologists (SS and MK) evaluated all cases for blinding purposes. A minimum follow-up of 12 months was ensured in all cases. Results: Fifty eyes of 50 patients underwent the sliding limbus-conjunctival flaps surgery at a mean age of 50.40 ± 15.05 years. There were 27 (54%) males and 23 (46%) females with nasal pterygium (100%), having an average horizontal size of 2.96 mm. A "with the rule" astigmatism was seen in 44 (88%) eyes with a horizontal keratometry value of 42.00 ± 2.83, which increased significantly to 42.23 ± 2.02 (p>0.05) after surgery. The visual acuity was improved by 1 Snellen's line in 21 cases, 2 lines in 4 cases, and by 3 lines in 1 case. No change in visual acuity was seen in 24 cases. The early minor postoperative complications were self-resolving. At a mean follow-up of 14.5 months, the recurrence was found in 2 patients (4%), one in the 3rd and the other in the 9th month. Conclusion: The sliding limbus-conjunctival flaps technique is a simple, safe, and efficient procedure for primary pterygium cases. Pterygium surgery positively affects the visual acuity and keratometry values in most patients, making it a cosmetic and functional ophthalmic surgical procedure.

A machine learning approach to predict the glaucoma filtration surgery outcome.

This study aimed at predicting the filtration surgery (FS) outcome using a machine learning (ML) approach. 102 glaucomatous patients undergoing FS were enrolled and underwent ocular surface clinical tests (OSCTs), determination of surgical site-related biometric parameters (SSPs) and conjunctival vascularization. Break-up-time, Schirmer test I, corneal fluorescein staining, Meibomian gland expressibility; conjunctival hyperemia, upper bulbar conjunctiva area of exposure, limbus to superior eyelid distance; and conjunctival epithelial and stromal (CET, CST) thickness and reflectivity (ECR, SCR) at AS-OCT were considered. Successful FS required a 30% baseline intraocular pressure reduction, with values ≤ 18 mmHg with or without medications. The classification tree (CT) was the ML algorithm used to analyze data. At the twelfth month, FS was successful in 60.8% of cases, whereas failed in 39.2%. At the variable importance ranking, CST and SCR were the predictors with the greater relative importance to the CART tree construction, followed by age. CET and ECR showed less relative importance, whereas OSCTs and SSPs were not important features. Within the CT, CST turned out the most important variable for discriminating success from failure, followed by SCR and age, with cut-off values of 75 µm, 169 on gray scale, and 62 years, respectively. The ROC curve for the classifier showed an AUC of 0.784 (0.692-0.860). In this ML approach, CT analysis found that conjunctival stroma thickness and reflectivity, along with age, can predict the FS outcome with good accuracy. A pre-operative thick and hyper-reflective stroma, and a younger age increase the risk of FS failure.

Delayed presentation of surgically induced scleral necrosis after I-BRITE procedure treated with immunosuppressive therapy.

Surgically induced scleral necrosis (SISN) is an uncommon complication of ocular procedures. Cosmetic eye-whitening surgery involves conjunctival and Tenon's capsule dissection, cautery, and mitomycin C application. We report the case of a 36-year-old white woman referred to our clinic for severe pain, scleral inflammation, and necrosis in both eyes 9 years after I-BRITE, an elective eye-whitening procedure. An extensive workup yielded negative results. The patient improved with aggressive lubrication and topical and high-dose systemic prednisone (60 mg), with recurrence upon steroid tapering. Concomitant weekly methotrexate was added, resulting in inflammatory control and allowing discontinuance of topical and oral steroids.