Pterygium, a proliferative fibrovascular conjunctival growth encroaching on the cornea, often leads to irritation, visual disturbance, and cosmetic concerns. Conjunctival autograft transplantation (CAG), introduced by Kenyon et al. in 1985, has since become a mainstay technique—reducing recurrence and enhancing patient outcomes in both primary and recurrent cases [1]. Later, Ayala has shown the benefits of biologic adhesive in pterygium surgery, reporting reduced surgical time and improved graft stability [2]. Kim and colleagues echoed these findings, validating the use of fibrin adhesive for conjunctival limbal grafts in a Korean cohort [3]. Yet, concerns over adhesive use led Koranyi et al. (2004) to pioneer a no-suture, small-incision method, demonstrating favourable early results [4]. A follow-up study by the same group in 2005 confirmed its long-term viability [5]. Subsequent adaptations expanded on the glue-free approach. Malik et al. showed the efficacy of sutureless, glue-free limbal CAG in primary pterygium with low recurrence [6]. Sharma et al. (2015) corroborated these results, emphasising improved patient comfort [7]. Rangu et al. (2014) further reinforced that glue-free autografting is both feasible and effective [8]. Comparative studies by Choudhury et al. demonstrated that autologous blood coagulum efficiently secures grafts with similar outcomes to sutures [9]. At the same time, Alam et al. reported excellent results in a 30-case series using a glueless technique [10]. Dasgupta et al. (2016) highlighted its practicality in a tertiary Indian setting [11]. Studies by Kulthe et al. and Rathi et al. have shown the safety of no suture and glue-free surgical techniques [12,13]. Several case series, including Babu et al. and Viswamithra et al., reinforced the technique’s reproducibility and effectiveness across diverse surgical environments [14,15]. Despite its advantages, the removal of fibrin glue raises concerns. Rare complications such as symptomatic parvovirus B19 transmission via sealant [16] and aprotinin-related anaphylaxis [17] underscore the need to reevaluate adhesive use. Earlier critiques on surgical techniques and management by Starck et al. further illustrate the importance of minimising foreign material usage [18]. Panda et al. later summarised fibrin’s range of ophthalmic uses and potential complications [19], while Bahar et al. provided an evidence-based comparison between fibrin and Vicryl sutures [20]. Overall, sutureless, glue-free conjunctival autografting appears to offer an effective, low-cost, patient-friendly alternative—avoiding both sutures and adhesives—while maintaining low recurrence and complication rates. The current clinical study explores its outcomes in a structured cohort, focusing on safety, efficacy, and postoperative satisfaction.

Study Design & Setting This prospective interventional case series was conducted at a tertiary-care ophthalmology center between March 2022 and May 2025. Written informed consent was secured from all participants. Sample Size & Selection Fifty eyes of fifty consecutive patients with primary pterygium were enrolled. Inclusion criteria comprised all adults (regardless of age or sex) presenting with unilateral primary pterygium (nasal, temporal, or both). Exclusion criteria were: prior pterygium surgery, other ocular pathology, or refusal to participate. Preoperative Evaluation Each patient underwent a comprehensive baseline assessment including: • Demographics & History: Age, sex, pterygium duration/symptoms. • Visual Acuity: Uncorrected and pinhole-corrected Snellen VA. • Slit-Lamp Examination: Detailed anterior segment evaluation and standardized photography to document pterygium location, extent, and grade (Type I–III based on corneal involvement; Grade I–III by vascularity and episcleral visibility). • Keratometry: Manual measurement of corneal astigmatism. • Intraocular Pressure: Applanation tonometry. • Lacrimal System: Syringing to rule out nasolacrimal obstruction. • Posterior Segment: Dilated fundus examination. • Systemic Screening: Blood sugar, blood pressure, ECG, HIV, and HbsAg testing. Surgical Procedure All procedures were performed by a single experienced surgeon under strict asepsis using the standardized, sutureless and glue-free conjunctival autograft technique: 1. Anesthesia: Peribulbar block with a mixture of 2% lignocaine + adrenaline + hyalase (3 mL) and 0.5% bupivacaine (2 mL), followed by gentle pressure to minimize chemosis. 2. Pterygium Excision: The head was dissected from the cornea to the limbus using a crescent blade; only pathologic tissue and adjacent Tenon’s capsule were removed. 3. Hemostasis & Blood Layer Formation: Natural hemostasis was favored; small vessels were nicked if necessary to provide a thin autologous blood layer over the scleral bed. 4. Graft Harvesting: A tunneled conjunctivo-limbal graft from the superotemporal quadrant (1 mm oversized) was harvested, preserving orientation. 5. Graft Placement: The autologous graft was transferred onto the scleral defect, ensuring proper orientation, and held in place for several minutes until secure adherence. 6. Closure & Injection: Subconjunctival gentamicin-dexamethasone was injected, and the eye was patched for 24 hours. Postoperative Care & Follow-Up Postoperative regimens included a tapering course of antibiotic-steroid combination drops and preservative-free lubricants—four times daily for four weeks. Follow-up visits were scheduled at day 1, day 4, week 1, month 1, and month 3. Outcome Assessment Primary outcomes included changes in Snellen uncorrected visual acuity and manifest astigmatism from baseline to 3 months. Patients were monitored for early complications (graft edema, retraction, sub-graft hemorrhage, dehiscence, graft loss) and late outcome—pterygium recurrence by three months. Data Analysis Astigmatic changes were analyzed using paired t-tests comparing pre- and postoperative values. A p value < 0.05 was considered statistically significant. Description: This composite figure illustrates the sequence of surgical steps followed during the procedure, starting from instrument layout, patient preparation, pterygium excision, graft harvesting, placement, and final graft positioning.

This prospective clinical study included 50 eyes of 50 patients with primary pterygium, all of whom underwent sutureless and glue-free conjunctival autografting at a tertiary care center between March 2022 and May 2025. Patients were followed for a duration of three months. The key findings are summarized below: 1. Demographics • Age distribution: The majority of patients were aged 51–60 years (30%), followed by those aged 61–70 years (26%). The mean age was 56.18 years (range: 30–76 years). • Gender distribution: Females comprised 56% of the cohort, while males accounted for 44%. 2. Pterygium Characteristics • Location: Nasal pterygium was observed in 96% of cases; temporal in 4%. • Type: Type 3 was the most common (48%), followed by type 2 (44%) and type 1 (8%). • Grade: Grade 3 was seen in 60% of patients, grade 2 in 38%, and grade 1 in 2%. 3. Presenting Symptoms • Fleshy growth: 80% • Foreign body sensation: 76% • Redness: 68% • Watering: 66% • Diminished vision: 40% • Photophobia: 30% 4. Surgical Parameters • Mean operative time: 16 minutes (range: 14–20 minutes). 5. Postoperative Complications • Early complications: o Graft edema: 4% o Graft retraction: 4% o Sub-graft hemorrhage: 8% • Late complication: o Recurrence at 3 months: 2% (1 case) 6. Visual and Refractive Outcomes • Uncorrected Visual Acuity (UCVA): o Preoperative: 48% had 6/12, 30% had 6/18, 10% had 6/24 o Postoperative: 50% achieved 6/12, 48% achieved 6/9, and 2% reached 6/6 • Astigmatism: o Mean astigmatism reduced from 2.36 ± 0.56 D preoperatively to 1.21 ± 0.56 D postoperatively o Statistical significance: Paired t test showed a highly significant reduction (t = 8.22; p < 0.0001) 7. Recurrence Analysis • By Gender: No significant association with recurrence (p = 0.37) • By Age Group: Recurrence was not significantly associated with age (<50 vs ≥50; p = 1.0)

This prospective clinical study assessed the outcomes of sutureless and glue-free conjunctival autografting for primary pterygium in 50 eyes over a three-month follow-up. Below, findings are discussed in light of existing literature: 1. Demographics & Pterygium Characteristics • The mean age in our study was 56.2 years, with most patients aged 51–60. This is relatively higher compared to other studies: Sayali et al. (46.3 y) [12], Vishwamitra et al. (44 y) [15], and Malik et al. (42.8 y) [6]. Differences may reflect regional demographic trends or referral patterns. • A female preponderance (56%) was observed, consistent with Ashok et al. (56.2% female) [7] and Dasgupta et al. (73% female) [11], indicating a slight gender skew that might be related to health-seeking behavior or increased sun exposure among women in the region. • 96% of pterygia were nasal, aligning closely with Sayali et al. (97.5%) [12]. This reinforces the nasal preference of pterygium due to localized UV exposure and ocular surface anatomy. 2. Surgical Efficiency • Mean operative time was 16 minutes, comparable to Rangu et al. (16 min) [8], Choudhury et al. (15 ± 2 min) [9], Dasgupta et al. (16 ± 2 min) [11], and Sayali et al. (18 ± 1.3 min) [12]. This demonstrates that the no-suture, no-glue technique does not significantly prolong surgery and is feasible in high-volume settings. 3. Complications • Graft edema occurred in only 4% of cases, consistent with Gunjan et al. (4%) [13] and Ravi Babu et al. (4%) [14], suggesting effective handling and positioning of the graft. • Graft retraction was noted in 4%, falling within the range reported in literature (3.3–7.5%). For instance, Malik et al. reported 7.5% [6], while Ashok et al. [7] and Jawed et al. reported around 3–4% [10]. • Sub-graft hemorrhage was seen in 8% of cases, closely matching Malik et al. (10%) [6] and Ravi Babu et al. (8%) [14]. These minor events resolved without intervention. • Recurrence at three months was 2%, similar to Sharma et al. (1.25%) [7], Vishwamitra et al. (0.78%) [15], and Ashok et al. (1.25%) [7]. Slightly higher rates in Dasgupta et al. (1.67% at six months) [11] and the zero recurrence in Ravi Babu et al. reflect sample variability and follow-up duration differences [14]. 4. Visual and Refractive Outcomes • There was a significant reduction in mean astigmatism—from 2.36 D pre-op to 1.21 D post-op (p < 0.0001). This suggests the technique not only ensures graft stability but also improves corneal surface regularity, enhancing unaided visual acuity. • The postoperative visual acuity shift (48% achieving 6/9, 50% at 6/12, and 2% at 6/6) further confirms the effectiveness of this approach. Clinical Implications The sutureless and glue-free technique offers several advantages: 1. Cost-effectiveness: Eliminates the need for fibrin glue, sutures, or membranes. 2. Reduced complications: Low rates of graft edema, retraction, hemorrhage, and recurrence. 3. Operational efficiency: Short and consistent surgical times. 4. Refractive stability: Significant improvement in corneal astigmatism and visual acuity. These outcomes are on par with those reported in other studies and reinforce the technique’s suitability for routine ophthalmic practice—especially in settings where cost, economy of materials, and patient comfort are paramount. LIMITATIONS & FUTURE DIRECTIONS • The 3-month follow-up may underrepresent longer-term recurrence and refractive stability; extended monitoring is advised. • While outcomes are promising, larger studies across multiple centers would enhance generalizability. • Comparative studies directly contrasting sutureless, glue-free, and traditional fibrin-glue or sutured methods would provide more definitive guidance.

The technique of suture less and glue-free conjunctival autografting proves to be a safe, efficient, cost-effective, and refractively advantageous option for primary pterygium surgery. With low complication and recurrence rates and acceptable visual outcomes, it is a strong alternative to conventional methods. However, this technique warrants further validation in multicenter randomized trials with longer follow-up.

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