excised pterygium as possible. A 27or 30-gauge needle on a 3-mL syringe is used to inject 2% lidocaine with epinephrine between the conjunctival epithelium and TenonÕs layer in order to aid separation. Care is taken not to place the needle into the area that will be the future conjunctival autograft, but to place the needle outside the gentian violet marks. A blunt-tipped Westcott scissor is used to incise the epithelium along the previously marked tracts and blunt and sharp dissections are used to dissect the epithelium away from TenonÕs layer. Non-toothed forceps should be used only when handling the conjunctiva. Careful lifting of the conjunctival epithelium allows TenonÕs layer to be put on stretch, and TenonÕs Þbers are cut close to the epithelium, with care taken not to buttonhole the conjunctiva. Dissection of the graft is carried forward to the limbus.

4.3.3.3 Securing the Conjunctival Autograft

It is important that the conjunctival epithelium remains uppermost and to ensure this position, inversion of the graft must not occur. The conjunctival graft should be slid over the cornea towards the bare sclera to maintain the epithelium up. We orient the graft limbus to limbus although we are likely not transferring any limbal stem cells with our autograft harvesting technique. The graft should be spread to cover the entire area of bare sclera. We previously placed 10-0 nylon sutures in the graft to adhere it to the episclera. In this technique, 10-0 nylon sutures are used to secure the graft Þrst at the superior and inferior limbus, followed by the superior and inferior edges of the posterior most aspect of the graft. A surgeonÕs slip-knot technique, or any other tying technique the surgeon is familiar with, may be used (Fig. 4.17).

We now use Þbrin glue as an alternative to suturing. In this technique, the conjunctival graft, epithelial side up, is spread to cover the entire area of the bare sclera. Two tying forceps are used to grasp the pointed superior and inferior ends of the graft nearest the limbus Þrst. The anterior half of the graft is laid back onto itself to mid graft position, and the glue is applied in two parts. The Þbrinogen is applied to the back of the graft and the thrombin is applied to the bare sclera. The ends of the graft are again grasped with the tying forceps and the anterior half of the graft is laid back onto the sclera and pressed into position with the tying forceps. The thrombin activates the Þbrinogen,

forming the Þbrin glue. The graft is held pressed to the bare sclera for 30 s. The superior and inferior ends of the posterior aspect of the graft are grasped with the tying forceps and the posterior half of the graft is laid back onto itself and the glue is applied as prior. The graft is laid back down onto the bare sclera and pressed into position and held for 30 s. It is smoothed out gently with the tying forceps. Any excess glue is removed.

4.3.3.4 Fibrin Glue vs. Nylon Sutures

Currently, many surgeons are attaching their conjunctival autografts by means of suturing. The use of sutures can be associated with several disadvantages that include a prolonged operating time, postoperative irritation and pain, and suture-related complications such as granuloma formation and others. Sutures can present a nidus for infection as well.

Tissue adhesives are an alternative means for attaching a conjunctival autograft and may avoid the complications just mentioned with suture use. Several studies have reported on their efÞcacy in securing a conjunctival autograft following pterygium removal and in decreasing the postoperative complications of suture use [7, 8, 10]. Tisseel is a two component tissue adhesive that mimics natural Þbrin formation [8]. The glue has two components. One component consists of Þbrinogen mixed with factor XIII and aprotinin, and the other component is a thrombin-calcium chloride solution. All components are prepared from human blood that has been extensively screened. When the two components are mixed, the thrombin activates the Þbrinogen and forms the Þbrin glue. The two components can be administered sequentially as described in our technique above, or can be placed in a double syringe applicator (Duploject) that comes in the operative kit.

4.3.4 Postoperative Management

Postoperatively, prednisolone drops are administered four times daily along with topical Vigamox (Alcon, Fort Worth, TX). If a large epithelial defect is present from removal of the apex of the pterygium off the cornea, a bandage contact lens is placed for comfort until the defect heals. Topical preservative-free artiÞcial tears