Original Article

Conjunctival Autograft versus Combined Amniotic
Membrane and Mini-Simple Limbal Epithelial
Transplant for Primary Pterygium Excision

Ashok Jha1, MS; Abhay Simba2, MS

1Department of Ophthalmology, Military Hospital Gaya, Gaya, India
2Department of Ophthalmology, Anugrah Narayan Medical College, Gaya, India

ORCID:
Ashok Jha: https://orcid.org/0000-0001-7072-4168

Abstract

Purpose: To compare outcomes of conjunctival autograft (CAG) and combined
amniotic membrane with mini-simple limbal epithelial transplant (mini-SLET) after
primary pterygium excision.
Methods: All consenting adults with primary pterygium were included in this
study. After pterygium excision, patients were randomized to receive either CAG
or mini-SLET and both grafts were held in place with fibrin glue. The patients
were followed-up at days 1, 3, 7, 14, and 30 and subsequently at the third, sixth,
and ninth months. The recurrence rate was considered as the primary outcome
measure whereas the operating time, postoperative symptoms, and surgical
complications were considered the secondary outcome measures.
Results: The study comprised of 264 eyes of 264 patients, of which 233 (88%)
completed the nine months of follow-up. Of these, 118 (51%) received CAG and 115
(49%) received mini-SLET. The groups were comparable at baseline. Recurrence
of pterygium was seen in two (1.6%) eyes in the CAG group and three (2.6%) eyes
in the mini-SLET group (P = 0.68). Operative time for mini-SLET (20.33 ± 1.28
min) was significantly higher than that for CAG (12.01 ± 1.26 min) (P < 0.001). Graft
displacement was observed in one case in group II (P = 0.999). The Lim Bon Siong
(foreign body sensation, lacrimation, pain, and irritation) score in the CAG group
was statistically significant for all four symptoms at days 1 and 3; however, at day
7, foreign body sensation, pain, and irritation scores were significantly higher for
the CAG group.
Conclusion: In this study, the overall recurrence rate was very low and
comparable between mini-SLET and the established technique of CAG after
performing the primary pterygium excision. Despite a longer surgical time, mini-
SLET appears to be a viable option for the management of primary pterygium.

Keywords: Conjunctival Autograft (CAG); Mini-simple Limbal Epithelial Transplant (mini-
SLET); Pterygium

J Ophthalmic Vis Res 2022; 17 (1): 4–11

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Two Techniques for Pterygium Excision; Jha et al

INTRODUCTION

Pterygium is a benign, fleshy triangular ocular
lesion that can cross the limbus and encroach on
the cornea, with subsequent visual impairment.[1]
It most often involves nasal conjunctiva and may
necessitate surgical removal if associated with
visual impairment, astigmatic refractive errors,
or cosmetic concerns. Postoperative recurrence
is not uncommon, hence surgical excision has
been coupled with various adjunctive measures
like beta irradiation[2] and anti-metabolites such
as Mitomycin C.[3, 4] Although these methods are
relatively safe, complications such as secondary
bacterial infection, punctate keratitis, scleral
melting, and raised intraocular pressure (IOP)
have been reported. To prevent these side effects
and achieve superior results in terms of graft
stability and potentially lower recurrence rates,
human amniotic membrane grafting (AMG)[5] and
conjunctival autografting (CAG)[6] were introduced
to cover the bare sclera after pterygium excision.
Of these, ipsilateral CAG is now the surgical
procedure of choice, owing to the ease of the
procedure and the difficulties in procuring AMG.
Additionally, the efficacy and low recurrence rate
of the CAG method has been corroborated by
many authors.[6–9]

Tissue adhesives like fibrin glue[10] which are
used to secure the grafts in place after pterygium
excision present many benefits such as lesser
operating time, reduced discomfort during the
postoperative period, and reduced complications
associated with sutures.[11, 12] Alternatively, the CAG
can be secured using autologous in situ blood
coagulum.[13–15]

More recently, Hernández-Bogantes et al have
described a technique of using a combination
of AMG and small pieces of autologous limbal
epithelial cells (mini-simple limbal epithelial
transplant [SLET])[16] to cover the bare sclera
using tissue adhesive. Authors reported excellent

Correspondence to:

Ashok Jha, MS. Department of Ophthalmology, Military
Hospital Gaya, Bihar 823005, India.
E-mail: ashokjha1025@gmail.com
Received 04-05-2020; Accepted 12-02-2021

Access this article online

Website: https://knepublishing.com/index.php/JOVR

DOI: 10.18502/jovr.v17i1.10164

outcomes with this new technique, albeit in only 10
eyes. Given these encouraging results, we believe
that this may be an alternative technique to CAG
for surgical management of pterygium. At present
there are very few head to head studies comparing
outcomes of the well-established CAG with the
relatively new mini-SLET after primary pterygium
excision. Hence, this study was performed to
assess the efficacy and recurrence rate after the
two aforementioned procedures.

METHODS

This prospective, randomized, interventional study
was duly approved by the local Institutional
Ethics Committee (Ethical clearance certificate
no. 29/MH/2015 dated Aug 11, 2015). This study
was conducted in accordance with the tenets
of the Declaration of Helsinki. Patient enrollment
occurred between August 2015 and January 2019.

All consecutive adult patients visiting the
outpatient department of our hospital with primary
pterygium and requiring surgical excision for
cosmesis, intense foreign body sensation, and
reduced vision either due to induced astigmatism
or encroachment on the visual axis were invited
to participate in the study. Patients who agreed
to follow-up for nine months after surgery were
recruited after their informed consent. Patients with
other ocular surface disorders, hypersensitivity to
blood constituents, and seropositivity to Hepatitis
B, Hepatitis C, and HIV were excluded from the
study.

Sample size calculation was based on presumed
differences in the recurrence rates of pterygium
in the two groups. Given 1:1 randomization, 90%
power, and a precision error of 5% to detect a
difference of 10% or more in proportion of patients
experiencing recurrent pterygium, a required
minimum sample size of 230 eyes (115 in each
group) was obtained. To account for a 15% loss to
follow-up, we recruited 264 patients for the study.

Using simple randomization, the patients
were divided into two groups: one received

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How to cite this article: Jha A, AbhaySimba. Conjunctival Autograft versus
Combined Amniotic Membrane and Mini-Simple Limbal Epithelial Transplant
for Primary Pterygium Excision. J Ophthalmic Vis Res 2022;17:4–11.

JOURNAL OF OPHTHALMIC AND VISION RESEARCH Volume 17, Issue 1, January-March 2021 5

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Two Techniques for Pterygium Excision; Jha et al

the CAG and the other received the mini-SLET
treatment. This simple randomization utilized
serially generated computer codes along with
allocation concealment. A parallel allocation
strategy was used in a 1:1 allocation. The evaluating
ophthalmologist (AS) was masked to the type of
graft used. The operating surgeon (AJ) and
patients were masked to the procedural details
and the type of graft used. The sealed envelopes
for the type of graft were opened just before the
completion of the pterygium excision. The graft
status was masked in all cases at every follow-up
visit during the clinical testing.

Thorough medical and ocular history and
demographic details such as age and gender
of the participants were obtained. Thereafter, a
comprehensive examination of the eyes included
best-corrected visual acuity assessment, slit-lamp
evaluation of the pterygium, and the anterior
and posterior segment evaluation using a
+90D lens. Pterygia were divided into three
grades based on the classification proposed
by Tan and coworkers:[17] T1 = unobscured and
distinguished episcleral vessels underneath the
body of the pterygium; T2 = partially obscured or
indistinct episcleral vessels; and T3 = completely
obscured episcleral vessels by fibrovascular
tissue. Serial clinical photographs of patients
were taken preoperatively, per-operatively, and
postoperatively on days 1 and 30 in addition to the
sixth and ninth months for both cohorts [Figure 1].

Peribulbar anesthesia (2% lidocaine
hydrochloride) was used for all of the surgeries,
which were performed by a single surgeon (AJ).
Westcott scissors were used to draw horizontal
incisions along the superior and inferior borders
of the body of pterygium. Subsequently, using
Moorefield’s conjunctival forceps, the pterygium
was reflected toward the limbus making another
peripheral incision parallel to the limbus. The
remaining fibrovascular tissues underneath the
bulbar conjunctiva were dissected and excised to
the maximum possible extent.

The bare sclera was then measured by a caliper.
In the CAG group, a near tenon-free CAG, which
was 1 mm larger in area than the bare sclera
was harvested from the supero-temporal region.
This thin graft was stuck to the exposed sclera
using fibrin glue (Baxter, TISSEEL) with correct
orientation. The angled flat part of two iris spatulas
was maneuvered horizontally and vertically utilized

to expand the graft to its maximum possible size
besides removing excess glue from the sclera bed.

In the mini-SLET cohort, after an initial one clock
hour (10–11 o’clock for right eye and 1–2 o’clock
for left eye) peritomy performed with Westcott
scissors, a limbal tissue 2 × 2 mm in size was
excised with the help of a crescent blade. Using
Vannas scissors, this strip was then sliced into
six to eight pieces under increased magnification.
These pieces were then affixed on the inlay AMG
closer to the limbus using fibrin glue. Thereafter, an
AMG overlay was used to maintain graft pieces in
the exact position. Freeze-dried AMG (Amnio-care,
Biocover Labs, India), available in 3 × 3 cm size was
used for the study. A bandage contact lens was
placed on the cornea at the end of the procedure.

Using a patented fibrinotherm device, the
fibrin glue (TISSEEL VH, Baxter AG) used in the
above described procedures was prepared by
reconstituting thrombin and freeze-dried protein
concentrate in calcium chloride and fibrinolysis
inhibitor solutions, respectively. Both thrombin and
fibrin were suctioned into separate syringes, which
were mounted with a 27G canula. To use the glue,
almost an equal number of drops of fibrin and
thrombin were utilized for both the cohorts. Total
operating time was noted for both the groups.
Mitomycin C was not used in either group.

In the first week of the postoperative period,
patients received 1% prednisolone acetate and
0.5% moxifloxacin eye drops every 4 and 6 hr,
respectively, followed by tapering dosages of
topical steroid, which continued for one month. The
patients were reviewed on postoperative days 1, 3,
7, 14, and subsequently at months 1, 3, 6, and 9.

While early postoperative visits involved the
assessment of graft positioning, later visits
included reporting of the recurrence and
disintegration of limbal pieces on the slit lamp by a
masked investigator. Recurrence was considered
the primary outcome measure, which was defined
as any fibrovascular growth that occurred at the
surgical site at any time during the follow-up period.
Operating time and surgical complications were
considered the secondary outcome measures.
Four symptoms (foreign body sensation, epiphora
[watering], pain and irritation) were evaluated,
based on a 5-point scale adapted from Lim Bon
Siong R et al. The patients were asked to complete
a questionnaire in which 0 meant no pain, 1 meant
presence of easily tolerable pain, 2 meant pain

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Two Techniques for Pterygium Excision; Jha et al

causing some discomfort, 3 meant presence of
pain partially interfering with sleep or usual activity,
and 4 meant pain completely interfering with usual
activity or sleep.

Statistical Analysis

The statistical analysis was performed using
SPSS (Statistical Package for the Social Sciences)
software version 20. A P-value < 0.05 was
considered statistically significant. Comparison of
continuous variables such as age, preoperative
BCVA, operative time, and the dimensions of
graft between the two groups was done using
the parametric unpaired t-test. Pearson’s Chi-
square test or the Fisher’s exact test were used
for comparative analysis of categorical variables
like gender, laterality, grades of pterygium, and
indication of surgery between the two groups.

RESULTS

A total of 264 consecutive eyes of 264 patients
were enrolled in the study, of which 31 eyes
(15 in CAG and 16 in mini-SLET groups) were
ruled out due to inadequate follow-up. Hence,
data from 233 eyes (n = 118 CAG and 115 in
mini-SLET) that finished nine months of follow-
up was included in the final analysis. Table 1
depicts the baseline characteristics of CAG and
mini-SLET groups. Baseline characteristics were
statistically insignificant between the two groups.
The comparative analysis of graft size and the
operating time has been summarized in Table
2. The mean operative time for mini-SLET group
(20.33 ± 1.28 min) was significantly higher (P <
0.001) than the CAG group (12.01 ± 1.26 min). Four
postoperative symptoms have been compared in
Table 3 using the nonparametric Mann–Whitney U-
test. Both groups exhibited foreign body sensation
until day 7. A statistically significant difference in
the median score of foreign body sensation was
noted on day 1 (P < 0.001), day 3 (P < 0.001),
and day 7 (P < 0.001) between the CAG and mini-
SLET groups. This symptom improved significantly
between days 1 and 7 in both group I (P < 0.001)
and group II (P < 0.001) as demonstrated by the
Wilcoxon signed-rank test. Both groups showed
persistence of epiphora (watering) till day 7. A
statistically significant difference in the median
score of epiphora (watering) was observed on day

1 (P < 0.001) and day 3 (P < 0.001) between the
two groups. It was noted that this symptom, too,
showed significant improvement at days 1 and 7 in
both group I (P < 0.001) and group II (P < 0.001).
Pain persisted until days 7 and 3 in groups I and
II, respectively. Both the study and control groups
exhibited significant difference in the median score
of pain on day 1 (P < 0.001), day 3 (P <0.001),
and day 7 (P = 0.008). Despite a median score
of 6 and 0, the significant difference at days 1
and day 7, respectively, is ascribed to the variance
in the distribution of pain score between the two
groups. A significant improvement in this symptom
was observed between day 1 and day 7 in both
the groups (P < 0.001). Irritation in the operated
eye persisted until day 7 in both the groups.
The median score for irritation was noted to be
statistically significant on day 1 (P < 0.001), day 3
(P < 0.001), and day 7 (P < 0.001) between the two
groups. Both the study and control groups showed
significant improvement in this symptom between
day 1 and day 7 (P < 0.001), and between day 1 and
day 14, respectively.

Recurrence was observed at the first, third, sixth,
and ninth months. Two (1.6%) eyes in the CAG
group exhibited recurrence whereas three (2.6%)
had recurrence in mini-SLET group (P = 0.681).
Two patients in the CAG group and one in the
mini-SLET group showed recurrence within three
months. Recurrence in the remaining two patients
in the mini-SLET group was observed between the
third and sixth months. Two cases in each group
underwent revision surgery whereas one patient
in the mini-SLET group refused surgery. Within the
six months follow-up period, no recurrence was
observed in any of the patients who underwent
revision surgery.

One eye (0.87%) in the mini-SLET group
exhibited AMG displacement on the first
postoperative day, which was repositioned on
the very same day. None of the eyes in the study
experienced any other adverse effects related to
the grafts.

DISCUSSION

In this randomized study, we found a very low rate
of recurrence in eyes that received CAG versus
mini-SLET, with statistically insignificant difference
in the recurrence rates between the two groups.
The operating time was significantly higher in

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Two Techniques for Pterygium Excision; Jha et al

Table 1. Comparison of baseline characteristics between the CAG Group and the mini-SLET group

Characteristics CAG group (n = 118) Mini-SLET group (n = 115) P-value

Age (yr) 53.81 ± 14.28 (range = 22–80) 52.38 ± 14.62 (range = 26–78) 0.446∗

Sex F = 49.15% (n = 58) F = 44.35% (n = 51) 0.437†

M = 50.85% (n = 60) M = 55.65% (n = 64)

Laterality Right eye = 57.6% (n = 68) Right eye = 53.9% (n = 62 ) 0.696†

Left eye = 42.4% (n = 50) Left eye = 46.1% (n = 53)

Grade

I 13.5% (n = 16) 12.2% (n = 14) 0.920†

II 61.9% (n = 73) 61.7% (n = 71)

III 24.6% (n = 29) 26.1% (n = 30)

Occupation Outdoor = 61.1% (n = 72) Outdoor = 67.8% (n = 78) 0.282†

Indoor = 38.9% (n = 46) Indoor = 32.2% (n = 37)

Indications for surgery 0.895†

Cosmesis 40.7% (n = 48) 40% (n = 46)

Foreign body sensation 29.7% (n = 35) 26.1% (n = 30)

Reduced VA due to
Astigmatism

16.1% (n = 19) 22.6% (n = 26)

Threatening Visual Axis 13.5% (n = 16) 11.3% (n = 13)

Preoperative BCVA (LogMar) 0.46 ± 0.38 (range = 0–1.46) 0.43 ± 0.26 (range = 0.16–1.18) 0.476∗

∗Unpaired t-test; †χ2test

Table 2. Comparison of the size of the graft and operative time between the CAG group and mini-SLET group

Measures CAG group (n = 118) Mini-SLET group (n = 115) P-value

Dimensions of the graft (mm)

Horizontal 5.10 ± 0.41 (range = 4.2–6.5) 5.14 ± 0.45 (range = 4.5–6.8) 0.448∗

Vertical 6 ± 0.32 (range = 5.5–8.0) 6.09 ± 0.54 (range = 5.5–8.0) 0.097∗

Operative time (min) 12.01 ± 1.26 (range = 10.1–14.0) 20.33 ± 1.28 (range = 18–22) <0.001∗

∗Unpaired t-test

the mini-SLET group, however, none of the eyes
experienced intra- or postoperative complications
attributable to the surgery.

Pterygium is postulated to occur due to
localized dysfunction of nasal limbal stem cells
consequential to exposure to UVB light.[18] This
theory forms the basis of the incorporation of limbal
stem cells in the surgical treatment of pterygium.
Of all the techniques described in literature,[3–6]
CAG modality has been found to be associated
with the lowest recurrence rate.[7, 8, 10] The CAG
can be attached to the bare sclera by sutures,
fibrin glue, or autologous in situ blood coagulum.
Amongst the three techniques of fixing CAG, fibrin

glue definitely scores over others with the least
operative time.[19]

Use of SLET for the treatment of limbal stem cell
deficiency was first advocated by Sangwan et al.[20]
Subsequently, mini-SLET[16] was innovatively used
for treating 10 patients suffering with primary
pterygium. The basis of using mini-SLET for
pterygium surgery was localized deficiency
or dysfunction of limbal stem cells.[21, 22] The
AMG acts as a basement membrane and a
substrate supporting the growth of epithelial
progenitor cells.[23] AMG is also endowed with anti-
inflammatory properties owing to the presence
of protease inhibitors.[24] However, AMG itself is

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Two Techniques for Pterygium Excision; Jha et al

Table 3. Comparative outcome of the postoperative symptom score between the CAG group and mini-SLET group

CAG group (n = 118) Mini-SLET group (n = 115) P-value∗

Min Max Median Min Max Median

Foreign body sensation
Day 1 3 9 9 0 9 6 <0.001
Day 3 0 9 6 0 6 3 <0.001
Day 7 0 6 3 0 3 0 <0.001
Day 14 0 6 0 0 0 0 0.255
Day 30 0 0 0 0 0 0 0.999

Epiphora (watering)
Day 1 0 9 6 0 9 6 <0.001
Day 3 0 6 3 0 6 3 <0.001
Day 7 0 6 0 0 6 0 0.511
Day 14 0 0 0 0 0 0 0.999
Day 30 0 0 0 0 0 0 0.999

Pain
Day 1 0 9 6 0 6 3 <0.001
Day 3 0 9 3 0 6 0 <0.001
Day 7 0 6 0 0 6 0 0.008
Day 14 0 6 0 0 0 0 0.089
Day 30 0 0 0 0 0 0 0.999

Irritation
Day 1 3 9 9 0 9 6 <0.001
Day 3 0 9 6 0 6 3 <0.001
Day 7 0 6 3 0 3 0 <0.001
Day 14 0 6 0 0 6 0 0.183
Day 30 0 0 0 0 0 0 0.999

Statistically significant values are in boldface after ∗Mann–Whitney U-test

Figure 1. Serial clinical photographs of two patients of primary pterygium: (Patient 1 [A∼F]; Patient 2 [G∼L]): preoperative,
intraoperative, and postoperative. Pterygium excision with CAG with fibrin glue (A–F) and pterygium excision with mini-SLET (G–
L). (A) A case of primary nasal pterygium (left eye[LE]) before pterygium excision with CAG. (B) Dissection of pterygium. (C) POD 1.
(D) POD 30 graft well taken. (E & F) Postoperative months 6 and 9, respectively: restoration of near normal anatomy without any
recurrence. (G) A case of primary nasal pterygium (Right eye [RE]) before pterygium excision with mini-SLET. (H) Intraoperative
photograph showing dissected pterygium with eight limbal pieces. (I) POD 1. (J) POD 30: well-settled graft. (K & L) Postoperative
months 6 and 9, respectively: restoration of near normal anatomy without any signs of recurrence.

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Two Techniques for Pterygium Excision; Jha et al

devoid of limbal stem cells, hence its solitary use
to cover the bare sclera after pterygium excision,
despite providing a mechanical barrier, does not
address the underlying pathology of limbal stem
cell deficiency. As a result, this may in turn lead to
potentially more recurrences and tilt the balance
toward CAG in terms of beneficial outcomes.

An extensive MEDLINE search did not reveal
any similar study of this magnitude; hence we
undertook a randomized trial to compare the
aforementioned two techniques as mini-SLET
appeared to be a viable prospect for the treatment
of pterygium.[16] In 2015, Hernández-Bogantes
E et al,[16] elicited this interesting innovation
in 10 patients with primary pterygium without
any recurrence after eight months of follow-up.
Sati et al[25] reported a randomized control trial,
comparing the outcomes between 42 cases of
CAG and 40 cases of mini-SLET. The study
reported a 9.5% recurrence in the CAG group and
2.5% recurrence in the mini-SLET group. Although
clinically meaningful, these differences were not
found to be statistically significant. We experienced
much lower rates of recurrence in the CAG group
and almost similar in the mini-SLET group. Mini-
SLET incorporates the use of AMG and limbal stem
cells, which could lower recurrence rates as is
evident in our study. Mini-SLET is a miniaturized
modification of the original SLET technique first
described by Sangwan et al.[20] However, mini-
SLET technique scores over SLET in terms of
placing the limbal stem cells’ pieces over amniotic
membrane in proximity to the limbus. In our
opinion, mini-SLET offers an alternative solution to
patients with insufficient conjunctiva due to prior
surgeries or those suspected of suffering with
glaucoma. Additionally, it is more likely to restore
the normal anatomy of the limbus.

There were a few limitations of the study such as
the relatively low overall numbers of recurrences,
which made it difficult to make robust conclusions
while using statistical tools. Follow-up of <12
months and the considerable number of excluded
eyes (12%) also contributed toward limiting our
evaluations. The strength of this study included
its randomized and masked study design, the
relatively large sample size, and the longer follow-
up period, which exceeded that of other similar
studies.

In summary, the overall recurrence rate was
very low in this study and comparable between
mini-SLET and the established technique of CAG

for primary pterygium excision. Despite a longer
surgical time, mini-SLET appears to be a viable
alternative to CAG in the management of primary
pterygium. The mini-SLET may be considered
as the procedure of choice for all cases of
primary pterygium surgery, especially, if cost and
availability are not an issue. Also, mini-SLET
is more likely to replace the abnormal limbal
stem cells compared to CAG. In particular, this
should be adopted as the procedure of choice as
conjunctival-sparing surgery (especially in young
patients, glaucoma, and cicatrizing conjunctivitis).

Acknowledgements

The authors would like to thank Dr. Charima Priya
for excellent counselling and follow-up of patients.

Financial Support and Sponsorship

The authors did not receive any financial support
for the research, authorship, and/or publication of
this article.

Conflicts of Interest

The authors report no conflict of interest.

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