Conjunctival Autograft Fixation in Primary Pterygium Surgery: A Network Meta-Analysis of Randomized Trials

Pterygium is a common ocular surface disorder that can impair vision and cause discomfort. Surgical excision with conjunctival autograft (CAG) is the standard treatment.

Despite the widespread use of CAG, postoperative recurrence and graft-related complications remain significant challenges, affecting patient outcomes and healthcare resource utilization. In primary pterygium surgery, CAG fixation can be achieved using fibrin glue (FG), autologous blood, autologous FG (a_FG), or sutures (Vicryl, nylon, silk), yet the comparative effects of these techniques on recurrence, graft stability, and postoperative complications are not well established.

A systematic search of PubMed, Embase, Scopus, and Cochrane Library was conducted up to October 22, 2024, to identify randomized controlled trials (RCTs) comparing CAG fixation methods in primary pterygium surgery. Studies evaluating FG, autologous blood, a_FG, nylon, silk, or Vicryl sutures were included. Primary outcomes were recurrence, graft failure, and granuloma formation; secondary outcomes were graft dehiscence, displacement, and retraction. A frequentist network metaanalysis was performed in R, with results expressed as odds ratios (OR) with 95% confidence intervals (CI), and treatment rankings determined using P-scores. Quality assessments were performed using the Cochrane RoB 2 tool, GRADE, funnel plots and Egger 's test. The protocol was registered in PROSPERO (CRD42024611035).

We analyzed 35 RCTs including 2501 eyes: FG (n = 681), a_FG (n = 94), autologous blood (n = 797), silk (n = 54), nylon (n = 504) and Vicryl sutures (n = 371). FG significantly reduced recurrence compared to Vicryl (OR: 0.39; 95% CI: 0.22-0.69), nylon (OR: 0.38; 95% CI: 0.18-0.82), and autologous blood (OR: 0.52; 95% CI: 0.28-0.96). a_FG was associated with the highest odds of graft failure versus Vicryl (OR: 51.01; 95% CI: 1.36-1919.74), whereas Vicryl ranked best for minimizing graft failure. For granuloma formation, FG showed lower odds compared to silk (OR: 0.11; 95% CI: 0.01-0.98). Secondary outcomes revealed that Vicryl had favorable graft stability, while autologous blood carried higher risks of displacement and dehiscence. No significant publication bias was detected.

FG demonstrates the most favorable profile for reducing recurrence, whereas Vicryl provides superior graft stability. Autologous blood may be considered selectively but carries higher graft-related risks. These findings support individualized selection of fixation methods based on patient-specific risk profiles and resource availability in primary pterygium surgery.