1. Common clinic scenarios
'Doctor, I've worked in fisheries for 30 years, my eyes are always red, and over recent years a white tissue has crept onto the black of my right eye and my vision is getting blurry. Online they call this «pterygium» — can it be operated on? How do I pick a method that won't recur?'
'Doctor, I had pterygium surgery five years ago with sutures. It came back within a year, now it's worse. Another doctor said you can use «glue» instead of sutures — faster recovery, less recurrence. Is that true?'
'Doctor, I've heard of a «no sutures, no glue, just your own blood» method — cheap and quick. Is that real? Is it stable?'
These three scenarios reflect the three questions most often asked about pterygium surgery: what is pterygium, how to reduce recurrence, and how the different fixation methods differ. A May 2026 network meta-analysis (NMA) by Terres et al. in American Journal of Ophthalmology synthesised 35 RCTs (2,501 eyes) and is currently the most complete comparison of the 6 main fixation methods. This article distils it in clinic-friendly language.
2. Common patient Q&As
Prevalence: ~2% in temperate regions; >20% near the equator. Taiwan's subtropical climate plus outdoor occupations puts it in the global "pterygium belt."
High-risk groups: outdoor workers (fishermen, farmers, construction, military), age 20-50 at onset, slightly male-predominant. Long sun exposure, coastal glare, hot/dry/windy environments are key risk factors.
① Vision-threatening: pterygium extending >3 mm onto the cornea or beginning to cover the pupil, with significant induced astigmatism.
② Cosmetic concern: socially distressing redness or thick tissue.
③ Persistent inflammation / discomfort: recurrent redness, foreign-body sensation, tearing, contact-lens intolerance despite medical care.
④ Rapid progression: significant growth within 1-2 years, threatening the central cornea.
For small, vision-stable pterygia, observation + sun protection + artificial tears is reasonable. Surgery doesn't remove the UV source, so post-op sun protection and ocular surface care must continue.
Why CAG? Without covering with healthy tissue, fibrovascular tissue regrows quickly. A conjunctival autograft provides fresh healthy epithelium and dramatically lowers recurrence (from ~50% → under ~10%).
Timing: most recurrences occur within 6-12 months post-op; staying clear at 1 year predicts long-term stability. Risk factors: younger patients (<40 yr), preoperative chronic inflammation, incomplete Tenon's excision, continued UV exposure, premature steroid taper.
① Fibrin glue (FG): commercial biological glue (fibrinogen + thrombin), applied under the graft for instant bonding. Pros: sutureless, no foreign-body sensation, less inflammation, lowest recurrence. Cons: higher cost, requires stock, blood-derivative restrictions in some countries.
② Vicryl: synthetic absorbable suture (polyglactin), absorbs in ~6-8 weeks. Pros: most mechanically stable, cheap, widely stocked. Cons: takes time to suture, foreign-body sensation, more inflammation, recurrence slightly higher than FG.
③ Nylon: non-absorbable, requires suture removal. Pros: durable, cheap. Cons: needs removal, more discomfort, less popular in modern pterygium surgery.
④ Silk: natural protein fibre, needs removal. No longer recommended: highest granuloma risk (Terres 2026： vs FG OR 9), strong inflammatory reaction.
⑤ Autologous blood (a_blood): graft is allowed to autocoagulate to the bed — no sutures, no glue. Pros: fully autologous, zero materials cost. Cons: weak fixation, significantly higher displacement/dehiscence (vs Vicryl OR 7.40 / 10.08); only for selected low-risk patients.
⑥ Autologous fibrin glue (a_FG): fibrinogen extracted from patient's own plasma. Limited evidence, variable strength; highest failure rate in this NMA (very wide CI).
• "Am I high-recurrence-risk?" (young, ongoing outdoor work, pre-op inflammation → favours FG)
• "Can I follow up reliably?" (poor compliance / can't return for suture removal → favours absorbable suture or glue)
• "Budget concerns?" (out-of-pocket differences vary; check with your facility)
• "Recurrent case?" (higher risk → FG plus possibly adjuncts like amniotic membrane)
• "Which method are you (the surgeon) most experienced with?" (surgeon experience strongly affects outcome)
Bottom line: NMA gives population-level evidence, but surgeon experience, your local hospital's resources, and your own factors are decisive.
• Sun protection: outdoor activity → UV400 sunglasses + wide-brim hat; especially important in Taiwan's high-UV months (late spring to autumn). UV is the strongest environmental driver of recurrence.
• Post-op drops: your doctor will prescribe topical steroid + antibiotic drops. Steroid dose/duration follows your doctor's taper — don't stop on your own. Long-term use needs IOP and lens monitoring.
• Follow-up: typical schedule is week 1, month 1, month 3, month 6, month 12.
Red flags (same-day return): (1) sudden severe pain or vision loss; (2) visible graft displacement or detachment; (3) persistent redness or discharge (infection); (4) increased bare sclera; (5) new fibrovascular tissue creeping onto the cornea within 6 months.
3. Key takeaways: 8 things you really need to know
30-second takeaways
- Largest NMA: Terres 2026 synthesised 35 RCTs and 2,501 eyes — the most complete fixation-method evidence to date
- FG is best for recurrence: vs Vicryl OR 0.39 (significant); vs nylon 0.38; vs a_blood 0.52
- Vicryl is best for graft stability: lowest failure, displacement, dehiscence, retraction rates
- a_blood is cheap but unstable: displacement OR 7.40, dehiscence 10.08, retraction 20.10 (all vs Vicryl, significant)
- Silk no longer recommended: highest granuloma risk; literature consensus advises against use in pterygium surgery
- No single best method: individualise by recurrence risk, stability needs, budget, surgeon experience
- 3 critical post-op essentials: sun protection (UV400 sunglasses), steroid drops per doctor's taper, regular follow-up
- Taiwan: subtropical high-prevalence region; for cost and NHI coverage details, ask your ophthalmologist and your hospital's pre-service notice
4. Pterygium pathology and epidemiology
Pterygium was historically seen as a "benign fibrovascular conjunctival overgrowth" — modern research reframes it as a limbal stem cell-associated disorder, characterised by: (1) centripetal proliferation of altered limbal epithelial cells; (2) dissolution of Bowman's layer; (3) epithelial-mesenchymal transition; (4) activation of fibrovascular stroma with inflammation, neovascularisation, and ECM remodelling.
Environmental risk factors: chronic UV, heat, geographic location (more near equator), chronic ocular surface inflammation, nutrition. Prevalence: ~2% in temperate regions, >20% near the equator — the global "pterygium belt." Taiwan's subtropical climate + outdoor occupations places it in this band. Demographics: slight male predominance, onset typically 20-40 yr, clinical peak 40-60 yr.
Clinical presentation: tearing, dry eye, conjunctival hyperaemia, foreign-body sensation, induced corneal astigmatism, pseudo-dry-eye symptoms; severe cases threaten vision. Historical recurrence: bare excision 24-89% (varies by technique, Tenon excision depth, inflammation control); modern CAG with appropriate fixation reduces this to 3-20%.
5. What is a network meta-analysis? How are 6 methods compared?
Network meta-analysis (NMA) is an advanced evidence-synthesis method. Pairwise meta-analyses compare two methods at a time; NMA compares multiple treatments simultaneously, integrating direct evidence (A vs B) and indirect evidence (A vs C, C vs B → infer A vs B), producing pairwise effect estimates across all methods and probabilistic P-score rankings for each outcome.
| Item | Detail |
|---|---|
| Inclusion | Primary pterygium patients; CAG; comparing at least 2 of FG/a_FG/a_blood/Vicryl/nylon/silk; RCT |
| Exclusion | Recurrent pterygium; adjuncts (mitomycin C, amniotic membrane, radiation); unspecified suture; non-comparative designs |
| Scale | 35 RCTs, 2,501 eyes, across Asia, South America, Africa, Middle East |
| Primary outcomes | Recurrence, graft failure, granuloma formation |
| Secondary outcomes | Graft dehiscence, displacement, retraction |
| Analysis | Frequentist NMA in R (meta/gemtc/rjags); random-effects model; Cochrane RoB 2; GRADE; P-score ranking |
6. Outcome 1： Recurrence — fibrin glue is best
Recurrence is the primary efficacy endpoint, defined as "any postoperative fibrovascular tissue extending >1 mm from the limbus onto the cornea." NMA results (Vicryl as reference):
| vs Vicryl | Odds ratio (OR) | 95% CI | Interpretation |
|---|---|---|---|
| Fibrin glue (FG) | 0.39 | 0.22-0.69 | ✅ Significantly lower (~61% lower) |
| Nylon | 1.01 | 0.44-2.34 | Comparable to Vicryl |
| Silk | 1.12 | 0.29-4.31 | No significant difference (wide CI) |
| a_blood | 0.52 | 0.28-1.00 | Borderline (trends lower) |
P-score recurrence ranking: FG #1, followed by a_blood, a_FG, nylon, silk, Vicryl. FG vs nylon OR 0.38 (0.18-0.82), significant; FG vs a_blood OR 0.52 (0.28-0.96), also significant.
Mechanism: FG's advantage stems from (1) immediate uniform bonding minimising graft micromotion and inflammatory exposure; (2) no needle penetration, no mechanical irritation; (3) stable epithelial interface promoting rapid coverage; (4) reduced post-op inflammation overall. These factors together lower fibrovascular regrowth probability. Literature consistently reports FG recurrence at ~3-5% vs ~15-20% with sutures.
7. Outcome 2： Graft stability — Vicryl is best
Graft stability covers 4 secondary endpoints: failure (need re-suturing or repositioning), dehiscence (separation from surrounding conjunctiva), displacement (post-op shifting), retraction (graft pulls back exposing sclera). Vicryl ranked #1 on every stability metric:
| Outcome vs Vicryl | a_blood OR | Interpretation |
|---|---|---|
| Displacement | 7.40 (1.91-28.68) | ❌ a_blood significantly 7× higher |
| Dehiscence | 10.08 (1.16-87.69) | ❌ a_blood significantly 10× higher |
| Retraction | 20.10 (1.59-253.75) | ❌ a_blood significantly higher (wide CI, interpret cautiously) |
| Failure | 2.31 (0.46-11.48) | No significant difference |
Mechanism: Vicryl is a synthetic absorbable suture providing moderate-tension secure mechanical fixation, self-absorbing in 6-8 weeks. Unlike non-absorbable sutures (nylon, silk), no removal needed; unlike glue or autologous blood, it doesn't rely on biological adhesion. For patients with limited follow-up reliability or where secure mechanical fixation is paramount, Vicryl is the most dependable option in the network.
But Vicryl's recurrence rate is higher (significantly vs FG) — so it's a stability-vs-recurrence trade-off.
8. Outcome 3： Granuloma and other complications — silk is worst
Subconjunctival granuloma is a post-op local inflammatory fibrovascular mass causing persistent discomfort, cosmetic concern, and occasionally requiring excision. Terres 2026： FG vs silk granuloma OR 0.11 (0.01-0.98, significant) — silk's granuloma risk is 9× higher than FG. Historical literature long noted silk's prominent foreign-body inflammatory response, so silk is no longer a recommended option in modern pterygium surgery.
Other minor complications (foreign-body sensation, subconjunctival haemorrhage, infection) were less consistently reported and excluded from the primary analysis. Clinical consensus: sutureless methods (FG, a_blood) are more comfortable than sutures (Vicryl, nylon, silk).
9. Individualised choice: how to discuss with your doctor
💡 6 questions to ask your ophthalmologist
- 1. How severe is my pterygium? Is surgery essential? — confirm whether non-surgical options suffice (artificial tears, sun protection, anti-inflammation)
- 2. Am I "high-recurrence-risk"? — young, continued outdoor work, severe pre-op inflammation, prior recurrence → FG should be prioritised
- 3. Can I follow up reliably? — poor compliance / can't return for suture removal → absorbable suture (Vicryl) or glue preferred
- 4. Which method are you (the surgeon) most experienced with? — surgeon experience strongly affects outcomes
- 5. How are costs structured? — NHI vs out-of-pocket; FG self-pay specifics vary — check with your facility
- 6. How do I prevent recurrence post-op? — sun protection, steroid drop schedule, follow-up intervals, recurrence red flags
10. Taiwan context and NHI notes
⚠️ Costs & coverage — always confirm with your hospital
- Costs for pterygium surgery, fixation consumables (sutures, fibrin glue, etc.), NHI coverage vs out-of-pocket components can vary by hospital. Confirm pricing directly with your ophthalmologist and the facility before surgery, and refer to the latest NHIA announcements.
- Post-op topical steroids and antibiotics: agent and duration are prescribed by your ophthalmologist based on your case; check coverage details with your prescriber, pharmacist, or the NHIA.
- Sunglasses / wide-brim hat: not NHI-covered, but the single most important environmental intervention to prevent recurrence — UV400 or higher recommended, with a wide-brim hat for outdoor work or prolonged sun exposure.
11. Post-op red flags: when to return immediately
🚨 Post-pterygium-surgery red flags
- Sudden severe pain or significant visual decline
- Visible graft displacement or detachment (graft shifted from original position)
- Persistent redness, swelling, purulent / yellow-green discharge (suspect infection)
- Bare sclera area enlarging (white area expanding)
- New fibrovascular tissue creeping onto cornea within 6 months — early recurrence signal
- Blurring, headache, nausea while on post-op steroid drops — possible steroid-induced IOP rise
If any of the above, return to your surgeon or ophthalmology ER the same day.
12. Conclusion: individualised choice + long-term sun protection
Terres et al. 2026 NMA delivers three key messages:
- No single best method — FG best for recurrence, Vicryl best for stability; choice depends on your individual recurrence risk, compliance, budget, surgeon experience
- Silk is no longer recommended — highest granuloma risk (vs FG OR 9); modern pterygium surgery should avoid silk
- Autologous blood only for carefully selected low-risk cases — significantly higher displacement, dehiscence, retraction (vs Vicryl OR 7-20)
The most important message for patients: surgery only removes this episode of pterygium; long-term success depends on post-op lifestyle, sun protection, and ocular surface care. Taiwan's subtropical UV is high; outdoor workers especially should make UV400 sunglasses + wide-brim hat standard. Remember: you can redo the surgery, but the sun won't stop shining.
📚 HsiaoEye Related Articles — Cornea & Conjunctiva / Ocular Surface
- Why Do My Dry-Eye Symptoms Not Match the Exam? — Pterygium often presents with pseudo-dry-eye symptoms
- 8 Dry-Eye Myths — Foundations of post-op ocular surface care
- Recurrent SK After HZO — Another ocular surface disease needing long-term topical steroid management
- Ophthalmic Trauma — Overlooked Burden — Common ocular risks for outdoor workers
References
- Terres MT, Hira S, de Avila MF, Pereira EMM, Shamsher E, Wagner F, Ribeiro GR, Assis MLM, Mannan A, Bertholde GD, Vilela M, Piovezan AP. Conjunctival Autograft Fixation in Primary Pterygium Surgery: A Network Meta-Analysis of Randomized Trials. Am J Ophthalmol. 2026;285:240–253. doi:10.1016/j.ajo.2026.02.005.
- Lan A, Xiao F, Wang Y, Luo Z, Cao Q. Efficacy of fibrin glue versus sutures for attaching conjunctival autografts in pterygium surgery: a systematic review with meta-analysis and trial sequential analysis of evidence. Oncotarget. 2017;8(25):41487–41497.
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- Karalezli A, Kucukerdonmez C, Akova YA, Altan-Yaycioglu R, Borazan M. Fibrin glue versus sutures for conjunctival autografting in pterygium surgery: a prospective comparative study. Br J Ophthalmol. 2008;92(9):1206–1210.
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- Cioba C, Marafon SB, Fortes BGB, et al. Autologous fibrin glue versus sutures for conjunctival autograft in primary pterygium: a randomized clinical trial. Int Ophthalmol. 2023;43(7):2371–2381.
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