May 2015

 

CATARACT

 

Maintaining wound architecture and integrity with sealant


by Jai G. Parekh, MD, MBA

 
   

Mixing key components in less than 7 seconds

Simple and gentle application of the sealant Source: Jai G. Parekh, MD, MBA

For a number of years, clear corneal incisions have been the standard for cataract surgery. This procedure requires less healing time, generally has minimal effect on astigmatism, and in the majority of cases the incisions are self-sealing. However, there are instances in which a suture is needed to ensure the integrity of the wound. Normal hydrostatic forces of the cornea tend to create good wound closure, but wound leakage is far more prevalent than many think, with some reports listing the incidence rate up to 85%.1,2,3,4 It is imperative to prevent wound leakage from occurring in order to reduce the likelihood of bacteria entering the anterior chamber and causing infection. But until recently there has not been an alternative to suturing these wounds.

The risk of losing wound integrity is increased when dealing with more complicated cataract cases. My practice treats a large number of older patients, many of whom are more complex cases as they have diabetes, kidney disease, and rheumatoid arthritis. Some are on tamsulosin with dense cataracts (requiring more intraoperative instrumentation), or are otherwise at greater risk of developing wound complications. In order to ensure proper wound closure, I began to suture all my high-risk patients. This gave me greater peace of mind in regard to maintaining the architecture of the wound, but it also introduced several worrisome issues. For sutures, I tend to use one standard 10-0 nylon suture using a 3-1-1 technique with buried knot format. While sutures are mostly efficient for my patients, they do have disadvantages other than wound leakage. In addition to relative time factors and inducing some astigmatism, they need to be removed, which can at times be problematic. Also, sutures can create a possible breeding ground for infection and inflict problems with the cornea, especially if you have a patient with a propensity for eye rubbing. Sutures also still have a published leak percentage up to 34.1%.4

New standard for wound closure

Before when closing wounds in my more complicated patients I might have put in a stitch, but now I am using the ReSure Sealant (Ocular Therapeutix, Bedford, Mass.). It has become the standard of care for all my complex cataract patients. I use the ReSure Sealant with equal if not greater confidence in knowing that the wound is truly closed. For me, this sealant has been a game changer in how we take care of the wound at the hospital level. Not only has it improved overall wound architecture and maintenance of wound integrity, but it has also given me true peace of mind that I have done everything possible to take care of the wound. This is especially true with my dense cataract and tamsulosin patients, as they not only have a greater risk of complications such as floppy iris syndrome but also have more vulnerable wounds. Out of my first 108 patients using the sealant, nearly one-third were taking tamsulosin. For these patients, I have used iris retractors and other techniques to help give my patients the best care possible. However, these devices require extra manipulation of the wound during insertion and removal, which can stretch or augment the incision, leaving the wound vulnerable to leakage, especially if these same patients have diabetes, renal disease, or arthritis. The sealant has by far been the most effective means of ensuring wound closure I have found to date. In all of my cases, I have seen excellent outcomes with no wound problems, all with astigmatically neutral incisions.

Learning curve?

There is little to no learning curve with this sealant. The hydrogel, comprised of polyethylene glycol (PEG), trilysine, buffering salts, and more than 89% water, reconstitutes within seconds. It takes only seconds to apply by simply painting the wound with the sealant. In fact, glues used off-label for corneal lacerations are more challenging. The sealant is also tinted with FD&C Blue No. 1, which aids in visualization of placement but dissipates quickly, leaving the sealant clear. The first week following surgery, the sealant sloughs off in the tears, eliminating the need for further visits for removal.

Postoperatively, I see my patients within the first 24 hours, and then I see them at 710 days, at which point the sealant is typically gone, re-epithelialization has occurred, and 98% to 99% of the cornea is healed. Patient comfort has greatly improved, as sutures can sometimes cause irritability. I have had no complaints of foreign body sensation related to the sealant.

References

1. Chee SP. Clear corneal incision leakage after phacoemulsificationdetection using povidone iodine 5%. Int Ophthalmology 2005 AugOct:26:175179.

2. Mifflin MD, Kinard K, et al. Comparison of stromal hydration techniques for clear corneal cataract incisions: conventional hydration versus anterior stromal pocket hydration. J Cataract Refract Surg. 2012 Jun; 38(6):933937.

3. Herretes S, Stark WJ, et al. Inflow of ocular surface fluid into the anterior chamber after phacoemulsification through sutureless corneal cataract wounds. Am J Ophthalmol. 2005 Oct;140;737740.

4. Masket S, Hovanesian J, et al. Hydrogel sealant versus sutures to prevent fluid egress after cataract surgery. J Cataract Refract Surg. 2014 Dec; 40:20572066.

Editors note: Dr. Parekh is the chief eye surgeon and managing partner at Brar Parekh Eye Associates, Woodland Park/Edison, N.J., and chief of cornea and external diseases/director of research at St. Josephs Healthcare System. Dr. Parekh is also a clinical associate professor of ophthalmology on the cornea service at the New York Eye & Ear Infirmary of Mt. Sinai, New York. He has no financial interests related to this article.

Contact information

Parekh: kerajai@gmail.com

Maintaining wound architecture and integrity with sealant Maintaining wound architecture and integrity with sealant
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