Repair of a leaking bleb with fibrin glue

Polyethylene Glycol-Based Synthetic Hydrogel Sealant for Filtration Bleb Leaks: An In Vivo and Histologic Study

Purpose

To evaluate the efficacy of polyethylene glycol (PEG)-based synthetic sealant for closing bleb leaks after glaucoma filtration surgery.

Methods

Tube shunt surgery that included implantation of a 22-gauge indwelling catheter and intraoperative mitomycin C was performed in the left eyes of 11 New Zealand white rabbits. Seven days postoperatively, all filtration blebs were perforated with an 18-gauge needle to create a bleb hole. In six rabbits, the holes were covered with the sealant and irradiated with blue-green light for 60 seconds; in the five control rabbits, the holes were untreated. For 3 weeks after the tube shunt surgery, the eyes were checked for bleb leaks, and the intraocular pressure (IOP) was measured in both eyes. Finally, the operated eyes were enucleated for histologic examination.

Results

The bleb leaks stopped in the eyes in which sealant was used and persisted in the other eyes. The sealant preserved the bleb function; the IOPs in these eyes were significantly (P < 0.05) lower than the right eyes that did not undergo surgery. Hematoxylin and eosin staining showed that the holes were closed and covered with conjunctival epithelial cells in the eyes in which sealant was applied; the holes were open in the control eyes. Immunohistochemical staining showed that the bleb holes in which the sealant was applied had fewer inflammatory cells.

Conclusions

The PEG sealant has the potential to seal bleb leaks effectively.

Translational Relevance

Application of the PEG sealant can be used as adjunct therapy for bleb leaks in glaucoma surgery.

Incision-Free Minimally Invasive Conjunctival Surgery (MICS) for Late-Onset Bleb Leaks After Trabeculectomy (An American Ophthalmological Society Thesis)

PURPOSE

This study describes an incision-free minimally invasive conjunctival surgical (MICS) technique to repair late-onset leaking blebs after trabeculectomy.

METHODS

A surgical technique to repair leaking blebs without incision or excision of conjunctiva is described. This is followed by retrospective review of all patients treated at the Glaucoma Unit at St. Michael's Hospital for bleb leaks repaired with MICS from 2012 to 2017. With Research Ethics Board approval, clinical data obtained from the charts included demographic information, vision, intraocular pressure (IOP) data before and after surgery, need for additional medication, and complications. Resolution of the bleb leak without the need for additional therapy or intervention for glaucoma control was considered a success.

RESULTS

The MICS approach was applied to 14 eyes of 13 consecutive patients with a leaking bleb. Mean age of presentation was 70.2 ± 14.8 years, and all patients had a history of mitomycin use at the time of glaucoma surgery. The onset of bleb leak following trabeculectomy ranged from 7 months to 16.3 years. Mean pre-operative IOP was 4.5 ± 2.8 mm Hg; IOP measured 12.3 ± 3.0 mm Hg immediately after the procedure. Complete resolution of the bleb leak was observed following surgery in all cases. The follow-up period ranged from 2 weeks to 61 months (10.2 ± 18.1). Recurrent bleb leak was reported in 1 patient 2 years following initial surgery. In all cases, the initially repaired filtering blebs remained functional at last follow-up, and no additional medications were required.

CONCLUSIONS

The MICS procedure is an effective option for treating late-onset leaking blebs without cutting or excising conjunctival tissue. The minimal requirements of this method make it additionally accessible to low-resource settings. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Human Fibrin Sealant: Effective Hemostasis in Otolaryngologic Surgeries

In otolaryngologic surgeries, achieving hemostasis is of paramount importance for reducing associated morbidities. Topical hemostatic agents have been studied mainly in endonasal operations. Its use in other surgeries has been minimally reported. In this "real world data" study, we retrospectively evaluated the surgeries between June 2014 and December 2014, where topical hemostatic agent-Evicel^® (Ethicon BioSurgery, US) was used to achieve hemostasis. All the patients were followed till 15 day post operation. The data on Evicel^® preparation time, intraoperative blood loss, hemostasis time, length of hospital stay, blood transfusion given, and complications were evaluated. The quality of life was assessed by using discomfort score and it was statistically analyzed for patients underwent surgery for chronic rhinosinusitis and chronic otitis media. The surgical clinical data of 103 patients (63 males and 40 females) were considered for the analysis. In all patients, hemostasis was achieved in less than 1 min. The intraoperative blood loss was between 23 and 99 ml for all surgeries. No postoperative bleeding was reported and blood transfusion was not required for any patients. The hospital stay was 1-2 days. In endonasal surgeries, nasal packing was not required in 36.9% of patients. The discomfort score was statistically improved in patients underwent surgery for chronic rhinosinusits and chronic otitis media (p < 0.001). No complications were reported till day 15 postoperatively. Evicel^®, a topical human fibrin sealant found to be effective in achieving hemostasis and for better clinical outcome in various otolaryngologic surgical procedures.

Intracameral Air and Fibrin Glue for the Management of Late Bleb Leak following Glaucoma Surgery

Background and Objectives

To report a case of delayed-onset bleb-associated endophthalmitis (BAE) with bleb leak successfully managed with pars plana vitrectomy, intravitreal antibiotics, intracameral air, and fibrin glue.

Patient and Methods

A 66-year-old pseudophakic female presented with BAE and bleb leak. A 25-gauge pars plana vitrectomy, cultures, and intravitreal antibiotics and steroid injections were performed. The infusion was switched to air filling the anterior chamber and bleb with air. Fibrin glue (Tisseel®) was applied over the leaking bleb.

Results

BAE and bleb leak resolved with return of visual acuity to 20/25 and a functioning bleb with no recurrence of bleb leak after 1 year of follow-up.

Conclusion

The combination of intracameral air and fibrin glue may have a role in the management of bleb leaks.

Prospective study on a novel treatment for leaking cystic bleb: Efficacy and safety of collagen crosslinking

IMPORTANCE

Management of cystic bleb leak is difficult. It would be essential to look for a method to strengthen the original pathological conjunctiva and reverse bleb leak.

BACKGROUND

To evaluate the long-term efficacy and safety of collagen crosslinking in patients with leaking cystic bleb.

DESIGN

Prospective interventional case series at a university-based hospital.

PARTICIPANTS

Twelve eyes in 12 subjects with late-onset bleb leak from cystic bleb, without indications for prompt surgical interventions were included.

METHODS

The subjects underwent crosslinking with 0.1% riboflavin application to bleb surface, followed by ultraviolet irradiation for 30 minutes. The subjects were followed up at baseline and at 1 week, 1 month, 3 months, 6 months post-treatment and then every 6 months afterwards.

MAIN OUTCOME MEASURES

Interval from treatment to cessation of bleb leak, recurrence rate of bleb leak and side effects of treatment.

RESULTS

The mean follow-up after crosslinking was 29.33 ± 12.45 months. Bleb leak subsided in 11 (92%) of 12 patients after a single session of crosslinking, after 1 to 8 weeks (median 3 weeks). Time to leak cessation was significantly correlated with the number of prior glaucoma interventions (R = .71, P = .014). Bleb wall at 3 months was significantly thicker than at baseline (0.70 ± 0.67 vs 0.81 ± 0.62 mm, P = .008). None of the patients experienced any complications.

CONCLUSIONS AND RELEVANCE

Crosslinking achieves resolution of cystic bleb leak which lasts for at least 12 months, without the need of subsequent surgical interventions. Crosslinking is a simple, non-invasive treatment for bleb leak. It aims to restore the integrity of conjunctiva.

Ocular Biocompatibility of Poly-N-Isopropylacrylamide (pNIPAM)

Purpose. To study the safety of intravitreal injections of poly-N-isopropylacrylamide (pNIPAM) tissue adhesive in rabbit eyes. Methods. Twelve study rabbits received an intravitreal injection of 0.1 mL 50% pNIPAM in the right eye. Follow-up examinations included color fundus photography, fundus fluorescein angiography (FA), optical coherence tomography (OCT), and electroretinography (ERG). Subsequent to the last follow-up assessment, the rabbits were sacrificed and histopathological study on the scleral incision sites was performed. Results. All study animals developed mild to moderate levels of inflammatory reaction in the conjunctiva, anterior chamber, and the anterior vitreous during the first month of follow-up. After this period, the level of the inflammatory reaction progressively decreased and completely disappeared after the third month of follow-up. The lens and cornea remained clear during the entire follow-up period. OCT and FA did not show areas of retinal damage or neovascularization. Histological and ERG studies of eyes injected with pNIPAM demonstrated absence of retinal toxicity. Conclusion. Intravitreal injections of pNIPAM were nontoxic in this animal study, and pNIPAM may be safe to be used as a bioadhesive in certain retinal diseases.

Comparison of intra-operative 0.02% mitomycin C and sutureless limbal conjunctival autograft fixation in pterygium surgery: five-year follow-up

PURPOSE

To compare efficacy and safety between fibrin sealant assisted limbal conjunctival autograft fixation and intra-operative MMC in pterygium surgery.

METHODS

Prospective, comparative, interventional case series. Forty eyes of 40 patients with nasal primary pterygium, 18 male and 22 female, were enrolled. The patients were assigned to two groups, and each contained nine male and 11 female based on the pterygium area encroaching onto the cornea. In one group, the conjunctival autograft was attached to the sclera with fibrin sealant, and in the other group, 0.02% MMC was applied after the pterygium was removed. All the patients were followed up postoperatively on days 1, 3, 7 and 14 then at months 1, 2, 6, 12 and 60. The main outcome measures included operating time, postoperative discomfort, cornea endothelial damage, recurrence rate and complications.

RESULTS

The average operating time was significantly shorter (p = 0.044) in the fibrin sealant group, and fewer postoperative symptom complaints were received as well. On postoperative month 1, no significant differences in the mean endothelial cell count, mean CV and mean 6A% were observed between these two groups. By the end of 5-year follow-up, the recurrence rate was 0% in the fibrin sealant group and 20% in the MMC group (p = 0.106), and there were no severe visual acuity threatening complications in either group.

CONCLUSION

There were no severe complications after long-term follow-up if intra-operative MMC was strictly and carefully used. Overall, this sutureless method is more effective than traditional MMC.

Autologous Transplantation of a Free Tenon's Graft for Repairing Excessive Bleb Leakage after Trabeculectomy: A Case Report

Purpose

To report a case of autologous transplantation of a free Tenon's graft to repair excessive bleb leakage after trabeculectomy.

Case Report

A 39-year-old Japanese woman presented with severe hypotony in her left eye. She had undergone trabeculectomy with mitomycin C 14 years ago. Slit-lamp examination showed an ischemic and ruptured bleb, excessive bleb leakage, and an extremely shallow anterior chamber. A large scleral defect was vaguely observed through the bleb conjunctiva. The hypotony was attributed to excessive bleb leakage. A surgical revision was required. First, the avascular bleb conjunctiva and the melted scleral flap were excised. A scleral defect was observed. Thick fibrotic tissue, i.e., the autologous Tenon's graft, was separated from the underlying sclera, cut to the desired size to cover the defect, and sutured to the sclera with 10-0 nylon sutures. Irrigation with balanced salt solution through the paracentesis confirmed deepening of the anterior chamber with no bleb leakage. In the current case, a layer of amniotic membrane was applied to cover the largely exposed sclera. Two weeks postoperatively, the surgical site was totally re-epi-thelialized with no aqueous leakage. Three months postoperatively, vascularization into the surgical site was observed. The intraocular pressure remained within normal levels without recurrent bleb leakage.

Conclusions

Autologous transplantation of a free Tenon's graft successfully repaired excessive bleb leakage through a scleral defect after trabeculectomy. This technique is easier, safer, and may be more cost effective for repairing excessive bleb leakage after trabeculectomy than conventional management techniques.

Use of a fibrin adhesive for conjunctival closure in trabeculectomy

PURPOSE

To assess the safety and efficacy of a fibrin tissue adhesive (Tissucol Duo(®) ) used to close the conjunctiva in trabeculectomy.

METHODS

A nonrandomized prospective study including 57 patients with chronic simple glaucoma who underwent trabeculectomy surgery. All the trabeculectomies were conducted by the same surgeon using the same surgical technique with the exception that conjunctival closure was achieved by either running Nylon 10/0 suture (n = 29) or using the fibrin glue (n = 28). Preoperative and postoperative data were obtained on intraocular pressure (IOP), number of hypotensive medications used, self-reported discomfort and complications arising during and after surgery.

RESULTS

No differences were detected between the two patient groups regarding the intraocular pressure reduction achieved during follow-up. In the first 2 weeks of follow-up, reported discomfort assessed using a visual analogue scale was significantly lower in the Tissucol Duo(®) group. Two patients in the Tissucol Duo(®) group suffered conjunctival dehiscence and suturing was required at 24 hours postsurgery. Remaining complications were similar in the two groups.

CONCLUSION

The use of Tissucol Duo(®) seems to be a safe and efficient option for conjunctival closure in trabeculectomy that simplifies the surgical procedure and reduces patient discomfort in the immediate postoperative period.

Comparison of autologous in situ blood coagulum versus sutures for conjunctival autografting after pterygium excision

Our aim was to compare the efficacy and safety of autologous in-situ blood coagulum versus sutures for attaching conjunctival limbal autografts (CAG) among patients undergoing primary pterygium excision over a period of 1 year. Thirty-two eyes of 32 patients with primary pterygium were randomly divided in into two groups: group I (16 eyes) underwent CAG with 10-0 monofilament nylon sutures and group II (16 eyes) underwent CAG with patient's own in-situ blood coagulum acting as bioadhesive or fixative followed by bandaging for 48 h. Patients were followed up postoperatively on the 2nd day, 1 week, 2 weeks, 4 weeks, and 12 months. All the surgeries were done by the same surgeon. Graft success, recurrence rate, operating time, patient comfort, graft retraction or any other complication were studied. The duration of surgery was significantly less (P < 0.001) in group II (mean duration 15 ± 2 min) than group I (mean duration 67 ± 2 min). Postoperative symptoms were fewer for group II than group I. Rate of recurrence was equal in both groups (one patient in each group, 6.25 %). But complications regarding graft failure and graft retraction were more common in group II (two patients, 12.5 %) than group I (one patient, 6.25 %); however, the difference was not statistically significant (Z = 0.61). Thus, autologous in-situ blood coagulum is a useful method for graft fixation in pterygium surgery with shorter operating time and less postoperative discomfort.

Interventions for late trabeculectomy bleb leak

BACKGROUND

Late trabeculectomy bleb leaks are a common complication after filtering glaucoma surgery. Although asymptomatic, late bleb leaks may lead to hypotony and are associated with bleb related infections.

OBJECTIVES

To assess the effects of interventions for late trabeculectomy bleb leak.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 7), MEDLINE (January 1946 to July 2012), EMBASE (January 1980 to July 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 18 July 2012.

SELECTION CRITERIA

We included randomised and quasi-randomised trials in which any treatments for eyes with late bleb leak (interventional and non-interventional) were compared with each other.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors when additional information was needed.

MAIN RESULTS

The review included one multicentre trial based in the USA with 30 eyes of 30 participants. The trial compared two surgical procedures (conjunctival advancement and amniotic membrane transplant) to cover a filtering bleb leak. Conjunctival advancement has been shown to be more effective in sealing filtering bleb leaks.

AUTHORS' CONCLUSIONS

Although a variety of treatments have been proposed for bleb leaks, there is no evidence of their comparative effectiveness.The evidence in this review was provided by a single trial that compared two surgical procedures (conjunctival advancement and amniotic membrane transplant). The trial did show a superiority of conjunctival advancement, which was regarded as standard treatment, to amniotic membrane transplantation. There is a need for more randomised trials to validate the findings of this single trial and provide more information on the different types of interventions, especially non-surgical treatments compared to surgical procedures. We recommend that any intervention should be compared to a standard procedure, which is to date conjunctival advancement.

Management of complications in glaucoma surgery

Surgical option for glaucoma is considered when other modalities are not working out to keep the intraocular pressure under control. Since the surgical procedures for glaucoma disrupt the integrity of the globe, they are known to produce various complications. Some of those complications can be vision-threatening. To minimize the morbidity, it is very important that one should know how to prevent them, recognize them and treat them. The objective of this article is to provide insight into some of those complications that will help the ophthalmologists in treating glaucoma patients in their clinical practice.

Recurrence rate using fibrin glue-assisted ipsilateral conjunctival autograft in pterygium surgery: 2-year follow-up

AIMS

To determine the recurrence rate after pterygium excision with ipsilateral conjunctival autograft using fibrin glue.

METHODS

One hundred eleven eyes of 92 patients operated for primary pterygium were retrospectively evaluated for recurrence rate and intraoperative and postoperative complications. Pterygia were preoperatively divided in atrophic/grade 1 (n = 2; 1.80%), intermediate/grade 2 (n = 85; 76.58%), or fleshy/grade 3 (n = 24; 21.62%) types. All patients were operated using an ipsilateral conjunctival autograft fixed with fibrin glue. Only patients with 2-year follow-up were included in this study.

RESULTS

Two years after surgery, the mean recurrence rate was 4.50% (n = 5). No intraoperative complications were noted. Postsurgical complications were graft pseudoedema (n = 45; 40.54%), graft retraction (n = 3; 2.70%), and donor site granuloma (n = 1; 0.90%).

CONCLUSION

Fibrin glue-assisted ipsilateral conjunctival autograft seems to be safe and efficacious and associated with a low rate of recurrence.

In vitro conjunctival incision repair by temperature-controlled laser soldering

The common method of closing conjunctival incisions is by suturing, which is associated with several disadvantages. It requires skill to apply and does not always provide a watertight closure, which is required in some operations (e.g., glaucoma filtration). The purpose of the present study was to evaluate laser soldering as an alternative method for closing conjunctival incisions. Conjunctival incisions of 20 ex vivo porcine eyes were laser soldered using a temperature-controlled fiberoptic laser system and an albumin mixed with indocyanine green as a solder. The control group consisted of five repaired incisions by a 10-0 nylon running suture. The leak pressure of the repaired incisions was measured. The mean leak pressure in the laser-soldered group was 132 mm Hg compared to 4 mm Hg in the sutured group. There was no statistically significant difference in both the incision's length and distance from the limbus between the groups, before and after the procedure, indicating that there was no severe thermal damage. These preliminary results clearly demonstrate that laser soldering may be a useful method for achieving an immediate watertight conjunctival wound closure. This procedure is faster and easier to apply than suturing.

"Bleb window"-pexy for the management of symptomatic, oversized blebs

PURPOSE

To describe a simple method and outcomes of remodeling dysesthetic, oversized filtering blebs.

PATIENTS AND METHODS

Retrospective chart review of the initial consecutive patients who had undergone "bleb window"-pexy (BWP) over a 1-year period. Patients with symptomatic, oversized, and dysmorphic blebs that did not show signs of spontaneous resolution were candidates for the technique, regardless of the intraocular pressure. Under topical anesthesia, a conjunctival window was created in the filtering bleb at the palpebral fissure (nasal or temporal) using Westcott scissors. The cut edges of conjunctiva and Tenon capsule were then glued to the underlying bare sclera using autologous fibrin tissue glue. In the case of extended (360 degrees) blebs (2 patients), 2 conjunctival windows were performed (nasal and temporal). Main outcome included symptomatic relief, restoration of bleb architecture, and preservation of filtration.

RESULTS

Six eyes from 6 patients underwent BWP. The mean follow-up period was 6.6+/-1.7 months (3.5 to 8.3 mo). All patients documented a rapid symptomatic relief within the first postoperative day. All had successful reduction in bleb size and adequate filtration without further antiglaucoma medications or surgery. Best corrected visual acuity improved 2 Snellen lines in 1 eye. Lens status remained unchanged in all cases. No complications or recurrences were noted.

CONCLUSIONS

Early results showed that BWP is safe, easy, and minimally invasive technique for the rapid relief of dysesthesia symptoms from dysmorphic filtering blebs. A larger sample size with longer follow-up is necessary to confirm the clinical utility.

Fibrin Glue as a Suture Substitute: Histological Evaluation of Trabeculectomy in Rabbit Eyes

PURPOSE

To describe the outcome of the use of fibrin adhesive (Quixil) in penetrating trabeculectomy in a rabbit model.

METHODS

Fibrin adhesive was used experimentally to attach the conjunctiva and the scleral flap in two groups of 17 New Zealand albino adult rabbits (34 eyes). In the first experiment (20 eyes), the fibrin adhesive was used to reattach the tissue after conjunctival peritomy and scleral flap only in 14 eyes (experiment I). In 6 eyes (controls), the conjunctiva was attached with nylon sutures. In the second experiment (14 eyes), the fibrin adhesive was used after conjunctival peritomy, scleral flap, and penetrating trabeculectomy in 8 eyes (experiment II). In a control group of 6 eyes, nylon sutures were used to attach the scleral flap and the conjunctiva after penetrating trabeculectomy. Biomicroscopy and histopathological examinations were performed on postoperative days 1, 3, 7, 14, 21, and 30. Intraocular pressure was measured before and after surgery in the second experiment. Main outcome measures are histological presence of adhesive in the tissue, degree of capillary congestion, inflammatory reaction, collagen density [scar formation] and clinical (IOP measurements before and after surgery, conjunctival chemosis, anterior chamber reaction, presence of filtering bleb and wound leakage).

RESULTS

In experiments I and II, the adhesive was well identified histologically in the tissue as an amorphic eosinophilic substance for up to day 3 and nearly disappeared by day 7. An acute inflammatory reaction was noted for up to 14 days, which converted to chronic inflammation with collagen deposits and scar formation by day 30. Similar inflammatory reaction was observed in the control group. The adhesive had no adverse effects on ocular tissue compared with sutures. One eye in experiment II demonstrated wound dehiscence. Intraocular pressure dropped from 17.35 mmHg preoperatively to 8.28 mmHg on postoperative day 1 in experiment II, and from 17.2 mmHg to 11.5 mmHg in the controls. No significant change in intraocular pressure was noted in experiment I.

CONCLUSIONS

The fibrin adhesive had no adverse effects on ocular tissue compared with sutures. It might serve as an effective substitute for conjunctival and scleral wound closure in trabeculectomy surgery.

Conjunctivolimbal autograft using a fibrin adhesive in pterygium surgery

Purpose

To evaluate the efficacy and safety of fibrin bioadhesive in conjunctivolimbal autograft surgery for primary pterygium.

Methods

Thirty-six eyes in 34 patients were reviewed with nasal primary pterygium who were treated with pterygium excision with superior conjunctivolimbal transplantation with fibrin bioadhesive. Surgical durations were recorded and the patients were followed up on the first day after surgery and then at 1, 2, 4, 8 and 12 weeks postoperatively. The graft-recipient site attachments were examined and subjective symptoms of patients were recorded at every follow-up examinations.

Results

The mean patient age was 57.9±10.1 (ranging from 33 to 83) years. The mean follow-up period was 22.05±5.78 weeks. The mean surgery time was 18.04±5.65 minutes. The subjective symptoms (pain, foreign body sensation, tearing and discomfort) disappeared in 23 of 36 eyes (64%) in one week after surgery, and all discomforts subsided within two weeks after surgery in all patients. The conjunctivolimbal autograft was correctly positioned and fixed in 34 of 36 eyes (94.4%) throughout the follow-up period. Graft dehiscence was seen in two eyes (5.6%), one eye was treated with remedial sutures, and the other eye showed a spontaneous healing without remedial sutures. Transient graft edema occurred in four eyes (11.2%) but subsided spontaneously within a month. There were no cases of pterygium regrowth or complications due to the fibrin bioadhesive.

Conclusions

The use of fibrin bioadhesive in conjunctivolimbal autograft surgery in primary pterygium simplifies surgical techniques, shorten surgical duration, and produce less postoperative subjective symptoms. Therefore, the fibrin bioadhesive is a safe and effective tool to attach conjunctivolimbal autograft in primary pterygium surgery.

Novel use of fibrin glue in the treatment of conjunctivochalasis

PURPOSE

To report on the novel use of fibrin glue in the treatment of conjunctival resection for conjunctivochalasis.

METHODS

A 78-year-old woman with bilateral, symptomatic conjunctivochalasis had a conjunctival resection by using fibrin glue, as a suture substitute, to attach the conjunctiva.

RESULTS

The use of fibrin glue facilitated the surgical procedure, was well tolerated by the patient, and produced excellent results with relief of symptoms.

CONCLUSIONS

The use of fibrin glue during the conjunctival resection was effective in simplifying the procedure and theoretically decreased the risk of suture-related complications and the postoperative irritation related to the presence of sutures in situ.

Repair of anterior staphyloma with dehydrated dura mater patch graft

A case of postoperative large anterior staphyloma of the sclera was treated with a dehydrated cadaveric dura mater patch graft. Structural integrity of the globe and a good cosmetic result were obtained after the surgery. During the follow-up of 2 years, no recurrence of staphyloma developed.

A prospective randomized double-blind trial of fibrin glue for reducing pain and bleeding after tonsillectomy

OBJECTIVES

Varying surgical techniques as well as a large selection of analgesics and other medications have been evaluated over the years in the hopes of reducing post-tonsillectomy pain. Several publications in recent years have demonstrated the efficacy of fibrin glue in reducing post-tonsillectomy bleeding and pain. The objectives of this study were to evaluate the effect of fibrin glue on pain and bleeding after tonsillectomy.

STUDY DESIGN

A prospective randomized double-blind study was performed on 168 consecutive patients undergoing tonsillectomy for obstructive sleep apnea and chronic tonsillitis.

METHODS

Patients were randomly assigned to the treatment protocol. In the study group, the tonsillar beds were coated with fibrin glue (Quixil, OMRIX biopharmaceuticals) at the end of the operation. Patients in the controlled group underwent tonsillectomy without the use of fibrin glue. The patients were then monitored for postoperative bleeding, and a patient-based pain assessment instrument was used to evaluate pain, ability to eat and analgesics consumption for 10 days after surgery.

RESULTS

Ninety-six patients returned for postoperative follow up and filled in the questionnaire. As our medical center is the only hospital in the southern district of Israel and we hospitalize every person who presents with post-tonsillectomy bleeding, we can assume that any patient from either group who presented with post-tonsillectomy bleeding would be familiar to us. Analysis showed that no statistically significant differences relating to postoperative pain, bleeding, use of analgesics and postoperative eating resumption were detected between the patients treated with fibrin glue and controls.

CONCLUSIONS

We cannot substantiate a significant beneficial effect of fibrin glue in post-tonsillectomy pain control, prevention of bleeding or facilitating eating and thus find no indication for the routine use of fibrin glue in tonsillectomy.

Human amniotic membrane transplantation with fibrin glue in management of primary pterygia: a new tuck-in technique

PURPOSE

To report the use of fibrin glue for attaching the human amniotic membrane graft with a tuck-in technique after primary pterygium excision.

METHODS

Twelve patients with primary pterygium (grade 2 or 3) underwent pterygium excision. The bare sclera was covered with an oversized human amniotic membrane graft by using fibrin glue for graft adherence. The edges of the graft were tucked underneath the adjacent free margin of conjunctiva on 3 sides. Various parameters such as operative time, patient's postoperative comfort, graft adherence, time of graft epithelialization, and recurrence of pterygium were assessed.

RESULTS

The amniotic membrane graft adhered successfully in 11 patients. Average surgical time was 15.5 minutes (range, 13-21 minutes). The postoperative period was generally comfortable. Epithelialization of the graft was rapid, occurring within 7 days in 11 eyes. In 1 patient, the graft was found dislodged partially on the first postoperative day. Eleven eyes showed no recurrence at the end of 1-year follow-up.

CONCLUSIONS

Use of fibrin glue for attaching human amniotic membrane graft in primary pterygium surgery is effective. It not only reduces the surgical time but also minimizes postoperative discomfort and complications.

New Surgical Approach for Superior Conjunctivochalasis

PURPOSE

To show poor adhesion between the conjunctiva and the sclera in eyes with superior conjunctivochalasis (CCh) and to introduce a new surgical approach by reinforcing adhesion between the conjunctiva and the sclera for correcting this deficiency.

METHODS

After conjunctival peritomy and removal of the loose Tenon remnants, "Tenon reinforcement" for conjunctival adhesion to the underlying sclera was achieved by transplantation of cryopreserved amniotic membrane with fibrin glue (group A, 9 eyes of 6 patients) or 10-0 nylon sutures (group B, 8 eyes of 6 patients) in 17 eyes of 12 patients with refractory superior CCh.

RESULTS

The mean age of patients was 68.2 +/- 9.8 years (range, 54-80 years). Superior CCh was associated with a superior limbic keratoconjunctivitis (SLK)-like clinical feature before surgery and found to exhibit dissolved Tenon capsule during surgery in all patients. During a mean follow-up of 3.7 +/- 1.9 months after surgery, all eyes achieved smooth conjunctival surface without any sign of CCh. Complete resolution of symptoms was seen in 9 eyes (52.9%) and significant resolution in 8 eyes (47.1%). There was no significant difference between groups A and B in improvement of symptoms and signs. No complications related to surgery were noted during follow-up.

CONCLUSIONS

We propose that loose and dissolved Tenon tissue is correlated with the development of superior CCh, which may result in an SLK-like appearance by blink-related microtrauma. Reinforcement of conjunctival adhesion onto the sclera by amniotic membrane with either fibrin glue or sutures is effective in alleviating symptoms and signs in eyes with superior CCh.

Hypotony maculopathy

Hypotony maculopathy, first described in 1954 by Dellaporta, usually occurs after antiglaucomatous surgery or after perforating eye injuries; it is characterized by hypotony associated with fundus abnormalities, including papilloedema, vascular tortuosity and chorioretinal folds. In hypotony maculopathy, the scleral wall collapses inward, resulting in redundancy of the choroid and retina, leading to chorioretinal wrinkling. As the antero-posterior diameter of the vitreous cavity decreases, the very thick perivofeal retina surrounding the very thin foveal retina is thrown into radial folds around the fovea. It has been reported that hypotony maculopathy occurs in up to 20% of cases of glaucoma filtering surgery and has become more common after the introduction of antimetabolites. Young age, myopia, primary filtering surgery, systemic illnesses and elevated preoperative intraocular pressure (IOP) have been found to be associated with hypotony maculopathy. Hypotony maculopathy is treated with procedures designed to elevate IOP, which may reverse the inward scleral bowing and improve visual acuity. The successful treatment of hypotony maculopathy depends on the correct identification of its cause. Once the cause is detected, treatment should be employed as soon as possible because delayed normalization of the IOP may result in permanent macular chorioretinal changes and poor vision. This review will explore the definition, mechanisms, clinical findings and treatment of hypotony maculopathy.

Indocyanine Green Staining Facilitates Detection of Bleb Leakage During Trabeculectomy

PURPOSE

To report a new technique to visualize bleb leakage using indocyanine green (ICG) staining during trabeculectomy.

PATIENTS AND METHODS

The ICG solution was widely applied over the filtering bleb including the conjunctival wound before completion of trabeculectomy. This procedure was performed in 48 eyes of 44 consecutive patients undergoing trabeculectomy between December 2004 and October 2005.

RESULTS

Without staining, bleb leakage was not identified by the direct observation under the operating microscope. ICG staining clearly visualized aqueous leakage from the bleb in 5 eyes (10.4%). The bleb leakage in these eyes was easily repaired with 10-0 nylon sutures, and no eyes, including these 5 cases, showed bleb leakage after surgery. There were no intraoperative and postoperative complications related to ICG application.

CONCLUSIONS

The application of ICG during trabeculectomy is a simple and useful technique to facilitate detection and repair of the bleb leakage.

Ocular surface sealants and adhesives

Tissue adhesives, both synthetic and biologic, have a long history of use in ophthalmology. Cyanoacrylate-based glues have traditionally been the most widely used glues for various purposes. They have been specially useful for treating corneal perforations and have had significantly improved long-term outcomes. More recently, fibrin-based glues have gained a major role as a suture substitute for attaching biologic tissues and as surface sealants. The literature supports expanded use of fibrin glue in this fashion. Other new agents, such as polyethyelene glycols, have been underutilized and hold promise, especially as surface protectants. Numerous other glues are being developed and show promise as ocular surface sealants and protective membranes. Advances in knowledge about tissue adhesives are leading to more effective and efficient ophthalmic care.

Pterygium Surgery: Conjunctival Autograft Using a Fibrin Adhesive

PURPOSE

To evaluate the efficiency and safety of using a fibrin adhesive (Tissucol Duo, Baxter AG, Vienna, Austria) to avoid the need for sutures during conjunctival autograft surgery for primary pterygium.

METHODS

Twenty patients (20 eyes) with primary nasal pterygium were subjected to conjunctival autograft surgery. The free conjunctival graft placed over the bare sclera was fixed to the surrounding conjunctiva and cornea using the fibrin glue. An occlusive patch was applied. The outcome of surgery and any possible complications were periodically assessed.

RESULTS

Mean patient age was 54.9 years (28-75 years). The mean follow-up time was 26.05 +/- 3.15 (SD) weeks. The time of surgery was 15 to 20 minutes. During the postoperative course, none of the patients felt pain, and only 5/20 (25%) had the mild sensation of the presence of a foreign body. In 18/20 (90%) patients, the conjunctival autograft was observed to be correctly positioned and fixed in all the follow-up exams. No sutures were used during or after surgery. There were no cases of regrowth of the pterygium.

CONCLUSION

Our findings demonstrate the safety and efficiency of Tissucol Duo as a conjunctival adhesive for pterygium autograft surgery as treatment of primary pterygium. Because of its fast and easy application, this product considerably reduces the time of surgery. Its use also avoids complications derived from sutures and diminishes the sensation of a foreign body in the eye following surgery.

Intraoperative Healon5 injection into blebs for small conjunctival breaks created during trabeculectomy

Leakage from a conjunctival break created during trabeculectomy may cause serious complications such as shallow anterior chamber, hypotony, and a flat bleb in the early postoperative period. Therefore, careful handling of the conjunctiva with a nontoothed forceps is essential. However, thin conjunctiva is susceptible to mechanical injury and is difficult to repair with suturing, especially when the point of leakage is close to the scleral flap. In 3 consecutive cases in which a small break in the thin conjunctiva adjacent to the scleral flap was created during trabeculectomy, sodium hyaluronate 2.3% (Healon5) was intraoperatively injected into the bleb. The break was successfully closed with an intraoperative injection of Healon5 into the bleb. This procedure appears to be a simple, safe, and effective method for closure of a small conjunctival break.

Surgical Management of Scleral Defects

PURPOSE

To evaluate the results of surgical management of scleral defects using fascia lata, cornea, and sclera as graft materials.

METHODS

The scleral defects of 8 patients were repaired surgically. Six had previous intraocular surgery, 1 had eye trauma, and the other had both intraocular surgery and trauma. Corneoscleral grafts were used in 3 eyes, scleral grafts in 4, and fascia lata was used in 1 eye.

RESULTS

In 7 patients, we achieved the desired cosmetic and tectonic success. During the follow-up period, a recurrent defect was seen in 1 patient, and a second operation was required.

CONCLUSIONS

Surgical techniques using fascia lata, corneal, and scleral grafts are effective for scleral defects.

Advances in the use of adhesives in ophthalmology

PURPOSE OF REVIEW

To summarize the known uses of available medical tissue adhesives in the management of diseases of the anterior segment, highlighting recent developments in the field.

RECENT FINDINGS

Human fibrin glues may be used in place of cyanoacrylate tissue adhesives in the treatment of progressive corneal thinning and small perforations, potentially resulting in less corneal and conjunctival inflammatory reaction. Additional currently proposed uses of fibrin glues in ophthalmic surgery include minimizing sutures in recurrent pterygium surgery, forniceal reconstruction, amniotic membrane transplantation, and lamellar corneal grafting.

SUMMARY

After reviewing the literature pertaining to the current use of tissue adhesives in ophthalmic surgery, the authors conclude that the main indication for cyanoacrylate tissue adhesives is for the treatment of progressive corneal thinning and small, uncomplicated corneal perforations. Human fibrin glues appear to be equally effective in such cases and have the advantage of biocompatibility, allowing application over a larger surface area and the use of a superficial covering layer such as amniotic membrane or conjunctiva for further reinforcement and promotion of rapid re-epithelialization. Other applications of human fibrin glues in ophthalmic surgery are evolving, but their widespread use is limited by concern over the theoretic risk of viral transmission and the complexity of their preparation and application in comparison with traditional sutures.

Evaluation of a New Bioadhesive Copolymer (ADAL??) to Seal Corneal Incisions

OBJECTIVE

To evaluate the efficacy and clinical tolerance of a new acrylic copolymer tissue adhesive, ADAL, in corneal surgery.

METHODS

Corneal incisions were performed on 24 New Zealand albino rabbits. The incision was either sealed with ADAL bioadhesive, hydrated with balanced salt solution, or closed with 10-0 nylon surgical sutures. The incisions underwent weekly tensile strength testing and clinical, histopathologic, and confocal microscopy evaluations.

RESULTS

Clinical evaluation revealed good sealing and no incision leakage in any group. There was no anterior chamber reaction in any case. Compared with the hydrated group, there was somewhat more incisional vascularization and localized corneal opacity in the ADAL group, but there were no cases of severe corneal opacity or neovascularization. On histologic analysis, a slightly larger inflammatory reaction was noted in the ADAL group compared with the hydrated group. Tensile strength during the first week was statistically significantly greater in the ADAL group (2.93 Newtons) than in the control groups (1.40 Newtons, hydrated group; 1.43 Newtons, sutured group) (P < 0.001). Confocal microscopy study revealed a unique dendritic keratocyte shape and structure resembling shiny crystalline particles after disappearance of the adhesive from the cornea.

CONCLUSIONS

Corneal surgical incisions sealed with ADAL adhesive have superior tensile strength in the first postoperative week compared with incisions closed with sutures or hydrated with salt solution. Thereafter, findings in both groups became similar. The use of ADAL adhesive was not associated with any deleterious effects during the corneal incision-healing process compared with hydration or sutures.

The use of autologous fibrinogen concentrate in treating ocular hypotony after glaucoma filtration surgery

Antimetabolite therapy with 5-fluouracil (5-FU) or mitomycin-C (MMC) has significantly improved the success rate of glaucoma filtration surgery. However, in some eyes, when filtration is excessive, persistent hypotony may develop. In this study, we describe the experience of using autologous fibrinogen concentrate (AFC) to treat patients with persistent hypotony after glaucoma filtration surgery. Among seven MMC-augmented trabeculectomy patients who developed persistent postoperative hypotony, the effects of AFC intrableb injections were evaluated. Under a microscope, 0.2 ml AFC and bovine thrombin were injected into the blebs of the patients from both sides of the filtering blebs. Postoperative best-corrected visual acuity, anterior chamber status, intraocular pressure (IOP) and fundus examination were followed and compared with those preoperative. On the second day, the mean IOP of seven eyes elevated from preoperative 3.4 +/- 2.1 mmHg to 12.6 +/- 4.2 mmHg, and the anterior chamber became deep without obvious inflammatory response. Within two weeks, macular edema and visual acuity were noted to improve in six eyes (85.7%). In addition, after a mean follow-up of 25 months, the trabeculectomy procedure remained successful in all eyes. AFC appears to be safe and effective in the treatment of ocular hypotony after glaucoma filtration surgery.

Control of intraocular pressure after trabeculectomy

Control of intraocular pressure (IOP) is the goal of trabeculectomy, and pursuit of this goal does not end with the completion of the surgical procedure. Proper postoperative management of the trabeculectomy patient requires an understanding of possible events that alter IOP and knowledge of the treatments to control IOP. Recent changes in surgical technique, including the use of antimetabolites, have provided new challenges in the postoperative management of trabeculectomy patients. Interventions are described to restore the flow of aqueous to the filtering bleb in the early postoperative period, to manage flat anterior chambers with both high and low intraocular pressures, to manage a failing filtering bleb, and to manage hypotony. Herein we discuss current methods for controlling IOP in the postoperative period.

Dysfunctional filtering blebs

Guarded filtration surgery, is commonly used to control the intraocular pressure (IOP) in glaucomatous patients. Filtration surgery lowers the IOP by creating a fistula between the inner compartments of the eye and the subconjunctival space (i.e., filtering bleb). There are several options to improve the function of filtering blebs and to prevent their failure. However, improvement of IOP control after guarded filtration procedures is associated with a higher frequency of bleb-related complications. Early (e.g., bleb leak, excessive filtration, flat anterior chamber, filtration failure) and late (e.g., bleb leak, excessive filtration and hypotony, symptomatic blebs, bleb encapsulation, filtration failure, bleb infection) complications associated with filtering procedures should be managed adequately to prevent further problems. Techniques to improve the function of filtering blebs and to treat postoperative complications have progressed over the past decade.

Management of bleb leaks after glaucoma filtering surgery. Use of autologous fibrin tissue glue as an alternative

PURPOSE

To study the nature of bleb leaks after contemporary glaucoma filtering surgery as well as to evaluate various treatment modalities, including autologous fibrin tissue glue (AFTG) prepared in a modified manner.

METHODS

Patients who presented to a Glaucoma Service during a 1-year period with a postoperative bleb leak were studied. Evaluation of various treatment modalities, including AFTG, was performed.

RESULTS

Thirty-five episodes of bleb leaks were encountered in 25 eyes of 22 patients in a 1-year period. There was no statistically significant association between late or early leaks and the age or the race of the patient, previous eye surgery, or the use of antimetabolites at the time of filtering surgery. Eleven (31.4%) of the leaks were refractory to nonsurgical treatment modalities, 8 or them being of the late type. Successful healing of the leaks was obtained in 9 of the 12 episodes in which AFTG was used. However, there were no statistically significant differences between AFTG and the other treatment modalities.

CONCLUSION

Bleb leaks are a common complication of contemporary glaucoma filtering surgery. Various nonsurgical and surgical modalities can be used in the treatment. In early as well as late bleb leaks, AFTG offers an alternative nonsurgical treatment and is at least as efficacious and may, in some ways, be superior to other nonsurgical modalities of treatment.