Adal-1 bioadhesive for sutureless recession muscle surgery: a clinical trial

Surgical adhesives in ophthalmology: history and current trends

Tissue adhesives are gaining popularity in ophthalmology, as they could potentially reduce the complications associated with current surgical methods. An ideal tissue adhesive should have superior tensile strength, be non-toxic and anti-inflammatory, improve efficiency and be cost-effective. Both synthetic and biological glues are available. The primary synthetic glues include cyanoacrylate and the recently introduced polyethylene glycol (PEG) derivatives, while most biological glues are composed of fibrin. Cyanoacrylate has a high tensile strength, but rapidly polymerises upon contact with any fluid and has been associated with histotoxicity. Fibrin induces less toxic and inflammatory reactions, and its polymerisation time can be controlled. Tensile strength studies have shown that fibrin is not as strong as cyanoacrylate. While more research is needed, PEG variants currently appear to have the most promise. These glues are non-toxic, strong and time-effective. Through MEDLINE and internet searches, this paper presents a systematic review of the current applications of surgical adhesives to corneal, glaucoma, retinal, cataract and strabismus surgeries. Our review suggests that surgical adhesives have promise to reduce problems in current ophthalmic surgical procedures.

Comparative evaluation of cyanoacrylate and fibrin glue for muscle recession in strabismus surgery

PURPOSE

To compare the safety and efficacy of fibrin glue and cyanoacrylate glue for refixating the recessed muscle to the sclera in patients undergoing strabismus surgery.

METHODS

In this prospective, randomized, and interventional case series, there were 15 patients in each group. Two different types of glue were used for refixating the muscle to the sclera after its recession: fibrin glue (fibrin group) and cyanoacrylate glue (cyanoacrylate group). Resection was performed as usual with a 6-0 polyglactin suture. The conjunctiva was closed with the same glue that was used for muscle recession.

RESULTS

Average time required per muscle attachment was 1.48±0.694 minutes in the fibrin group and 2.42±0.584 minutes in the cyanoacrylate group. There was no significant difference in pain at all postoperative visits in both groups. Significantly more chemosis was observed in the cyanoacrylate group at postoperative 3 weeks. At all other postoperative visits, there was no significant difference in chemosis in both groups. There was significantly more conjunctival reaction in the cyanoacrylate group at 1 and 3 weeks and 3 months; the difference was highly significant at 3 months (P=.00). Total inflammatory score was significantly high in the cyanoacrylate group at 1 week, 3 weeks, and 3 months.

CONCLUSIONS

Both fibrin and cyanoacrylate glue are equally efficacious for muscle reattachment; however, fibrin glue is more biotolerant compared to cyanoacrylate glue and results in less postoperative inflammation, and is thus recommended for recession in strabismus surgery.

Fixation of Extraocular Muscles to Porous Orbital Implants Using 2-Ocetyl-Cyanoacrylate Glue

PURPOSE

To assess the efficacy of recti muscle fixation with 2-ocetyl-cyanoacrylate tissue glue to porous orbital implants in human subjects undergoing enucleation.

METHODS

This was a prospective interventional study with a historical control group. Over a 1-year period, patients who received orbital implant fixation using 2-ocetyl-cyanoacrylate tissue glue were enrolled in the study. Functional assessment was carried out by measurement of implant motility at the 6-month postoperative period, which was compared with a historical control group of patients with sutured implants. Structural assessment was carried out with a random sample of orbital MRIs.

RESULTS

Twelve patients received the glue-fixation technique. There were no intraoperative or immediate postoperative complications. There was no statistically significant difference between the glued and sutured groups' horizontal implant movement (7.0 mm ± 1.5 mm vs. 6.8 mm ± 1.8 mm, respectively; p = 0.85) or vertical implant movement (5.6 mm ± 1.7 mm vs. 5.0 mm ± 1.4 mm, respectively; p = 0.39). Sample orbital MRI demonstrated good muscle approximation to the implants as well as contrast enhancement suggestive of successful fibrovascular proliferation.

CONCLUSIONS

Recti muscle fixation using 2-ocetyl-cyanoacrylate tissue glue to porous orbital implants appeared safe and produced good functional and structural results in this proof-of-concept study. This novel technique of implant fixation may offer benefits in terms of reduced operating room time and cost savings.

Cyanoacrylate tissue adhesive on a polyglactin scaffold in strabismus surgery: a laboratory study

BACKGROUND

The use of cyanoacrylate tissue adhesives in strabismus surgery has been variously successful, depending primarily on achieving adequate bond strength and minimizing extraocular muscle slippage. We investigate a novel approach to this problem, involving cyanoacrylate tissue adhesive on a polyglactin 910 scaffold as a means to secure extraocular muscle to the sclera for strabismus surgery.

METHODS

In this experimental laboratory study, butyl-cyanoacrylate was used to fix a polyglactin 910 scaffold to the sclera of cadaver eyes. After allowing for polymerization, a force was applied to the mesh until the polyglactin-sclera bond failed. The maximum load (g) required for bond failure was recorded. The effects of surface area of the polyglactin 910 mesh as well as time required for cyanoacrylate tissue adhesive polymerization on bond strength were investigated.

RESULTS

All combination of variables tested, except for experiments involving polyglactin 910 mesh that is 30 mm(2) with a polymerization time of 15 seconds or 30 seconds and polyglactin 910 mesh that is 40 mm(2) with a polymerization time of 15 seconds, achieved a bond strength that was significantly greater than those forces seen in a physiologic setting (P > 0.05). Increasing area or time resulted in increasing bond strength. Area and time were found to be independent variables.

CONCLUSIONS

The cyanoacrylate tissue adhesive-derived polyglactin-sclera bond achieved a maximum load greater than those seen in a physiologic setting. Our novel approach demonstrates a clinically feasible alternative to traditional means for bonding muscle to sclera in strabismus surgery.

Effect of fibrin glue as an adjuvant to hang-back surgery

BACKGROUND

The hang-back surgery is a useful technique in the field of strabismus surgery. The aim of this study is to determine the stabilizing effects of fibrin glue as an adjuvant to hang-back surgery.

MATERIALS AND METHODS

Four (4)-mm hang-back recessions of the superior rectus muscle was performed in 32 eyes of 16 rabbits. Only in the left eye of the 16 rabbits, fibrin glue was applied between the recessed muscle bed and the sclera at the end of hang-back surgery (fibrin glue group). After 6 weeks, we compared the stability of the recessed rectus muscle between the fibrin glue group and the control group by evaluating the displacement of the muscle.

RESULTS

The frequency of stable insertion of the recessed muscle at the intended site was greater in the fibrin glue group (9 eyes) compared to the control group (3 eyes) (p=0.028). In the control group, 5 eyes showed anterior displacement and 8 eyes showed posterior displacement and in the fibrin glue group, 1 eye showed anterior displacement, and 6 eyes showed posterior displacement. Anterior displacement was more common in the control group (6.3% Vs 31.3%). The control group and the fibrin glue group showed similar histological findings on microscopic examination.

CONCLUSIONS

Fibrin glue is effective in stabilizing the new rectus muscle insertion and decreasing the displacement in the hang-back surgery.

Cut and paste: a novel method of re-attaching rectus muscles with cyanoacrylate during recessions in strabismus

Aim:

Bio-adhesives like cyanoacrylate offer an alternative to sutures to attach tissues, including in ophthalmology. This prospective trial evaluated the suitability and bio-tolerance of iso-amyl cyanoacrylate in rectus muscle recession surgery for strabismus.

Materials and Methods:

We randomized one eye in each of 10 cases of bilateral horizontal rectus recessions to 6/0 polyglactin and the other to iso-amyl-cyanoacrylate. We compared time to reattachment (from disinsertion), complications and inflammatory scores (0 to +3: nil, mild, moderate and severe) on Day One, at two and at four to six weeks post surgery.

Results:

There were no significant group differences in inflammatory scores (Wilcoxon, all values of P>0.05). All attachments held firm. Gluing took significantly longer by 5.24±1.91 min (95% CI for difference: 3.87-6.61). There were no complications.

Conclusion:

We feel that although it takes marginally longer, iso-amyl cyanoacrylate offers an effective and safe alternative to sutures for muscle recession in strabismus surgery. Since it is cheaper (vs. polyglactin) and offers multi-use possibility it may also prove to be cost-effective.

Cyanoacrylate adhesive use in primary operation and reoperation in rabbit eye muscle surgery

PURPOSE

To compare the performance of 2-octyl-cyanoacrylate to 6-0 polyglactin 910 suture in rabbit superior rectus muscle surgery after operation and reoperation procedures.

METHODS

A prospective noninferiority trial was conducted in rabbits. Bilateral superior rectus muscle recessions were performed using cyanoacrylate in one eye and polyglactin suture in the other. At 5 weeks, reoperations to advance the superior rectus muscle were performed on 20 rabbits. Slippage, tensile strength, ease of reoperation, operative time, and inflammatory reaction were recorded. For the primary outcomes, the predetermined margin of noninferiority was 1 mm for slippage and 100 g for tensile strength.

RESULTS

In both groups, the proportion of slippage > or =1 mm from the recession site was 1.9%. For the reoperation, it was 36.8% and 15.7% in the suture and cyanoacrylate groups, respectively, and the mean slippage was 0.60 mm and 0.42 mm. Mean tensile strength was 842.8 g for suture and 777.2 g for cyanoacrylate after the first operation and 877.73 g and 844.87 g after the reoperation. There was no difference between groups for surgical difficulty or inflammatory index. For the first operation, surgery using cyanoacrylate was on average 3.85 min faster than suture.

CONCLUSIONS

Cyanoacrylate can achieve an adequate muscle-sclera bond in the immediate period after surgery to avoid major slippage and does not affect the long-term process of wound healing for both recession and advancement procedures. It is well tolerated and does not add technical difficulty even if used for reoperations. Because it eliminates the risk of globe perforation, cyanoacrylate may be a good alternative to sutures in strabismus surgery.