Hydrogel Sealant may effectively close clear corneal incisions in combined glaucoma procedures
Wound closure methods in the setting of cataract procedures have received investigative attention as of late. Insufficient closure of surgical wounds exposes the patient to a high risk of infection as well as hypotony and corneal decompensation. Suturing remains the gold standard of closure for surgical wounds, yet studies evaluating the effectiveness of wound closure have found that 24–34% of sutured corneal incisions demonstrate leakage under minimal strain (the force equivalent to a blink). In pursuit of a more reliable closure, compounds such as cyanoacrylate, fibrin glues, and polyethylene-glycol (PEG) based sealants have been implemented as adjunctive or replacement techniques. ReSure, a hydrogel PEG-based sealant, is currently the only sealant approved by the FDA for use in closing a leaking corneal incision.
ReSure has been extensively studied in the setting of simple cataract procedures, demonstrating a corneal wound leakage rate of less than 1%. The properties of this hydrogel sealant offer significant advantages: it is immunologically inert, it absorbs as the epithelium heals, and it does not expand as it polymerizes. ReSure is commonly employed in closure of leaking clear corneal wounds in simple cataract surgery but has not been studied in the setting of cases combining cataract surgery plus glaucoma surgery. These combined cases involve a much higher degree of manipulation of the wound due to the additional steps involved in filtration surgery, angle manipulation or placement of a drainage device. Additionally, combined glaucomacases by design involve larger amplitude changes in intraocular pressure, which can also influence integrity of the clear corneal incision.3 Based on these mechanistic considerations, it is prudent to optimize wound integrity in these cases.
The purpose of this study by Machiele et al was to evaluate the effectiveness of ReSure as a closure device in the setting of combined cataract and glaucoma procedures. ReSure was able to maintain a watertight CCI 100% of the time over hundreds of combined cases.
This was a retrospective case series. Subjects studied were patients in a 6-year period undergoing combined phacoemulsification and glaucoma surgery. All cases were performed by the same surgeon. Wound closure methods correlated with discrete timeframes, as ReSure replaced suture midway through the study period, thereby establishing sutured closure as an analogous control group.
All cases included a phacoemulsification procedure requiring a 2.4 mm clear corneal incision. Upon completion of the phacoemulsification portion of the case, the wound was closed with either ReSure hydrogel or standard 10–0 suture closure. The researchers assessed the rate of Seidel-positive corneal wound leak on postoperative day one.
In all cases employing ReSure, no wound leak was observed at postoperative day one. Within the suture group, 3 cases showed Seidel positivity of the corneal incision. This equated to a statistically significant difference in wound leak frequency of 2.04% (P = 0.012).
Corneal wound closure is a crucial area of refinement. While sutureless clear corneal incisions are the mainstay of simple cataract procedures, the current standard of closure for combined cataract glaucoma cases calls for a single suture applied to the CCI. Sutured closure, however, has considerable disadvantages—sutured corneal wounds have been shown to leak with minimal force applied to the ocular surface. Corneal wound leakage is as a well-known pathway for infection. As an advancement in closure methods, ReSure stands to mitigate the risk of severe complications of wound leak such as endophthalmitis.
Beyond economic considerations, ReSure affords a time-saving benefit to patient and practitioner in bypassing postoperative suture removal. CCI suture is typically removed during the post-operative week 2 or 3 visit; eliminating this step in a follow-up exam can save time in a busy clinic while also sparing the patient any additional discomfort or stress. ReSure has been previously demonstrated to have no impact on surgery duration when compared with sutured closure, meaning there is a clear advantage in cumulative time-savings.
In this study, authors demonstrated that regardless of the type or complexity of the case, ReSure was able to maintain a watertight CCI 100% of the time over hundreds of combined cases. Suture, though the standard of practice, did not perform to this level, presenting with 3 cases of Seidel positive CCI leaks at POD1. ReSure has been shown to have no impact on postoperative IOP and is tolerated well by patients with no significant difference in level of ocular comfort compared with sutured closure. Given the statistically significant difference in surgical outcomes and the large volume of patients in this study, authors concluded that ReSure is highly effective and superior to suture in closure of CCI in combined cataract and glaucoma procedures.
Source: Machiele et al; Clinical Ophthalmology 2022:16 861–865
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