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Fibrin adhesive an alternative to sutures in pterygium surgery
Rapid recovery and patient comfort are two advantages of using fibrin glue instead of traditional sutures, surgeon says.
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Fibrin tissue adhesive is an alternative to sutures that provides rapid recovery and patient comfort, according to John A. Hovanesian, MD, FACS.
During the American Society of Cataract and Refractive Surgery meeting in Washington, Dr. Hovanesian taught a course on using fibrin adhesive in pterygium surgery.
Fibrin glue (Tisseel VH, Baxter International) has been commonly used to maintain hemostasis in cardiac and abdominal surgery for 7 years in the United States, according to Dr. Hovanesian.
Although its use in ophthalmic surgery is off-label, many surgeons have found the glue significantly reduces surgical time and enhances patient comfort in surgery for pterygium, epithelial ingrowth after LASIK, amniotic membrane transplantation and even lamellar keratoplasty, according to a press release from Baxter.
Dr. Hovanesian and colleagues conducted a two-part retrospective study from 2003 to 2004 to compare glue with sutures in terms of surgery duration and patient comfort, and to conduct 6- and 12-month follow-up visits with patients to assess long-term outcomes.
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Images: Hovanesian JA |
Worth the cost
Tisseel glue costs about $75 for a single-use 1-cc unit dose. The adhesive is more expensive than a traditional suture, but Dr. Hovanesian said that in his practice the saving of time in the operating room makes it worthwhile.
He estimated that his average surgical time is reduced by more than 30% when he uses fibrin glue.
Risk of infection
According to Dr. Hovanesian, Tisseel is derived from human and bovine plasma.
“Although it carries a theoretical risk of contamination with HIV, hepatitis B or C, prion-mediated disease or even bovine spongiform encephalopathy, it has been used in 8 million surgeries over a 25-year period around the world, and there have been no reported infections with these agents,” he said.
Patient comfort
He studied 49 eyes undergoing pterygium autografts with Tisseel and found that 4% of the patients reported moderate to severe pain, compared with 38% of patients who received sutures.
In another study of 98 eyes treated with Tisseel for pterygium surgery, no pterygium recurrences were reported at the 6-month follow-up.
Pterygium surgery techniques
The pterygium/autograft technique is similar to a traditional approach, Dr. Hovanesian said. The pterygium is first excised from the cornea and conjunctiva.
“I take care to remove the entire pterygium, but it is not necessary to excise more than 1 mm of normal conjunctiva around it,” he stated in the press release. “It helps to avoid excess cautery on the sclera because cautery causes greater discomfort after surgery, and Tisseel is a natural anticoagulant anyway.”
The autograft, taken from superior limbal conjunctiva, should be thin, leaving Tenon’s fascia in place as much as possible, he said. This technique ensures a desirable cosmetic result in the graft while causing minimal scarring of the superior conjunctiva in the event that future glaucoma surgery becomes necessary.
Preventing recurrence
In the 98 pterygium/autograft procedures studied, Dr. Hovanesian said there were no recurrences during the 6- to 12-month follow-up period.
The graft should include some superior limbal stem cells to prevent recurrence, he said in the press release.
“It’s important to dissect the graft into the peripheral clear cornea,” he explained (Figure 1a).
The graft is then inverted onto the patient’s cornea with epithelium laid against epithelium and cut free using Vannas scissors (Figure 1b).
He suggests that patients receive fluoroquinolone eye drops and prednisolone acetate 1%, four times a day.
“Pain medications may be prescribed but are generally not necessary,” he said. “Most patients can return to work the next day.”
For Your Information:
- John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-951-9244; e-mail: DrHovanesian@harvardeye.com. Dr. Hovanesian has no financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Baxter International, maker of Tisseel, can be reached at One Baxter Parkway, Deerfield, IL 60015-4625; 800-422-9837; fax: 847-948-3642; Web site: www.baxter.com.
- Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.