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Novel hydrogel tissue adhesive minimizes surgically induced astigmatic change
The ocular bandage appears to speed refractive stability postoperatively.
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In this era of cataract surgery as refractive surgery, patients are more demanding than ever regarding their clinical outcomes. Not only do they want great unaided visual acuity, but they want it as soon as possible after surgery. Anything that compromises visual acuity will have a negative impact on their surgical experience, particularly if they opted for an advanced-technology IOL such as a toric or multifocal IOL. Our practice is always investigating ways to provide a patient with the best vision possible in the shortest amount of time.
Careful attention to lens selection guidelines and monitoring of surgically induced astigmatism to ensure it is appropriately compensated for has always been my standard, and this delivers excellent clinical outcomes. However, I was interested in seeing if visual recovery in the immediate and early postoperative period could be hastened by a new hydrogel tissue adhesive.
Tissue adhesives have been used in ophthalmology for decades, but issues with biocompatibility and other performance characteristics limited their application. A novel hydrogel tissue adhesive (ReSure Adherent Ocular Bandage, Ocular Therapeutix) is now CE marked and provides a modern alternative to previous technology. It is more biocompatible and has demonstrated an ability to improve the structural integrity of clear corneal incisions, sealing the incision against micro-leaks and providing a barrier to fluid ingress. Because wound leaks in the immediate postoperative period are considered a major contributing factor to endophthalmitis, prevention of these micro-leaks may lead to a decrease in the overall risk of the disease.
My interest was whether there were refractive or keratometric advantages in addition to the ability to seal the wound. With my 3-mm incisions, I was using stromal hydration at the time of surgery to better seal the wound, and I felt this might have an undesired topographic effect on the corneal surface.
A. John Kanellopoulos
The study
In a recent randomized, parallel-arm, consecutive case study conducted at the LaserVision.gr Institute in Athens, Greece, with 155 participants, I evaluated 3-mm clear corneal cataract incisions using the ReSure bandage (group A) as a method for wound closure vs. the current standard of care, stromal hydration (group B). Stromal hydration was used for group A only when the wounds were not spontaneously watertight, because it is imperative to have a dry surface prior to application of the bandage.
A combination of IOLs were implanted: 25% toric (AcrySof IQ Toric, Alcon) and 75% standard (AcrySof ReSTOR, Alcon). All patients were evaluated on the basis of age, gender, uncorrected visual acuity, best corrected visual acuity, IOP, and changes in refractive cylinder and keratometric astigmatism. Any postoperative complications were also recorded.
Calculating results
In the first week following surgery, group A showed an average of 0.45 D post-cylindrical change, whereas group B showed a mean 1.2 D change. The refractive astigmatism in group A at 1 week was similar to that observed at 1 and 3 months (means of 0.35 D and 0.37 D, respectively). There was a significant shift in refraction in group B from the 1-week result, with a mean refractive astigmatism of 0.8 D at 1 month and 0.75 D at 3 months.
Postoperative topography after use of sealant (right eye) and stromal hydration (left eye). Note the localized topographic irregularity in the eye in which stromal hydration was used.
Image: Kanellopoulos AJ
A review of the autokeratometry taken in these time periods showed the same pattern with regard to corneal astigmatism, supporting the notion that the refractive instability of the stromal hydration group in the immediate postoperative period was corneal in nature.
The differential results noted above were similar regardless of the type of IOL used, whether toric or standard. No significant differences in IOP were recorded and no postoperative complications were observed.
Dual benefit
In this trial, the tissue adhesive proved useful in stabilizing the incision, preventing wound gape and resulting in better wound apposition during the healing process. Accomplishing this without the topographic changes resulting from stromal hydration appears to be the key factor in attaining faster stabilization of visual acuity after clear corneal cataract surgery. While there may be no long-term implications, the immediate postoperative period is an important one for your patients, particularly those who have elected advanced-technology IOLs. That is the time when they will be discussing their surgical experience, and their visual outcome, with friends and family.
I am completing my detailed analyses of these results and hope that they will be published in the near future.