Sealant as First Line for Wound Closure in the Clinic

Nonsurgical wounds, too, can be closed with this alternative approach.

By Huck A. Holz, MD

Sutures have long been the traditional means of treating wound leaks that will not self-seal after cataract surgery. Sutures, however, do not always seal a wound as well as previously thought: Some authors report incidence rates of persistent wound leak as high as 85%.1-4 Sutures also have potential disadvantages, including inducing astigmatism and being a possible nidus for infection.

Use of an ocular sealant to address wound leaks is an alternative that is gaining recognition. In several trials conducted to test the efficacy of sutures versus a sealant after cataract surgery, leak rates and adverse events were significantly lower when a sealant was used.5,6

The ease of use, efficacy, and convenience for the surgeon, and increased comfort for the patient, may make a sealant ideal for surgical use and for wound treatment in the clinic.

FIRST-LINE TREATMENT

In the past, corneal wounds treated in the clinic have often been addressed with sutures, bandage contact lenses, or cyanoacrylate glue. Sutures often necessitate a visit to the OR, in addition to a follow-up visit for removal. Use of cyanoacrylate adhesive requires a bandage contact lens to avoid significant discomfort. Using a sealant as an alternative has resulted in a significant increase in positive patient experience in my hands. The application process is fast and efficient, and there is no need for an OR visit or suture removal.

I use ReSure Sealant (Ocular Therapeutix) instead of sutures for many nonsurgical wounds seen in the clinic. Containing polyethylene glycol and trilysine, this sealant is typically used for wound closure in clear corneal incisions after uncomplicated cataract surgery. I have also found it very useful, however, as a first line approach to wound closure in the clinic. The hydrogel sealant is easy to use at the slit-lamp and is much more comfortable for the patient than a suture or cyanoacrylate adhesive. Visual recovery time is also faster.

The sealant tends to be most effective for small, penetrating corneal wounds. One caution is that, in order to create an effective bond, the cornea must be thoroughly dried before the sealant is applied. Therefore it should not be used if the wound leak is brisk. While many assume a sealant can be used to stop a leak when there is active fluid egressing, this is not the case. However, in the case of an active leak, one may either inflate or deflate the chamber to transiently stop the leak, allowing application of the sealant.

CASE EXAMPLES

Case No. 1.

A 7-year-old boy presented on Christmas Eve with a 1.5 mm paracentral penetrating corneal injury from a wire. The anterior chamber was somewhat shallow relative to the other eye. As this was a small wound, the parents were given the option of trying a wound sealant rather than a suture. ReSure Sealant hydrogel was applied in the minor procedure room, saving the patient from having to undergo treatment in the OR. The wound was Seidel negative the next day and remained so during follow-up. The child’s visual acuity had returned to 20/20 by the 2-month follow-up with no further issues.

Case No. 2.

A 65-year-old man presented to my clinic with inferior dehiscence of a corneal transplant wound after blunt trauma. After two attempts by another physician to suture the wound closed, it was still Seidel positive. The wound leak was fairly slow, with a relatively small leak next to one of the sutures. The patient elected to try ReSure Sealant rather than return to the OR a third time. At the slit lamp, an eyelid speculum was placed and a cellulose sponge was used to dry the area. The sealant was applied, and a bandage contact lens was applied. The sealant successfully sealed the wound. At 2-week follow-up the contact was removed; the glue had hydrolyzed, and the wound remained sealed.

APPLICATION PEARLS

ReSure is effective for wounds in which the tissues are already fairly well apposed. The surface has to be completely dry for the sealant to adhere; thus, it does not work for brisk leaks without manipulation of the chamber to create at least transient closure, allowing enough time to apply the sealant to a dry surface.

It is best to use a lid speculum to apply the sealant at the slit lamp. I use a pediatric lid speculum because it is gentler on the eyelids and therefore better tolerated by the patient. I always dab the ocular surface with a cellulose sponge to dry the area before application, then I ask the patient to fixate on a particular point in the distance that brings the wound area to an accessible position. I apply the sealant as expeditiously as possible because it dries in less than 20 seconds from the time mixing begins. While still at the slit lamp, I use fluorescein to test for effect.

In most cases involving trauma, I also apply a bandage contact lens over the wound in the clinic to avoid erosion of the sealant with normal blinking. In these cases, the sealant needs to last 3 days or so, as opposed to the approximately 48 hours that the ReSure Sealant normally lasts before dissipating. The contact lens bandage protects the sealant from the blinking motion, and thus provides an insurance policy that the sealant is still apt to be there when I follow up with the patient at 24 and 72 hours to check that the wound is still well-apposed and Seidel negative. If all is well at the second follow-up, I generally remove the contact lens bandage and let the sealant dissipate on its own.

CONCLUSION

While the ReSure Sealant is more costly than a suture, the benefits from the patient’s perspective may be well worth the extra price. Additionally, when factoring in the time and effort saved from avoiding a trip to the OR and suture removal, the cost differential may not be so pronounced. OR time is expensive, and eliminating the need for a visit to the OR as well as follow-up office visits make the sealant a potentially beneficial method of wound treatment on all fronts. n

1. Chee SP. Clear corneal incision leakage after phacoemulsification–detection using povidone iodine 5%. Case Report. Int Ophthalmol. 2005;26(4-5):175-179.

2. Mifflin MD, Kinard K, Neuffer MC. Comparison of stromal hydration techniques for clear corneal cataract incisions: conventional hydration versus anterior stromal pocket hydration. J Cataract Refract Surg. 2012;38(6):933-937.

3. Herretes S, Stark WJ, Pirouzmanesh A, et al. Inflow of ocular surface fluid into the anterior chamber after phacoemulsification through sutureless corneal cataract wounds. Am J Ophthalmol. 2005;140(4);737-740.

4. Masket S, Hovanesian J, Levenson J, et al. Hydrogel sealant versus sutures to prevent fluid egress after cataract surgery. J Cataract Refract Surg. 2014; 40(12):2057-2066.

5. Krader CG. Hydrogel sealant better than sutures. Ophthalmology Times. January 1, 2014.

6. Krader CG. Closing cataract incisions: sealant superior to sutures. Ophthalmology Times. October 1, 2014.

Huck A. Holz, MD
• Ophthalmic surgeon and corneal specialist, Kaiser Permanente Santa Clara, California
huck.holz@kp.org
• Financial interest: none acknowledged