NOV 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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56 EW RESIDENTS November 2013 EyeWorld journal club UCLA residents review "Surgical outcomes bandage to clear corneal incisions during by Tina Ku, MD, Christine Lin, MD, and Nathaniel Roybal, MD, PhD Background Kevin M. Miller, MD Everyone has his or her opinion about incision closure, but we don't often get good clinical studies to analyze our options. I asked the UCLA residents to review this prospective study of clear corneal incisions that appears in this month's JCRS. –David F. Chang, MD, chief medical editor As residents, we are taught that clear corneal incision architecture and self-sealing capacity are key components in limiting intraoperative and postoperative complications associated with cataract surgery. Clear corneal incisions are reported to have a higher rate of postoperative endophthalmitis than sclerocorneal incisions, and this is strongly associated with wound leak and postoperative complications.1 Interestingly, residents do not have a higher rate of endophthalmitis than experienced surgeons despite higher rates of vitreous loss.2 A laboratory study used optical coherence tomography to demonstrate that low intraocular pressure is associated with internal wound gape of clear corneal incisions.3 Although intraocular pressure Surgical outcomes after application of a liquid adhesive ocular bandage to clear corneal incisions during cataract surgery Harvey S. Uy, MD, Kenneth R. Kenyon, MD J Cataract Refract Surg (Nov.) 2013; 39:1668–1674 Purpose: To compare the anatomic and refractive outcomes in eyes having phacoemulsification with 1 of 3 clear corneal incision (CCI) closure methods. Setting: Ambulatory surgical center, Makati, Philippines. Design: Prospective randomized clinical trial. Methods: Patients having phacoemulsification cataract surgery had wound closure using no additional treatment (control), a single 10-0 nylon suture, or a liquid adhesive ocular bandage (OcuSeal). The main outcome measures were wound edge closure rates, surgically induced astigmatism (SIA), foreign body sensation, and intraocular pressure (IOP) one, three, five, seven, and 14 days postoperatively. Results: The study evaluated 90 eyes. There was a significant improvement in wound edge closure rates in the suture group and the ocular bandage group compared with the control group (P<.001). A significant increase in SIA occurred in the sutured group but not in the control or ocular bandage groups (P<.001). The ocular bandage group had significantly less foreign body sensation than the control and suture groups (P<.001). There were no significant differences in IOP between the groups (P=.515). Conclusions: The liquid adhesive ocular bandage resulted in improved wound edge closure, reduced SIA, and diminished foreign body sensation. Suturing was associated with improved wound edge closure but increased SIA and foreign body sensation. Unsutured incisions led to delayed wound edge closure and increased foreign body sensation. Financial disclosure: Dr. Kenyon has financial interests with Beaver-Visitec International. is usually highest on postoperative day one secondary to retained viscoelastic, a significant number of eyes are hypotonous (<5 mm Hg) 30 minutes postoperatively.4 In a controlled laboratory study, Hovanesian demonstrated that a synthetic tissue-adherent hydrogel polymer ocular bandage allowed for more secure closure of clear corneal cataract wounds.5 We applaud the efforts of Drs. Uy and Kenyon in testing liquid adhesive ocular bandages and their role in controlling postoperative wound gape in this prospective randomized clinical trial. Study summary The study evaluated 90 eyes from 90 patients who underwent one of three methods—stromal hydration, single radial 10-0 nylon suture, or OcuSeal liquid adhesive ocular bandage (Beaver-Visitec International, Waltham, Mass.)—for clear corneal incision (CCI) closure following routine phacoemulsification cataract surgery from January 1, 2011 to April 30, 2011. Exclusion criteria included history of corneal surgery, corneal dystrophy, corneal opacity, glaucoma, or other significant ocular comorbidities, as well as eyes that experienced intraoperative complications or that required enlargement of the CCI. The study defined the primary outcome measures to be: 1) surgically induced astigmatism (SIA) measured by automated keratometry, 2) foreign body sensation (FBS) measured by a visual analog scale (VAS) ranging from 0 (no FBS) to 4 (severe FBS necessitating medication), and 3) rate of wound closure measured by whether staining was or was not present along the CCI edge over the follow-up period of 14 days. Wounds that were closed with a suture resulted in greater SIA (mean 1.3 D) compared to wounds closed with stromal hydration or OcuSeal (mean 0.6 D for both methods, P=0.0001). The suture closure group experienced greater FBS (approximately 1.5 on postoperative day [POD] one to approximately 1.2 on POD 14), followed by the stromal hydration group (approximately 0.9 on POD one to approximately 0.5 on POD 14), and lastly the OcuSeal group (approximately 0.5 on POD one to approximately 0.4 on POD 14; P=0.0001). Both suture and OcuSeal groups had a greater proportion of eyes with complete wound closure compared to the eyes of the stromal hydration group at each time point of the follow-up period (P=0.002 or less). All eyes were Seidel negative regardless of wound closure method during the postoperative follow-up. Comments Overall, this was a well-designed single blinded prospective randomized controlled trial. The clear corneal incisions were made consistently by the same surgeon in otherwise normal eyes. The authors took into account that prolonged operating times and extensive intraocular maneuvers would adversely affect wound closure and all patients with intraocular complications were thus excluded from the study. In terms of the patient population, the preoperative characteristics of all three treatment groups were similar. Ninety eyes of 90 patients underwent cataract surgery, but the authors did not specify if it was the patient's first or second eye. This could potentially influence how patients responded in the subjective VAS rating of foreign body sensation and whether they were able to stay masked if they felt subjectively different compared to their first surgery. Although the study mentions that the patients and clinical staff were masked to the treatment group assignments, it is not clear whether it was the clinical staff or the surgeon who was responsible for postoperative clinical assessments. Corneal sutures can be seen with the naked eye and some patients may be able to unmask themselves, which could affect their subjective VAS rating. Another area of concern was how wound closure was defined. The authors defined a negative wound closure as one with fluorescein staining present along the edge of the CCI wound and a positive wound closure as one where no staining was visualized. Although the ocular bandage and suture groups had a significantly greater proportion of positive wound edge closures, no wounds were Seidel positive in any group and there was no

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