NOV 2013

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

Issue link: https://digital.eyeworld.org/i/220233

Contents of this Issue


Page 59 of 122

November 2013 EW RESIDENTS 57 after application of a liquid adhesive ocular cataract surgery" Faculty ophthalmologist's note Jules Stein Eye Institute third-year residents (from left to right) Tina K. Ku, MD, C. Nathaniel Roybal, MD, PhD, and Christine F. Lin, MD, contributed to this journal article review. Source: Kevin M. Miller, MD difference in adverse events between the groups. Additionally, it is unclear whether the designation of negative and positive wound closures were linked to any adverse effects and if this was a meaningful way to measure the strength of the wound closure. Since only the control group underwent hydration of the wound at the end of the case, we do not know whether wound hydration would lead to increased staining of the wound edge. It was surprising to us that even 14 days after surgery, 39% of control group eyes still had negative wound edge closures. Another potentially confounding factor is that, depending on preoperative corneal cylinder, the incision may have been placed temporally or along the steep axis when the corneal astigmatism was more than 0.50 D. The mean corneal astigmatism was 0.94 D, 0.91 D, and 0.82 D in the control, suture, and bandage groups, respectively, so it would have been nice to see if incision location was a contributing factor in the primary outcomes. For example, a superiorly placed incision may be linked to less foreign body sensation and better wound closure because of coverage from the upper eyelid. As mentioned in the authors' discussion, the results of the study cannot be applied to cases with other wound sizes. Also, the brief 14 day postoperative follow-up is not enough time to assess whether the refractive benefits and postoperative comfort of the ocular bandage are sustained over longer periods of time. In summary, poorly constructed incisions are associated with potentially serious adverse events and the authors have presented good evidence that the use of a liquid adhesive ocular bandage results in better epithelial wound coverage and less astigmatism and foreign body sensation as compared to suturing. The authors' critique of placing corneal sutures includes operating time and material costs as well as the possibility of suture related complications. For the ocular bandage group, it appears that there are similar issues in addition to a learning curve to determine adhesive curing time. Further study of the economics of the two groups may help us decide how and if to use ocular adhesives in clinical practice. How should this study be used in clinical practice? In general, we did not feel that it would affect how we performed wound closure in routine cases. As residents, when we are able to create a staged square-profile CCI in an uncomplicated case we usually hydrate the wound without placement of a suture. It is in the longer, complicated cases with perhaps a shorter or shallow wound where we end up with concerns about the quality of wound closure. It would be interesting to have an additional study with eyes that have imperfect CCIs or have longer operating times although understandably it would be difficult to manage confounding factors. To date, none of the studies on ocular adhesives or liquid bandages address the clinical scenario under which these surgical adjuncts are most likely to be used. A well-constructed and well-hydrated clear corneal tunnel incision seals quite well at the end of surgery and can usually withstand a high amount of pressure applied at the limbus. There is no need for a suture or ocular adhesive in these cases. The interesting group, the one that needs to be studied, is the rather small subset of eyes that leak despite standard stromal hydration. The study that begs to be done is one comparing sutures to ocular adhesives in this scenario. Which is better? Can ocular adhesives close an incision when there is a small leak? Is an ocular adhesive more effective than a suture in terms of cost utility and patient satisfaction under these circumstances? Hopefully, future studies will address this important issue as it directly impacts intraoperative decisionmaking. EW –Kevin M. Miller, MD, Kolokotrones Professor of Clinical Ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles References 1. Wallin T, Parker J, Jin Y, Kefalopoulos G, Olson RJ. Cohort study of 27 cases of endophthalmitis at a single institution. J Cataract Refract Surg 2005; 31(4):735-41. 2. Hollander DA, Vagefi MR, Seiff SR, Stewart JM. Bacterial endophthalmitis after residentperformed cataract surgery. Am J Ophthalmol 2006; 141(5):949-51. 3. Hovanesian JA. Cataract wound closure with a polymerizing liquid hydrogel ocular bandage. J Cataract Refract Surg 2009; 35(5):912-6. 4. Shingleton BJ, Rosenberg RB, Teixeira R, O'Donoghue MW. Evaluation of intraocular pressure in the immediate postoperative period after phacoemulsification. J Cataract Refract Surg 2007; 33(11):1953-7. 5. McDonnell PJ, Taban M, Sarayba M, Rao B, Zhang J, Schiffman R, Chen Z. Dynamic morphology of clear corneal cataract incisions. Ophthalmology 2003; 110(12):2342-8. Contact information Miller: kmiller@ucla.edu

Articles in this issue

Links on this page

Archives of this issue

view archives of Eyeworld - NOV 2013