For decades, cataract surgeons have had two options for wound closure: hydration and more hydration. Oh, and a third choice of suturing the wound. We have long had to grapple with the decision of suturing a wound versus hydrating it—but the reality is that neither approach solves all of the potential problems associated with corneal incisions.
The unfortunate truth about corneal incisions is that they don’t always spontaneously close with hydration. This is due to the wound architecture, the peripheral corneal elasticity and compliance, and/or corneal changes from an extended case. Femtosecond laser corneal incisions are also a bit trickier to close than anticipated: The corneal architecture seems to change a bit due to the laser application, creating a wound that is potentially at risk for leaking. However, placing a suture has felt like an admission of defeat in many ways. Patients expect no-needle, no-stitch cataract surgery, which typically we try to provide. Placing a suture takes time during surgery and requires an office visit to remove.
Further, we know that just because a corneal incision is closed and watertight at the end of surgery does not mean the patient will not inadvertently reopen the incision through eye rubbing or contact with the tip of the eye drop bottle when placing drops. Unfortunately, creating a watertight closure in the OR does not always mean it will be watertight in the real world. A patient-induced wound burp can cause significant issues, including toric IOL rotation, reverse optic capture, Z syndrome in Crystalens (Bausch + Lomb) patients, and the potential for endophthalmitis. In the past, we had no real solution to these problems, as even sutured wounds can leak when stressed.
CORNEAL INCISIONS: CLOSED VERSUS SEALED
It has been said that Steve Jobs was famous for creating products that you didn’t know you needed and then suddenly couldn’t live without. In my opinion, when it comes to corneal incisions, the ReSure Sealant from Ocular Therapeutix is such a product.
The ReSure Sealant is a fairly new option to help when the wound just doesn’t want to close and to seal the wound when the surgeon feels it is appropriate. There are several scenarios in which I feel that sealing should be considered. The first category of patients that I consider using the sealant on is our nursing home patients. It has been well established that nursing home patients are more likely to be exposed to more virulent and multidrug-resistant bacteria. Also, many of these patients live in nursing homes due to cognitive deficits such as Alzheimer disease and thus may be more likely to rub their eyes and fail to comply with other activity restrictions. For these reasons, having a sealed wound may help protect them from adverse events such as IOL dislocation or infection.
The second category of patients I consider using the ReSure Sealant on is my toric and premium IOL patients. Centration of multifocal IOLs, posterior flexion of the Crystalens, and axis alignment and maintenance of toric IOLs are extremely important. In fact, I believe that most toric IOLs rotate due to an abrupt shallowing of the anterior chamber due to a compression-induced wound leak. Minimizing the possibility of wound leaks through the use of a sealant may reduce the incidence of postoperative IOL displacement of all sorts.
The third category comprises my complex cataract patients. Recently, I had a patient with such a fibrotic anterior capsule that I was unable to penetrate it with a cystotome. The only option was to cut the capsule using my MicroSurgical Technology scissors. This necessitated a second 2.4-mm wound 180° away from the primary incision. Of course, this was a white cataract with a small pupil. The use of iris hooks was also required, as I needed wider exposer than a capsular tension ring would allow. All in all, I had two 2.4-mm incisions, a 1-mm paracentesis, and five 25-gauge (0.5 mm) hook incisions—that’s 8.3 mm of total corneal incision for phaco! Needless to say, I was happy to have the ReSure Sealant in the OR that day. I was able to successfully remove the cataract, place an IOL in the bag, and seal the wounds without difficulty. This was a unique case for sure, but we never know what we will encounter.
As the visionary leader of Apple once implied, many times, consumers don’t know what they want until it is shown to them. As surgeons, we sometimes do not know just how beneficial an addition to our surgical toolset can be until we experience a need for it firsthand. I encourage all young surgeons to stay nimble and open-minded—there is a plethora of products on the market and in the pipeline that may someday prove essential to your practice.