Download Adherent ocular bandage for clear corneal incisions used in cataract

ARTICLE
Adherent ocular bandage for clear corneal
incisions used in cataract surgery
Daniel Calladine, MB BS, BMedSci, MRCOphth, Mina Ward, RCN,
Richard Packard, MD, DO, FRCOphth
PURPOSE: To assess an adherent ocular bandage for clear corneal incisions (CCIs) in cataract
surgery using optical coherence tomography (OCT).
SETTING: Prince Charles Eye Unit, Windsor, United Kingdom.
DESIGN: Case-control study.
METHODS: Patients having coaxial microincision cataract surgery (MICS) were allocated to an
adherent ocular bandage group or to a control group. The CCIs were examined postoperatively within
2 hours and at 24 hours and 7 days using OCT imaging and a slitlamp fluorescein 2% Seidel test.
RESULTS: The ocular bandage group comprised 22 eyes and the control group, 23 eyes. The mean
intraocular pressure (IOP) in the immediate postoperative period was significantly lower in the
control group (13.4 mm Hg G 5.28 [SD]; range 5 to 23 mm Hg) than in the bandage group
(19.4 G 5.94 mm Hg, range 11 to 29 mm Hg) (P<.001, t test). In the bandage group, all incisions
were Seidel negative. In the control group, 1 main incision was Seidel positive. In 2 cases, the bandage successfully captured a micro-leak and thus maintained an intact anterior chamber.
Differences in OCT architectural features between the bandage group and control group were noted.
CONCLUSIONS: The adherent ocular bandage protected the incisions, selectively adhering to
deepithelialized areas and rapidly clearing from reepithelialized areas. The bandage helped maintain
a more desirable IOP in the immediate postoperative period, likely by preventing micro-leaks.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned. Additional disclosure is found in the footnotes.
J Cataract Refract Surg 2010; -:-–- Q 2010 ASCRS and ESCRS
There has been much debate about whether clear corneal incisions (CCIs) are self-sealing and whether they
increase the risk for endophthalmitis in cataract
surgery over that with older-generation incisions,
such as scleral tunnels.1–4 The suggested mechanism
for endophthalmitis is that tear-film contaminates
enter the anterior chamber of a hypotonous eye
through a leaking or unstable incision. Observational
ex vivo animal studies using Indian ink and in vivo
human studies using fluorescein show how dye can
pass into the anterior chamber through a leaking
incision.5–7 We believe the critical time during which
the structural integrity of CCIs is most likely to be
compromised is the immediate postoperative period,
which is typically defined as the first few hours after
surgery. Studies using optical coherence tomography
(OCT)8 found architectural features of reduced structural integrity, such as gaping and loss of coaptation,
during this period.
Various incision construction techniques to improve
the strength of CCIs have been advocated; these include a square9 or a nearly square10 configuration
and a multiplane architectural profile.11 However, several factors can lead to poor incision architecture, such
as incorrect construction by a junior surgeon in training, a difficult operative case in which the wound
might stretch, if the incision is enlarged, or the learning
curve associated with using a new blade. Moreover,
despite achieving the correct incision architecture, it
is not uncommon to see epithelial damage around
CCIs in the immediate postoperative period, the damage being caused by manipulation during surgery.
Retrospective analyses of endophthalmitis cases typically show involvement of the incision with gaping
and leaking; however, it is not clear whether these features contribute to the development of endophthalmitis or are consequential.12,13 We suggest that epithelial
damage and epithelial gaping at the external lip of the
Q 2010 ASCRS and ESCRS
0886-3350/$dsee front matter
doi:10.1016/j.jcrs.2010.06.058
Published by Elsevier Inc.
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ADHERENT OCULAR BANDAGE FOR CCIS
incision may provide a site for infection and be risk
factors for endophthalmitis.
An adherent ocular bandage applied to a CCI at the
end of surgery may protect the wound and improve its
structural integrity. Ideally, the ocular bandage would
adhere firmly to any area of epithelial damage and
epithelial gaping to help seal the incision. The presence
of the bandage should be temporary and provide
the maximum sealing over the first 24 hours, when
it is most needed. The bandage would gradually be
replaced by healing epithelium over the next few
days, behaving as an adjunct to natural wound healing. The bandage should be simple and easy for the
surgeon to apply and be of a soft smooth biocompatible material to prevent patient discomfort. We suggest
that such a device would improve the structural integrity of incisions in the immediate postoperative period
and help prevent leaking and hypotony.
PATIENTS AND METHODS
Study Design
This prospective randomized control trial comprised
patients with healthy eyes apart from cataract who had
coaxial microincision cataract surgery (MICS) by the same
surgeon (R.P.) at Prince Charles Eye Unit, Windsor, United
Kingdom. The patients were recruited from a fast-track
cataract surgery assessment clinic. Full approval for the
study was obtained from the Berkshire Medical Research
and Ethics Committee. Eyes were excluded from the study
for surgical complications, if the incision required enlargement or suturing, if the incision leaked at the end of surgery,
or if the main incision required stromal hydration.
Before surgery, patients were allocated using block
randomization to an intervention group, which received an
adherent ocular bandage, or to a control group. The surgeon
was masked to the group allocation until the standard
Submitted: April 26, 2010.
Final revision submitted: June 6, 2010.
Accepted: June 8, 2010.
From Prince Charles Eye Unit, King Edward VII Hospital, Windsor,
United Kingdom.
Additional financial disclosure: Mr. Calladine received financial contribution from Ocular Therapeutix, Inc., Bedford, Massachusetts,
USA, toward travel expenses to present this paper at the 2010
ASCRS Symposium on Cataract, IOL and Refractive Surgery.
Presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 2010, and the
ESCRS Symposium on Cataract, IOL and Refractive Surgery, Paris,
France, September 2010, and the XXVIII Congress of the ESCRS,
Paris, France, September 2010.
Corresponding author: Daniel Calladine, MB BS, BMedSci, Prince
Charles Eye Unit, King Edward VII Hospital, Saint Leonards Road,
Windsor SL4 3DP, United Kingdom. E-mail: drdancalladine@
doctors.org.uk.
cataract operation was completed, at which time the surgeon
applied the ocular bandage to the main incision and both
side-port incisions There was no further intervention in the
control group. Patients were masked to their group allocation for the duration of the study.
Adherent Ocular Bandage
The ReSure Adherent Ocular Bandage (Ocular Therapeutix, Inc.) was used in this study. The in situ–forming hydrogel bandage is designed for ophthalmic applications and is
composed mainly of polyethylene glycol and water. The
hydrogel bandage is applied to the eye as a liquid and
polymerizes on the ocular surface in approximately 30 seconds. It contains a small amount of FD&C Blue no. 1 colorant
as a visual aid to assist the surgeon in determining its thickness and placement during application. The blue colorant is
designed to diffuse from the bandage within a few hours of
application, leaving behind an optically clear and transparent material.
Surgical Technique
All cases were completed using topical anesthesia of lidocaine hydrochloride 2% gel. Initially, 2 side-port incisions
were made with a 15-degree blade and sodium hyaluronate
1% (Provisc). The ophthalmic viscosurgical device (OVD)
was injected into the anterior chamber before the main incision (CCI) was created with a new 2.2 mm wide Windsor
knife (Core Surgical) in the temporal cornea using a 3-plane
incision construction technique, as recommended by the
knife’s manufacturer. Initially, the globe was stabilized by
holding the second instrument side port with a pair of
forceps. The tip of the blade was buried steeply into the
superficial third of the corneal stroma, just inside the limbus,
and then flattened onto the globe. It was advanced forward
within the corneal stroma almost parallel to the surface corneal curvature until the incision measuring mark was
reached. The handle was then lifted to direct the blade
down toward the center of the pupil and advanced to
complete the incision. The blade has a tapered triangular
facet on its upward surface to provide a gradual increase
in tissue cutting resistance with passage of the blade.
Together with the blade-support technology, this prevents
sudden release of stored (flexed) potential energy as cutting
resistance changes. The base of the facet can also be used as
an incision-length measuring guide to standardize incision
length.
A capsulorhexis was created with a preformed cystotome
and a cross-action capsulorhexis forceps. This was followed
by nucleus hydrodissection using lignocaine 1%. Conventional coaxial MICS was then performed using an Infiniti
OZil handpiece (Alcon, Inc.), a curved 30-degree Kelmanstyle 0.9 mm diameter phaco needle, and a green ultra sleeve.
Irrigation/aspiration of soft lens matter was performed
through the 2 side ports using bimanual handpieces. In all
eyes, an AcrySof SN60WF IQ intraocular lens (IOL) (Alcon,
Inc.) was injected through a C-cartridge using a woundassisted technique. After the OVD was removed, stromal
hydration was performed on the side-port incisions with
a balanced salt solution; the main incision was not hydrated.
Intracameral cefuroxime was injected through the side port
and the eye left moderately firm at the end of surgery. The
incision was tested for leaking using a cellulose sponge test.
In eyes receiving an adherent ocular bandage, the incisions were dried thoroughly with a cellulose sponge while
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the surgical assistant prepared the bandage. Before application of the bandage, all incisions were checked to ensure
there were no active leaks and that the incisions remained
dry. The surgeon then transferred 1 drop of the adherent ocular bandage onto each incision using the accompanying
nonabsorbent foam applicator tip. The most efficient way
to apply the adherent ocular bandage was by using the
side edge of the foam applicator tip and a blotting technique.
This technique allowed the surgeon to transfer a small, controlled amount of the bandage precisely over the incisions. If
the wound remained uncovered after the first application,
a second transfer of bandage material was applied.
Patient Examinations
RESULTS
Of the 47 patients successfully recruited into the study,
2 were excluded from the study analysis; 1 patient
failed to attend all 3 postoperative examinations, and
the other patient had leakage from the main incision
at the end of surgery. Stromal hydration with a balanced salt solution was performed on the incision,
and the leaking appeared to have stopped when
viewed through the operating microscope. The bandage group comprised 23 patients with a mean age
of 71 years (range 59 to 87 years) and the control
group, 22 patients with a mean age of 76 years (range
60 to 89 years). All 45 patients had immediate, 1-day,
and-7 day postoperative examinations.
In all cases in the intervention group, the adherent
ocular bandage was successfully applied without
complication. Nineteen eyes (82.6%) required 1 application of the bandage, with the material completely
covering the external lip of the main incision and
side-port incisions, and separate applications for
each incision. The remaining 4 eyes (17.4%) required
a second application of the bandage material to ensure
complete coverage of the entire external lip of the
incision.
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All eyes were examined within 2 hours after surgery. A
slitlamp fluorescein 2% Seidel test using cobalt blue light
was performed on the main incision and side-port
incisions. Intraocular pressure (IOP) was measured with
a Goldmann applanation tonometer. All CCIs were then
examined using a Fourier-domain AS-OCT imaging system
(RTVue, Optovue, Inc.). A 2.5 mm 2.5 mm imagecapture grid consisting of 17 slices spaced approximately
0.15 mm apart was obtained for each CCI using the
AS-OCT device’s raster scanning program (Figure 1). This
enabled the total architecture of each CCI to be captured in
a series of approximately 14 slices across its full width. The
image-capture grid was individually oriented to the radial
meridian of each incision to ensure the OCT images accurately represented the longitudinal cross-section. It also
allowed identification of subtle variations in incision
architecture at different locations across the width of the
incision (Figure 2). The raster grid was used to identify the
OCT image obtained from the midpoint of the CCI by counting in 7 or 8 images from 1 side. The AS-OCT device’s
software was used to determine the number of incision
planes and to measure the incision length (Figure 3). To improve the accuracy of the incision length, each plane of the
incision was measured separately and added together.
Each slice through the image was individually examined
for the following architectural features of reduced structural
integrity: epithelial damage, epithelial gaping, endothelial
misalignment, endothelial gaping, loss of coaptation, and
local detachment of Descemet membrane.
In addition to the 2-hour examination (hereafter called the
immediate examination), patients were examined approximately 24 hours (between 22 hours and 25 hours) after surgery and 7 days after surgery. If the adherent ocular
bandage was present after 7 days, the patient was reexamined at 2 weeks.
Figure 1. Raster image-capture program
showing a 2.5 mm 2.5 mm image-capture
grid and corresponding 17 longitudinal OCT
slices spaced approximately 0.15 mm apart
across the full width of the incision.
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ADHERENT OCULAR BANDAGE FOR CCIS
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Figure 2. The series of OCT images produced by the raster image-capture program show the variation that can occur
in wound architecture across the same incision. Epithelial gaping is seen in images
8 to 16, endothelial gaping in 7 to 12, loss
of coaptation together with endothelial
gaping in 3 and 15, and local detachment
of Descemet membrane in 6 to 15. A schematic drawing of the raster grid (bottom
left) encompasses the whole clear corneal
incision (CCI).
Wound Architecture
On OCT, a 3-plane architectural profile was seen at
the midpoint of all the main incisions and a 2-plane profile was seen toward the edges. The mean main incision
length was 1.76 mm G 0.14 (SD) (range 1.48 to 2.00 mm)
in the bandage group and 1.73 G 0.18 mm (range 1.46 to
1.93 mm) in the control group; the difference between
the 2 groups was not statistically significant.
The architectural features in the main CCI (endothelial
misalignment, endothelial gaping, loss of coaptation,
local detachment of Descemet membrane) were similar
in frequency and appearance between the bandage
group and the control group at all 3 postoperative examinations (Figure 4). The frequency of epithelial damage
and epithelial gaping was similar between the 2 groups
at the immediate examination (Figure 5); however, the
appearance of the features was markedly different. In
the control group, the features were completely exposed
to the ocular surface, whereas in the bandage group the
features were covered with a smooth film of the adherent ocular bandage and not exposed to the ocular surface
(Figure 6).
At immediate postoperative examination, the bandage covered the entire external lip of 18 CCIs (81%).
In the remaining 4 CCIs (19%), the bandage partially
covered all areas of epithelial damage and gaping
and was absent from areas of undamaged epithelium.
At 1 day, the entire external lip of 2 main incisions
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ADHERENT OCULAR BANDAGE FOR CCIS
Figure 4. Frequency of endothelial misalignment, endothelial gaping, loss of coaptation, and local detachment of Descemet membrane
over time (DM Z Descemet membrane; OCT Z optical coherence
tomography).
remained completely covered with the ocular bandage;
16 main incisions had a partial covering and 4 had no
bandage. In the main incisions with partial covering,
the bandage covered all deepithelialized areas. In these
cases, the bandage typically formed a smooth plug in
the external lip of the incision with a smooth surface
profile in line with the surrounding epithelium. At 7
days, there was no ocular bandage on 15 CCIs; 7
CCIs had small, localized areas of bandage over deepithelialized areas. The 7 eyes with remaining bandage
were observed and reexamined 2 weeks after surgery,
at which time no bandage material was present and the
incisions were completely healed.
The extent and time course of coverage by the adherent ocular bandage showed a positive trend with the
amount of epithelial damage and epithelial gaping.
A spectrum of coverage was seen from one extreme
in CCIs with more extensive damage, in which the
adherent ocular bandage was present at all 3 time
points and was gradually replaced by healing epithelium up to 2 weeks postoperatively (Figure 7). In
contrast, in CCIs with little epithelial damage and epithelial gaping in the immediate postoperative period,
the bandage was completely gone by 1 day (Figure 8).
Analysis of the OCT raster images from the sideport incisions showed a similar occurrence of
Figure 5. Frequency of epithelial damage and epithelial gaping over
time (OCT Z optical coherence tomography).
Figure 6. Comparative OCT images. Top: Image of an incision in the
bandage group shows total coverage of the epithelial damage and
epithelial gaping. Bottom: Image of an incision in the control group
shows exposure of these features to the ocular surface.
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Figure 3. The AS-OCT system’s analyzing software shows measurements of the CCI in 3 planes.
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ADHERENT OCULAR BANDAGE FOR CCIS
Figure 7. Sequential OCT images from the same location of a main
CCI taken in the immediate postoperative period and at 1 day, 7
days, and 2 weeks show significant epithelial damage that is entirely
covered by the adherent ocular bandage and absent by 2 weeks.
Figure 8. Sequential OCT images from the same location of a main
CCI taken in the immediate postoperative period and at 1 day, 7
days, and 2 weeks show no epithelial damage and rapid clearance
of the adherent ocular bandage by 1 day postoperatively.
architectural features and patterns of bandage adherence and clearance. The side-port incisions tended to
have a 1- or 2-plane architectural profile, in contrast
to the 3-plane profile of the main incisions.
anterior chamber and an IOP of 20 mm Hg. The eye
was observed and reexamined after 2 more hours, by
which time the incision had self-sealed; the IOP was
15 mm Hg and the anterior chamber remained deep
and formed (Figure 9). Figure 10 shows slitlamp photographs of the ocular bandage in an eye immediately
postoperatively after instillation of fluorescein 2% and
cobalt blue light; the bandages lost their blue color
within 1 hour of application
In the bandage group, the bandage appeared to capture a micro-leak from the main incision. A pocket of
fluid could be seen under the bandage at the external
lip of the CCI (Figure 11). All incisions were dry before
application of the bandage; therefore, the micro-leak
must have occurred in the first few hours after surgery.
The same was observed in 1 patient, who was
excluded from the study analysis because of stromal
hydration of the main incision. This patient was
randomized to the bandage group, and although the
bandage was successfully applied and although the
incision was dry after stromal hydration, the immediate postoperative examination showed a micro-leak
under the bandage at the external lip of the incision
(Figure 12). Both incisions with micro-leaks remained
Seidel negative.
Intraocular Pressure
The mean IOP was statistically significantly lower in
the control group (mean 13.4 G 5.28 mm Hg; range 5
to 23 mm Hg) than in the bandage group (mean 19.4
G 5.94 mm Hg; range 11 to 29 mm Hg) in the immediate postoperative period (P!.001, 2-tailed unpaired t
test of equal variance). At 1 day and 7 days, there
was no significant difference between the 2 groups.
The most hypotonous eye in the study was in the control group at the immediate postoperative examination. This eye had an IOP of 5 mm Hg and was
Seidel negative with a deep and formed anterior
chamber.
Seidel Test
All incisions in the bandage group were Seidel negative. In the control group, 1 main incision had a small
Seidel-positive leak. The eye had a deep and formed
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ADHERENT OCULAR BANDAGE FOR CCIS
Figure 9. The OCT images from the midpoint (top and middle left) and
lower half (middle right and bottom) of a CCI in the control group,
which was the only Seidel-positive eye in the study. Loss of coaptation could be traced from the epithelial to endothelial edge of the incision; this is shown in part in the bottom image, which is where the
Seidel-positive leak was localized.
DISCUSSION
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We believe that the importance of correct CCI architecture is greatest in the immediate postoperative period
because this is when incisions are most likely to be
unstable and thus leak. Therefore, incision architecture
evaluation must be performed within this time frame.
We performed the first postoperative examination
within 2 hours of surgery. This is in contrast to all
other OCT studies of 2.2 mm CCIs, in which the first
OCT examination was performed 1 day postoperatively.13–15 The previous studies are helpful for
comparison between different-sized incisions and
phacoemulsification techniques; however, we do not
believe they address the most critical time period,
immediately postoperatively, which is the time to determine whether the correct incision architecture has
been achieved.
Maintaining a consistent OCT examination between
cases can be challenging. The minimum examination
would be a single longitudinal cross-sectional OCT
slice at a location chosen arbitrarily by the examiner.
However, a single OCT slice neglects the majority of
the incision either side of it and is difficult to make consistent between cases. Performing several single OCT
slices across the incision is time consuming and difficult to make consistent. The maximum examination
would be a 3-dimensional (3-D) OCT image of the
whole CCI. However, the long acquisition time of
these image-capturing programs leads to aberrations
and distortions from eye movements. Objective programs for analyzing 3-D images are also limited and
cannot measure wound parameters in most cases.
The raster image-capture program of the AS-OCT
system we used avoids these problems, making it
well suited to examining CCIs in the immediate postoperative period. A 2.5 mm 2.5 mm image-capture
grid with longitudinal cross-sectional slices spaced approximately 0.15 mm apart was used to capture the architecture of the whole incision in a single image
acquisition. The AS-OCT system’s software was then
used to identify the midpoint of each incision by
counting in slices from 1 side, which allowed consistent comparison between cases. Using the software,
we could measure each plane of the incision separately
to improve the accuracy of incision length measurement. We could also examine across the whole width
of the incision for architectural features of reduced
structural integrity and to accurately map the coverage of the adherent ocular bandage. The OCT images
obtained using the raster image-capture grid show
how incision architecture can vary, even within the
same incision at different positions. These features
Figure 10. Slitlamp photographs show the
transparent appearance of the adherent ocular bandage in the immediate postoperative examination (left), after instillation of
fluorescein 2% with a white light (middle),
and with a cobalt blue light (right), which
highlights the bandage.
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Figure 11. Three adjacent OCT images of the same CCI in the bandage group. A small leak of aqueous (white arrow) was contained
in the adherent ocular bandage; a Seidel-negative state was
maintained.
tend to be localized to one part of the incision and can
easily be missed when a single longitudinal crosssectional OCT slice is used.
The frequencies of all architectural features were
generally similar to or higher than those reported in
previous OCT studies.1,14–19 The finding of increased
frequency of features, such as epithelial damage, is
probably due to the higher resolution of the Fourierdomain AS-OCT imaging system and the raster
image-capture grid, which identified localized occurrences of these features. With continued improvements in the resolution ability and scanning speeds,
OCT imaging systems are likely to identify subtle
occurrences of CCI architectural features more often.
We believe the main incision lengths and 3-plane
architectural profile in our study were highly consistent in the 45 cases. This is an improvement over results in our previous OCT study, in which we used
a different 2.2 mm wide blade.8 We attribute this improved consistency to the design of the blade used in
the present study, which helped standardize the incision length and profile between the 2 groups. Similar
OCT imaging studies of incision architecture have
used wider blades9,18,19 or different microincision
blades but did not state the incision length measured
using OCT imaging or comment on the number of
incision planes produced.14–16 These differences, together with the fact that this is the first study of CCIs
using an adherent ocular bandage and the RTVue
Fourier-domain AS-OCT imaging system, make it difficult to draw meaningful comparisons with previous
studies.
Application of the adherent ocular bandage was
easy, although we stress the importance of properly
drying the incision with a cellulose sponge before
to improve adherence and coverage of the bandage
Figure 12. A series of OCT images from
1 eye excluded from the study because
the main incision was leaking at the
end of surgery and required stromal
hydration to seal it. Images show the
main incision at its midpoint and the
raster grid from the immediate postoperative examination (top and middle
left). Expanded views of slices 10 to 13
inclusive from the raster grid show
the micro-leak contained beneath the
adherent ocular bandage (top right).
Images taken at 1 day show the midpoint of the incision and previous
area of the micro-leak (bottom left; A*
is from the same location as A). An image taken at 7 days shows the midpoint
of the incision (bottom right).
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ADHERENT OCULAR BANDAGE FOR CCIS
material. The bandage selectively adhered to deepithelialized areas and rapidly cleared from reepithelialized
areas. Furthermore, in the most severe cases of epithelial damage, the bandage acted as a pseudoepithelium,
with a smooth and continuous profile, in line with the
surrounding epithelium. There were no complications
from the gradual replacement of the bandage material
by the healing epithelium over the weeks after surgery. However, prolonged adherence of the bandage
to deepithelialized areas occurred in 7 of the 22 cases
for between 1 week and 2 weeks postoperatively. It
could be argued that in these cases, complete epithelial
healing was slower than in control eyes. Thus, there is
an inevitable compromise between the ability of
hydrogel material to adhere firmly to deepithelialized
areas in the immediate postoperative period versus its
ability to be replaced by healing epithelial cells over
the days and weeks after surgery. With respect to
this, we believe the bandage used in this study
achieved a good compromise because there was no
statistically significant delay in epithelial healing and
the bandage material appeared to behave as an
adjunct to natural wound healing.
In the immediate postoperative period, IOP was significantly higher in the bandage group than in the
control group (P!.001, t test). A likely explanation is
that the bandage prevented transient micro-leaks
from the wound in the immediate postoperative
period. One eye in the control group was Seidel positive and leaking from the inferior half of the incision.
Because the eye had good IOP (20 mm Hg) and
a deep, formed anterior chamber, we elected to
observe the case with a view of returning to the operating room to hydrate or suture the incision to help it
seal. This was not necessary because the CCI selfsealed after 2 more hours, the IOP remained normal
(15 mm Hg) with a deep and formed anterior chamber,
and the IOL was centrally placed in the capsular bag
with no visible tilting. No eye in the bandage group
had a Seidel-positive incision. However, 1 incision
appeared to develop a micro-leak into a potential
space under the ocular bandage. The bandage
contained the micro-leak, maintaining an intact anterior chamber. We believe this case shows the benefits
of how the adherent ocular bandage helps maintain
the structural integrity of the incision in the immediate
postoperative period. Furthermore, a captured microleak was also seen in one case that was excluded from
the study analysis. In this case, the main incision was
leaking at the end of surgery and had stromal hydration, which at the time appeared to stop the leaking;
the incision remained dry during application of the
bandage. Although this is a single case, it highlights
how stromal hydration alone may be insufficient to
9
prevent further micro-leaks from CCIs in the immediate postoperative period.
In conclusion, this study found that this adherent
ocular bandage helped CCIs seal in the immediate
postoperative period, at which time they are likely to
be less stable and at the greatest risk for leaking. The
bandage also appears to help maintain a more desirable IOP in the immediate postoperative period; we
hypothesize this was because the bandage prevents
micro-leaks. The bandage adhered firmly to areas of
epithelial damage and epithelial gaping and provided
a smooth protective barrier that took on the natural
curvature of the corneal surface. The bandage selectively adhered to areas of epithelial damage and epithelial gaping and rapidly cleared from intact
epithelium, indicating the bandage will stay where it
is needed. In light of these findings, we advocate the
use of the adherent ocular bandage when the surgeon
wants the added security of a sealed incision. Specific
examples would include only-eye surgical cases, previously operated eyes, and use of premium IOLs (presbyopia-correcting or toric IOLs) that require precise
placement and a stable anterior chamber depth.
Also, if there were doubt about the quality of the incision architecture, such as if the incision were accidentally created too steep or short, the ocular bandage
would improve the incision’s structural integrity.
REFERENCES
1. Masket S. Is there a relationship between clear corneal cataract
incisions and endophthalmitis? [guest editorial]. J Cataract
Refract Surg 2005; 31:643–645
2. Nichamin LD, Chang DF, Johnson SH, Mamalis N, Masket S,
Packard RB, Rosenthal KJ. ASCRS white paper. What is the
association between clear corneal incisions and postoperative
endophthalmitis? J Cataract Refract Surg 2006; 32:
1556–1559
3. Busbee BG. Endophthalmitis: a reappraisal of incidence and
treatment. Curr Opin Ophthalmol 2006; 17:286–291
4. Taban M, Behrans A, Newcomb RL, Nobe MY, Saedi G,
Sweet PM, McDonnell PJ. Acute endophthalmitis following
cataract surgery; a systematic review of the literature. Arch
Ophthalmol 2005; 123:613–620. Available at: http://archopht.
highwire.org/cgi/reprint/123/5/613. Accessed July 22, 2010
5. Taban M, Sarayba MA, Ignacio TS, Behrens A, McDonnell PJ.
Ingress of India ink into the anterior chamber through sutureless
clear corneal cataract wounds. Arch Ophthalmol 2005; 123:
643–648. Available at: http://archopht.ama-assn.org/cgi/
reprint/123/5/643.pdf. Accessed July 22, 2010
6. Sarayba MA, Taban M, Ignacio TS, Berens A, McDonnell PJ. Inflow of ocular surface fluid through clear corneal cataract incisions:
a laboratory model. Am J Ophthalmol 2004; 138:206–210.
Available at: http://download.journals.elsevierhealth.com/pdfs/
journals/0002-9394/PIIS0002939404003320.pdf. Accessed July
22, 2010
7. Chawdhary S, Anand A. Early post-phacoemulsification hypotony as a risk factor for intraocular contamination: in vivo model.
J Cataract Refract Surg 2006; 32:602–613
J CATARACT REFRACT SURG - VOL -, - 2010
FLA 5.0 DTD JCRS6824_proof 30 September 2010 8:30 pm
ADHERENT OCULAR BANDAGE FOR CCIS
8. Calladine D, Packard R. Clear corneal incision architecture in
the immediate postoperative period evaluated using optical
coherence tomography. J Cataract Refract Surg 2007; 33:
1429–1435
9. Ernest PH, Lavery KT, Kiessling LA. Relative strength of scleral
corneal and clear corneal incisions constructed in cadaver eyes.
J Cataract Refract Surg 1994; 20:626–629
10. Masket S, Belani S. Proper wound construction to prevent shortterm ocular hypotony after clear corneal incision cataract
surgery. J Cataract Refract Surg 2007; 33:383–386
11. Fine IH, Hoffman RS, Packer M. Profile of clear corneal incisions
demonstrated by optical coherence tomography. J Cataract
Refract Surg 2007; 33:94–97
12. 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; 31:735–741
13. Cooper BA, Holekamp NM, Bohigan G, Thompson PA. Casecontrol study of endophthalmitis after cataract surgery comparing scleral tunnel and clear corneal wounds. Am J Ophthalmol
2003; 136:300–305. Available at: http://download.journals.
elsevierhealth.com/pdfs/journals/0002-9394/PIIS0002939403002022.
pdf. Accessed July 22, 2010
14. Elkady B, Piñero D, Alió JL. Corneal incision quality: microincision cataract surgery versus microcoaxial phacoemulsification.
J Cataract Refract Surg 2009; 35:466–474
15. Dupont-Monod S, Labbé A, Fayol N, Chassignol A, Bourges J-L,
Baudoin C. In vivo architectural analysis of clear corneal incisions using anterior segment optical coherence tomography.
J Cataract Refract Surg 2009; 35:444–450
16. Berdahl JP, Jun B, DeStafeno JJ, Kim T. Comparison of a torsional handpiece through microincision versus standard clear
corneal cataract wounds. J Cataract Refract Surg 2008;
34:2091–2095
17. Calladine D, Tanner V. Optical coherence tomography of the
effects of stromal hydration on clear corneal incision architecture. J Cataract Refract Surg 2009; 35:1367–1371
18. Torres LF, Saez-Espinola F, Colina J, Retchkiman M, Patel MR,
Agurto R, Garcia G, Diaz JL, Huang D, Schanzlin DJ,
Chayet AS. In vivo architectural analysis of 3.2 mm clear corneal
incisions for phacoemulsification using optical coherence
tomography. J Cataract Refract Surg 2006; 32:1820–1826
19. Schallhorn JM, Tang M, Li Y, Song JC, Huang D. Optical coherence tomography of clear corneal incisions for cataract surgery.
J Cataract Refract Surg 2008; 34:1561–1565; Available
at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556292/pdf/
nihms66920.pdf. Accessed July 22, 2010
First author:
Daniel Calladine, MB BS, BMedSci,
MRCOphth
Prince Charles Eye Unit, King Edward
VII Hospital, Windsor, United
Kingdom
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print & web 4C=FPO
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