EyeWorld India December 2014 Issue

32 EWAP CATARACT/IOL December 2014 Dr. Kim attributes part of the difficulty with the sutures to the fact that many surgeons today are not using them often. “When you don’t suture, you lose your skill,” he said. “The other issue is when you look at what a suture is doing, it is compressing two sides of the wound together, but it’s not actually sealing that wound.” However, the ReSure Sealant completely covers the length of the wound. “I think you’re getting a better seal of the wound with something like a sealant compared to a suture,” Dr. Kim said. “Ironically, while the study was designed to show non-inferiority of the sealant compared to suture, investigators found the ReSure Sealant to be statistically superior to suture,” he said. Dr. Kim views the sealant as something that should be on the shelves of every operating room because practitioners never know when they are going to encounter a scenario in which a better means of wound closure may be needed. Suturing can be a real hassle, he said. “The OR staff has to find the suture and open it, then the surgeon has to load, place, tie, cut, and bury the suture—this is something that could take several minutes,” he said. Meanwhile, the ReSure Sealant takes less than 30 seconds to prepare and apply, Dr. Kim said. Popular uses There are many clinical scenarios that warrant the use of the ReSure Sealant, he thinks. Routine cataract surgery is one, as is the premium cataract channel. Premium patients are paying extra out-of-pocket for multifocal, accommodating, or toric lenses and have higher expectations for outcomes. “If you get a wound leak or a complication, the lens is not in the ideal position, or the refractive outcome is not what you want, these are the patients who are going to be more vocal and unhappy,” Dr. Kim said. “Because of the higher expectations I think that’s an ideal scenario to use this.” In addition, more complex cases, such as those in which a Malyugin ring (MicroSurgical Technology, Redmond, Wash., U.S.) or an iStent (Glaukos, Laguna Hills, Calif., U.S.) are inserted, may also benefit. “Any cases where the wound dynamics may be unusual or abnormal, such as high myopes or those with keratoconus, these are patients who I think are good candidates,” Dr. Kim said. You also have to consider patient risk factors. Patients who are having trouble putting in their drops and may be rubbing their eyes as well as those who are mentally disabled are likely prime candidates, he noted. In addition, monocular patients, those who have MRSA, or those who are immunocompromised could benefit, Dr. Kim said. Instances in which the femtosecond laser is used for cataract surgery may provide an ideal opportunity for this product. “There have been some reports of surgeons not being able to close the incision at the end of the case with stromal hydration with the femtosecond laser,” he said. However, use of this may be most impactful off-label on DSEK patients, Dr. Kim thinks. Because it is such a large wound (typically 4–5 mm), a suture is ultimately placed. Unfortunately, this can compromise the air bubble used for the DSEK technique, he finds. “During the suture placement, the air typically escapes very quickly, the chamber collapses, and the graft either dislocates or touches the iris and the lens,” Dr. Kim said. “So, there’s trauma to the endothelium.” Use of the ReSure Sealant has changed the way Dr. Kim approaches his DSEK cases. “At the end of my DSEK, I put the air bubble in, have the graft nicely centered, then I put the ReSure Sealant right on the 4.1 mm wound and inflate the eye to the normal high pressure and let it sit for 8 minutes,” he said. “I do the venting incisions, lower the pressure, and put some balanced salt solution into the anterior chamber while the sealant securely seals the wound.” He finds this allows him to complete the procedure without running the risk of traumatizing the graft or inducing astigmatism due to a suture. Overall, Dr. Kim views use of the ReSure Sealant to prevent wound leaks as akin to routinely wearing a seatbelt in a car. “That’s the thing we learned from this clinical study—the wound leak rates are high,” he said. “The problem is you don’t know which of these cases is going to end up with endophthalmitis, epithelial downgrowth, or IOL dislocation,” he said. He encourages practitioners to take the approach of using something that is going to add security in terms of wound sealing. “I think this is an approach that more and more surgeons will look at once they realize that their wounds could be leaking more often than they think,” he said. EWAP Editors’ note: Dr. Kim has financial interests with Ocular Therapeutix. Contact information Kim : terry.kim@duke.edu Seal - from page 31