Use of Tisseel Fibrin Sealant to Repair Descemet Membrane Perforation During DALK

1. Use of Tisseel Fibrin Sealant to Repair Descemet Membrane Perforation During DALK Ketcherside C.S., Berger G.R., Taravella M. University of Colorado The authors have no financial interests

2. Background • Tisseel is a commercially available two-component fibrin sealant which acts as tissue glue with sealing, hemostatic and gluing properties. • The glue has two components • (1) a freeze-dried powder composed of human fibrinogen, fibrinonectin, plasminogen and Factor XIII reconstituted in a bovine aprotinin solution (2) a solution composed of human thrombin reconstituted in a calcium chloride solution. • When both of these solutions interact, through the action of thrombin, the fibrinopeptides are broken down to fibrin monomers. These monomers aggregate by cross-linking, leading to the formation of fibrin clot. • Tisseel is also available as a frozen, pre-filled syringe. Srinivasan S, Dollin M, McAllum P et al. Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observer masked clinical trial. British Journal of Ophthalmology 2009;93:215-218

3. Some Uses of Tisseel • ILK • Pterygium excision • Multiple uses with amniotic membrane transplant • Corneal perforation • Vitrectomy • Conjunctivochalasis • PCIOL sutureless implantation • Scleral melt • Lamellar keratoplasty • LASIK complications • Glaucoma surgery • Cataract wound closure

4. What we did… • Routine Deep Anterior Lamellar Keratoplasty with Big Bubble technique • Good trephination to start • Attempted to dissect deep stroma and perforated anterior chamber with 27 gauge needle • Chamber remained deep with air fill • Able to use Big Bubble dissection in alternate area of the cornea

5. What we did… • Proceeded as usual while taking care to avoid area of perforation and dissect this area last • With dissection of tissue over perforation, chamber collapsed • Reformed chamber with air and used single drop of Tisseel to seal the Descemet’s perforation • We experienced no further complication

6. Perforation

7. Use of Alternate Site

8. Dissect this area last

9. One drop of Tisseel

10. Lamellar graft in place

11. References • Malta JB, Soong HK, Shtein R et al. Femtosecond laser-assisted keratoplasty: laboratory studies in eye bank eyes. Curr Eye Res. 2009 Jan;34(1):18-25. • Srinvasan S, Dollin M, McAllum P et al. Fibrin glue versus sutures for attaching the conjunctival autograft in pterygium surgery: a prospective observer masked clinical trial. Br J Ophthalmol. 2009 Feb;93(2):215-8. • Chawla B, Tandon R. Sutureless amniotic membrance fixation with fibrin glue in symptomatic bullous keratopathy with poor visual potential. Eur J Ophthalmol. 2008 Nov-Dec;18(6):998-1001. • Batman C, Ozdamar Y, Mutevelli S et al. A comparative study of tissue glue and vicryl suture for conjunctival and scleral closure in conventional 20-gauge vitrectomy. Eye. 2008 Sep 5. • Brodbaker E, Bahar I, Slomovic AR. Novel use of fibrin glue in the treatment of conjunctivochlalasis. Cornea. 2008 Dec;27(10):1170. • Agarwal A, Kumar DA, Jacob S et al. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg. 2008 Sep;34(9):1433-8. • Casas VE, Kheirkhah A, Blanco G et al. Surgical approach for scleral ischemia and melt. Cornea. 2008 Feb;27(2):196-201. • Duarte MC, Kim T. Sutureless lamellar keratoplasty: a modified approach for fibrin glue application. Cornea. 2007 Oct;26(9):1127-8. • Narvaez j, Chakrabarty A, Chang K. Treatment of epithelial ingrowth after LASIK enhancement with a combined technique of mechanical debridement, flap suturing, and fibrin glue application. Cornea. 2006 Oct;25(9):1115-7. • Kahook MY, Noecker RJ. Fibrin glue-assisted glaucoma drainage device surgery. Br J Ophthalmol. 2006 Dec;90(12):1486-9