Few patients retain a clear lens after a perforating injury of the cornea and lens1,2; traumatic cataract is the usual result. Analysis of the literature and patient files suggest that posttraumatic fibrinogen exudation plays a significant role in this development, which is supported by serial experimentation on human lenses in vitro as well as rabbit and rat eyes in vivo.3 We developed a microsurgical technique of fibrinogen-based capsule tear sealing that has been applied in an initial series of patients. A posttraumatic thin fibrin layer covering the capsule tear is usually insufficient but delays the lens damage so a successful intervention is possible after intervals of many hours and even days.4
Swollen degenerated lens matter exiting from the capsule tear as well as such matter located deeper is drawn from the lesion site using a 1.0 mL syringe. (Degenerated lens matter remaining underneath the fibrin seal would continue to swell and break the seal.) Air is injected into the anterior chamber if the lesion is within the middle two thirds of the anterior lens surface (air-bubble technique [Figure 1]). Balanced salt solution is preferred in more peripheral tears if the anterior chamber has to be filled (underwater technique).4
Two-component fibrinogen glue is commercially available (Tisseel or Tissucol [Baxter]). About 3 to 4 μL of the first component, the thrombin–calcium chloride solution, is injected around the lesion site to create a barrier to prevent spreading of 3 to 4 μL of the second component, the fibrinogen solution. The 2 glue components are applied in succession. Anterior lens capsule tears as well as through-and-through perforations are sealed.
The pupil must remain dilated and moderate cycloplegia maintained to avoid accommodation stress, which could reopen the lesion. Depending on the lesion size, formation of new capsule material and a firm scar can take up to 3 months.5 For this reason, accommodation is kept to a narrow range for 6 to 12 weeks but does not cause total paralysis to allow full recovery afterward and avoid permanent paralysis.
The glue is barely visible within the aqueous humor until clotting induces some opacity, which comes too late to prevent the application of excess amounts of the glue. A company specializing in the production of ophthalmic microsurgical instruments has developed a high-quality microapplicator comprising 2 syringes for simultaneous or subsequent application of preselected small amounts of the fibrinogen glue components (Figure 2). Both syringes with the glue components fit into the red plastic supports delivered with the glue, and a pressure rod moves both pistons each time the lever is activated. The amount of glue per lever activation can be adjusted with a control. Scale readings 1 to 8 correspond to about 3 to 20 μL. Repeated lever movements deliver the same glue amounts again and again from both syringes. The first models are now being tested in ophthalmic and ear, nose, and throat surgery. Blunt twin cannulas (curved or straight, 0.8 mm × 0.5 mm = 21 × 25 gauge) were developed to facilitate the application.
The results of our first series of 31 patients have been reported.4 The long-term follow-up (8 to 12 years) shows that the successfully treated lenses remained as clear as they were in the postoperative weeks (Figures 3 and 4) and accommodation returned after discontinuation of the topical atropine.
Fibrinogen sealing of peripheral capsule tears sometimes included a small part of the pupil rim (2 of 31 patients). This seal broke down during spontaneous fibrin absorption. It could be dissolved using the recombinant tissue-plasminogen activator or streptokinase,6,7 but we never needed that. A second sealing intervention after some days was well tolerated if the first application provided an incomplete seal. An attempt should always be made to restore the lens. Sealing the capsule tears proved helpful even if the cataract could not be prevented; it stopped the swelling and dissolution of lens matter for several days. The posttraumatic phacoanaphylactic inflammation induced by degenerated lens matter was markedly reduced, and subsequent surgical interventions were easier. We do not yet have sufficient experience to recommend this technique for children aged 10 years or younger.
The human lens epithelium has remarkable regenerative powers. Up to now this has been seen as a hindrance due to the formation of secondary cataracts. In the future, we may learn to make better use of the regenerative powers.8 Fibrinogen-based sealing of capsule incisions may prove helpful after capsule bag refilling with artificial lens matter, providing the latter has not interfered with the survival of the lens epithelium.9–11 Laser welding of capsule patches has been tested in vitro.12 Phase separation inhibitors or vitamin E proved helpful in the prevention or reduction of lens opacities in animal experiments.13,14
This application represents a departure from the U.S. Food and Drug Administration approved uses of the glue15 so this off-label use should be included in patients' informed consent form.
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