Preliminary in vitro evaluation of 2-octyl cyanoacrylate (Dermabond) to seal corneal incisions

A Comparison between 2-Octyl Cyanoacrylate and Conventional Suturing for the Closure of Epiblepharon Incision Wounds in Children: A Retrospective Case-Control Study

Background: Tissue adhesive has been widely used in ophthalmic surgery for various procedures, proving both effective and safe. However, no studies have compared the surgical efficacy of the tissue adhesive 2-octyl cyanoacrylate (SurgiSeal®) to that of traditional suture closure in Asian children undergoing surgery for lower lid epiblepharon. Methods: This is a single-center retrospective case-control study. Surgical correction for epiblepharon was performed on 22 patients from November 2019 to May 2023. A total of 20 patients who were followed up for at least 1 month were included for analysis. After standardized epiblepharon surgery, group A underwent wound closure with a subcuticular suture and 2-octyl cyanoacrylate, and group B underwent closure with a 6-O fast-absorbing surgical gut suture. Patients were followed up at 1, 4, and 12 weeks post-surgery. Results: A total of 10 patients (20 eyes) underwent skin closure with tissue adhesives (group A), and 10 patients (18 eyes) underwent wound closure using conventional suture material (group B). No significant differences in the sex ratio, mean age at operation, pre- and postoperative best-corrected visual acuity (BCVA), or average surgical time were observed between groups. Both groups exhibited improved postoperative BCVA, with symptom relief and a significant decrease in the severity of keratopathy after surgery. Neither recurrence nor complications were reported during follow-up. The aesthetic results were similar between groups, while caregivers of children in the tissue adhesive group expressed high satisfaction regarding the ease of postoperative care. Conclusions: Successful closure of lower lid epiblepharon surgery wounds in children can be performed using 2-octyl cyanoacrylate (SurgiSeal®). This method is simple, safe, and effective when compared to conventional sutures.

Tissue Adhesives: From Research to Clinical Translation

Sutures, staples, clips and skin closure strips are used as the gold standard to close wounds after an injury. In spite of being the present standard of care, the utilization of these conventional methods is precarious amid complicated and sensitive surgeries such as vascular anastomosis, ocular surgeries, nerve repair, or due to the high-risk components included. Tissue adhesives function as an interface to connect the surfaces of wound edges and prevent them from separation. They are fluid or semi-fluid mixtures that can be easily used to seal any wound of any morphology - uniform or irregular. As such, they provide alternatives to new and novel platforms for wound closure methods. In this review, we offer a background on the improvement of distinctive tissue adhesives focusing on the chemistry of some of these products that have been a commercial success from the clinical application perspective. This review is aimed to provide a guide toward innovation of tissue bioadhesive materials and their associated biomedical applications.

Ocular adhesives: Design, chemistry, crosslinking mechanisms, and applications

Closure of ocular wounds after an accident or surgery is typically performed by suturing, which is associated with numerous potential complications, including suture breakage, inflammation, secondary neovascularization, erosion to the surface and secondary infection, and astigmatism; for example, more than half of post-corneal transplant infections are due to suture related complications. Tissue adhesives provide promising substitutes for sutures in ophthalmic surgery. Ocular adhesives are not only intended to address the shortcomings of sutures, but also designed to be easy to use, and can potentially minimize post-operative complications. Herein, recent progress in the design, synthesis, and application of ocular adhesives, along with their advantages, limitations, and potential are discussed. This review covers two main classes of ocular adhesives: (1) synthetic adhesives based on cyanoacrylates, polyethylene glycol (PEG), and other synthetic polymers, and (2) adhesives based on naturally derived polymers, such as proteins and polysaccharides. In addition, different technologies to cover and protect ocular wounds such as contact bandage lenses, contact lenses coupled with novel technologies, and decellularized corneas are discussed. Continued advances in this area can help improve both patient satisfaction and clinical outcomes.

Tunable Adhesion for Bio-Integrated Devices

With the rapid development of bio-integrated devices and tissue adhesives, tunable adhesion to soft biological tissues started gaining momentum. Strong adhesion is desirable when used to efficiently transfer vital signals or as wound dressing and tissue repair, whereas weak adhesion is needed for easy removal, and it is also the essential step for enabling repeatable use. Both the physical and chemical properties (e.g., moisture level, surface roughness, compliance, and surface chemistry) vary drastically from the skin to internal organ surfaces. Therefore, it is important to strategically design the adhesive for specific applications. Inspired largely by the remarkable adhesion properties found in several animal species, effective strategies such as structural design and novel material synthesis were explored to yield adhesives to match or even outperform their natural counterparts. In this mini-review, we provide a brief overview of the recent development of tunable adhesives, with a focus on their applications toward bio-integrated devices and tissue adhesives.

Surgical adhesives in ophthalmology: history and current trends

Tissue adhesives are gaining popularity in ophthalmology, as they could potentially reduce the complications associated with current surgical methods. An ideal tissue adhesive should have superior tensile strength, be non-toxic and anti-inflammatory, improve efficiency and be cost-effective. Both synthetic and biological glues are available. The primary synthetic glues include cyanoacrylate and the recently introduced polyethylene glycol (PEG) derivatives, while most biological glues are composed of fibrin. Cyanoacrylate has a high tensile strength, but rapidly polymerises upon contact with any fluid and has been associated with histotoxicity. Fibrin induces less toxic and inflammatory reactions, and its polymerisation time can be controlled. Tensile strength studies have shown that fibrin is not as strong as cyanoacrylate. While more research is needed, PEG variants currently appear to have the most promise. These glues are non-toxic, strong and time-effective. Through MEDLINE and internet searches, this paper presents a systematic review of the current applications of surgical adhesives to corneal, glaucoma, retinal, cataract and strabismus surgeries. Our review suggests that surgical adhesives have promise to reduce problems in current ophthalmic surgical procedures.

Wound closure and tissue adhesives in clear corneal incision cataract surgery

PURPOSE OF REVIEW

Achieving secure wound closure in clear corneal incision cataract surgery remains highly desired for its role in reducing infection risk and leak-related complications, including hypotony, corneal edema, and lens dislocation. Although classic techniques of stromal hydration or wound suturing represent traditional approaches, the introduction of newer and more effective ocular surface adhesives has increased the options that are available. This review aims to provide an update on the peer-reviewed literature regarding wound closure and the currently available and investigational tissue adhesives used to seal clear corneal incisions in cataract surgery.

RECENT FINDINGS

Stromal hydration and sutured closure of clear corneal incisions remain viable options for wound closure. Wound sealants, particularly polyethylene glycol (PEG)-based hydrogels, have been found to provide watertight wound seal with less foreign-body sensation and surgically induced astigmatism compared with sutures, and less adverse effects and greater ease of use compared with cyanoacrylate and fibrin glues.

SUMMARY

Stromal hydration, sutured closure, and use of a corneal adhesive are all wound closure options for clear corneal incisions. Of the currently available tissue adhesives, PEG hydrogel sealants have become the most widely accepted, with an improved side-effect and biocompatibility profile.

Surgical site infection in spinal surgery: a comparative study between 2-octyl-cyanoacrylate and staples for wound closure

BACKGROUND

Surgical site infection (SSI) after spinal surgery is a devastating complication. Various methods of skin closure are used in spinal surgery, but the optimal skin-closure method remains unclear. A recent report recommended against the use of metal staples for skin closure in orthopedic surgery. 2-Octyl-cyanoacrylate (Dermabond; Ethicon, NJ, USA) has been widely applied for wound closure in various surgeries. In this cohort study, we assessed the rate of SSI in spinal surgery using metal staples and 2-octyl-cyanoacrylate for wound closure.

METHODS

This study enrolled 609 consecutive patients undergoing spinal surgery in our hospital. From April 2007 to March 2010 surgical wounds were closed with metal staples (group 1, n = 294). From April 2010 to February 2012 skin closure was performed using 2-octyl-cyanoacrylate (group 2, n = 315). We assessed the rate of SSI using these two different methods of wound closure. Prospective study of the time and cost evaluation of wound closure was performed between two groups.

RESULTS

Patients in the 2-octyl-cyanoacrylate group had more risk factors for SSI than those in the metal-staple group. Nonetheless, eight patients in the metal-staple group compared with none in the 2-octyl-cyanoacrylate group acquired SSIs (p < 0.01). The closure of the wound in length of 10 cm with 2-octyl-cyanoacrylate could save 28 s and $13.5.

CONCLUSIONS

This study reveals that in spinal surgery, wound closure using 2-octyl-cyanoacrylate was associated with a lower rate of SSI than wound closure with staples. Moreover, the use of 2-octyl-cyanoacrylate has a more time saving effect and cost-effectiveness than the use of staples in wound closure of 10 cm in length.

Optimization of Fibrin Glue Spray Systems for Ophthalmic Surgery

PURPOSE

To optimize fibrin glue (FG) spray for ophthalmic surgery using two spray applicators, EasySpray and DuploSpray systems, by varying the distance from point of application and the pressure/flow rate, and to compare the adhesive strength of sutured and sutureless (FG sprayed) conjunctival graft surgery in a rabbit model.

METHODS

FG was sprayed on a 0.2 mm-thick sheet of paper using EasySpray by variously combining application distances of 2.5, 5, 7.5, and 10 cm with pressures of 10, 15, and 20 psi. DuploSpray was used at the same distances but with varying flow rates of 1 and 2 L/min. Subsequently, FG was sprayed on porcine corneas and FG thickness was analyzed by histology. In addition, adhesive strength of the conjunctival graft (0.5 × 0.5 cm) attached to the rabbit cornea by sutured and sutureless surgery (FG spray) was compared using a tension meter.

RESULTS

Histology measurements revealed that the FG thickness decreased with increases in distance and pressure of spray using the EasySpray applicator on paper and porcine corneal sections. The adhesive strength of the sutured conjunctival graft (41 ± 4.85 [kilopascal] KPa) was found to be higher than the graft attached by spraying (10 ± 2.3 KPa) and the sequential addition of FG (6 ± 0.714 KPa).

CONCLUSIONS

The EasySpray applicator formed a uniform spread of FG at a distance-pressure combination of 5 cm and 20 psi. The conjunctival graft attached with sutures had higher adhesive strength compared with grafts glued with a spray applicator. Although the adhesive strength of FG applied through the applicator was similar to the drop-wise sequential technique, the former was more cost effective because more samples could be sprayed compared with the sequential manual technique.

TRANSLATIONAL RELEVANCE

The standardization of the spray system for the application of FG in ophthalmology will provide an economical method for delivering consistent healing results after surgery.

Comparison of bursting pressure after scleral tunnel incision sealed with sutures or an adherent ocular bandage in human globes

OBJECTIVE

To evaluate the efficiency of a hydrogel adherent ocular bandage for sealing of scleral tunnel incisions in human eye globes.

METHODS

A 4-mm scleral tunnel incision was made in each of 10 globes and bursting pressure was measured using the Seidel test to check for wound leakage. Globes were sealed using either two interrupted 10-0 nylon sutures (n = 5) or an adherent ocular bandage in the form of polyethylene glycol hydrogel (n = 5). Bursting pressure was then measured for a second time.

RESULTS

Bursting pressure was significantly higher after wound sealing in both groups. There were no statistically significant differences in bursting pressure between the two groups before or after sealing.

CONCLUSIONS

The adherent ocular bandage successfully protected the incision in ex vivo human globes immediately after surgery, with a sealing efficiency comparable to two nylon sutures, suggesting that it is a safe and effective alternative to conventional suturing.

Evaluation of tensile strength of tissue adhesives and sutures for clear corneal incisions using porcine and bovine eyes, with a novel standardized testing platform

BACKGROUND

Tissue adhesives for ophthalmologic applications were proposed almost 50 years ago, yet to date no adequate tissue glues have been identified that combine strong sealing properties with adequate safety and absence of postsurgical side effects. In recent years, cataract surgeries and Descemet's stripping with endothelial keratoplasty procedures have significantly increased the number of clear corneal incisions performed. One of the obstacles to discovery and development of novel tissue adhesives has been the result of nonstandardized testing of potential tissue glues.

METHODS

We developed an instrument capable of controlling intraocular pressure in explanted porcine and bovine eyes in order to evaluate sealants, adhesives, and surgical closure methods used in ophthalmic surgery in a controlled, repeatable, and validated fashion. We herein developed and validated our instrument by testing the adhesive properties of cyanoacrylate glue in both porcine and bovine explant eyes.

RESULTS

The instrument applied and maintained intraocular pressure through a broad range of physiological intraocular pressures. Cyanoacrylate-based glues showed significantly enhanced sealing properties of clear corneal incisions compared with sutured wounds.

CONCLUSION

This study shows the feasibility of our instrument for reliable and standardized testing of tissue adhesive for ophthalmological surgery.

2-Octyl-cyanoacrylate for wound closure in cervical and lumbar spinal surgery

It is claimed that wound closure with 2-octyl-cyanoacrylate has the advantages that band-aids are not needed in the postoperative period, that the wound can get in contact with water and that removal of stitches is not required. This would substantially enhance patient comfort, especially in times of reduced in-hospital stays. Postoperative wound infection is a well-known complication in spinal surgery. The reported infection rates range between 0% and 12.7%. The question arises if the advantages of wound closure with 2-octyl-cyanoacrylate in spinal surgery are not surpassed by an increase in infection rate. This study has been conducted to identify the infection rate of spinal surgery if wound closure was done with 2-octyl-cyanoacrylate. A total of 235 patients with one- or two-level surgery at the cervical or lumbar spine were included in this prospective study. Their pre- and postoperative course was evaluated. Analysis included age, sex, body mass index, duration and level of operation, blood examinations, 6-week follow-up and analysis of preoperative risk factors. The data were compared to infection rates of similar surgeries found in a literature research and to a historical group of 503 patients who underwent wound closure with standard skin sutures after spine surgery. With the use of 2-octyl-cyanoacrylate, only one patient suffered from postoperative wound infection which accounts for a total infection rate of 0.43%. In the literature addressing infection rate after spine surgery, an average rate of 3.2% is reported. Infection rate was 2.2% in the historical control group. No risk factor could be identified which limited the usage of 2-octyl-cyanoacrylate. 2-Octyl-cyanoacrylate provides sufficient wound closure in spinal surgery and is associated with a low risk of postoperative wound infection.

DermabondTM Tissue Adhesive Versus Steri-StripsTM in Unilateral Cleft Lip Repair: An Audit of Infection and Hypertrophic Scar Rates

Objective:

The purpose of this study was to compare the infection and hypertrophic scar rates in unilateral cleft lip repairs, having had Steri-Strips or Dermabond tissue glue applied across the repair as the final stage.

Design:

Retrospective study over 13 years of 307 unilateral cleft lip repairs by a single surgeon. The application of either Steri-Strips from 1992 to 1998 (121 patients) or Dermabond tissue adhesive from 1998 to 2006 (186 patients) was used in the final stage of the repair.

Setting:

Regional Centre for Cleft Lip and Palate Care, South West of England.

Participants:

307 consecutive unilateral cleft lip patients seen from 1992 to 2006.

Main Outcome Measures and Results:

There were five (4%) infections in the Steri-Strip group. All infections were with Staphylococcus aureus . No infections occurred in the Dermabond group (p < .001). There were 15 (12%) hypertrophic scars in the Steri-Strip group and 33 (18%) hypertrophic scars in the Dermabond group (p  =  .142). Revision surgery was required in a total of seven (6%) patients in the Steri-Strip group. No revisions were required in the Dermabond group (p. 1).

Conclusion:

We found a lower infection and revision rate and a similar hypertrophic scar rate when Dermabond was used instead of Steri-Strips in the final stage of unilateral cleft lip repair and suggest this study further supports the use of octyl-2-cyanoacrylate tissue adhesive in unilateral cleft lip repair.

Tissue adhesives in corneal cataract incisions

PURPOSE OF REVIEW

The purpose of this review is to provide an updated overview of the peer-reviewed literature on the use of a variety of tissue adhesives used to seal corneal incisions in cataract surgery. We will review recent publications on the complications, safety profile, and efficacy of currently available and investigational tissue adhesives used for corneal incisions. We will also briefly review the relationship between clear corneal incisions and postoperative endophthalmitis.

RECENT FINDINGS

Tissue adhesives have recently been investigated as alternate methods for corneal wound closure. Cyanoacrylate and fibrin glues are used widely because of their safety and effectiveness in sealing corneal incisions. However, both of these adhesives have certain limitations. For instance, cyanoacrylate adhesives have been shown to cause foreign-body sensation, local inflammatory reaction, and conjunctival hyperemia. Fibrin-based adhesives carry the disadvantages of prolonged preparation time, increased cost, and the theoretical risk of viral transmission.

SUMMARY

Whereas currently available adhesives offer an alternative to sutures, other novel biomaterials are being evaluated for the sealing of corneal and cataract incisions. Hopefully, these studies will result in an optimal material tailored for ophthalmic use to facilitate wound closure and healing with an improved side-effect and biocompatibility profile.

Ocular surface sealants and adhesives

Tissue adhesives, both synthetic and biologic, have a long history of use in ophthalmology. Cyanoacrylate-based glues have traditionally been the most widely used glues for various purposes. They have been specially useful for treating corneal perforations and have had significantly improved long-term outcomes. More recently, fibrin-based glues have gained a major role as a suture substitute for attaching biologic tissues and as surface sealants. The literature supports expanded use of fibrin glue in this fashion. Other new agents, such as polyethyelene glycols, have been underutilized and hold promise, especially as surface protectants. Numerous other glues are being developed and show promise as ocular surface sealants and protective membranes. Advances in knowledge about tissue adhesives are leading to more effective and efficient ophthalmic care.