1. Fibrin Glue for Pterygium Surgery
Sathish Srinivasan FRCSEd, FRCOphth
Consultant Ophthalmologist
Ayr Hospital, Ayr
Scotland, UK

2. No financial interest

3. Introduction
Chemical composition
How to mix
How to apply
Results

4. A two-component fibrin sealant.
Contains two of the protein that makes the blood clot.
Fibrinogen and thrombin

5. SEALANT PROTEIN: solution composed of Human fibrinogen, plasminogen, fibronectin and Factor XIII reconstituted in a Bovine aprotinin solution
SEALANT SETTING: solution composed of Human thrombin reconstituted in a calcium chloride solution

6. Simulates Physiological Clotting
The Tisseel clot has a milky appearance due to the network of crosslinked fibrin strands. By contrast other fibrin sealants form a transparent clot with no structure, which is poor for cell migration as the wound heals.
The image on the left is a Tisseel clot, with a milky appearance from the network of fibrin strands.
The other image is another fibrin sealant, with a higher salt concentration. This leads to a different clot, which is brittle, and less strong.
These electron micrographs show the structure of a natural plasma fibrin clot (left image) and highlight the difference between TISSEEL (centre image) and other fibrin sealants (right image):
TISSEEL (centre) produces a fibrin matrix clot that is similar to the natural fibrin network in a plasma clot (left)
By contrast, the high sodium content of some other fibrin sealants results in:
impaired fibrin cross-linking, which produces an unstructured fibrin mass (right) with barely perceptible fibrin strands [Redl, 1986]
limited fibroblast migration and growth [Redl 1986; Sawada, 1994]
a weak and brittle fibrin clot [Redl, 1986]
The tensile strength of a TISSEEL clot is up to four times stronger than a high-sodium, brittle clot [Redl, 1986]
Redl H et al. Properties of different tissue sealants with special emphasis of fibrinogen-based preparations. Fibrin sealants in operative medicine. Springer Verlag,1986:Vol.5,
Sawada K et al. Comparative studies on the physiochemical properties of Tisseel and a newly developed fibrin sealant
Plasma clot Tisseel A non-physiologic sealant

8. What can you do with Tisseel?
Control intra-operative bleeding
Prevent post-operative haemorrhage
Repair leaks including CSF
Prevent post-op leakage including CSF
To promote tissue adhesion
To support a suture line
As the indication suggests, Tisseel helps control bleeding during the procedure, or prevent post-op haemorrhage.
It is also used to seal or prevent fluid leaks including CSF. Tisseel can be used to promote tissue adhesion and can be used to support a suture line.
The high strength of the Tisseel clot (up to 30 times stronger than a normal plasma clot) helps it stay in place, and prevent post-operative complications
Some surgeons refer to Tisseel as “the goodnight stitch”.

9. Fibrin Glue CAN…. CANNOT….
Complement good surgical haemostatic techniques, such as
Ligatures or sutures
Clips or staples
Electrocautery
Provide a water or fluid-tight seal
CANNOT….
Tisseel must not be used to control severe bleeding, as it is not designed for this purpose.
Stop arterial bleeding
Stop severe venous bleeding

10. Clinical experience with Tisseel
No documented transmission of:
HIV, Hepatitis B, Hepatitis C
Over 33 years of use in many countries
Available in 50 countries worldwide
More than 17 million applications to date
3500+ publications in most surgical disciplines
Data on file, Baxter Healthcare
As you can see, Tisseel has been around for a long time, and is used by almost every type of surgeon.
It also has a very good safety record.

12. Tisseel Kit has 4 components
1 vial: Sealer protein lyophilized concentrate.
1 vial: Lyophilized human thrombin.
1 vial: Aprotinin solution.
1 vial: Calcium chloride solution.

13. What's in it When reconstituted 1 ml of each solution contains:
Human Fibrinogen: mg in mg protein, aprotinin (bovine) 3000 KIU/ml. Inactive ingredients include human albumin, L-Histidine, niacinamide, polysorbate 80 and sodium citrate.
KIU: Kallidinogenase Inactivator unit.

14. Human thrombin 5 or 500 IU, in mg protein, calcium chloride 40 micromoles/ litre. Inactive ingredients include human albumin and sodium chloride.

15. Human plasma pools are tested for presence of genome sequences of HIV, HBV and HCV
Tisseel is vapor-heated to inactivate viruses
No evidence of disease transmission yet
What about prions in Bovine aprotinin

16. Pharmacokinetics Tisseel is intended for epilesional use only.
Intravascular pharmacokinetic studies have not been performed in humans.
Fibrin sealants are metabolized in the same way as endogenous fibrin – fibrinolysis and phagocytosis.

17. Contraindications
Not for intravascular use. Carries a high risk of thromboembolic complications.
Remember it has a bovine protein (aprotinin) : risk of anaphylactic reaction.
Risk is slightly higher in cases of previous exposure.

35. CASE 2: POSTOP DISLOCATION OF CONJUNCTIVAL GRAFT
Eye, 2007

37. Fibrin Glue versus Sutures for attaching the Conjunctival Autograft in Pterygium Surgery: A Prospective Observer Masked Clinical Trial
Sathish Srinivasan FRCSEd, FRCOphth
Michael Dollin MD
Penny McAllum FRANZCO
Yoav Berger MD
David S. Rootman MD, FRCSC
Allan R. Slomovic MD, FRCSC

38. Table 1. Scoring parameters for each of the three outcome variables
Subconjunctival Hemorrhage
Grade 0: None
Grade 1: ≤ 25% of the size of the graft
Grade 2: ≤ 50% of the size of the graft
Grade 3: ≤ 75% of the size of the graft
Grade 4: Hemorrhage involving the entire graft (no subconjunctival vessels visible)
Inflammation
Grade 0: No dilated corkscrew vessel in the graft
Grade 1: 1 bright red, dilated corkscrew vessel crossing the graft-bed margin
Grade 2: 2 bright red, dilated corkscrew vessels crossing the graft-bed margin
Grade 3: 3 bright red, dilated corkscrew vessels crossing the graft-bed margin
Grade 4: ≥ 3 bright red, dilated corkscrew vessels crossing the graft-bed margin
Graft Stability
Grade 0: All 4 sides of the graft margin are well apposed
Grade 1: Gaping/displacement of 1 side of the graft-bed junction
Grade 2: Gaping/displacement of 2 sides of the graft-bed junction
Grade 3: Gaping/displacement of 3 sides of the graft-bed junction
Grade 4: Graft completely displaced from the bed