1. Brian C.K. Au, M.D. University of Arizona – Department of Ophthalmology & University of Texas Medical Branch – Department of Ophthalmology ASCRS 2008 Annual Symposium Poster April 5-9, 2008

2. Financial Disclosure Brian C.K. Au, M.D. and co-authors do not have financial interests in any ophthalmic products or proprieties mentioned henceforth in this presentation. Co-Authors (University of Arizona ): Jason W. Friday, M.S. IV Stefano Lehman, M.D. Robert W. Snyder, M.D., Ph.D. Roxanna Ursea, M.D.

3. Introduction Dislocation of the corneal donor button is a common post- operative complication and cause of decreased visual acuity in Descemet’s Stripping with Endothelial Keratoplasty (DSEK). Clinical Question: Is there a tool or substance that can: 1) Reduce the rate of donor button dislocation after DSEK? 2) Effectively accomplish # 1 without intraocular toxicity?

4. Purpose and Setting Purpose: Part 1: To quantify the adhesive strength of Tisseel fibrin glue (Baxter, U.S.A.) when allowed to react in an in-vitro aqueous environment. Part 2: To determine whether Tisseel is toxic when injected into the anterior chamber using a rabbit model. Setting: Experimentation and Analysis: University Laboratory, University of Arizona Department of Ophthalmology; Tucson, Arizona, USA. Creation of Virtual Poster: University of Texas Medical Branch, Department of Ophthalmology and Visual Sciences; Galveston, Texas, USA.

5. Methods – Part 1: Adhesive Strength The adhesive strength of Tisseel fibrin glue was tested by using a Penscale tension device (My Weigh, U.S.A.), which measures the amount of force required to displace a donor button from a native cornea. Five measurements were taken with no adhesive for control, then 10 measurements were taken following injection of Tisseel between the opposing corneal surfaces submerged in balanced salt solution (BSS).

6. Methods – Part 2: Intracameral Toxicity The toxicity of Tisseel was tested using five New Zealand white rabbits, where 0.05 mL of both the fibrin and thrombin components were injected into the anterior chamber. Rabbits were monitored and graded, on a scale of 0-10, for signs of toxicity post-operatively for seven days using a Panoptic ophthalmoscope and a Tono-pen.

7. Methods – Tension Device 10 donor + 10 recipient New Zealand white rabbit clear corneas Donor corneas (epithelium & Descemet’s stripped) adhered to concave glass lens by superglue Recipients corneas (epithelium & Descemet’s stripped) adhered to convex epoxy lens by superglue System submerged in BSS Tisseel applied between donor and recipient corneal surfaces; then surfaces apposed in-vitro After 5 minutes, tension applied and weight required to separate corneal surfaces was recorded

8. Results Part 1 – Adhesive Strength: The average force required to dislocate the donor button with no adhesive was found to be negligible at zero Newtons (N). The average force required to displace a donor button adhered with Tisseel was 0.15N (p<0.003). Part 2 – Intracameral Toxicity: The toxicity study showed only mild inflammation on post-operative day one (average grade of 1.8) which decreased to an average grade of 0.8 by day seven.

9. Results – Part 1: Adhesive Strength Table 1: Tension Device Readings. The initial weight of the glass lens with fixed recipient button, the weight at the moment of release, and the calculated difference yields the force of dislocation (F = ma) against gravity (a = 9.8m/s 2 ). Experimental groups were separated into those corneas previously submerged in BSS (Group 1) and those that were used directly after preparation (Group 2). GroupsControlExperimental 1Experimental 2 Initial Wt. (grams)666666666666666 Wt. at release (grams)666662219182420 27211925 Wt. Difference (grams)000001613121814 21151319 Force (Newtons)000000.160.130.120.180.14 0.210.190.150.13

10. Results – Part 2: Intracameral Toxicity Table 2. Rabbits were graded on 10 signs of inflammation using a Panoptic ophthalmoscope and a Tono-pen. Of note, rabbit #5 suffered a small puncture of the anterior capsule intraoperatively. While it was not removed from the experiment, this unintended trauma was taken into account when analyzing experimental results. Post-Operative DayDay 1Day 3Day 5Day 7 Rabbit #12345123451234512345 LidsMild Erythema++--+----+----+----+ Marked Erythema-------------------- Edema-------------------- Conj.Erythema+++-+-++++-+-++-+--+ Chemosis---------+----+----- Discharge-------------------- Corneal Edema-------------------- Hypopyon-------------------- Cell + Flare-------------------- Pressure > 21 mmHg--+-+--------------+ Total Grade22203011130101301003

11. Results (4) Rabbit # 1 on post-operative day 7 – graded as 0/10.

12. Conclusion Part 1 – Adhesive Strength: Tisseel fibrin adhesive reacts in an aqueous environment and provides ample force to prevent donor corneal button dislocation following DSEK in an in-vitro model. Part 2 – Intracameral Toxicity: Tisseel appears to be non-toxic when injected into anterior chambers of rabbits. Intracameral use of Tisseel may reduce the rate of donor button dislocation following DSEK.