Fibrin Glue for Pterygium Autograft: Reliseal, Fibroseal and Tisseel Compared, Preparation and Technique
Last updated: November 2026
Fibrin glue has largely replaced sutures for fixing the conjunctival autograft in pterygium surgery. Three kits are common in Indian theatres: Reliseal and Fibroseal (Indian) and Tisseel (Baxter). All work the same way, but they differ in how they are stored, prepared and timed. This page explains the chemistry, preparation, technique and pitfalls so you are ready when the scrub nurse hands you the kit.
How fibrin glue works
Fibrin glue copies the last step of the clotting cascade. It has two parts that are kept apart until use:
| Component | Contains | Role |
|---|---|---|
| Sealer (fibrinogen) component | Concentrated human fibrinogen (with factor XIII), dissolved in aprotinin solution | Forms the fibrin mesh; aprotinin slows breakdown of the clot (fibrinolysis) |
| Activator (thrombin) component | Human thrombin, dissolved in calcium chloride solution | Converts fibrinogen to fibrin; calcium is needed for clotting and factor XIII activity |
When the two meet, a white, rubbery fibrin clot forms within seconds to a minute. The clot is absorbed over days to a couple of weeks, by which time the graft has adhered.
The three common kits
| Reliseal | Fibroseal | Tisseel (Baxter) | |
|---|---|---|---|
| Made in | India (Reliance group) | India | Austria/UK (Baxter) |
| Form | Freeze-dried kit | Freeze-dried human fibrinogen and thrombin kit | Freeze-dried kit, or frozen ready-filled double syringe |
| Listed contents | Fibrinogen 70 mg (yellow cap), bovine aprotinin solution 3000 KIU (red cap), thrombin 500 IU (blue cap), sterile water for injection | Human fibrinogen and human thrombin (1.0 mL kit commonly sold) | Sealer protein, aprotinin solution, thrombin 4 IU and 500 IU, calcium chloride solution |
| Storage | As per insert (refrigerated) | 2–8°C | Kit 2–25°C (do not freeze); frozen syringe at −20°C or colder |
| Warming needed? | As per insert | As per insert | Kit: dissolve at 37°C (Fibrinotherm or water bath). Frozen syringe: thaw (about 5 minutes in a sterile water bath for the 2 mL pack) |
| Use after preparation | As per insert | As per insert | Within 4 hours; do not refrigerate again |
The preparation principle is the same for all three, but warming steps, vial sizes and timings differ: always read the insert in the box, and confirm each vial by its label as well as its cap colour before mixing.
Colour key: which vial is which
| Kit | Fibrinogen (sealer) | Aprotinin | Thrombin | Diluent |
|---|---|---|---|---|
| Reliseal | Yellow cap (70 mg) | Red cap (bovine, 3000 KIU) | Blue cap (500 IU) | Sterile water for injection |
| Fibroseal | Not colour-coded in the leaflet | — | — | Water for injection |
| Tisseel kit | Sealer protein vial | Aprotinin solution vial; drawn with the blue-scaled syringe | Thrombin 4 IU and 500 IU vials; prepared with the black-scaled syringe | Calcium chloride solution (for thrombin) |
Reliseal: fibrinogen (yellow) is dissolved in the aprotinin solution (red), and thrombin (blue) in the sterile water provided. Memory aid for this kit only: yellow + red make the sealer, blue makes the activator. Reliseal aprotinin is bovine, so ask about previous fibrin glue or aprotinin exposure and allergy.
Fibroseal: the leaflet gives no cap colours, and in practice the pairing looks reversed compared with Reliseal: the yellow-capped vial is mixed with water, and the red-capped vial is mixed with the blue-capped vial.
Colours are not universal. The same cap colour can mean a different component in another brand. Never pair vials from habit or colour alone: read each label, and follow the leaflet of the kit in your hand.
Cap colours belong to each manufacturer and can change between batches or presentations.
Preparing the glue
General steps (check the kit insert)
- Check expiry and storage; bring a refrigerated kit to room temperature (or warm as the insert says).
- Sealer: add the aprotinin solution to the fibrinogen powder. Swirl gently; do not shake hard (foam spoils the glue). Fibrinogen dissolves slowly: wait until the solution is clear or slightly opalescent with no particles.
- Activator: add the calcium chloride solution to the thrombin powder and swirl until dissolved.
- Draw each solution into its own syringe with its own needle or cannula. Never let the two touch until application: a shared needle clots instantly.
- Label the syringes (e.g. "F" and "T") so you do not swap them.
- Use within the time on the insert; discard leftovers.
Slow or fast thrombin: Tisseel kits contain two thrombin strengths. 4 IU/mL sets in up to about a minute, giving time to position and smooth the graft; 500 IU/mL sets within seconds and is better for haemostasis. Many surgeons prefer the slow-setting thrombin, or dilute thrombin, for autografts. Indian kits usually provide one thrombin strength, so you have less working time: position the graft quickly.
Applying glue in pterygium surgery
- Excise the pterygium head and body; remove Tenon tissue thoroughly; achieve haemostasis with minimal cautery. A dry, clean bed is essential.
- Harvest a thin, Tenon-free superior bulbar conjunctival graft slightly larger than the bed; mark or keep track of the limbal edge.
- Apply a thin layer of one component to the scleral bed and the other to the graft undersurface (many surgeons put thrombin on the bed and fibrinogen on the graft; some apply one component to each surface on the bed in sequence).
- Slide the graft onto the bed, limbus to limbus, epithelial side up, and smooth it with a muscle hook or the side of forceps before the glue sets.
- Hold gently for about 1–2 minutes; then trim excess glue and any graft overhang.
- Check that the graft edges are apposed and there are no folds; pad or bandage contact lens as per your unit's practice.
Use the least glue that does the job: thick layers lift the graft, form lumps and cost more. One kit is usually enough for one or two eyes in the same session, within the use-by time.
Advantages and disadvantages
| Advantages | Disadvantages |
|---|---|
| Shorter surgery than suturing | Cost of the kit |
| Less pain, irritation and foreign body sensation after surgery | Short working time once mixed, especially with fast thrombin |
| Lower recurrence than sutures in most studies | Graft displacement or loss if the bed is wet or the graft is too thick |
| No suture-related granulomas, abscesses or removal | Made from pooled human plasma: theoretical risk of transmitting infection despite viral inactivation |
| Even adhesion without tension points | Allergy, rarely anaphylaxis, especially with repeated aprotinin exposure; cold-chain storage needed |
A Cochrane review comparing glue with sutures for conjunctival autografts found that glue probably reduces recurrence and shortens surgery, with graft displacement possibly a little more common. Autologous blood (letting the patient's own clot fix the graft) is a free alternative with no plasma-product risk, but it has more graft displacement and retraction in several trials.
Fibrin glue vs cyanoacrylate
Fibrin glue is biological and absorbable, used under conjunctiva and lamellar grafts. Cyanoacrylate ("superglue") is synthetic, sets hard, is not absorbed and is toxic beneath tissue; it is used on the corneal surface to seal small perforations, covered by a bandage contact lens, and never to fix a conjunctival graft.
Other eye uses of fibrin glue
Amniotic membrane fixation, lamellar and endothelial keratoplasty flaps, sealing small corneal perforations with a patch graft, LASIK epithelial ingrowth, conjunctival wound closure in glaucoma and strabismus surgery, and selected retinal procedures (e.g. optic disc pit, under trial conditions).
Pearls
- Ask the nurse to prepare the glue while you dissect, so it is ready but freshly made when the bed is dry.
- Never use one needle for both components; label the syringes.
- A dry bed and a thin, Tenon-free graft matter more than the brand of glue.
Common mistakes
- Pairing vials by cap colour learned on another brand.
- Shaking the fibrinogen vial: foam and undissolved protein give a weak clot.
- Applying thick layers of glue that lift the graft edges.
- Using fast-setting thrombin and running out of time to position the graft.
Test yourself: flip cards
Quick quiz
Related: Pterygium for Residents: Grading, Surgery and Preventing Recurrence, Keratoplasty Types: PK vs DALK vs DSAEK vs DMEK, Ocular Surface Squamous Neoplasia (OSSN): Diagnosis and Topical Chemotherapy, Cornea, Ocular Pharmacology: High-Yield Guide for Residents.
Key sources
- Baxter Healthcare. TISSEEL Kit summary of product characteristics (HPRA) and prescribing information
- Panda A, Kumar S, Kumar A, Bansal R, Bhartiya S. Fibrin glue in ophthalmology. Indian J Ophthalmol. 2009;57:371-379
- Romano V, Cruciani M, Conti L, Fontana L. Fibrin glue versus sutures for conjunctival autografting in primary pterygium surgery. Cochrane Database Syst Rev. 2016;12:CD011308
- ReliSeal product leaflet (Reliance Life Sciences): kit components and cap colours
- Supplier listings for Fibroseal kits (contents and storage)
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