Considering the incidence of endophthalmitis after cataract surgery, what techniques do you use and why?

Proper attention to detail prevents leaks

Eric D. Donnenfeld

Incision location during cataract surgery is one of the more controversial areas in ophthalmology. There are studies that document an increased risk of endophthalmitis with clear corneal incisions; however, most of these studies involve clear corneal incisions that were performed several years ago, and there is little new literature on the subject. What we know is that any leaking clear corneal incision certainly deserves to be sutured and that incision architecture is key to preventing wound leaks and endophthalmitis.

I prefer a three-plane clear corneal incision with a trap-door technique. With the proper attention to detail, these incisions do not leak and I believe do not present an increased risk of endophthalmitis as compared with scleral tunnel incisions. The other aspect of clear corneal incisions that deserves further attention is the length of the incisions. With new cataract techniques and microcoaxial surgery, we are now making smaller and smaller incisions, and in doing so, not only do we reduce our risk of postoperative astigmatism, we also reduce our risk of endophthalmitis. And with the modern 2.2-mm incisions we are commonly using today, I believe the risk is dramatically reduced from the 3-mm to 3.5-mm incisions we were using just 2 or 3 years ago.

In summary, I prefer to use clear corneal incisions because of the ease of the procedure, the reduced discomfort to the patient and the reduced postoperative tear film disruption, which is commonly seen with scleral tunnel surgery. However, having said this, I believe that it is always appropriate to place a suture when in doubt if you are using a clear corneal incision.

Eric D. Donnenfeld, MD, FACS, is the OSN Cornea/External Disease Section Editor.

Safety suture helps prevent influx of bacteria

George O. Waring III

My standard cataract technique is a three-plane clear corneal-limbal incision made at the edge of the vascular arcade. I use temporal for the right eye and superior for the left eye because a horizontally made incision in the left eye tends to increase astigmatism if it is made nasally. My closure involves a single 10-0 nylon suture with the knot buried. This is a “safety suture” — which patients appreciate — and is removed approximately 2 weeks after surgery. It is designed to decrease any influx of bacteria from the ocular surface through the corneal valve incision.

George O. Waring III, MD, FACS, FRCOphth, is a clinical professor of ophthalmology at Emory University in Atlanta.