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Sealing a leaky cataract wound: Suture vs. glue
Carlos Buznego, MD, favors sutures, while Raj Goyal, MD, MPH, FACS, utilizes hydrogel glue.
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CEDARS Debates is a monthly feature in Ocular Surgery News. CEDARS — Cornea, External Disease, and Refractive Surgery Society — is a group of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
This month, Dr. Carlos Buznego and Dr. Raj Goyal discuss wound management after cataract surgery. While this may seem rather simple initially, with the advent of new corneal adhesives, we now have another option to seal operative wounds. Which method is actually better, and why? We hope you enjoy the discussion.
Kenneth A. Beckman, MD, FACS
OSN CEDARS Debates Editor
Scenario
A 75-year-old man with a functioning filtering bleb, a dense cataract and intraoperative floppy iris syndrome undergoes phacoemulsification with IOL implantation, with incisions made with a manual keratome. During the procedure, iris jumps into the main temporal incision on a few occasions. Upon completion of the case, the chamber remains deep, but slow egress of aqueous is noted. How do you proceed?
1. Hydrate the corneal stroma at the wound edges.
2. Suture the wound closed.
3. Use hydrogel wound glue to seal the incision.
4. Remove the drape and go eat a doughnut.
Clear corneal cataract incisions, when made correctly, can be watertight even to high levels of IOP. However, surgeons should remain vigilant and closely inspect incisions because leaky wounds can be associated with hypotony, iris incarceration and even endophthalmitis. Risk factors for leaky wounds include poor wound construction, thermal injury, prolonged surgery and aggressive manipulation. A variety of patient factors can also contribute to the inability of a clear corneal incision to seal properly, including high myopia, loss of corneal elasticity and hypotony from functioning glaucoma drainage procedures. Floppy iris tissue that has already made its way out of the corneal incision also increases the risk of postoperative wound incarceration. At the conclusion of the cataract procedure, I reinflate the eye to a high normal pressure while carefully inspecting the wound. Shallowing of the chamber, evident anterior chamber flow toward the wound and evidence of aqueous leakage are all indications that the wound is not sufficiently intact and requires intervention to ensure integrity. Wound hydration will seal the wound while on the table, but it is well known that this is a transient solution, lasting only hours.
Maintain a well-sealed incision with a suture
Carlos Buznego
My approach is to place a suture to maintain a well-sealed incision. I apply a cellulose sponge moistened with 1% lidocaine solution (nonpreserved methylparaben free) that was “left over” from my hydrodissection earlier in the procedure. I do this while my assistant is preparing a short segment of 10-0 nylon suture. I reinflate the eye to a high normal pressure because suturing a soft eye will likely lead to a suture that is too tight and distorts the corneal contour. I aim to have about a 1- to 2-mm bite on either side of the wound. I utilize a sliding suture to best allow tension that is “just right.” I trim the knot closely and rotate it into the stroma. I routinely remove this suture on the 1-week visit at the slit lamp. After a drop of topical anesthetic, I cut the nylon with a sterile needle and remove it with sterile jeweler’s forceps. Although there is no discomfort, I sometimes do this without a full discussion (“I’m going to take a stitch out of your eye.”) in order to avoid the patient anxiety, and subsequent “status blepharospasmus,” that can result.
For more information:
Carlos Buznego, MD, can be reached at Center for Excellence in Eye Care, Baptist Medical Arts Building, 8940 North Kendall Drive, Suite 400-E, Miami, FL 33176; 305-598-2020; email: cbuznego19@gmail.com. Disclosure: Buznego has no relevant financial disclosures.
Maximize safety with hydrogel glue
Raj Goyal
Although suturing is a common method, we cannot overlook the risks incurred: corneal trauma, subconjunctival hemorrhages, possible nidus for infection, inflammation, neovascularization, induced astigmatism and the need for an additional visit. Because finances are important, we are aware that a 10-0 nylon suture costs $70 to $88 per suture and OR time costs $147 to $200 per minute. The total extra fees can climb at a varied range, from $217 to $288 for an experienced surgeon to $805 to $1,088 for a resident surgeon who takes 5 minutes to completely place a suture. The cost of hydrogel sealant is $90. Nontoxic and nonviral synthetic biocompatible gels are now available. The patient has no foreign body sensation or bandage contact lens, and the gel hydrolyzes in 5 to 7 days.
For more information:
Raj Goyal, MD, MPH, FACS, can be reached at Chicago Eye Specialists, 8541 S. State St., Suite 5, Chicago, IL 60619; 773-873-0052; email: rajkamalgoyal@yahoo.com. Disclosure: Goyal has no relevant financial disclosures.
Final thought
As you can see, there are various ways to approach this situation. Each option has merit. The take-home message is that regardless of which method is selected, careful attention to wound closure is critical after cataract surgery.