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ARTICLE
Year : 1960  |  Volume : 8  |  Issue : 2  |  Page : 47-51

Vindication of corneal incision and post-placed corneal sutures in cataract surgery


Bombay, India

Date of Web Publication6-May-2008

Correspondence Address:
K J Dastur
Bombay
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Dastur K J. Vindication of corneal incision and post-placed corneal sutures in cataract surgery. Indian J Ophthalmol 1960;8:47-51

How to cite this URL:
Dastur K J. Vindication of corneal incision and post-placed corneal sutures in cataract surgery. Indian J Ophthalmol [serial online] 1960 [cited 2020 Aug 6];8:47-51. Available from: http://www.ijo.in/text.asp?1960/8/2/47/40687

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Table 1

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Table 1

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Ever since the time of Daviel more than 200 years ago, technique of cata­ract surgery has undergone modifica­tion year after year, the underlying purpose being to make the surgery safe both for the surgeon and for the patient and thus reduce post-operative com­plications to a minimum. Thanks to the advances made in the last decade in pharmacology, the technique of akinesia local and general anaesthesia and the manufacture of delicate sharp needles and instruments, practically nothing is left to chance, and except for an occasional occurrence of retro­bulbar and choroidal haemorrhages the rest of the post-operative compli­cations have been considerably reduced.

Post-operative sepsis is almost a thing of the past. Vitreous loss during an uncomplicated cataract extraction can be prevented almost in all cases by (i) proper preoperative sedation of the patient; (ii) perfect anaesthesia; (iii) improved blepharostate of Arruga type; iv) introduction of alpha-chy­rnotrypsin and (v) "patient" surgery. So much is this true that today an expert assistant can be done away with at least for cataract surgery. Thus all the 35 cases operated by me at the Petit Parsi General Hospital were without any help of an expert assis­tant, and in non" of these there was vitreous escape. The same factors in technique enable surgeons to per­form ever larger number of intracap­sular extractions and thus reduce the frequency of iritis phaco-anaphylac­tica

Hence, the present day complica­tions after a cataract operation are mainly those arising from incomplete closure or delayed closure of the wound; e.g. iris prolapse, hyphaema, secondary glaucoma from blocking of the chamber angle, cystoid cicatrix and epithelial downgrowth into the anterior chamber.


  Merits of Corneal Incision Top


While the conventional sclero­corneal incision with a limbus based conjunctival flap sutured with a per­fectly placed sclero-corneal suture heals with firm union between the edges within 10-12 days, and thus effectively guards against all the above mentioned complications except hyph­aema, the incidence of hyphaema is only reduced from 9.75% (Hughes and Owen,(1947) to less than 2% (Stallard, 1958). Corneal incision, therefore is the only effective safe guard against hyphaema.

Many surgeons are reluctant to make an incision in the clear cornea without a conjunctival flap for the following reasons:

(i) healing is very slow;

(ii) infection of the wound edges may occur;

(iii) preplaced appositional suture of the McLean type cannot be applied because an effective groove cannot he made in the cornea and one has to be satisfied with a preplaced mattress suture of Stallard type, which causes less perfect apposition of wound edges and/or posterior gaping; or a post­placed appositional suture wherein perfect apposition is difficult to obtain.

A well-apposed corneal wound, how­ever, has several advantages :

(i) Post-operative hyphaema is rul­ed out.

(ii) The spur of the posterior lip is a more effective safeguard against late iris prolapse, that may occur any time after removal of cornea-scleral suture.

(iv) By routine tonography and gonioscopy pre- and post-operatively 17 cases of cataract operations, Miller, Keskey and Becker (1957) have found that section in clear cornea does not cause any measurable differences in topographic and gonioscopic alt0ra­tions. This is probably because the cili­arv body is less disturbed than if the incision is limbal.

Regarding the disadvantages of a corneal incision it may be stated that (i) with proper technique it is possible to obtain as perfect apposition of wound edges with post-placed sutures as with preplaced ones; (ii) the memo­rable work of Dunnington (1951) and others on ocular wound healing on monkey's eyes has enabled ophthalmic surgeons` to revise their views on the merits of purely corneal incision with­out a conjunctival flap. The conclusions drawn from their work are briefly stated below:

(1) Limbal incision without a con­junctival flap and a purely corneal inci­sion behave identically whether- with or without the suture application except that with the former incision however well apposed and stitched the incidence of post-operative hyphaema cannot be completely eliminated.

(2) Absence of conjunctival flap in a purely corneal incision does not signi­ficantly increase the incidence of such complications as fistula formation, epi­thelial (town growth, or cystoid cica­trix, provided that such a wound is well apposed and stitched properly.

(3) The tensile strength of the wound whether limbal or purely cor­neal, increases only after 4 or 5 days of the operation when fibroblasts, appear between the wound edges.


  Corneal Incision as Routine Procedure Top


All the above considerations have led me to make a purely corneal incision without a conjunctival flap, as a rou­tine procedure in cataract surgery since 1953. For the necessary courage requi­red to adopt this procedure as routine, I am grateful to Dr.Arruga of Barce­lona whose operative technique of inci­sion and post-placed suturing as also the post-operative results of his cata­ract cases I had the good fortune to see personally.

[Table - 1] includes 35 cases operated by me at the Petit Parsi General Hospital, while [Table - 2] shows 15 cases operated by me in my private clinic. These latter 15 cases have been selected from a total of J3 cases and the remaining 38 private cases have been omitted because there was nothing unusual about their pre-operative condition and post-operative course.

Technique.

Pre-operative : Besides the - usual pre-operative investigations and treat­ment, special mention must be made of the condition of the cornea. Cornea must be examined under slit lamp for evidence of early endothelial dystro­phy. This latter condition, corneal hvpoaesthesia or anesthesia and in ex­tremely xerotic cornea, corneal incision is avoided.

After perfect anesthesia and akine­sia, pre-operative sedation, and intro­duction of Arruga's Blepharostat, inci­sion is made with a thin Graefe Cata­ract knife, (from 2 to 10 O'clock) in the clear cornea 1 mm. within the lim­bos. The incision is then enlarged with McGuire corneo-sclearal scissors from 2 to 3 and 10 to 9 O'clock positions.

Iridectomy either button-hole or broad peripheral is done next; before introduction of the suture.

Post-Placed Corneal Suture

In order to obtain perfect apposition with post-placed suture the following instruments are essential:

(i) A good binocular loupe.

(ii) A very delicate corneal suture forceps with pointed ends, e.g. St. Martin Corneal Suture Forceps.

(iii) Grieshaber corneal suture needles 7 mm. size.

(iv) Black silk suture -No. 000 British or No. 6xo American.

Method I :

A small triangular piece of conjunc­tiva with its base to the limbs at 12 O'clock, is excised and a small dotted mark of gentian violet is made on the sclera exactly at 12 O'clock, before making the incision [Figure - 1].

After the corneal incision and iridec­tomy have been done a threaded suture needle is passed through the anterior lip of the incision ½ mm. inside its anterior edge, exactly opposite the dot­ted mark [Figure - 2].

The point of the needle is made to emerge at the upper border of the ante­rior lip of the incision through the mid­dle of its thickness. The needle is then introduced through the middle of the thickness of the border of the posterior lip of the incision, exactly at the dot­ted mark, and made to emerge mm. beyond the anterior edge of the pos­terior lip. [Figure - 2].

In all the 15 cases mentioned in [Table - 2], this method was applied.

Method II :

For this method a very delicate corneal suture forceps is absolutely indispensable.

Excision of the triangular piece of conjunctiva and marking of the sclera is omitted.

After the incision and iridectomy have been made the corneal suture is taken in exactly the same way as in Method I, except that the direction and point of entry of the needle through the posterior lip is determined by projecting the emerging suture (held taut) exactly in the 12 O'clock Meridian. The St. Martin's Corneal Suture Forceps is then applied conti­guous to the point so projected [Figure - 3].

A loop is left temporarily on the temporal side and after the delivery of the lens the suture is made taut so as to obliterate the loop. Before it is tied the iris is properly reposited and iris repositor is passed through the lips of the incision in order to remove entangled lens matter, tag of iris or a strand of blood clot if any. The suture is then tied firmly enough to co-opt the edges of the section but never too tightly. The surgical knot is manipulated so that it sits on the pos­terior lip exit of the suture.

Method II was applied in all the 35 cases mentioned in [Table - 1].


  Discussion Top


Incision way made corneal in all the 15 cases in [Table - 2] and in 29 cases in [Table - 1]. In the remaining 7 cases in [Table - 1] the incision was made limbal without a conjunctival flap for the following reasons :

Hypoesthesia of the cornea - 1

Old debilitated patients - 3

Trachomatous xerosis - 2

Prorminant arcus senilis - 1

A 2-10 O'clock incision with a cata­ract knife can be made slowly in the proper plane without the risk of cutting the iris. In none of the 50 cases men­tioned in the series was iris cut by knife during incision.

The suture is placed after doing an iridectomy so that it may not be acci­dentally cut (luring the latter proce­dure.

In all the 35 cases in [Table - 1], the suture was introduced by Method II mentioned above. In this series there were two cases of wound leakage but in both these the incision was limbal. [Table 4] and [Table 5] give the comparative results in the two groups. It seems that more effective apposition is obtainable by employing Method I.

Posterior gaffing and wound leakage.

The experiments of Dunnington on ocular wound healing have demonstra­ted that in order to avoid posterior gaping of wound edges the sutures must pass through at least half the thickness of the wound edges. It is quite evident that depth of suture bite is better controlled when the suture is post-placed than when its is pre-placed. Pre-placed suture is very often likely to be placed too superficially and there­fore gaping of the wound is fairly more frequent.

Cases 8 and 20 in [Table - 1] showed some evidence of posterior gaping with incarceration of iris. Pupils in both these cases were displaced upwards and anterior chambers were flat. These cases also showed wound leakage, tinder slit lamp on the 10th day. On the 10th day the sutures were removed and the leaking points were carbolized in both these cases. The shallow cham­bers became normal subsequently.

Gonioscopically after a month it was found that the iris prevented the view of the filtration angle in the upper seg­ments in both these cases.

Two months after the operation the corrected vision was 6/q, without astig­matism in case 8 and with astigmatism of + 0.75 @ 30 0 in case 20. The intra­ocular tension was normal and the wound appeared completely healed. Case 20, however, came up 14 months subsequently for a tiny warty excres­cence from the skin of the lid that ob­structed his vision. That time to my surprise I found a pin point iris tissue in the otherwise firmly healed wound. The eye was however quiet and the vision remained 6/9 with the same glasses. Tension in the eye was 17 mm. Hg. Schiotz.

Case No.4 in [Table - 1] showed that the chamber remained flat till the 7th day, but became normal after the re­moval of the corneo-scleral suture on the 9th day. In none of the 50 cases in the series did the anterior chamber flat­ten on removal of the suture; a compli­cation that has been reported by Hughes and Owen (1947) in man and by Dunnington (1951) in monkeys when sutures are placed too deeply.

None of the 52 cases sutured by Method I showed any eccentricity of pupil. The anterior chamber formed either on the operation table or by the third day, that is at the time of the first dressing. Cases No. 2 and 15 in [Table - 2] however showed chamber formation not till the 5th day. In case 2, however, an iridoencleisis of Holth had been clone previous to the cataract extraction.

Hypharma

Except for case No. 32 in [Table - 1] there -vas no case of hyphaema in the whole series. This case in which a lim­bal incision was made because of very prominent arcus senilis, showed blood­tinged iris on the third day of the operation with a thin brownish exudate in the pupillary area. The patient was a case of chronic bronchitis and had developed severe cough following the operation.

Even in the hands of seasoned sur­geons e.g. Stallard (1958) and Esca­pini (1958) hvphaema occurs in 2 to 3% of cataract operations when the in­cision is limbal. A corneal incision is the only effective way to prevent this complication.

Iris Prolapse

Case No, 20 in [Table - 1] already des­cribed, was the only case of iris prolapse that occurred several months after the operation. Here the incision made was limbal because of the tracho­matous xerotic conjunctiva. It is possi­ble that the spur of the posterior lip effectively guards against iris prolapse and therefore the prolapse is rarer with corneal than with limbal incision.

Secondary Glaucoma

Case No. 7 in [Table - 1], a diabetic developed high tension 15 days after needling for the after-cataract. Follow­ing cyclodialysis and under pilocarpin the tension has remained 22 mm. Hg Schiotz to date.

Case 3 in [Table - 2] was operated for hypermature cataract. Preoperatively tension in each eye was 19 mm. Hg.Sch. Three months after of acute glau­coma in other eye following accidental instillation of atropine eye drop in that eye instead of in the operated (left) eye. The glaucoma was controlled with miotic eye drops and acetazolamide.

8 months after the operation tension in the operated eye was found to be 40 mm. Hg. Cyclo-dialysis was in­effective and cyclo-diathermy was ad­vised but the patient refused any fur­ther operation on the eye; and there­after attended irregularly.

2 1/2 years after the operation tension in the right eye was 25 mm. Hg. and in the left eye was 40 mm. Hg.

In view of the high tension in RE (under mydiatic), it is probable that the glaucoma in the operated eye might not be post-operative secondary glaucoma but a primary glaucoma that escaped detection for lack of detailed examination for glaucoma.


  Results Top


[Table 4] and [Table 5] give the operative results of the cases in [Table - 1] and [Table - 2] respectively.

Out of the 35 cases in which sutures were applied by Method II there were two cases showing leakage of the wound and posterior gaping. In 26 of the 29 cases in this series as also in the 15 cases in [Table - 2] where the incision was corneal, A.C. formed either on the operating table or by the third post. operating day. While in the remaining 7 cases with limbal incision there were 2 cases of wound leakage and/or pos­terior gaping. Out of these 7 cases one had hyphaema on the third post-opera­tive day. Striate keratitis appears to be more frequent when the incision is cor­neal.

One case of post-operative glaucoma in this series followed cyclitis after needling; while the other in the other series [Table - 2] was really a case of chronic simple glaucoma with cataract. There was no significant difference in the amount of post-operative corneal astigmatism between limbal (average .82D) and purely corneal incision (average .98D).[10]


  Summary Top


(i) The present day complications of cataract surgery are mainly those due to defective wound healing.

(ii) Corneal incision made in the proper plane and sutured accurately with post-placed sutures healed un­eventfully.

(iii) Hyphaema and Iris Prolapse are totally eliminated while the inci­dence of post-operative glaucoma due to blockage of filtration angle is much reduced, when incision is made in clear cornea.

(iv) Two methods of post-placed corneal suturing have been described in detail.

 
  References Top

1.
Callahan A. (1950, South . Med. J­ 44, 179.  Back to cited text no. 1
    
2.
Dunnington (1951), Amer. J. Ophth., 34, 36.  Back to cited text no. 2
    
3.
Dunnington (x952), Amer. J. Oplith., 35, 167.  Back to cited text no. 3
    
4.
Dunnington (1955), Trans. Ophth. Soc. of U. K. 75, 137.  Back to cited text no. 4
    
5.
Dunnington (1957), Amer. J. Ophth., 43, 667.  Back to cited text no. 5
    
6.
Dunnington and Regan (1958) Arch. of Ophthal. 59, 315  Back to cited text no. 6
    
7.
Escapini (1958), Arch, of Ophthal.. 59, 653.  Back to cited text no. 7
    
8.
Hughes and Owen (1947), Arch. of Ophth. 38, 577.  Back to cited text no. 8
    
9.
Miller, Keskev, Becker (1957), Arch. of Ophth. 58, .101.  Back to cited text no. 9
    
10.
Stallard I-I. B. (1958), Eye Surgery p. 521, B. J. Wright & Sons, London.  Back to cited text no. 10
    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]
 
 
    Tables

  [Table - 1], [Table - 2]



 

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Merits of Cornea...
Corneal Incision...
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