|Year : 1972 | Volume
| Issue : 3 | Page : 113-119
A new technique of wound closure in cataract surgery
42-A, The Mall, Amritsar, India
42-A, The Mall, Amritsar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Parkash O. A new technique of wound closure in cataract surgery. Indian J Ophthalmol 1972;20:113-9
Since the first removal of lens by Daviel about 200 years ago, methods of making and closing cataract incisions are still widely debated. There are numerous techniques mentioned in the literature such as : Conjunctival would closure, corneal suture, corneo scleral sutures scleroconjunctival sutures and scleral sutures. (Mc LEAN; RYAN AND MAUMANEE  ).
However, in my personal experience, I have found that this new technique of cataract wound closure has further reduced these complications of hyphaema, iris prolapse, shallow chamber etc. This technique was conceived about 3 years ago and has been in practice since then.
| Method and Material|| |
The present series under discussion comprises of 2200 cases. They are split into two groups:
1st Group of 400 cases: In this study, a fornix based conjunctival flap has been used. The limbal wound is closed with 10.0 Nylon by employing 3 interlock running sutures. All these cases were operated by using a binocular loupe (Binomag), and the necessity of using an operating microscope was not felt.
2nd Group of 1800 cases: In this series no conjunctival flap has been made. The limbal wound is closed with 8.0 Virgin silk using double interlock running suture. This group was operated without the aid of a binocular loupe.
Technique: All the cases were operated under usual local anaesthesia. The lids were retracted with one central stitch in the upper lid and another in the lower lid. The usual superior rectus suture was inserted in all the cases.
In the first group of 400 cases:
Step I: A Fornix based conjunctival flap is fashioned by giving two radial incisions about 5 mm. long at 3 and 9 O'clock position in the conjunctiva at the limbus. The conjunctiva is undermined for 4-5 mm. beyond the limbus and then the conjunctiva is carefully cut with sharp scissors from its attachment with the cornea [Figure - 1].
No tag of conjunctiva is left attached to the cornea to avoid inturning of a small piece into the anterior chamber and thus prevent epithelialization. Very sparingly heat cautery is applied away from the limbus to control all the bleeding points.
Step II: Superior rectus suture is relaxed.
Step III: A knife incision with Barraquer's cataract knife is given in all cases from 3 to 9 O'clock or 9 to 3 O'clock position between the anterior and posterior limbus depending on the eye where intracapsular extraction is planned, and 2 to 10 O'clock or 10 to 2 O'clock position where extra capsular extraction is to be done. Thus a bevelled incision is obtained.
Step IV: A stay or guiding suture is inserted through the lips of the wound at 12 O'clock position with 10-0 Nylon monofilament suture and is looped out of the eye.
Step V: Two peripheral button hole iridectomies are made at 11 and 1 O'clock position. Intra or extra capsular extraction is done depending on the planned procedure. The single suture at 12 O'clock position is tied and then anterior chamber is inflated with sterile air ([Figure - 2]; Plate 1.).
Step VI: A running interlock suture is started at 9 O'clock position by passing the needle through both the lips of the wound and a knot is tied with three successive loops, then two successive loops, and lastly with one loop [Figure - 3]. A, B & C. This knot of the stitch with the help of forceps is brought towards the scleral side. [Figure - 3] A.
Suturing is continued clockwise towards the other end of incision. The second bite is taken at 10 O'clock position, a loop is made of the same thread towards the sclera. The needle is passed from the anterior lip of the wound. The point of emergence of the needle is adjusted in such a way that there is an exact approximation and the needle is passed through the same depth of the posterior lip of bevelled incision. The needle is pulled slightly and this forms the single or the l st lock. [Figure - 4].
The same needle with the thread is passed under the loop by holding the left side of the loop with the forceps. This forms the 2nd lock thus giving the 2nd time interlock. [Figure - 4]a. Similarly 3rd lock is devised when the same needle is passed third time under the loop; thus a third time interlock suture is formed. [Figure - 4]b. These three interlocks are made tight by pulling the thread with the needle and are brought towards the scleral side. [Figure - 4]c.
This very procedure is repeated in the successive bites until the 12 O'clock position is reached. Here the stay or guiding suture is cut with fine scissors. (Plate 1 & 2).
Same interlock type of suture is continued till the other end of the incision is reached taking 6 to 8 bites depending on the size of the wound. The last stitch of this running suture is passed through the lips of the end of the incision. A 10-15 mm of loop of thread is left on the anterior lip of the incision and then the needle is passed through the posterior lip of the incision. [Figure - 5]. The loop is tied with the needle end of the thread, first with two successive loops then with one [Figure - 5] A, B.
The whole length of the suture line is inspected. If any stitch is left loose, this can be tightened with two non-tooth forceps from one end of the incision to the other end. (Photo: 6). The knots at the end are made tight. This gives complete security to the wound. After tying both ends of the thread, the sutures are cut very short. It may be pointed out here that all these locks lie towards the scleral side of the wound. [Figure - 6]; Plate 3.
Radial incisions in the conjunctiva are closed at 9 and 3 O'clock with virgin silk and one interrupted stitch is enough on each side to close the conjunctival incision and thus the whole length of the interlock running suture is covered with conjunctival flap [Figure - 6]; Plate 4.
It is essential to observe the following precautions in the procedure:
(i) The previous knot and the thread in between the knots should be tight.
(ii) The suture should be placed radially.
(iii) There should be correct approximation.
(iv) The anterior chamber throughout the procedure of suturing should remain inflated with air.
(v) The number of locks depends upon the thickness and the type of the suturing material used i.e., three locks with 10-0 Nylon; two locks with 8-0 virgin silk and one lock with 7-0 silk.
The modification of this original technique which was carried out in the next group of 1800 cases, was made as a time saving procedure and this proved equally good.
Technique used in 2nd Group of 1800 cases:
In this series no fornix based conjunctival flap is employed. The incision is made with Barraquer's cataract knife just in front of the anterior limbus. Guiding or stay suture is passed with 8-0 virgin silk at 12 O'clock position. Here the suturing steps are the same except that only two locks are given instead of three locks. [Figure - 4]a. Nylon 10-0 monofilament requires 3 locks because of its being tensile and gets loose with 1 or 2 locks; while in the case of virgin silk, the grip on each knot is of desired strength.
| Discussion|| |
The essentials of any good method of closing a cataract wound are:
- It should be inserted through the lips of the incision at the same depth.
- It should give the best approximation.
- It should provide firm pressure on the whole length of the wound and there should not be any overlapping or overriding anywhere.
- There should not be any complication on the table such as vitreous disturbance while passing the suture.
- It should be simple, easy and less time consuming.
- It should minimise the post operative complications.
- It should lessen the discomfort to the patient after the operation in the form of foreign body sensations, watering, photophobia and blepharospasm. The eye should be white as far as possible after the operation.
- Post-operative astigmatism should be minimum.
To attain these criteria, number of methods of suturing the corneal wound had been devised but so far none of these singly seems to fulfil the desired criteria. Various methods of proper approximation of the corneal wound are: Pre-placed suturing; Post-placed suturing as the incision is being enlarged; a corneal bridge flap of Week's at 12 O'clock position; passing two interrupted sutures on each side and then cutting this bridge at the limbus. One stay or guiding suturing at 12 O'clock position immediately after the incision and then closing the wound after the delivery of the lens by different techniques.
In our personal observations, methods of placing the suture is of no significance. The presented technique of suturing gives the advantages of all the methods mentioned above. Consequently results with this technique have been very satisfactory, as it fulfils all the essential criteria of being a good closing suture. Advantages of the present method of suturing are:
- It gives perfect wound closure.
- The Post-operative complication rate is minimal.
- It is less time consuming.
- Once this method is grasped or seen, it is very easy to perform. It gives firm pressure not only at the knots but also at the area in between the knots by the intervening suture.
- Sutures are easy to remove after the operation at the end of the third week, where the conjunctival flap has not been made.
- It gives minimum foreign body sensation; especially when the conjunctival flap has been used. The eye is almost white after the operation where 10-0 Nylon suture has been employed. In other cases without conjunctival flap the interlock running suturing with 8-0 virgin silk the congestion, watering, foreign body sensation, photophobia are far less as compared to the same number of interrupted knots given with the same type of suture material.
| Summary|| |
A new technique of running 2-3 interlock suturing of cataract wound using 10-0 Nylon or 8-0 Virgin Silk has been described. This technique was used in two groups with a total of 2200 cases and has been found very satisfactory in this personal series.
| References|| |
McLean Jr: A new corneo scleral suture; Arch: Ophthal. 23: 554-559.(1940).
Ryan, S. J. and Maumenee, A. E.: The running interlock suture in cataract surgery Arch: Ophthal. 85: 302-303. (1971).
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]
[Table - 1], [Table - 2]