|Year : 1964 | Volume
| Issue : 3 | Page : 114-118
Role of various types of corneo-scleral sutures in surgery of cataract
|Date of Web Publication||13-Feb-2008|
B K Dhir
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dhir B K. Role of various types of corneo-scleral sutures in surgery of cataract. Indian J Ophthalmol 1964;12:114-8
For prevention of post-operative complications and for the purpose of improving visual acuity in cataract surgery, Williams (1867) was the first person to use corneo-scleral sutures. Thereafter, various techniques were devised for the application of sutures, both conjunctival and sclero-corneal. Liegard (1918) modified the previous techniques and used horizontal bites in the corneal and scleral lips across the wound.
Further modification began to take place in the technique of suture applications. Lindner and McLean (1940) applied lip to lip sutures after turning down a small conjunctival flap.
Kirby introduced the technique of 'post-placed' suture application, that is after the corneal section is made. After this, suturing of a section for cataract extraction has afforded a wild opportunity to exercise an ophthalmic surgeon's imagination and skill to devise and develop his own pet technique for that purpose. All of them have used fine silk as suture material and had to face a fresh problem while removing the sutures. Alger (1947) and Dunnington and Regan (1953) used absorbable material for corneoscleral sutures to overcome the difficulty of removing sutures after the operation.
In 1961, M. Bodin described a new technique of first forming a fornix-based conjunctival flap. A semipenetrating limbal groove is made from 9 to 3 o'clock position, across which two 6-0 silk sutures on corneal needles are placed at 10.30 and 1.30 o'clock positions. After opening the chamber with a keratome and enlarging the incision with scissors the operation is completed. The sclero-corneal sutures are, now tied, placing the knot on the cornea. The conjunctival flap is now brought forward and sutured on either side of the cornea.
This study has been undertaken to (1) determine the advantages of the use of sutures in cataract surgery and (2) to compare at least three methods of suture applications.
| Material and Methods|| |
In a series of 350 cases, 100 cases were operated without sutures, whereas in the other 250 cases comparison was made of the different methods of suturing. In the suture series, in 60 cases alphachymotrypsin was also used for enzymatic zonulolysis. In all the usual preoperative measures were taken. The following three methods of suturing were compared.
1. Liegard suture (90 cases)
At the 12 o'clock position, horizontal bites of 1 mm. are taken on either side of the limbus about 1 to 2 mm. from the limbus. A 6-0 silk suture on corneal needle is used. The suture loop is turned aside to allow a cataract knife incision to be made between the limbs of the loop without cutting the suture or the conjunctiva.
2. Pre placed Corneo-scleral Sutures (97 cases)
A 2.0 mm. wide limbal-based conjunctival flap is raised at the 12 o'clock meridian and a half penetrating scleral incision is made 1.5 mm. from the limbus, concentric with it. A 6-0 silk suture on a corneal needle is placed between the two lips of the wound at 10-30 and 1-30 o'clock positions, and brought out through the conjunctival flap. The suture loops are kept aside. A keratome-scissor incision is made between the two loops. After completion of the operation, the sutures are tied over the conjunctiva. One or more post placed sutures are applied as needed.
3. Buried Corneo-Scleral Sutures (63 cases)
A 3 mm. wide limbal-based conjunctival flap is raised from 9 to 3 o'clock positions. A half-penetrating scleral incision is made 1.5 mm. from the limbus, concentric with it. Corneal needles threaded with 6-0 silk or virgin silk are taken and passed through the two lips of sclera at 10-30 and 1-30 o'clock positions. The section is completed with keratome scissors as in the previous method.
After iridectomy and delivery of lens, the scleral sutures are tied, then the conjunctival flap is reposited and sutured into position with a continuous key-pattern suture.
In this type of suturing, in 33 cases 6-0 silk was used whereas virgin silk was used in 30 cases.
[Table - 1],[Table - 2] indicate the type of cataracts, the type of sutures and the number of operations performed under the different heads, in this series.
Type of extraction-In both suture and no-suture series the aim was to do intracapsular cataract extraction, except in the no-suture series where a few planned extracapsular extractions were also done.
The following types of extractions were done. [Table - 3]
Analysis of the suture series further into extractions with and without alpha-chymotrypsin shows that enzymatic zonulolysis increases the percentage of intracapsular extractions and reduces the number of 'failed forceps'. [Table - 4]
[Table - 5],[Table - 6] show at a glance the complications which took place. They are compared when the sutures were used and not used. In the former case they are again sub-classified under the type of sutures taken.
On studying the above observation tables it is clear that these complications are markedly reduced in the corneo-scleral suture series as compared to the no-suture series. However, striate keratitis (which cleared up in all cases) was 1.5 times more frequent when corneo-scleral stitches were taken. Also to be noted are the figures of 40% striate keratitis and 33 hyphema cases where silk was used as suturing material for edge-to-edge stitching The figures are significant.
Similarly iris prolapse appears to be significantly higher when alpha chymotrypsin was used even though sutures were applied.
Visual acuity was recorded and post-operative astignatism noted in 55 cases of the no-suture series and 155 cases of the suture series. [Table - 7],[Table - 8],[Table - 9]
From the above tables it is clear that in the suture series 90% of the cases were having 6/18 or better visual acuity, while in the no suture series only 33% of these cases were having 6/ 18 or better visual acuity. Hence it is clear that visual results are far better in the suture series.
The type of suturing used does not make any significant difference.
On studying the astigmatism two months after discharge from the hospital it was found that there was no astigmatism in 32.3% of the suture series and 20% of no-suture series. Astigmatism above 2.0-D cyl. was more common (23.6%) in the no-suture series as compared to 7.2 in the suture series. The type of suturing did not make any significant difference.
| Summary and Conclusion|| |
(1) 350 cases were selected for this series, out of which 100 cases were operated without corneo-scleral sutures and 250 cases with the various types of sutures. In 60 cases of c.s. suture series, alpha chymotrypsin was used for enzymatic zonulolysis.
(2) Vitreous prolapse was less in the suture series as compared to the no suture series.
(3) Striate keralitis was 1.5 times more common in the c.s. suture series, but it cleared in all the cases.
(4) Other post operative complications were less frequent in the c.s. suture series.
(5) Visual results were far better in the c.s. suture series
(6) Higher degree of astignatism was less frequent in the c.s. suture series while no astigmatism was more frequent in this series.
(7) Some complications were more frequent with one or other type of suturing [Table - 6], whereas iris prolapse appeared to be more common when zonulolysis was resorted to. These differences require a more careful study.
[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5], [Table - 6], [Table - 7], [Table - 8], [Table - 9], [Table - 10]
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