EyeWorld India March 2020 Issue

EWAP MARCH 2020 23 SECONDARY FEATURE S urgeons continue to evolve their approach to creating and sealing corneal incisions for cataract surgery. The main component to creating a well-sealed incision is the wound architecture used by the surgeon, John Hovanesian, MD, said. Surgeons commonly use either a two- or three-plane incision. The straightforward two-plane incision includes a cut from the limbus in the clear cornea toward the central cornea progressively becoming deeper as the blade advances and tilting it posteriorly near the end of the cut to form a second plane in the incision. The approach effectively creates an internal valve that closes. In the three-plane technique, before making the incision through the cornea, a vertical cut is made near the limbus to obtain depth in the cornea. Then, in the deepest part of the incision, the blade advances toward the central cornea and creates a second and then third plane. “And those can both work well,” Dr. Hovanesian said. “And generally, you want to have a little bit of length in the incision so that provides a greater valve size, and it provides a mechanical advantage for intraocular pressure to close the wound.” Kendall Donaldson, MD, who uses a blade to create three- plane incision, used to use a femtosecond laser to create incisions. “However, I later reverted to using a blade to make my primary incisions during femto cases, as the femto wounds were a little more difficult to close,” Dr. Donaldson said. Causes of leaking wounds Dr. Donaldson checks for wound leakage postop with a Weck-Cel sponge. “Typically, that is all that is necessary, as I can visualize any leakage from the wound,” Dr. Donaldson said. Common causes of leaking incisions include wounds that are too short, wounds with irregular edges, and longer surgical cases associated with increased manipulation and distortion of the wound. When incision closure help is needed Routine cataract cases rarely require extra help sealing an incision, but if a patient has vitreous loss or a history of endophthalmitis in the other eye, Dr. Donaldson always places a suture. Other patients who can benefit from postop incision sutures include: • Patients with continued leakage from the wound or thinning of the cornea at the limbus; • Patients with a history of radial keratotomy (RK); and • Patients with severe intraoperative floppy iris syndrome (IFIS). “If there is a small amount of leakage in these patients, the iris may become incarcerated in the wound causing a peaked pupil and increasing the risk for cystoid macular edema,” Dr. Donaldson said about severe IFIS patients. When using sutures, some surgeons bury the knot, but Dr. Hovanesian usually doesn’t because he removes the 10-0 nylon 1 day postop. “Usually the epithelium is sealed over the outside of the incision in one day, if you use the suture,” Dr. Hovanesian said. “At that point, the incision is more or less leak- proof.” Keys to sealing phaco corneal incisions by Rich Daly EyeWorld Contributing Writer This article originally appeared in the January-February 2020 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Contact information Donaldson: KDonaldson@med.miami.edu Hovanesian: jhovanesian@harvardeye.com ReSure Sealant on the eye at the time of surgery. The sealant has a blue color that disappears in 1 to 2 hours and it is also visible with fluorescein staining. ReSure Sealant is visible on the eye 1 day after surgery when stained with fluorescein. Source (all): John Hovanesian, MD