ESCRS 2014 Basic microsurgical suturing techniques for beginners Trauma, sclera, trabeculectomy B.O. Bachmann Dept. of Ophthalmology, University of Cologne, Germany Financial interests: none
Investigating corneal and scleral wounding Signs for open globe injury: Hypotonia Also secondary to ciliochoroidal hyperperfusion / effusion Anterior chamber depth Compare to other eye Shallow or abnormal deep Subconjunctival bleeding Can obscur extruded intraocular tissue or IOL Corectopia Positive Seidel test Deformation of the globe (Ultrasound / CT scan) 2
Suspected corneal or scleral wound: Before Surgery Rigid eye cover Protection from external pressure Alert to medical stuff that patient has an open globe injury Systemic antiobiotic prophylaxis Do notput pressure on globe No topical medication Risk of of extrusion of intraocular contents Risk of toxic medication Check Tetanus vaccination Lens calculation from healthy partner eye CT-Scan 3
Surgical goals after traumatic globe laceration Watertight globe Restoration of the original anatomy Restoration of function
Wound slippage If interrupted suture is not placed 90 to wound edge Overlap in one portion ( dog ear ) and gaping in the other 5 Hammil MB, Ophthalmol Clin N Am 2002
Needles Cuttingneedle Suture canal extends superficial Reverse cutting needle Suture canal extends deep Spatulatedneedle Needlestaysin tissueplane commonly used in anterior segment Taperpoint 6 Atraumatic Iris repair
Sutures Cornea Monofil, non-absorbable Polyamide (Nylon, ) Sclera Multifil absorbable Polyglycolic acid(vicryl, ) Multifil non-resorbable Silk
Prolapsed tissue removal or tissue repositioning Removal of prolapsed lens vitreous necrotic tissue Repositioning of prolapsed iris retina choroid Repositioning with BSS, viscoelastic or smooth instruments / spatula
Repositioning of the iris Injection of viscoelastics increasespressurein anterior chamber increase of iris prolaps Reduce volume of the anterior chamber before injection of viscoelastic either removal of aqueous or previously injected viscoelastic Alternative: Keep theirisin theanteriorchamberbyan assistant using a spatula whilesuturingcornea/ sclera
Repositioning of the iris
Simple corneal lacerations
Complex corneal lacerations
Complex corneal lacerations
Combined corneoscleral lesions
Suture loosening Single vs. running suture
Exploring the sclera after traumatic lesion LacerationsapproachingtheLimbus: Always perform peritomy Exploration for occult ruptures: Perform a 360 peritomy Repair all visible corneal and scleral ruptures first Isolate therectusmuscleson silkorusea retractortoelevatethe muscle belly
Lacerations approaching the rectus muscles
Lacerations extending through a muscle insertion: Temporary disinsertion of a rectus muscle Vicryl 6-0 double armed
Predilection sites for globe rupture after blunt trauma > 75 % parallel tolimbus > 75 % involvethetwoupperquadrants after cataract surgery Sclera thinnest underneaths muscle attachment (200-300 µm) and peripapillary Viestenz et al. Ophthalmologe 2008
Trabeculectomy: Principle steps Traction suture Conjunctival flap Scleral Flap Trabeculectomy / Iridectomy Scleral flap closure Conjunctival closure
Traction suture Good surgical exposure Corneal suture (6 0, 7 0 or 8-0 vicryl or silk suture) 2 mm from limbus Alternative: Superior rectus bridle suture (4 0 silk Suture) risk factor for trabeculectomy failure
Conjuntival flap: Fornix based Incision made at the limbus with base in the fornix Excellent exposure, less manipulation of conjunctiva, technical ease, shorter surgical time
Conjuntival flap: Fornix based Incision made at the limbus with base in the fornix Excellent exposure, less manipulation of conjunctiva, technical ease, shorter surgical time
Conjuntival flap: Limbus based Late bleb leaks and infection more commonly when antimetabolites were used localized, thin, cystic blebs
Conjuntival flap: Limbus based Late bleb leaks and infection more commonly when antimetabolites were used localized, thin, cystic blebs scar is a barrier for the filtering bleb
Prepare scleral sutures before trabeculectomy
Trabeculectomy and Iridectomy
Readapting the scleral flap
Readapting tenon and conjuntival flap