dramroo@yahoo.com Marian S. Macsai (Ed.) Ophthalmic Microsurgical Suturing Techniques dramroo@yahoo.com Marian S. Macsai (Ed.) Ophthalmic Microsurgical Suturing Techniques With 289 Figures, mostly in Color 123 dramroo@yahoo.com Marian S. Macsai, MD Professor and Vice Chair Ophthalmology Northwestern University Chief, Division of Ophtho Evanston Northwestern Healthcare 2050 P ngsten Rd. Glenview, Il 60025 USA ISBN-10 3-540-28069-3 Springer Berlin Heidelberg New York ISBN-13 978-3-540-28069-9 Springer Berlin Heidelberg New York Library of Congress Control Number: 2006935423  is work is subject to copyright. All rights are reserved, whether the whole or part of the material is con- cerned, speci cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, repro- duction on micro lms or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9th, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under German Copyright Law. Springer is part of Springer Science+Business Media. Springer.com © Springer-Verlag Berlin Heidelberg 2007  e use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a speci c statement, that such names are exempt from relevant protective laws and regu- lations an therefore free general use. Product liability:  e publishers cannot guarantee the accuracy of any information about dosage and applica- tion contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editor: Marion Philipp, Heidelberg, Germany Desk Editor: Martina Himberger, Heidelberg, Germany Production: LE-T E X Jelonek, Schmidt & Vöckler GbR, Leipzig, Germany Illustrations: Albert R. Gattung + Regine Gattung-Petith, Edingen-Neckarhausen, Germany Typesetting: Arnold & Domnick, Leipzig, Germany Cover Design: Frido Steinen-Broo, EStudio Calamar, Spain Printed on acid-free paper 24/3100/YL 5 4 3 2 1 0 This eBook does not include ancillary media that was packaged with the printed version of the book. dramroo@yahoo.com Dedication For my husband, Jack, and his never ending support and love. For Ezra, Max and Emma, my continued sources of inspiration and joy. For my parents who taught me to learn, to teach and to enjoy life. dramroo@yahoo.com Preface In any surgical  eld, the importance of suturing is self- evident. In eye surgery, due to the lack of elasticity of the tissues and the in uence of sutures on the visual outcome, proper microsurgical suturing technique is paramount. Inappropriate or careless suture placement and knot tying can impact visual function. If wound construction and closure are not astigmatically neutral, the visual outcome will be altered and further surgical intervention may be required. Wound related compli- cations are more severe in the eye than in the skin.  e close proximity of tissues allows for rapid spread of in- fection and the limited blood supply inhibits treatment.  e same limited blood supply alters wound healing.  e translation of hand tying techniques, intro- duced in every medical school curriculum, to micro- surgical instrument tying is not obvious. Essential dif- ferences exist in all aspects of ophthalmic microsurgical suturing techniques, from the use of the microscope itself to the instrumentation, tissue tactics, suture ma- terial and knot construction.  e experienced surgeon shares the challenges that face surgeons in training, as they attempt to master new skills and handle more complicated cases.  e role of wound closure and su- turing techniques are basic building blocks for every ophthalmic surgical procedure. Breaking down the complexity of microsurgical suturing to each of the numerous components required for tissue apposition that does not alter the function of the eye or impair the surgical outcome is the goal of this text. Expert surgeons from di erent specialties have con- tributed their time and knowledge to the creation of this text.  e uniform layout with key points identi ed at the beginning of each chapter allows the reader to quickly locate a particular technique.  e authors have made great e orts to describe each technique in a step- by-step fashion, so that the reader can reproduce the technique on their own. Accompanying digital video clips of surgical footage clarify and demonstrate the di erent techniques. Mastery of basic and advanced ophthalmic microsurgical suturing techniques will fa- cilitate expansion of any surgeon’s armamentarium. As ophthalmic surgery advances, a variety of skills are needed for the surgeon to stay current.  is text o ers the reader ophthalmic microsurgical suturing techniques that decrease the risk of postoperative in- fection and result in astigmatically neutral wound clo- sure. Equipped with the knowledge of alternative tech- niques, when complications arise, the reader can decrease the need for further surgical intervention and improve their surgical outcomes. dramroo@yahoo.com Acknowledgements A text of this diversity is not possible without the input and help of many authors. I thank each of the authors who have freely contributed their expertise on an ex- tremely tight schedule. Each was patient with the con- tinuous revisions, illustrations, and video issues. Your continued help and support made this idea a reality. I could not have assembled all this material without Peggy Dow, who kept me organized and on track. A special thanks goes to all the people at Springer who gave so much to this project, especially Marion Philipp and Martina Himberger. I thank Renee Gattung for her expert illustrations, and Patrick Waltemate at LE-TeX for his patience. dramroo@yahoo.com Contents 1 The Physics of Wound Closure, Including Tissue Tactics . . . . . . . . . . . . . . . . . . . . . . 1 Larry Benjamin 2 Needles, Sutures, and Instruments . . . . . . . . . . . . 9 Jennifer H. Smith and Marian S. Macsai 3 Knot-Tying Principles and Techniques . . . . . . . . 21 Anthony J. Johnson and R. Doyle Stulting 4 Microsurgical Suturing Techniques: Closure of the Cataract Wound . . . . . . . . . . . . . . . 29 Scott A. Uttley and Steven S. Lane 5 Suturing an Intraocular Lens . . . . . . . . . . . . . . . . 37 Julie H. Tsai and Edward J. Holland 6 Corneal Suturing Techniques . . . . . . . . . . . . . . . . 49 W. Barry Lee and Mark J. Mannis 7 Trauma Suturing Techniques . . . . . . . . . . . . . . . . 61 Marian S. Macsai and Bruno Machado Fontes 8 Iris Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . 71 Steven P. Dunn and Lori Stec 9 Sclera and Retina Suturing Techniques . . . . . . . 85 Kirk H. Packo and Sohail J. Hasan 10 Glaucoma Surgery Suturing Techniques . . . . . 101 Joanna D. Lumba and Anne L. Coleman 11 Amniotic Membrane Suturing Techniques . . . 107 Sche er C. G. Tseng, Antonio Elizondo, and Victoria Casas 12 Strabismus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Mark J. Greenwald 13 Refractive Surgery Suturing Techniques . . . . . 129 Gaston O. Lacayo III and Parag A. Majmudar 14 Pterygium, Tissue Glue, and the Future of Wound Closure . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Sadeer B. Hannush Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 dramroo@yahoo.com List of Contributors Larry Benjamin Department of Ophthalmology Stoke Mandeville Hospital Mandeville Road Aylesbury, Bucks HP21 8AL, UK E-mail: larry.benjamin@btopenworld.com Victoria Casas Ocular Surface Center, P.A. 7000 SW 97th Ave., Ste. 213 Miami, FL 33173-1492, USA E-mail: vcasas@ocularsurface.com Anne L. Coleman Jules Stein Eye Institute 100 Stein Plaza, #2118 Los Angeles, CA 90095-7065, USA E-mail: colemana@ucla.edu Steven P. Dunn Michigan Cornea Consultants 29201 Telegraph Rd., Ste. 101 South eld, MI 48034-7630, USA E-mail: StevenPDunn@ameritech.net Antonio Elizondo Ocular Surface Center, P.A. 7000 SW 97th Ave., Ste. 213 Miami, FL 33173-1492, USA Bruno Machado Fontes Av. des Americas 2300 / B, cs 27 Rio de Janeiro, RJ, Brazil 22640-101 E-mail: brunofontes@openlink.com.br; brunofontes@o almo.epm.br Mark J. Greenwald Department of Ophthalmology and Visual Science University of Chicago 5841 S. Maryland Avenue, M/C 2114 Chicago, IL 60637, USA E-mail: mgreenwa@uchicago.edu Sadeer B. Hannush Cornea Service, Wills Eye Hospital Je erson Medical College, Philadelphia, PA Correspondence: 400 Middletown Blvd. Suite 110 Langhorne, PA 19047, USA E-mail: SBHannush@comcast.net Sohail J. Hasan Ingalls Hospital Professional Bldg. 71 West 156th St., Ste. 400 Harvey, IL 60426, USA Edward J. Holland CEI-NKY 580 South Loop Rd., Ste. 200 Edgewood, KY 41017, USA E-mail: eholland@fuse.net Anthony Johnson Cornea/Refractive Surgery SAUSHEC Ophthalmology 3851 Roger Brooke Drive Fort Sam Houston, Tx 78234, USA E-Mail: Anthony.Johnson2@amedd.army.mil Gaston O. Lacayo III Rush University Medical Center Department of Ophthalmology 1725 W. Harrison St., Ste. 928 Chicago, IL 60612, USA E-mail: Gaston_O_Lacayo@rush.edu Stephen S. Lane 280 N. Smith Ave., Ste. 840 St. Paul, MN 55102, USA E-mail: sslane@associatedeyecare.com W. Barry Lee Eye Consultants of Atlanta 95 Collier Rd., Ste. 3000 Atlanta, GA 30309, USA E-mail: Lee0003@aol.com dramroo@yahoo.com XIV Joanna Lumba 1101 Welch Road, Suite B2 Palo Alto, CA 94304, USA E-mail: lumbajo@yahoo.com Marian S. Macsai Professor and Vice Chair Ophthalmology Northwestern University Chief, Division of Ophtho Evanston Northwestern Healthcare 2050 P ngsten Rd. Glenview, Il 60025, USA Parag A. Majmudar Rush University Medical Center Department of Ophthalmology 1725 W. Harrison St., Ste. 928 Chicago, IL 60612, USA E-mail: pamajmudar@chicagocornea.com Mark J. Mannis Department of Ophthalmology University of California 4860 Y St., Suite 2400 Sacramento, CA 95817, USA Kirk H. Packo Rush University Medical Center Department of Ophthalmology 1725 W. Harrison St., Ste. 945 Chicago, IL 60612, USA E-mail: kirk_packo@rush.edu Jennifer Hasenyager Smith 2032 Valor Ct. Glenview, IL 60026, USA E-mail: Jhsmith2020@yahoo.com Lori Stec Beaumont Eye Institute 3601 W.  irteen Mile Road Royal Oak, Michigan 48073, USA R. Doyle Stulting Emory Vision 875 Johnson Ferry Road Atlanta, GA 30342, USA E-mail: ophtrds@emory.edu Julie H. Tsai University of South Carolina School of Medicine Dept of Ophthalmology Four Medical Park, Suite 300 Columbia, SC 29203, USA E-mail: tsaij3@gmail.com Scheff er C. G. Tseng Ocular Surface Center, P.A. 7000 SW 97th Ave., Ste. 213 Miami, FL 33173-1492, USA E-mail: stseng@ocularsurface.com Scott A. Uttley St. Paul Eye Clinic 2080 Woodwinds Dr. Woodbury, MN 55125-2523, USA E-mail: uttle001@tc.umn.edu dramroo@yahoo.com [...]... interface Chapter 1 The Physics of Wound Closure, Including Tissue Tactics 1. 3 Suture Placement Tissue must be properly held in order to stabilize the area of tissue the needle is driven through If this maneuver of passing the needle through the wounds edge is controlled, the desired results are achieved (Figs 1. 1 and 1. 2) Using 0 .12 mm forceps, the tissue should be held with the two-teeth side of the... Similarly, poor wound repair on the eyelid margins can have a long-term effect on the ocular environment by affecting lid closure and tear flow This chapter addresses the forces and vectors involved in wound closure, the tactics used to achieve the desired effects, and how these relate to clinical principles 1. 2 Wound Architecture 1. 2 .1 Principles of Wound Closure The principles of wound closure vary,... structure detail(s) included in the closure There are a number of techniques for working with the lid, conjunctiva, and cornea and sclera Because of the inflexible nature of the cornea and sclera, tissue suturing here requires precise suture placement Successful ophthalmic wound closure results from proper technique modification and suture tension 1. 1 Introduction The closure of wounds in surgery relies on... under tension After the wound is closed, the initial sutures may be replaced with astigmatically neutral sutures, surgeon‘s knots (2 :1: 1), at the desired tension, to avoid over compression of tissue, which can easily happen with slip knots that are tied to tightly 1. 3 .1 Suture Technique The suture passes should be of equal depth in the tissue on either side of the wound and of equal length In this way,... closure Leak Leak A < B = Wound leak Fig 1. 4 Zones of compression Different lengths of suture bites result in different zones of compression When the zones of compression overlap, adequate wound closure is achieved (arrows) Chapter 1 The Physics of Wound Closure, Including Tissue Tactics 1. 5 Lid Margin Repair Everted wound edge Needle visible in depth of wound Fig 1. 5 Everting the wound edge Wound pouting... solution Care must be taken to recognize the margin of the surgical dissection when suturing conjunctiva When countertraction is applied, toothed forceps, such as 0 .12 -mm forceps, may be necessary to determine the margin of the surgical dissection and apply countertraction If countertraction is not applied properly, inadvertent suturing of epithelial tissue in a subepithelial space can result in the postoperative... margin about 1 mm from its surface and should be within the lid substance entirely In other words, the suture should not protrude through either skin at the front of the lid or conjunctiva at the back A well-placed tarsal suture will provide the necessary strength and tension for the lid margin to heal with no notching, and will allow early removal of supplementary skin and lid margin sutures 1. 6 Conjunctiva... depth placement, unequal length of suture passes and nonradial suture placement a 90° b Radial to the wound c Fig 1. 1 The needle is passed perpendicular to the surface of the tissue and exists equidistant from the point of entry when viewed form the anterior perspective of the laceration Fig 1. 2 a After the knot is tied and the ends are cut short, the suture is grasped with smooth forceps and rotated... the length of the suture bites and the degree of suture tension after the suture is tightened Adequate wound closure is achieved when the zones of compression of each interrupted suture overlap (Fig 1. 4) 1. 3.2 Force Vectors of Sutures All sutures produce vector forces that act in various directions as the suture is tightened The vector forces extend in three different directions: perpendicular to the... depends on their length and tension An adequate number of sutures have been used when the zone of compression of each suture overlap Figure 1. 4 shows the zone of compression for a single suture, which is the effective zone of closure that a suture exerts when tied at its particular tension These zones should overlap slightly to ensure that the wound will not open between the sutures, and the closer the sutures . Healthcare 2050 P ngsten Rd. Glenview, Il 60025 USA ISBN -1 0 3-5 4 0-2 806 9-3 Springer Berlin Heidelberg New York ISBN -1 3 97 8-3 -5 4 0-2 806 9-9 Springer Berlin Heidelberg New York Library of Congress. Retina Suturing Techniques . . . . . . . 85 Kirk H. Packo and Sohail J. Hasan 10 Glaucoma Surgery Suturing Techniques . . . . . 10 1 Joanna D. Lumba and Anne L. Coleman 11 Amniotic Membrane Suturing. 97th Ave., Ste. 213 Miami, FL 3 317 3 -1 492, USA E-mail: vcasas@ocularsurface.com Anne L. Coleman Jules Stein Eye Institute 10 0 Stein Plaza, # 211 8 Los Angeles, CA 9009 5-7 065, USA E-mail: colemana@ucla.edu Steven