5.5 mm Incisions Can be Safely Closed without Sutures

By Roibeard O’hEineachain

BARCELONA - Sutureless cataract surgery is safe even when it is necessary to enlarge a clear cornea incision to 5 mm, according to Arturo Pérez Arteaga MD, who will be presenting his findings here at the 6th Winter Refractive Surgery Meeting of the ESCRS.
“Sometimes the clear-corneal incision has to be enlarged for several reasons, which can include conversion to extracapsular surgery, insertion of a non-foldable IOL, and secondary IOL implantation. The natural concern of most surgeons is that the incision will spontaneously open after surgery and/or cause excessive astigmatism. Our experience indicates that even when an enlargement of the incision is needed during anterior segment surgery the wound will remain securely closed without a suture in the overwhelming majority of cases and induced astigmatism will remain within manageable levels,” said Dr. Pérez Arteaga, who is in private practice in San Javier Tlalnepantla, México.

In a review of 2,500 cataract patients who underwent cataract extraction and phacoemulisification and IOL implantation through a 5.5 mm clear corneal incision, there were no cases of spontaneous wound opening. There were only 33 cases (1.32%) of filtration, all of which resolved after short-term application of a soft contact lens or an ocular patch. No cases were found with unstable anterior segment in the short or long term, he told EuroTimes.

No Increase in Phaco Complications
The incidence of other complications was similarly low and included two cases (0.08%) of choroidal detachment, two cases (0.08%) of endophthalmitis, and five cases (0.2%) of retinal detachment. In addition there were four cases (0.16%) of IOL subluxation, two cases (0.08%) of IOL luxation, and three cases (0.12 %) of traumatic wound opening, all of which required sutures.

The overall mean astigmatism at two months post-operative was 1.53 D. In eyes with superior clear corneal incisions (79 %) the mean astigmatism was 1.67 D (sd=1.07), while in eyes with temporal incisions (21%) it was 1.03 D (sd=0.49). Nineteen patients (0.76%) were dissatisfied with their visual outcome because of symptomatic astigmatism. There was no statistically significant difference between the degree of astigmatism in patients with soft contact lens (1175 cases, 47%) after the surgery, and those without them (1325 cases, 53%), he noted.

The reasons for large incision surgery included cataract phacoemulsification with planned rigid IOL implantation in 1476 cases (59.04%), phaco-refractive surgery with planned rigid IOL implantation in 375 cases (15%) and cataract phacoemulsification with planned foldable IOL and conversion to rigid IOL in 197 cases (7.88%).
Other reasons included secondary implantation (183 cases, 7.32%), phaco-refractive surgery with planned foldable IOL and conversion to rigid IOL, (174 cases, (6.96%), planned cataract phacofracture: (56 cases, 2.24%) small nucleus no-stitches extracapsular surgery with rigid IOL (35 cases, 1.4%), and IOL explantation (four cases, 0.16%).

Technique Continues to Prove Useful
Dr. Perez Arteaga noted that he first began using 5.5 mm unsutured incisions at a time when foldable IOLs were difficult to obtain in Mexico. Since that time foldable IOLs have become more available, but he still finds that sometimes a large incision approach can be helpful.

“In 1996 I started to perform sutureless cataract surgery with success and I did my first case with a 5.5 mm incision with no stitches, no path, under topical anaesthesia with a 5.25mm PMMA IOL. Foldable IOLs were becoming available at that time but most of my implants were still PMMA. At the end of the same year I started to do refractive clear lensectomies, where I found that large incisions were all the more necessary because foldable lenses with very low or very high power were still difficult to find.

“I subsequently began using a large incision technique with secondary IOL implantation, sulcus fixation, IOL explantation and other techniques. With time, foldable lenses have become more available in my country so I’ve been using large incisions less frequently, but, for example, in cases when a posterior capsule has been broken and sulcus IOL placement is necessary I find there are very good reasons for them," he noted.
In all of his large incision surgeries Dr. Perez Arteaga uses topical anaesthesia and creates a clear corneal one-step incision with diamond knife 2.8, 3.0 or 3.2 mm. He enlarges this to 5.5 mm for IOL implantation or explantation with a Zaldivar blade in the same plane as the initial corneal incision. The incision can be created in any meridian in the eye and a stromal irrigation is performed at the end of the procedure, he said, adding:

“A 5.5mm clear corneal, no-stitch incision under topical anaesthesia is an easily performed and safe procedure for anterior segment surgery. It can be used for many procedures as an elective or a converting technique. There is no need to place any ocular patch and the patient will be just as able to leave the ambulatory surgery centre as the small incision patient

“The incidence of astigmatism when using large incision surgery is slightly more than the traditional small incision but it can be used to benefit a patient when the incision is placed in the topographic axis. In my series I have not found any spontaneous wound opening. The cases of wound filtration were mainly cases of corneal thermal burns resulting from the phacoemulsification procedure, as is occasionally seen in small incision patients. The complications are the same as in small incision patients and no complications are induced because of the technique itself.”