OPINIONS AND COMMENTARY

EyeMail Insights

by J.E. “Jay” McDonald II, M.D.

Listserv participants share management pearls

Clear corneal cataract begins and ends with the incision. Attention to the incision and its behavior post-op is a major driving force in successful outcomes. I think we all can pick a pearl or two out of the diversity of answers to the common occurrence described below.

What would you do if you had a one-day post-op, beautiful eye, 20/20 vision but an IOP of 9 mm Hg (usually my post-ops are in the high teens or 20s) and a Seidel positive side-port incision at 6 o’clock? The anterior chamber was relatively quiet at a one day post-op, and there was no chamber shallowing.

Gary Hirshfield, M.D.

Flushing, N.Y.

I’d probably put a bandage contact lens, increase the antibiotics to every two hours, and use a full-time shield, with close observation.

Drew Jusko, M.D.

Springfield, Mass.

I would do absolutely nothing other than the usual drops, follow daily until resolved, and if not resolved in three days, consider a suture.

Mitchell Gossman, M.D.

St. Cloud, Minn.

I’d try (in this order): a tight bandage contact lens, hydrate the incision with balanced salt solution (BSS), and place a suture.

Uday Devgan, M.D.

Los Angeles

Use Betadine (povidone–iodine, Purdue Pharma, Stamford, Conn.), Q-Tip prep/stromal hydration, and a bandage contact lens. Increase the antibiotic, and stop the steroid for 24 to 48 hours. Check daily, and suture if still positive after the second or third day of follow-up.

David B. Leach, M.D.

Moscow, Idaho

Perfect place for a bandage contact lens.

Dan Osborn, M.D.

Springfield, Mo.

Do nothing except maintain the post-op regimen with antibiotic. Follow daily until it closes in a couple of days.

Douglas E. Mazzuca, D.O.

Pennsville, N.J.

I would hydrate with BSS at the slitlamp and place a contact lens. Cover with frequent antibiotics. I would observe over 24 to 48 hours and if it is not resolved, I would suture.

Jeffrey Whitman, M.D.

Dallas

I have seen this a couple of times at the side port (but I Seidel every incision on post-op day one). I would hold the steroid and give a drop of timolol (Timoptic, Merck, Whitehouse Station , N.J. ) or other aqueous suppressant and see again in a day. I’ve never seen it persist on post-operative day two, but I suppose I’d consider a bandage soft contact lens or old-fashioned pressure patch by then if persistent. The number of responses to this posting suggests that this isn’t that rare!

Lee Wan M.D.

Oxnard , Calif.

I would leave it alone and check daily. These will usually seal by themselves in 24 to 72 hours. I would increase the antibiotic drops to six or eight times a day. I personally think the bandage contact lens is a negative. If you want to do something, you can take a 30-gauge needle and tb syringe with BSS and come in from the side at about 45 degrees and inject the stroma just above the wound, and it will seal it. A video of a variation of this technique that I use at the end of every procedure can be found at my Web site www.mcdonaldeye.com/ professional.

J.E. “Jay” McDonald II, M.D.

Fayetteville, Ark.

I would watch the eye for the next few days. After day three or four, if there is still a wound leak, I prefer to put in a stitch or two. Somehow, you can watch those “unstable wounds” for weeks and wish later on that you had stitched them.

They all seem to heal eventually and stop leaking, but the induced astigmatism resulting from watching them, which does occur sometimes, doesn’t seem worthwhile.

Robert L. Kantor, M.D.

Sarasota, Fla.

Interestingly, I just got a call from a local ophthalmologist who had a difficult cataract case and had to extend the temporal incision—he placed four or five sutures and today, the central one is broken. He is Seidel positive, and the IOP is 4 to 5 mm Hg. The chamber is formed. I haven’t seen him yet, but in this case I am inclined to put a suture in my minor room in the office because the IOP is so low. I doubt a bandage contact lens would apply here, as it sounds like a larger area of involvement than the patient in question in this thread. So, I guess these wound leaks ARE fairly common!

Parag A. Majmudar, M.D.

Chicago

Also, consider revising your surgical technique. What kind of blade is being used to create the side port incision? Is it a steel blade or a diamond? We use a diamond side port (lancet style) from Accutome (Malvern, Pa.) that involves a simple stab incision made parallel to the iris plane at the limbus. Only the tip is sharp, the sides are dull, and the width of the incision (1 mm) is constant from patient to patient. We have better fluidics during phacoemulsification, and the incisions virtually never leak. It is more difficult with a steel blade to make a consistently small side port.

While we’re talking about diamond blades, I might make a pitch for the Accutome (no financial interest) black diamonds that we’ve used now for about 10 years. They are relatively inexpensive (as far as diamonds go) because they are made from industrial diamonds. We use the 2.8-mm “freehand” version for a simple single-plane clear corneal incision at the limbus (see http://www.accutome.com/catalog/product_info.php?ids=0_5_91&products_id=795). I. Howard Fine, M.D. [Eugene, Ore.] validated this incision type in his talk in the Innovator’s Session at the ASCRS annual meeting as being quicker to heal and having less trauma than other incision types that require grooves. He also displayed Visante (Carl Zeiss Meditec, Dublin, Calif.) images showing that the single-plane incision actually has a curved profile when seen in the cross section.

Richard Schulze, Jr., M.D.

Savannah, Ga.

I use the same blade and leave it in to stabilize the eye as the main incision is made. I’ve had one or two out of thousands leak, never a meaningful amount, and they always resolve.

Use the 2.8 to 3.2 mm trapezoid “3D” blade from Rhein (Tampa, Fla.). I, too, advocate that style of incision. I have had no leaks in over three years and have used no sutures except those placed prophylactically with mentally retarded and other untrustworthy patients. In fact, the main incision is more secure than the side port on the table.

Dr. Gossman

You make a simple single-plane incision with this blade to make your clear corneal incision? Do you hydrate the wound, and how often do you have to place a suture, if ever?

Dr. Mazzuca

I make a “single-plane” clear corneal incision with the 2.8-mm blade, stabilizing the globe with a 0.12-mm forceps at the posterior aspect of my 12 o’clock side port. I hydrate perhaps 30% of my incisions, depending on how stable the wound looks on the table. I almost never place a suture, but if I do, I simply place a single interrupted suture of 10-0 nylon or Vicryl on the central aspect of the wound and bury the knot. Dr. Fine’s talk at ASCRS was convincing that single-plane incisions are the way to go and that grooves are unnecessary. I’ve always felt that grooves simply created more trauma and more of a potential nidus for infection at the limbus.

Dr. Schulze

I have always scratched my head on the groove, too. I think that the key to a secure incision is surface area kissing on either side of the incision to take advantage of self-sealing feature (higher IOP = more secure) and endothelial pump.

Dr. Gossman

I also do a modified “Langerman incision” and feel it seals better and is more robust to external pressure. Langerman made a groove with a diamond AK knife set near 600 microns. I simply groove with the diamond keratome tip turned down. The groove should be in the perilimbal capillary plexis, i.e., it should bleed. This will result in good healing. The diamond incision does not start at the bottom of the groove, but at about half depth, and the keratome is advanced slowly with the tip pointed slightly upward toward the corneal apex. Once the corneal valve is wide enough, one can bevel down to enter the anterior chamber. Advancing the blade parallel to the iris often results in a corneal valve that is not wide enough. The most likely incision to leak for me is the paracentesis. Make it slightly angled toward the corneal dome or at a minimum parallel to the iris and hydrate well.

Richard L. Lindstrom, M.D.

Minneapolis

It is very rare that I find myself on the other side of the fence from Dr. Lindstrom, but this is one such area. I’ve been a groover ever since David Langerman [M.D.] designed this incision circa 1994. In my experience, the groove accomplishes two things. First, it increases the aspect ratio of the wound for a given level of wound security (in other words, a rectangular, grooved incision can be as stable as a square incision). I recall seeing a study to collaborate this years back. It also eliminates having a wafer thin area of tunnel roof adjacent to the area where the knife enters the cornea. It has been years since I needed to place a single stitch in a cataract incision, and I cannot recall having a Seidel positive wound in many years (every couple years we do see a Seidel positive paracentesis). It has also been quite a few years since a single post-cataract endophthalmitis. I don’t think there is a right or wrong answer here, but in my mind the advantages of the groove outweigh any disadvantages.

Joel K. Shugar, M.D., M.S.E.E. Perry, Fla.

I’m with Dr. Shugar. The “groove” also is called a hinge, is not trivial, and contributes to the final wound stability by decoupling external pressure forces. The work of Paul Ernest [M.D., Jackson, Mich.] is really compelling in this area. See Ernest PH, Fenzl R, Lavery KT, Sensoli A. Relative stability of clear corneal incisions in a cadaver eye model. J Cataract Refract Surg 1995 Jan; 21(1):39-42.

Dan Eisenberg, M.D.

Las Vegas

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Contact Information

Devgan: devgan@ucla.edu

Eisenberg: glaucoma@cox.net

Garrett: jmgarrett@chartermi.net

Gossman: mgossman@esppa.com

Hirshfield: Gary11021@aol.com

Jusko: juskomd@gmail.com

Kantor: rlkantor@kantoreye.com

Leach: davidleach_md@hotmail.com

Lindstrom: rllindstrom@mneye.com

Majmudar: pamajmudar@chicagocornea.com

Mazzuca: docmazz@comcast.net

Osborn: dro218@yahoo.com

Schulze: richardschulze@comcast.net

Shugar: stareyes@gtcom.net

Wan: wlwan@coastaleye.net

Whitman: Whitman@keywhitman.com

The following is a short abstract from Dr. Fine’s lecture at the 2007 ASCRS•ASOA Congress & Symposium as mentioned by Dr. Schulze. He now advocates a single-plane incision over a tongue and groove or T-incision based upon his results with optical coherence tomography (OCT). Bear in mind, however, that Dr Fine uses a bimanual technique with its smaller 1.1-mm incisions to remove the cataract. The additional 2.8-mm incision that he creates for insertion of the IOL is “virgin”—i.e., not stretched by phaco manipulation nor heated by ultrasound. Therefore, this 2.8 incision never (I know you’re not supposed to ever say never in medicine) leaks with the bimanual technique, no matter whether a single-plane or hinged incision is made. In my experience, with bimanual, the only incision that may leak is the smaller sized incision. There are certainly other factors for wound leakage such as type of phaco machine, length of surgery, type of blade, amount of sound time, tightness of incision, and of course, how gentle we are with the tissues.

Profiles of clear corneal incisions visualized by optical coherence tomography I. Fine; R. S. Hoffman; M. Packer

To examine the incision construction and architecture of clear corneal incisions and side- port incisions utilizing OCT. The authors demonstrate unexpected findings regarding phacoemulsification clear corneal incisions as studied by OCT. The “single-plane” incision is actually arcuate and longer than the chord length, and has tongue-in-groove architecture, creating stability. Swelling from stromal hydration lasts for longer than 24 hours. Side-port incisions, constructed utilizing different knife designs and incision lengths, are being studied using a slitlamp OCT to elucidate optimal architecture for bimanual microincision phacoemulsification. The profiles of clear corneal incisions are different than had been previously envisioned. Proper clear corneal incision architecture promotes immediate sealing and infection prophylaxis.

Mike Garrett, M.D., Iron Mountain, Michigan

ABOUT THE AUTHOR

J.E. “Jay” McDonald II, M.D., is the EyeMail editor. He is director of McDonald Eye Associates, Fayetteville, Ark. Contact him at 479-521-2555 or mcdonaldje@mcdonaldeye.com.

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