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Closure technique for leaking wound resulting from thermal injury during phacoemulsification
TECHNIQUE
Closure technique for leaking wound resulting from thermal injury during phacoemulsification Keshab Haldar, MD, FRCSEd, Rashmi Saraff, MD, FRCSEd
We describe a method of wound closure with a conjunctival flap in cases of wound burn. A fornix-based conjunctival flap is raised to adequately cover the wound. Then, a single horizontal mattress suture with 10-0 monofilament nylon is passed to appose the wound. The conjunctival flap is hinged to the corneal end of the loop so the conjunctival flap covers the wound when the suture is tied. The wound is thus sealed by conjunctiva with optimum suture tension. This suture was applied in 5 patients with clear corneal incisions who developed wound burn during phacoemulsification. All had an uneventful recovery with a sealed wound from the first postoperative day and satisfactory visual outcomes with low residual astigmatism at the final refraction. Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:1412–1414 Q 2014 ASCRS and ESCRS
Thermal injury to the sclerocorneal or clear corneal tunnel can occur during phacoemulsification. A large cross-sectional study conducted in the United States and Canada documented an incidence of 0.037%,1 and another study in the U.S. reported an incidence of 0.098%.2 Although the incidence is low, wound burn can be a serious complication. It is caused when the metallic phaco needle is overheated, and the heat is transmitted to the stromal tissue around the wound. An increase in tissue temperature beyond 60 C can cause acute tissue contracture and distortion, leading to loss of the self-sealing capacity of the wound.1 Although various techniques to close these wounds have been described, a wound burn is difficult to manage and can leave high residual astigmatism.3 This article describes a technique we have used to treat cases of wound burn.
Submitted: September 10, 2013. Final revision submitted: February 16, 2014. Accepted: February 19, 2014. From the Rotary Narayana Nethralaya, Kolkata, India. Corresponding author: Keshab Haldar, MD, FRCSEd, Rotary Narayana Nethralaya, CN 5, Sector V, Salt Lake, Kolkata, Pin code 700091, India. E-mail: [email protected].
1412
Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
SURGICAL TECHNIQUE Step 1: Conjunctival Flap After the irrigation/aspiration is completed, the anterior chamber is formed with balanced salt solution. The wound is assessed. A fornix-based rectangular conjunctival flap is raised; it should cover the wound adequately. The flap is freed from the underlying Tenon. Step 2: Passing the Suture Two points are marked on the conjunctival flap (Figure 1, a and b). They should be a few millimeters apart and at least 2.0 mm from the free limbal margin. With a double-ended 10-0 monofilament nylon suture, a needle is passed through each conjunctival point from the epithelial side through the stromal side. Next, a corneoscleral bite through the wound is passed with 1 of the needles, from the corneal to the scleral side (Figure 1, c and d). The second corneoscleral bite is passed in the same direction with the other needle (Figure 1, e and f). The 2 bites should be parallel to form a mattress suture across the wound. The suture can also be placed with a single-arm suture. In this situation, 1 corneoscleral bite is taken from the limbal to the corneal side (Figure 1, d and c). After that, the 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.07.016
TECHNIQUE: CLOSURE FOR LEAKING WOUND FROM THERMAL INJURY
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Figure 1. Placement of the suture. The arrows show the free limbal margin of the conjunctival flap. Conjunctival bites (a and b), first corneoscleral bite (c and d), and second corneoscleral bite (e and f) are shown. The ends (d and f) are tied to complete the suture.
Figure 2. Appearance of the wound at the end of surgery.
suture is passed through the 2 points in the conjunctiva (Figure 1, a and b). The second corneoscleral bite is taken from the corneal to the limbal side (Figure 1, e and f).
DISCUSSION Wound burn can be a serious and devastating complication of phaco surgery. As it is caused by overheating of the phaco tip, care should be taken so the tip does not become too hot during surgery. The phaco machine and its attachments should be set up properly so a continuous flow is maintained around the tip during the procedure. Techniques such as phaco chop require less energy than trench divide-and-conquer and help keep the tip cool. Ophthalmic viscosurgical devices (OVD) can be a factor as use of ultrasound energy in an OVD-filled eye can release heat, causing wound burn.1 It is important to diagnose the condition at an early stage. Appearance of a milky white fluid around the phaco tip can be an early warning sign.4 As the tissue damage progresses, a white area appears in the stroma around the wound. Subsequent contracture of the tissue makes it impossible to achieve a watertight closure. Persistent dehiscence of the wound may give rise to other complications such as a flat anterior chamber and iris prolapse.4 Conventional treatment involves multiple interrupted sutures for wound closure. Postoperatively, small leaks can be managed by bandage contact lenses or tissue adhesives. Aqueous suppressants and frequent antibiotic drops may be needed and daily follow-ups required. If the wound continues to leak, a wound revision may be necessary.4 A special gape suture can be used.5 Subsequently, the patient may require treatment for high residual astigmatism. In severe cases, a corneal patch graft may be needed.6 We have described a technique that achieves a sealed wound at the end of surgery. Frequent follow-ups and
Step 3: Tying the Suture The suture is tied with adequate tension so the conjunctiva is pulled down to cover the gaping wound (Figure 1, d and f). The knot is automatically covered by the conjunctiva (Figure 2). RESULTS The closure technique was used in 5 eyes in 5 patients with wound burn during phacoemulsification. The patients were reviewed 1 day, 1 week, 2 weeks, 4 weeks, and 6 weeks postoperatively. Sutures were kept in place at least for 2 weeks. Between 2 and 4 weeks, when the wound looked secured, the sutures were removed. Final refraction was done at 6 weeks. All 5 patients had age-related cataract, grade III (2 patients) and grade IV (3 patients). The average age of the 4 men and 1 woman was 67 years. All cases had clear corneal incisions. Postoperatively, the corrected visual acuities were 6/6 in all cases. At the final refraction at 6 weeks, 1 patient had no residual astigmatism, 3 patients had 0.5 diopter (D) of residual astigmatism, and 1 patient had 1.0 D. Because the cataracts were advanced in all 5 cases, preoperative refractive data were not available. Postoperative recovery was uneventful in all cases.
J CATARACT REFRACT SURG - VOL 40, SEPTEMBER 2014
1414
TECHNIQUE: CLOSURE FOR LEAKING WOUND FROM THERMAL INJURY
Figure 3. In the early postoperative period, the “W” pattern is clearly visible. The central point of the “W” is hanging from the conjunctival flap.
extra medications are not necessary postoperatively. The technique induces very little residual astigmatism, and the vision remains clear from the early postoperative period. Considering these factors, we think this technique is better than other available techniques for treating wound burns during phacoemulsification. The suture can also be used to treat leaking wounds from other causes. The suture acts in 2 ways. First, the conjunctival flap covers the external opening of the wound directly and seals it. Second, it exerts an optimum pull to appose the wound. Postoperatively, as the conjunctiva tends to go back to its original position, the loop of the suture hinged to the conjunctiva is pulled up. This changes the rectangular shape of the mattress suture and gives the lower end a “W” shape (Figure 3). The central portion of the “W” hangs from the conjunctiva in the middle. The conjunctiva provides a spring-like suspension and exerts optimum apposing tension to keep the wound closed. As a result, the astigmatism remains low from the early postoperative period. We recommend suture removal after 1 month. After suture removal, the conjunctiva gradually retracts to the limbus (Figure 4). With this technique, it is possible to achieve predictable results in all cases. The suture can be modified according to the situation. By changing the width of the flap, a larger wound can be covered. By modifying the length and hinge points of the flap, the tension on the wound can be modified. To conclude, we feel that unless there is extensive tissue damage, this suture can successfully manage any wound burn and wound leak with comfortable postoperative recovery and a satisfactory visual outcome.
Figure 4. At 3 months, the conjunctiva has retracted to the limbus.
WHAT WAS KNOWN Usual practice in the case of a leaking wound during phacoemulsification is to close the wound with a suture. This may cause higher astigmatism postoperatively. WHAT THIS PAPER ADDS We describe a technique that uses a conjunctival flap hinged to a horizontal mattress suture to close a leaking wound. In addition to cases of wound burn, this suture is effective in cases of unstable corneoscleral wounds in which wound reinforcement is required. REFERENCES 1. Sorensen T, Chan CC, Bradley M, Braga-Mele R, Olson RJ. Ultrasound-induced corneal incision contracture survey in the United States and Canada. J Cataract Refract Surg 2012; 38:227–233 2. Bradley MJ, Olson RJ. A survey about phacoemulsification incision thermal contraction incidence and causal relationships. Am J Ophthalmol 2006; 141:222–224 3. Sugar A, Schertzer RM. Clinical course of phacoemulsification wound burns. J Cataract Refract Surg 1999; 25:688–692 4. Kohnen T, Wang L, Friedman NJ, Koch DD. Complications of cataract surgery. In: Yanoff M, Duker JS, eds, Ophthalmology, 3rd ed. Philadelphia, PA, Mosby Elsevier, 2009; 484–492 5. Sippel KC, Pineda R. Phacoemulsification and thermal wound injury. Semin Ophthalmol 2002; 17:102–109 6. Khodabakhsh AJ, Zaidman G, Tabin G. Corneal surgery for severe phacoemulsification burns. Ophthalmology 2004; 111:332–334
J CATARACT REFRACT SURG - VOL 40, SEPTEMBER 2014
First author: Keshab Haldar, MD, FRCSEd Rotary Narayana Nethralaya, Kolkata, India
Closure technique for leaking wound resulting from thermal injury during phacoemulsification Keshab Haldar, MD, FRCSEd, Rashmi Saraff, MD, FRCSEd
We describe a method of wound closure with a conjunctival flap in cases of wound burn. A fornix-based conjunctival flap is raised to adequately cover the wound. Then, a single horizontal mattress suture with 10-0 monofilament nylon is passed to appose the wound. The conjunctival flap is hinged to the corneal end of the loop so the conjunctival flap covers the wound when the suture is tied. The wound is thus sealed by conjunctiva with optimum suture tension. This suture was applied in 5 patients with clear corneal incisions who developed wound burn during phacoemulsification. All had an uneventful recovery with a sealed wound from the first postoperative day and satisfactory visual outcomes with low residual astigmatism at the final refraction. Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2014; 40:1412–1414 Q 2014 ASCRS and ESCRS
Thermal injury to the sclerocorneal or clear corneal tunnel can occur during phacoemulsification. A large cross-sectional study conducted in the United States and Canada documented an incidence of 0.037%,1 and another study in the U.S. reported an incidence of 0.098%.2 Although the incidence is low, wound burn can be a serious complication. It is caused when the metallic phaco needle is overheated, and the heat is transmitted to the stromal tissue around the wound. An increase in tissue temperature beyond 60 C can cause acute tissue contracture and distortion, leading to loss of the self-sealing capacity of the wound.1 Although various techniques to close these wounds have been described, a wound burn is difficult to manage and can leave high residual astigmatism.3 This article describes a technique we have used to treat cases of wound burn.
Submitted: September 10, 2013. Final revision submitted: February 16, 2014. Accepted: February 19, 2014. From the Rotary Narayana Nethralaya, Kolkata, India. Corresponding author: Keshab Haldar, MD, FRCSEd, Rotary Narayana Nethralaya, CN 5, Sector V, Salt Lake, Kolkata, Pin code 700091, India. E-mail: [email protected].
1412
Q 2014 ASCRS and ESCRS Published by Elsevier Inc.
SURGICAL TECHNIQUE Step 1: Conjunctival Flap After the irrigation/aspiration is completed, the anterior chamber is formed with balanced salt solution. The wound is assessed. A fornix-based rectangular conjunctival flap is raised; it should cover the wound adequately. The flap is freed from the underlying Tenon. Step 2: Passing the Suture Two points are marked on the conjunctival flap (Figure 1, a and b). They should be a few millimeters apart and at least 2.0 mm from the free limbal margin. With a double-ended 10-0 monofilament nylon suture, a needle is passed through each conjunctival point from the epithelial side through the stromal side. Next, a corneoscleral bite through the wound is passed with 1 of the needles, from the corneal to the scleral side (Figure 1, c and d). The second corneoscleral bite is passed in the same direction with the other needle (Figure 1, e and f). The 2 bites should be parallel to form a mattress suture across the wound. The suture can also be placed with a single-arm suture. In this situation, 1 corneoscleral bite is taken from the limbal to the corneal side (Figure 1, d and c). After that, the 0886-3350/$ - see front matter http://dx.doi.org/10.1016/j.jcrs.2014.07.016
TECHNIQUE: CLOSURE FOR LEAKING WOUND FROM THERMAL INJURY
1413
Figure 1. Placement of the suture. The arrows show the free limbal margin of the conjunctival flap. Conjunctival bites (a and b), first corneoscleral bite (c and d), and second corneoscleral bite (e and f) are shown. The ends (d and f) are tied to complete the suture.
Figure 2. Appearance of the wound at the end of surgery.
suture is passed through the 2 points in the conjunctiva (Figure 1, a and b). The second corneoscleral bite is taken from the corneal to the limbal side (Figure 1, e and f).
DISCUSSION Wound burn can be a serious and devastating complication of phaco surgery. As it is caused by overheating of the phaco tip, care should be taken so the tip does not become too hot during surgery. The phaco machine and its attachments should be set up properly so a continuous flow is maintained around the tip during the procedure. Techniques such as phaco chop require less energy than trench divide-and-conquer and help keep the tip cool. Ophthalmic viscosurgical devices (OVD) can be a factor as use of ultrasound energy in an OVD-filled eye can release heat, causing wound burn.1 It is important to diagnose the condition at an early stage. Appearance of a milky white fluid around the phaco tip can be an early warning sign.4 As the tissue damage progresses, a white area appears in the stroma around the wound. Subsequent contracture of the tissue makes it impossible to achieve a watertight closure. Persistent dehiscence of the wound may give rise to other complications such as a flat anterior chamber and iris prolapse.4 Conventional treatment involves multiple interrupted sutures for wound closure. Postoperatively, small leaks can be managed by bandage contact lenses or tissue adhesives. Aqueous suppressants and frequent antibiotic drops may be needed and daily follow-ups required. If the wound continues to leak, a wound revision may be necessary.4 A special gape suture can be used.5 Subsequently, the patient may require treatment for high residual astigmatism. In severe cases, a corneal patch graft may be needed.6 We have described a technique that achieves a sealed wound at the end of surgery. Frequent follow-ups and
Step 3: Tying the Suture The suture is tied with adequate tension so the conjunctiva is pulled down to cover the gaping wound (Figure 1, d and f). The knot is automatically covered by the conjunctiva (Figure 2). RESULTS The closure technique was used in 5 eyes in 5 patients with wound burn during phacoemulsification. The patients were reviewed 1 day, 1 week, 2 weeks, 4 weeks, and 6 weeks postoperatively. Sutures were kept in place at least for 2 weeks. Between 2 and 4 weeks, when the wound looked secured, the sutures were removed. Final refraction was done at 6 weeks. All 5 patients had age-related cataract, grade III (2 patients) and grade IV (3 patients). The average age of the 4 men and 1 woman was 67 years. All cases had clear corneal incisions. Postoperatively, the corrected visual acuities were 6/6 in all cases. At the final refraction at 6 weeks, 1 patient had no residual astigmatism, 3 patients had 0.5 diopter (D) of residual astigmatism, and 1 patient had 1.0 D. Because the cataracts were advanced in all 5 cases, preoperative refractive data were not available. Postoperative recovery was uneventful in all cases.
J CATARACT REFRACT SURG - VOL 40, SEPTEMBER 2014
1414
TECHNIQUE: CLOSURE FOR LEAKING WOUND FROM THERMAL INJURY
Figure 3. In the early postoperative period, the “W” pattern is clearly visible. The central point of the “W” is hanging from the conjunctival flap.
extra medications are not necessary postoperatively. The technique induces very little residual astigmatism, and the vision remains clear from the early postoperative period. Considering these factors, we think this technique is better than other available techniques for treating wound burns during phacoemulsification. The suture can also be used to treat leaking wounds from other causes. The suture acts in 2 ways. First, the conjunctival flap covers the external opening of the wound directly and seals it. Second, it exerts an optimum pull to appose the wound. Postoperatively, as the conjunctiva tends to go back to its original position, the loop of the suture hinged to the conjunctiva is pulled up. This changes the rectangular shape of the mattress suture and gives the lower end a “W” shape (Figure 3). The central portion of the “W” hangs from the conjunctiva in the middle. The conjunctiva provides a spring-like suspension and exerts optimum apposing tension to keep the wound closed. As a result, the astigmatism remains low from the early postoperative period. We recommend suture removal after 1 month. After suture removal, the conjunctiva gradually retracts to the limbus (Figure 4). With this technique, it is possible to achieve predictable results in all cases. The suture can be modified according to the situation. By changing the width of the flap, a larger wound can be covered. By modifying the length and hinge points of the flap, the tension on the wound can be modified. To conclude, we feel that unless there is extensive tissue damage, this suture can successfully manage any wound burn and wound leak with comfortable postoperative recovery and a satisfactory visual outcome.
Figure 4. At 3 months, the conjunctiva has retracted to the limbus.
WHAT WAS KNOWN Usual practice in the case of a leaking wound during phacoemulsification is to close the wound with a suture. This may cause higher astigmatism postoperatively. WHAT THIS PAPER ADDS We describe a technique that uses a conjunctival flap hinged to a horizontal mattress suture to close a leaking wound. In addition to cases of wound burn, this suture is effective in cases of unstable corneoscleral wounds in which wound reinforcement is required. REFERENCES 1. Sorensen T, Chan CC, Bradley M, Braga-Mele R, Olson RJ. Ultrasound-induced corneal incision contracture survey in the United States and Canada. J Cataract Refract Surg 2012; 38:227–233 2. Bradley MJ, Olson RJ. A survey about phacoemulsification incision thermal contraction incidence and causal relationships. Am J Ophthalmol 2006; 141:222–224 3. Sugar A, Schertzer RM. Clinical course of phacoemulsification wound burns. J Cataract Refract Surg 1999; 25:688–692 4. Kohnen T, Wang L, Friedman NJ, Koch DD. Complications of cataract surgery. In: Yanoff M, Duker JS, eds, Ophthalmology, 3rd ed. Philadelphia, PA, Mosby Elsevier, 2009; 484–492 5. Sippel KC, Pineda R. Phacoemulsification and thermal wound injury. Semin Ophthalmol 2002; 17:102–109 6. Khodabakhsh AJ, Zaidman G, Tabin G. Corneal surgery for severe phacoemulsification burns. Ophthalmology 2004; 111:332–334
J CATARACT REFRACT SURG - VOL 40, SEPTEMBER 2014
First author: Keshab Haldar, MD, FRCSEd Rotary Narayana Nethralaya, Kolkata, India