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Denuding the Cornea in Cataract Surgery*
NOTES, CASES, INSTRUMENTS
230
thinning. In addition, the buccal area from which the graft has been taken does not re quire sutures, but is epithelized within a few days. The patient suffers little discom fort, and the lip is left with no trace of the dissection or at least an area of cicatrization which is unnoticeable. The grafts also heal in the recipient eye with very little scar for mation and in a few months assume the char acter of almost normal conjunctiva. 9 East 91st Street (28).
DENUDING THE CORNEA IN CATARACT SURGERY* L. J. ALGER,
M.D.
Pasadena, Texas
Evidently my idea of denuding the cornea in cataract surgery, that is, removing the epithelium along the edge of the corneal in cision in order to prevent epithelial downgrowth has been thought of by others but no one has reported trying it. In an extensive and detailed symposium on cataract surgery7 presented at the 1954 session of the American Academy of Oph thalmology and Otolaryngology, someone asked the question, "to prevent epithelial downgrowth, would it be helpful to scrape away the epithelium at the limbal area before inserting sutures or making a corneal sec tion? A fornix-based flap is recommended to cover this disnuded area." Frederick Davis was asked to reply and he said, "Denuding the epithelium of the cornea at the limbal area of the incision would induce adhesion of the conjunctiva to the cornea if a fornixbased flap were drawn down and sutured firmly over it. The flap would likely produce some permanent disfigurement of the upper limbal border which might prove objec tionable to some patients." At that time, I had been using this very method for eight years and had not noticed * Read at the annual meeting of the Texas State Ophthalmological Society, April 22, 1958.
the occurrence of any noticeable disfigure ment. It is the purpose of this paper to pre sent a series of 257 cases in which I have used this method. When I began using absorbable sutures in cataract surgery, I first tried chromic su tures, but they are extremely slow in absorb ing and often had to be removed the same as silk sutures. I then tried plain 4-0 catgut and found that, by using the Stallard suture (often called the Liegard or Kalt), I could use this coarse 4-0 plain suture very easily. Before long, however, I had two cases that developed what appeared to be epithelial downgrowth and, for that reason, I consid ered abandoning this suture. Apparently others have had unhappy ex periences with this suture. Goar1 says he "once adopted the Stallard suture so the wound could be closed easily," but he dis carded it because "a mattress suture may turn the edges of the wound in and this is a pro lific source of epithelial downgrowth." Epithelial invasion of the anterior cham ber is not, however, a condition limited to the use of the Stallard suture. It is a grave and malignant complication found in all methods of cataract surgery. It seems to be increasing rather than decreasing in fre quency and often is found even when long and painstaking care has been used in clos ing the operative wound with any of the known methods of corneoscleral sutures. Pincus2 reported five cases in two years' time, all with corneoscleral sutures of vari ous types, one with a fornix-based flap and the other four with no flap. Calhoun3 re ported 17 cases in which the technique varied from little or no suture to three corneoscleral sutures. Berliner4 reported nine cases. None of them had conjunctival flaps; in all Kirby and Stallard sutures were used. Theobald and Haas 5 reported 14 cases, six with corneal incisions, three with fornixbased flaps and Verhoeff corneoscleral su tures. Nine had small limbus-based flaps not covering the wound at the sides. Both Ber liner and Theobald and Haas recommend a
NOTES, CASES, INSTRUMENTS large limbus-based flap with an apron suffi ciently broad so that the base covers the en tire edge of the corneal incision. They are willing, apparently, to sacrifice corneoscleral sutures and risk the complications of a col lapsed anterior chamber, a prolapsed iris, and more frequent hyphema, and forego a means of quickly closing the corneal wound after delivery of the lens. They risk these complications to avoid the danger of epi thelial downgrowth. I did not wish to abandon corneoscleral sutures so I decided to try something new in an attempt to avoid epithelial invasion. I de cided to denude the cornea of epithelium for two or three mm. along the edge of the corneal wound. I commenced by freeing the flap from the limbus then, using a Gill knife, thoroughly denuding the cornea and limbus for about three mm. all along the edge of the wound. I then placed the Stallard suture in the conventional manner, bringing the ends through the fornix-based flap. The incision was made with a von Graefe knife and often enlarged with scissors. The cataract was re moved, the flap and corneal incision tied into the Stallard suture, and the remainder of the wound entirely covered by means of two plain 4-0 gut sutures, one on either side bit ing into the flap and then into the conjunc tiva near the limbus. The results were most gratifying. The conjunctival flap adhered to the raw cornea almost immediately and soon joined its con junctiva to that of the cornea to make a com pletely sealed wound. I now have used this technique in 257 cases in my private practice without a single case even appearing to have an epithelial downgrowth.* After using this technique, I discovered that avoiding epithelial downgrowth was only one of the advantages to be gained from de nuding the cornea. There was far less intra* Often there will be difficulty differentiating be tween epithelial downgrowth and fibroblastic in growth. Swan 6 gives an excellent description of these two conditions and clearly defines their differentiat ing characteristics.
231
ocular inflammation. By denuding the cornea and covering the entire incision with a flap, the entire area became at once a well sealedoff wound—almost as well sealed from in fection from the outside as is the peritoneal cavity following an abdominal closure. There were no panophthalmitis cases in the series, and only a moderate number of cases of iritis. The anterior chamber usually formed at once. That the wound was well sealed off from the conjunctival secretion was evident from the fact that often an edematous bleb, similar to a filtering trephination bleb, formed beneath the conjunctiva. As healing progressed, this bleb disappeared and the conjunctiva flattened and retracted. There was a surprisingly low incidence of hyphema (only two in 257 cases). The un usually low incidence of hyphema merits dis cussion. Hyphema has always been an an noying, dangerous, and, at times, a serious complication of cataract surgery. It is well known that leaving blood in the anterior chamber at the time of surgery does little or no harm. However, later—from three to eight days following surgery—hemorrhage presents a serious problem. Unless the blood is removed or completely dissolved within a few days, glaucoma will follow. Hughes had hyphema in 20 percent of his series of 453 cases. He did not feel that the type of suture was important. Stallard,8 how ever, thought that the type of suture was very important. He had 30 to 35 percent of hyphema cases before using his suture. After using it, he did 107 cases without a single hemorrhage. Phillips, using the Stallard su ture, has reported 120 consecutive cases without a hemorrhage. Peters was not so fortunate. He says, "the freedom from post operative hemorrhage since adopting this (the Stallard) suture has not been my for tune. I see it with unpleasant frequency in spite of this or any other suture." Verhoeff,9 McLean,10 Kirby, 11 Lehfeld and Donnelly,12 and Leech and Sugar13 say that the incidence of hyphema was reduced by corneoscleral sutures as against no cor-
232
NOTES, CASES, INSTRUMENTS
neoscleral sutures. ( I n each report, the author was describing his own suture.) Devoe reported as many intraocular hemor rhages when using the corneoscleral sutures as when using conjunctival sutures—20 per cent of 453 cases. Vail found hyphema rare in corneal sec tions, as does R a y K. Daily. 14 Since the Stallard suture is often placed well into the cornea, this may account for the fact that hy phema has been such a rare occurrence in my series of cases. The firm adherence of the conjunctival flap to the cornea may also be significant in preventing hyphema. After a cataract operation performed as I have described, the wound will leak but not to the surface. It will leak beneath the con junctiva, forming a bleb. As healing takes place, this bleb disappears. Chandler ( 1 9 4 7 ) , Reese (1948), Leahey ( 1 9 5 1 ) , and Dunnington (1946) disagree with those who be lieve that injection of air is sufficient to cure a flat anterior chamber. This puzzles me for usually air injection has worked well in this series. This is perhaps due to the fact that, although there occasionally is sufficient wound leakage in this technique to allow the chamber to remain flat, nevertheless, this leakage is subconjunctival, and, therefore, air will not leak out when injected. Ordinar ily, following air injection, the wound will heal spontaneously when given time.
SUMMARY
Denuding the cornea of epithelium for two or three mm. along the line of the corneal in cision has been considered by other sur geons as a means of avoiding epithelial downgrowth. However, it was feared that denuding the cornea of epithelium and cov ering the area with a flap would cause dis figurement along the upper border of the cornea. A series of 257 cases is presented here which shows that this disfigurement does not occur. The wound heals cleanly, and the method has been effective in avoiding epithelization of the anterior chamber. Other advantages of the technique a r e : 1. The wound is tightly closed and the in terior of the eye is sealed from infection from without. 2. N o cases of panophthalmitis have oc curred, and there has been very little intra ocular inflammation. 3. Hyphema occurs very rarely. There were only two cases of hyphema in this ser ies of 257 cases as compared with an average of 20 percent reported by various authors using other methods. 4. The anterior chamber forms rapidly. 5. Cases of collapsed anterior chamber usually are readily repaired with air injec tion. Pasadena
Professional
Building.
REFERENCES
1. Goar, E. L.: Am. I. Ophth., 36:1245, 1949. 2. Pincus, M.: Arch. Ophth., 43:509-519 (Mar.) 1950. 3. Calhoun, F. P., Jr.: Clinical recognition of epithelization of the anterior chamber following extraction. Tr. Am. Ophth. Soc, 47:498-553, 1949. 4. Berliner, M.: X V I I Internat. X V L Cong. Ophth., 2:1123-1321, 1955. 5. Theobald, G. D , and Haas, J.: Tr. Am. Acad. Ophth., 52:470, 1948. 6. Swan, K. C : Arch. Ophth., 45:630-644 (June) 1951. 7. Tr. Am. Acad. Ophth., May-June, 1954, p. 415. 8. Stallard, W.: A corneoscleral suture in cataract extractions. Brit. J. Ophth., 22:269, 1938. 9. Verhoeff, F. H.: Tr. Am. Ophth. Soc, 25:48, 1927. 10. McLean, J. M.: A new corneoscleral suture. Arch. Ophth., 23:554 (Mar.) 1940. 11. Kirby, D.: Arch. Ophth, 25:866 (Mar.) 1941. 12. Lehrfeld, L , and Donnelly, E. J.: Arch. Ophth., 24:401 (Aug.) 1940. 13. Leech, V. M , and Sugar, H. S.: Ibid. 14. Daily, R. K.: Personal communication.
cataract
230
thinning. In addition, the buccal area from which the graft has been taken does not re quire sutures, but is epithelized within a few days. The patient suffers little discom fort, and the lip is left with no trace of the dissection or at least an area of cicatrization which is unnoticeable. The grafts also heal in the recipient eye with very little scar for mation and in a few months assume the char acter of almost normal conjunctiva. 9 East 91st Street (28).
DENUDING THE CORNEA IN CATARACT SURGERY* L. J. ALGER,
M.D.
Pasadena, Texas
Evidently my idea of denuding the cornea in cataract surgery, that is, removing the epithelium along the edge of the corneal in cision in order to prevent epithelial downgrowth has been thought of by others but no one has reported trying it. In an extensive and detailed symposium on cataract surgery7 presented at the 1954 session of the American Academy of Oph thalmology and Otolaryngology, someone asked the question, "to prevent epithelial downgrowth, would it be helpful to scrape away the epithelium at the limbal area before inserting sutures or making a corneal sec tion? A fornix-based flap is recommended to cover this disnuded area." Frederick Davis was asked to reply and he said, "Denuding the epithelium of the cornea at the limbal area of the incision would induce adhesion of the conjunctiva to the cornea if a fornixbased flap were drawn down and sutured firmly over it. The flap would likely produce some permanent disfigurement of the upper limbal border which might prove objec tionable to some patients." At that time, I had been using this very method for eight years and had not noticed * Read at the annual meeting of the Texas State Ophthalmological Society, April 22, 1958.
the occurrence of any noticeable disfigure ment. It is the purpose of this paper to pre sent a series of 257 cases in which I have used this method. When I began using absorbable sutures in cataract surgery, I first tried chromic su tures, but they are extremely slow in absorb ing and often had to be removed the same as silk sutures. I then tried plain 4-0 catgut and found that, by using the Stallard suture (often called the Liegard or Kalt), I could use this coarse 4-0 plain suture very easily. Before long, however, I had two cases that developed what appeared to be epithelial downgrowth and, for that reason, I consid ered abandoning this suture. Apparently others have had unhappy ex periences with this suture. Goar1 says he "once adopted the Stallard suture so the wound could be closed easily," but he dis carded it because "a mattress suture may turn the edges of the wound in and this is a pro lific source of epithelial downgrowth." Epithelial invasion of the anterior cham ber is not, however, a condition limited to the use of the Stallard suture. It is a grave and malignant complication found in all methods of cataract surgery. It seems to be increasing rather than decreasing in fre quency and often is found even when long and painstaking care has been used in clos ing the operative wound with any of the known methods of corneoscleral sutures. Pincus2 reported five cases in two years' time, all with corneoscleral sutures of vari ous types, one with a fornix-based flap and the other four with no flap. Calhoun3 re ported 17 cases in which the technique varied from little or no suture to three corneoscleral sutures. Berliner4 reported nine cases. None of them had conjunctival flaps; in all Kirby and Stallard sutures were used. Theobald and Haas 5 reported 14 cases, six with corneal incisions, three with fornixbased flaps and Verhoeff corneoscleral su tures. Nine had small limbus-based flaps not covering the wound at the sides. Both Ber liner and Theobald and Haas recommend a
NOTES, CASES, INSTRUMENTS large limbus-based flap with an apron suffi ciently broad so that the base covers the en tire edge of the corneal incision. They are willing, apparently, to sacrifice corneoscleral sutures and risk the complications of a col lapsed anterior chamber, a prolapsed iris, and more frequent hyphema, and forego a means of quickly closing the corneal wound after delivery of the lens. They risk these complications to avoid the danger of epi thelial downgrowth. I did not wish to abandon corneoscleral sutures so I decided to try something new in an attempt to avoid epithelial invasion. I de cided to denude the cornea of epithelium for two or three mm. along the edge of the corneal wound. I commenced by freeing the flap from the limbus then, using a Gill knife, thoroughly denuding the cornea and limbus for about three mm. all along the edge of the wound. I then placed the Stallard suture in the conventional manner, bringing the ends through the fornix-based flap. The incision was made with a von Graefe knife and often enlarged with scissors. The cataract was re moved, the flap and corneal incision tied into the Stallard suture, and the remainder of the wound entirely covered by means of two plain 4-0 gut sutures, one on either side bit ing into the flap and then into the conjunc tiva near the limbus. The results were most gratifying. The conjunctival flap adhered to the raw cornea almost immediately and soon joined its con junctiva to that of the cornea to make a com pletely sealed wound. I now have used this technique in 257 cases in my private practice without a single case even appearing to have an epithelial downgrowth.* After using this technique, I discovered that avoiding epithelial downgrowth was only one of the advantages to be gained from de nuding the cornea. There was far less intra* Often there will be difficulty differentiating be tween epithelial downgrowth and fibroblastic in growth. Swan 6 gives an excellent description of these two conditions and clearly defines their differentiat ing characteristics.
231
ocular inflammation. By denuding the cornea and covering the entire incision with a flap, the entire area became at once a well sealedoff wound—almost as well sealed from in fection from the outside as is the peritoneal cavity following an abdominal closure. There were no panophthalmitis cases in the series, and only a moderate number of cases of iritis. The anterior chamber usually formed at once. That the wound was well sealed off from the conjunctival secretion was evident from the fact that often an edematous bleb, similar to a filtering trephination bleb, formed beneath the conjunctiva. As healing progressed, this bleb disappeared and the conjunctiva flattened and retracted. There was a surprisingly low incidence of hyphema (only two in 257 cases). The un usually low incidence of hyphema merits dis cussion. Hyphema has always been an an noying, dangerous, and, at times, a serious complication of cataract surgery. It is well known that leaving blood in the anterior chamber at the time of surgery does little or no harm. However, later—from three to eight days following surgery—hemorrhage presents a serious problem. Unless the blood is removed or completely dissolved within a few days, glaucoma will follow. Hughes had hyphema in 20 percent of his series of 453 cases. He did not feel that the type of suture was important. Stallard,8 how ever, thought that the type of suture was very important. He had 30 to 35 percent of hyphema cases before using his suture. After using it, he did 107 cases without a single hemorrhage. Phillips, using the Stallard su ture, has reported 120 consecutive cases without a hemorrhage. Peters was not so fortunate. He says, "the freedom from post operative hemorrhage since adopting this (the Stallard) suture has not been my for tune. I see it with unpleasant frequency in spite of this or any other suture." Verhoeff,9 McLean,10 Kirby, 11 Lehfeld and Donnelly,12 and Leech and Sugar13 say that the incidence of hyphema was reduced by corneoscleral sutures as against no cor-
232
NOTES, CASES, INSTRUMENTS
neoscleral sutures. ( I n each report, the author was describing his own suture.) Devoe reported as many intraocular hemor rhages when using the corneoscleral sutures as when using conjunctival sutures—20 per cent of 453 cases. Vail found hyphema rare in corneal sec tions, as does R a y K. Daily. 14 Since the Stallard suture is often placed well into the cornea, this may account for the fact that hy phema has been such a rare occurrence in my series of cases. The firm adherence of the conjunctival flap to the cornea may also be significant in preventing hyphema. After a cataract operation performed as I have described, the wound will leak but not to the surface. It will leak beneath the con junctiva, forming a bleb. As healing takes place, this bleb disappears. Chandler ( 1 9 4 7 ) , Reese (1948), Leahey ( 1 9 5 1 ) , and Dunnington (1946) disagree with those who be lieve that injection of air is sufficient to cure a flat anterior chamber. This puzzles me for usually air injection has worked well in this series. This is perhaps due to the fact that, although there occasionally is sufficient wound leakage in this technique to allow the chamber to remain flat, nevertheless, this leakage is subconjunctival, and, therefore, air will not leak out when injected. Ordinar ily, following air injection, the wound will heal spontaneously when given time.
SUMMARY
Denuding the cornea of epithelium for two or three mm. along the line of the corneal in cision has been considered by other sur geons as a means of avoiding epithelial downgrowth. However, it was feared that denuding the cornea of epithelium and cov ering the area with a flap would cause dis figurement along the upper border of the cornea. A series of 257 cases is presented here which shows that this disfigurement does not occur. The wound heals cleanly, and the method has been effective in avoiding epithelization of the anterior chamber. Other advantages of the technique a r e : 1. The wound is tightly closed and the in terior of the eye is sealed from infection from without. 2. N o cases of panophthalmitis have oc curred, and there has been very little intra ocular inflammation. 3. Hyphema occurs very rarely. There were only two cases of hyphema in this ser ies of 257 cases as compared with an average of 20 percent reported by various authors using other methods. 4. The anterior chamber forms rapidly. 5. Cases of collapsed anterior chamber usually are readily repaired with air injec tion. Pasadena
Professional
Building.
REFERENCES
1. Goar, E. L.: Am. I. Ophth., 36:1245, 1949. 2. Pincus, M.: Arch. Ophth., 43:509-519 (Mar.) 1950. 3. Calhoun, F. P., Jr.: Clinical recognition of epithelization of the anterior chamber following extraction. Tr. Am. Ophth. Soc, 47:498-553, 1949. 4. Berliner, M.: X V I I Internat. X V L Cong. Ophth., 2:1123-1321, 1955. 5. Theobald, G. D , and Haas, J.: Tr. Am. Acad. Ophth., 52:470, 1948. 6. Swan, K. C : Arch. Ophth., 45:630-644 (June) 1951. 7. Tr. Am. Acad. Ophth., May-June, 1954, p. 415. 8. Stallard, W.: A corneoscleral suture in cataract extractions. Brit. J. Ophth., 22:269, 1938. 9. Verhoeff, F. H.: Tr. Am. Ophth. Soc, 25:48, 1927. 10. McLean, J. M.: A new corneoscleral suture. Arch. Ophth., 23:554 (Mar.) 1940. 11. Kirby, D.: Arch. Ophth, 25:866 (Mar.) 1941. 12. Lehrfeld, L , and Donnelly, E. J.: Arch. Ophth., 24:401 (Aug.) 1940. 13. Leech, V. M , and Sugar, H. S.: Ibid. 14. Daily, R. K.: Personal communication.
cataract