Eyeworld

38 | EYEWORLD | JANUARY/FEBRUARY 2020 SKILL FOCUS ATARACT C by Rich Daly Contributing Writer Common causes of leaking incisions in- clude wounds that are too short, wounds with irregular edges, and longer surgical cases associ- ated with increased manipulation and distortion of the wound. When incision closure help is needed Routine cataract cases rarely require extra help sealing an incision, but if a patient has vitreous loss or a history of endophthalmitis in the oth- er eye, Dr. Donaldson always places a suture. Other patients who can benefit from post- op incision sutures include: • Patients with continued leakage from the wound or thinning of the cornea at the limbus; • Patients with a history of radial keratotomy (RK); and • Patients with severe intraoperative floppy iris syndrome (IFIS). "If there is a small amount of leakage in these patients, the iris may become incarcer- ated in the wound causing a peaked pupil and increasing the risk for cystoid macular edema," Dr. Donaldson said about severe IFIS patients. When using sutures, some surgeons bury the knot, but Dr. Hovanesian usually doesn't because he removes the 10-0 nylon 1 day post- op. "Usually the epithelium is sealed over the outside of the incision in 1 day, if you use the suture," Dr. Hovanesian said. "At that point, the incision is more or less leak-proof." Using surgical glue Another wound sealing option is the ReSure Sealant (Ocular Therapeutix), which is FDA approved for cataract wounds. The hydrogel material is designed to be painted on an exter- nal wound at the end of surgery, dissolving and hydrolyzing over several days to provide time for the wound to self-seal. "The material is easy to use, it can be stored in the operating room for months, and is clinically proven to work better than sutures at sealing incisions," said Dr. Hovanesian, who served on the clinical trials for the sealant. EyeWorld is introducing a new column to run in addition to the Device Focus and Pharmaceutical Focus columns. The Skill Focus column will take a look at specific procedures and techniques, offering expert insights and pearls for perfecting this skill. S urgeons continue to evolve their ap- proach to creating and sealing corneal incisions for cataract surgery. The main component to creating a well-sealed incision is the wound architecture used by the surgeon, said John Hovanesian, MD. Surgeons commonly use either a two- or three-plane incision. The straightforward two-plane incision in- cludes a cut from the limbus in the clear cornea toward the central cornea progressively becom- ing deeper as the blade advances and tilting it posteriorly near the end of the cut to form a second plane in the incision. The approach effectively creates an internal valve that closes. In the three-plane technique, before making the incision through the cornea, a vertical cut is made near the limbus to obtain depth in the cornea. In the deepest part of the incision, the blade advances toward the central cornea and creates a second then third plane. "Those can both work well," Dr. Hovane- sian said. "Generally, you want to have a little bit of length in the incision so that provides a greater valve size, and it provides a mechanical advantage for intraocular pressure to close the wound." Kendall Donaldson, MD, who uses a blade to create a three-plane incision, used to use a femtosecond laser to create incisions. "However, I later reverted to using a blade to make my primary incisions during femto cases, as the femto wounds were a little more difficult to close," Dr. Donaldson said. Causes of leaking wounds Dr. Donaldson checks for wound leakage post- op with a Weck-Cel sponge. "Typically, that is all that is necessary, as I can visualize any leakage from the wound," Dr. Donaldson said. Keys to sealing phaco corneal incisions About the doctors John Hovanesian, MD Clinical assistant professor UCLA Jules Stein Institute Los Angeles, California Kendall Donaldson, MD Medical director Bascom Palmer Eye Institute Plantation, Florida Relevant disclosures Hovanesian: Ocular Therapeutix Donaldson: Alcon, Bausch + Lomb, Johnson & Johnson Vision

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