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79 EW INTERNATIONAL by Matt Young and Gloria D. Gamat EyeWorld Contributing Writers visual results are better," he ex- plained. In DSAEK and DMEK, the advantages of sutureless attachment of the donor cornea tissue to the recipient cornea leads to faster visual rehabilitation, better vision, and lower refractive errors. "The sutureless technique avoids ocular surface and suture-re- lated problems such as irritation, broken sutures and risk of infection, thereby resulting in greater wound strength and reduced postoperative irregularity and astigmatism," Dr. Ang said. Through the years, other modalities have been suggested by experts as alternative procedures in wound closure of corneal incisions, including tissue adhesives and tem- perature-controlled photothermal welding. In the U.S., the Food and Drug Administration (FDA) has recently approved a polyethylene glycol (PEG) hydrogel (ReSure Sealant, Ocular Therapeutix, Bedford, Mass.) for the indication of sealing corneal incisions smaller than 3.5 mm in cataract surgery. Furthermore, the off-label use of this PEG hydrogel in sealing corneal incisions and maintaining air in the anterior chamber has been found to potentially shorten surgery, decrease suture-induced corneal astigmatism, and obviate the need for suture re- moval in DSEK as well as combined DSEK/cataract surgery procedures. "Modern methods of cornea surgery include the use of smaller incisions and methods that reduce the need for sutures; these advances have enabled patients to enjoy faster recovery, better visual results, greater comfort, greater safety, and less com- plications," Dr. Ang concluded. EW Reference Theodoulidou S, et al. The role of sideport incision in astigmatism change after cataract surgery. Clin Ophthalmol. 2015;5(9):1421–8. Editors' note: Dr. Ang has no financial interests related to this article. Contact information Ang: leopk12@gmail.com Due to the advantages provid- ed by sutureless attachment of the donor cornea (or "sutureless graft attachment") in DSAEK and DMEK, Dr. Ang emphasized that patients will benefit from faster visual reha- bilitation. (Using "sutureless graft at- tachment" is technically more accu- rate than "sutureless surgery," as the procedures require sutures to close the scleral tunnel through which the posterior lamella or endothelium is inserted. But because the sutures are at the sclera, which is covered by the conjunctiva, this does not result in the problems caused by sutures on the cornea in penetrating kerato- plasty.) "The main advantage of suture- less DSAEK or DMEK is that it avoids ocular surface and suture-related problems, thus resulting in greater wound strength and reduced post- operative irregularity and astigma- tism," he explained. There are only a few occa- sions when patients are unsuitable for sutureless wound closure in phacoemulsification surgery. "Sometimes the wound does not appose well, which may occur if the surgery is more prolonged or if there is a cornea burn," Dr. Ang said. In this case, according to Dr. Ang, a single suture is usually sufficient to appose the wound. Future of wound closure in corneal incisions The application of sutures may be the standard for sealing corneal inci- sions and wound repair mainly due to the efficiency and strength, but it is not necessarily the best method. A number of corneal surgeons have recognized the complications that come with using sutures: induced astigmatism, potential infection, and neovascularization. The innovations in ophthal- mic surgery are rapidly progressing. In the process, the incisions are becoming smaller and smaller. There are numerous advantages to a small wound, Dr. Ang said. "The wound is more stable [when smaller], there is less chance of wound leak, less chance of infec- tion, it is more stable following trauma, the recovery is faster, and "For DSAEK and DMEK, an air bubble is injected into the anteri- or chamber for a few minutes to enhance adherence of the posterior lamellar to the inner layer of the recipient cornea," he said. Impact on patient outcomes Clear corneal incisions enable a decrease in surgical time, offer faster postoperative recovery, and most importantly, lower induced astig- matism compared to scleral tunnel incisions. In congenital cataract surgery, researchers have found that scler- al tunnel incisions have a higher induced astigmatism than clear corneal incisions at all time points. On the other hand, when investigat- ed in adults, investigators found that astigmatism can be minimized with sutureless clear corneal incisions. More recent findings on reduc- ing induced astigmatism in cataract surgery include a proposal in Clinical Ophthalmology to surgeons that operate only from the superior posi- tion; in order to produce an incision that is as "astigmatically neutral" as possible, the side-port incision should be performed at a 90-degree to 110-degree distance. In addition, scientific literature suggests that "paired opposite" clear corneal incisions are an effective method for cutting down on pre-existing corne- al astigmatism in cataract surgery. "For phacoemulsification surgery, sutureless surgery allows the operation to be astigmatically neutral," Dr. Ang said. "An astig- matically neutral surgery is more predictable and allows us to achieve more ideal visual outcomes with the use of premium lenses such as multi- focal lenses or toric lenses." In Singapore, Dr. Ang is ex- tensively using sutureless surgery in his clinical practice, not just in phacoemulsification. "The other procedure that has improved results because of the lesser need for sutures is posterior lamellar keratoplasty such as DSAEK and DMEK," he said. "The posterior lamella (comprising the posterior cornea stroma and Descemet's mem- brane) or the endothelium alone is secured in place without the need for sutures." Advantages of clear corneal incisions abound in phacoemulsification, DSAEK, and DMEK S utureless clear corneal cataract incisions have increasingly gained popu- larity worldwide since the procedure was introduced in cataract surgery and their use for corneal transplants arrived on the international scene. "At the end of surgery, a little hydration of the wound allows the wound to appose very well without any wound leak, so there is no need for stitches; the wound is self-heal- ing," said Leonard Ang Pek Kiang, MD, medical director and senior consultant ophthalmologist, Lang Eye Centre, Mount Elizabeth Novena Hospital, Singapore. Today, the same sutureless procedure also can be applied to posterior lamellar keratoplasty such as Descemet's stripping automated endothelial keratoplasty (DSAEK) and/or Descemet's membrane endo- thelial keratoplasty (DMEK), Dr. Ang noted. November 2015 No suture in the future T opical anesthetic with no sutures was state of the art for cataract surgery in 1915. Using cocaine solution for comfort and 10 days of postop bed rest with sand bags, it was possible to remove a cataract. At the time, this was nothing less than the miracle of restoring sight to the blind. One hundred years later, cataract surgeons around the world have circled back to topical anesthetic and sutureless surgery. It is with interest that we see old concepts improved upon, supported by new technology, and used to benefit our patients. Sutureless cataract and now corneal surgery have become the new normal. Thankfully, the sand bags are gone forever. John A. Vukich, MD, international editor International outlook

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