November 2015




International outlook

No suture in the future

by Matt Young and Gloria D. Gamat EyeWorld Contributing Writers


Topical 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


Advantages of clear corneal incisions abound in phacoemulsification, DSAEK, and DMEK

Sutureless clear corneal cataract incisions have increasingly gained popularity 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-healing, 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 Descemets stripping automated endothelial keratoplasty (DSAEK) and/or Descemets membrane endothelial keratoplasty (DMEK), Dr. Ang noted. For DSAEK and DMEK, an air bubble is injected into the anterior 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 astigmatism compared to scleral tunnel incisions. In congenital cataract surgery, researchers have found that scleral tunnel incisions have a higher induced astigmatism than clear corneal incisions at all time points. On the other hand, when investigated in adults, investigators found that astigmatism can be minimized with sutureless clear corneal incisions.

More recent findings on reducing induced astigmatism in cataract surgery include a proposal in Clinical Ophthalmology to surgeons that operate only from the superior position; 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 corneal astigmatism in cataract surgery.

For phacoemulsification surgery, sutureless surgery allows the operation to be astigmatically neutral, Dr. Ang said. An astigmatically neutral surgery is more predictable and allows us to achieve more ideal visual outcomes with the use of premium lenses such as multifocal lenses or toric lenses. In Singapore, Dr. Ang is extensively 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 Descemets membrane) or the endothelium alone is secured in place without the need for sutures. Due to the advantages provided 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 rehabilitation. (Using sutureless graft attachment is technically more accurate 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 keratoplasty.) The main advantage of sutureless DSAEK or DMEK is that it avoids ocular surface and suture-related problems, thus resulting in greater wound strength and reduced postoperative irregularity and astigmatism, he explained. There are only a few occasions 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 incisions 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 ophthalmic 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 infection, it is more stable following trauma, the recovery is faster, and visual results are better, he explained. 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-related 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 temperature-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 removal 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 complications, Dr. Ang concluded.


Theodoulidou S, et al. The role of sideport incision in astigmatism change after cataract surgery. Clin Ophthalmol. 2015;5(9):14218.

Editors note: Dr. Ang has no financial interests related to this article.

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