“Sutureless cataract surgery” simply sounds good to many uninformed patients so it’s marketed as a “benefit”…

I’ve been convinced of the merit of suturing the cataract surgery incision since 2004.  At that time Peter J. McDonnell, M.D.  tested clear corneal incisions on cadaver eyes and found that they leaked without a suture.  Despite this evidence of the need to close the incision, it’s not been easy maintaining this preference as there are many pressures on cataract surgeons to avoid the use of a suture.  Some of these include:

  • Cost – Hospitals and Ambulatory Surgery Centers (ASCs) generally prefer not to open a suture packet as they can be expensive
  • Time – It takes extra time to place a suture (as much as 20% of the time to perform cataract surgery).
  • Marketing – “Sutureless cataract surgery” simply sounds good to many uninformed patients so it’s marketed as a “benefit”
  • Appearance – Placing a suture can result in a subconjunctival hemorrhage (a small bleed on the white part of the eye) which doesn’t look good.  A surgeon who places a suture risks having someone say to his or her patient, “When I had my cataract surgery my eye looked like nothing had been done to it.  Your eye looks awful!  Are you sure your surgeon is competent?”
  • Irritation – Occasionally the sutures can break resulting in a scratchy sensation in the eye.
  • Astigmatism – If the suture is tight it can result in astigmatism (though this can be relieved by removing the suture in the office a week or so after surgery).
  • Surgeon’s Reputation – Among eye surgeons, respect increases with the speed of your surgery and the fewer steps you take.  Because suturing takes extra time it destroys one’s ability to boast, “I can take out a cataract in [fill in some ridiculously short time here]”

Nevertheless, I believe the safety of my patients comes first and do not want to take any shortcuts that could increase the risk of a sight-threatening endophthalmitis (eye infection).  Sure, it means I can’t win at the cataract surgery version of Name That Tune – oh well.  Finally, however, there is a study that confirms that not only cadaver eyes leak, but so do the eyes of living humans when they are not sutured closed.

This week at the American Academy of Ophthalmology, John A. Hovanesian, MD, FACS presented a poster confirming that fully one-third (33%) of sutureless corneal wounds leak after cataract surgery with only one ounce of pressure on the eye!  An ounce is about as much as would be expected from tightly closing ones eyelids.  In my mind this is an unacceptably high rate of wound leakage and clearly justifies the use of a suture to close the cataract surgery incision.

Of note, however, is that the study was sponsored by Ocular Therapeutix and Dr. Hovanesian is a consultant for, has received lecture fees and grant support from, and is an equity owner of Ocular Therapeutix (which manufactures the ReSure® sealant currently under study for use during cataract surgery as an alternative to sutures).  Biased?  Perhaps, but the results make sense and have the support of the prior study performed by Dr. McDonnell.

References:

Sarayba MA, Taban M, Ignacio TS, Behrens A, McDonnell PJ: Inflow of ocular surface fluid through clear corneal cataract incisions: A laboratory model. Am J Ophthalmol 138:206-210, 2004.

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