Placing the Suture
We’re almost done. Believe it or not, however, these last steps can take up almost a third of the total time of surgery:
A single 10-0 Vicryl suture was then placed in the temporal corneal incision and the knot was buried in the corneal stroma.
These sutures are incredibly thin (about as thick as a strand of blond baby hair), difficult to work with (ever tried tying a knot of thin hair?), and expensive (about $15 per suture). Thus, suturing the incision is skipped by many surgeons.
No doubt you’ve seen advertisements for ‘no-stitch’ cataract surgery. It’s sexy not to place a suture. And, it probably isn’t necessary every time. If I am convinced beyond a doubt that the incision is watertight without the need for a suture then I won’t place one either.
There are many reasons given for not placing a suture as it (1) may result in irritation; (2) can result in surface bleeding aka a ‘sub-conjunctival hemorrhage;’ (3) might have to be removed in the office. Certainly no surgeon wants his or her patients to have a beet-red eye after surgery because a suture was placed. And, a sub-conjunctival hemorrhage can look awful: ‘what happened to your eye!’ is another phrase surgeons don’t want their patients to hear (it makes for bad advertising).
Additionally, as mentioned above, suturing is time consuming and expensive. Placing a suture can add five minutes to the time of surgery. This may not sound like much, but consider this: my average cataract surgery without placing a suture lasts 12-14 minutes. By placing a suture I have just increased my surgery time by almost 40%. Believe it or not, with the downward pressure on cataract surgery reimbursement (it is now about 1/10th of what it was in the 1970s) the only way for a surgeon and surgery center to make ends meet is to be efficient.
I like performing surgery and insurance companies know that most cataract surgeons would do this as a hobby. Thus, as long as I am not losing money on my surgery I’ll keep doing it. And, as long as my surgery center allows, I’ll keep placing a suture when I think it is needed. Why? Because placing a suture may decrease the risk of infection. I mentioned earlier that infection is one of the few things that can result in a loss of vision (or even blindness). If I can reduce the risk of infection from 1 in 500 to 1 in 1,000 or 2,000 then I will.
To date I have performed over 2,000 cataract surgeries without a single case of acute endophthalmitis (early infection of the eye). Most published studies on endophthalmitis report rates of 1 in 500 to 1 in 1,000. I believe part of the reason my patients have avoided this complication is my meticulous attention to incision closure and use of a suture when I feel it would benefit the integrity of the incision.
One more post to go…
© 2009 David Richardson, MD