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Gone are the days when standard
cataract surgery included a retrobulbar injection, a superior scleral wound with multiple
nylon sutures, and a gauze pad that
covered the eye until morning. Today’s surgeons are able to operate without performing any of these tasks. While this has been seen by most ophthalmologists as a significant improvement, are some doctors making a mistake in advertising the “no stitch/no needle/no patch” surgery?
No stitch? The rate of endophthalmitis following cataract surgery increased from 0.087% in the 1990s to 0.265% in the 2000-2003 period and clear corneal incisions were proven to carry relative risk of 2.55 over scleral tunnel incisions1. Herretes et al2 demonstrated that these wounds are not always “self-sealing”; following hydration of the corneal wound, slight pressure on the globe simulating patient manipulation led to influx of blood tinged tear film through the wound. Fortunately rates have now stabilized and as our incision sizes continue to decrease I am confident that endophthalmitis rates will continue to drop.
No needle? While cataract surgery under topical anesthesia certainly avoids the risks associated with a retrobulbar injection, new problems emerge. Lack of akinesia can make phacoemulsification more difficult. For the experienced surgeon, this can be controlled in the majority of cases. However, even the most dexterous ophthalmologist can run into trouble if the patient moves the eye inappropriately during careful parts of the operation.
No patch? Doctors are enthused to tell their patients that, while vision will be blurry, they will be able to see immediately following surgery. This benefit is not without consequences; many surgeons complain of the multiple phone calls they receive in the late evening from patients concerned about bizarre visual symptoms that range from occasional flashing to seeing purple animals.
What is the best solution for this? I encourage all physicians to modify their “no stitch” policy for wounds of questionable integrity, utilize peri- or retrobulbar anesthesia for that patient whose cooperation you are unsure of, and consider a fogged shield or patch for the initial post-operative period. Hopefully we can transition to a period of “Stitch? Needle? Patch? No problem.”
References:
1 Taban M, Behrens A, Newcomb RL, Nobe MY, Saedi G, Sweet PM, McDonnell PJ. Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol. 2005 May;123(5):613-20.
2 Herretes S, Stark WJ, Pirouzmanesh A, Reyes JM, McDonnell PJ, Behrens A. Inflow of ocular fluid into the anterior chamber after phacoemulsification through sutureless corneal cataract wounds. Am J Ophthalmol. 2005 Oct;140(4):737-740.