The Running Suture in Cataract Surgery by A. D

THE RUNNING SUTURE IN CATARACT SURGERY

BY A. D. Ruedemann, Jr., M.D., AND A. D. Ruedemann, Sr., M.D.

THE PURPOSE OF THIS PAPER is to review the method and technique of placement of a running suture in cataract surgery.

HISTORY The suture method described in this paper has been in routine use by Albert D. Ruedemann, Sr., for at least thirty years.* The suture was first used as a means of rapid closure of the corneal wound in cataract surgery utilizing general anesthesia. At least one other surgeon has used the running suture technique. Olmos' described a running suture in 1939 (Figure 1).

METHOD The suture placement and technique has remained essentially the same over the entire period of its use. Improvement in instrumentation and suture material, as well as needles, has increased the efficiency of the technique. The method is essentially as follows: 1. After adequate premedication and utilization of either local or general anesthesia, the eye is prepared and draped in a routine fashion. A lid speculum, usually the modified Park-Guyton speculum, is placed. A superior rectus bridle suture is placed. 2. A 6-0 braided black silk suture, double-armed, with a spatula needle is used. The usual needle holder is a modified Green's with a lock (Figure 2). The lock may be released by reverse thumb action. In routine cataract surgery the initial suture bite is at 12 o'clock through episcleral tissues (Figure 3). The needle is placed through *Miss G. Ritter, surgical nurse for Dr. Ruedemann, stated that he was using a running suture routinely when she started working for him in 1938. TR. AM. OPHTH. Soc., vol. 66, 1968 ".f,

FIGURE 1 Diagram taken from Olmos' original article.

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FIGURE 2 Modified Green's needle holder. 144 A. D. Ruedenmann, Jr., and A . D. Ruedemnann, Sr. and ~~~~~.1

FIGURE 3 Initial bite into episcleral tisstues at 12 o'clock.

the conjunctiva, Tenon's capsule, and episcleral tissues, tangentially to the limbus and approximately 1 mm superior to the limbal margin. The initial bite is approximately 1 1/2 to 2 mm long through episcleral tissues. The second bite is then taken in the corneal stroma, tangential to the limbus. Each bite is taken so that the radial arm of the suture will pull up radial to the center of the cornea. Two scleral and two corneal bites are taken on each side of the first scleral bite (Figure 4). The final scleral bite is not tied and is ultimately cut about 6 to 8 mm long. In all, a total of five scleral and four corneal bites are taken. This results in eight wound-crossing radial arms. XVhen a conjunctival bleb is present, as after glaucoma surgery, the first bite is corneal. Scleral bites are taken lateral to the bleb. The suture placement is continued Running Suture in Cataract Surgery 145

FIGURE 4 Two scleral bites and two corneal bites are placed on both sides of the central scleral bite. A loop of suture is allowed between each bite.

as before; however, only three corneal bites and four scleral bites are placed (6 crossing arms). 3. A loop of suture about 1 1/2 cm long is left between each bite. The suture ends, with needles attached, are placed to either side of the eye. The loops are then turned with an iris repositor and tying forceps allowing a clear area over the limbus on either side (Figure 5). 4. A von Graefe knife is then used to make the corneal section. This is usually somewhat less than 180 degrees (Figure 6). Curved Castro- viejo scissors, left and right, are used to make a single bite on either side of the wound to complete the section (Figure 7). 5. If Chymar is to be used, 2 cc of a 1: 10,000 solution are then utilized to irrigate the posterior chamber beneath the iris. This is irrigated from the anterior chamber at the end of two minutes. 6. A peripheral iridectomy is performed using iris forceps and DeWecker scissors (Figure 8). 7. The suture loops are checked for fraying or possible cut ends and 146 A. D. Ruedemann, Jr., and A. D. Ruedemann, Sr.

FIGURE 5 The suture loops are turned aside using an iris repositor and tying forceps. the two central sutures are isolated for rapid re-approximation of the wound. 8. The anterior chamber is then irrigated to free it of Chymar, blood, or other possible debris. 9. The lens is grasped with capsule forceps or a Bell erysiphake and delivered (Figure 9). The 12 o'clock suture loops are pulled down, loosely approximating the wound on either side of the loops. The iris and corneal wound is then dressed from the chamber side utilizing an anterior chamber irrigator (Figure 11). This removes rolled conjunctiva and iris from the wound edge. The suture is then pulled tight, all the loops are drawn taut, and air is placed in the anterior chamber FIGURE 6 A knife section is performed utilizing a von Graefe knife. ..

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FIGURE 7 The section is completed utilizing curved Castroviejo scissors. FIGURE 8 Peripheral iridectomy is performed utilizing iris scissors and forceps.

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FIGURE 9 The lens is grasped with capsule forceps. Running Suture in Cataract Surgery 149

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(Figure 12). The suture ends are then cut approximately 6 to 8 mm from the end of the scleral bite, the superior rectus suture is cut, pilocarpine is placed in the cul de sacs, and the eye is dressed witb a patcb and sbield. POSTOPERATIVE COURSE Depending upon the anesthetic tecbnique, the patient is permitted to get up late the same day or the next morning; depending upon the 150 A. D. Ruedemann, Jr., and A. D. Ruedemann, Sr. physical capabilities, he is allowed to walk to the bathroom and to sit up to eat the same day. The operated eye is dressed each succeed- ing day and medicated with either pilocarpine or atropine, depending upon the pupillary diameter. An attempt is made to keep the pupil moving. No other local drops are used; systemic medication is adminis-

FIGURE 12 The suture is pulled tight and air is placed in the anterior chamber. tered according to the general condition of the patient. Postoperative antibiotics may or may not be used for the first three days. The patient is allowed to wear dark glasses from the fifth postoperative day if binocular surgery is indicated. Temporary cataract spectacles are fitted by the seventh postoperative day. The patient is discharged from the eighth to the tenth day and sutures are removed from four- teen to twenty-one days postoperatively (Figure 13). The patient is usually seen in the second, third, and sixth postoperative weeks. A first refraction is attempted in the sixth postoperative week. Running Suture in Cataract Surgery 151

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FIGURE 13 Suture removal. This is essentially a two-snip technique. The 11 and 1 suture arms are usually loose by the second week. A scissors blade is slipped under the loop and the suture arm is cut. Then each suture section (3) is removed with narrow smooth-tipped forceps. This is generally an office procedure which is atraumatic and only local anesthesia by drops is neces- sary. The eye is dressed with a drop, depending upon pupil size, and the patient returns home.

RESULTS One hundred and one cases were taken as a representative cross section of the type of results obtained using this suture method. The cases are non-sequential, performed by the same surgeon (AAD.R., Jr.), and are otherwise unselected. One hundred and thirty-six eyes were operated on mn this series. The age range was 25 to 82, the average being 63.2 years.

PREOPERATIVE COMPLICATIONS A number of preoperative complications were noted (ITable 1). The uveitis cases were not operated on unless the eye had been quiet for at least one year. The diabetic and retinal detachment cases in this series were operated on only when the lens became intumescent. It 152 A. D. Ruedemann, Jr., and A. D. Ruedemann, Sr. should be noted that the running suture was not used in any cases of possible corneal dystrophy or when cornea guttata was noted by slit- lamp examination. All of these cases were operated on by a scleral section under a limbal flap, a scleral groove, and three interrupted McLean sutures. All juveniles and some adults were operated on with either a limbal-based flap or a limbal groove, or both, with interrupted preplaced catgut or braided silk sutures.

TABLE 1. PREOPERATIVE COMPLICATIONS

4 Uveitis-anterior segment-1 lens-induced 14 Diabetic-2 proliferans 12 Glaucoma-4 had glaucoma surgery prior to cataract surgery 1 Macular hemorrhage 4 Monocular 4 Detachment 2 High myopia (10 diopters or more) 1 Corneal infiltration (no dystrophy cases included in this series) 1 Polymyositis 1 Retinitis pigmentosa 1 Injury 1 Amblyopia with esotropia 1 Congenital heart 1 Large exotropia

All of the cases in this series were operated on by the method described. Most of the lenses were removed using capsule forceps or Bell erysiphake. Cold application was used in two cases. Chymar (alpha chymotrypsin) and Miocol (acetylcholine) were used in 14 cases (all under sixty years of age). Those patients who had glaucoma preoperatively and who had not previously had surgery for glaucoma were operated on utilizing a large and complete iridectomy which included the base. The running suture, with a corneal section by von Graefe knife was used in those patients who had been previously operated on for glaucoma with a superior bleb. Whenever a complete iridectomy was performed, the lens was removed by a sliding technique. In those patients in whom the round pupil was retained, the lens was removed by tumbling, either with forceps or erysiphake.

OPERATIVE RESULTS It should be noted that most of the cases in this series had general anesthesia, as have most patients undergoing this operation in the last thirty years. The average time for the total operation, whether under general or local anesthesia, was 21.4 minutes. All of the cases under Running Suture in Cataract Surgery 153 general anesthesia had endotracheal intubation. The average time for the surgical procedure itself was 14.5 minutes; the shortest operative period was 5 minutes. In all of the cases in which Chymar was adminis- tered, a two-minute wait was allowed for the enzyme to act.

SURGICAL COMPLICATIONS There were 5 extracapsular extractions (3.6 per cent). Of the 5 cases, 2 resulted in 20/20 vision and 1 in 20/50 vision (preoperative- lens-induced uveitis and glaucoma). The other 2 extractions were done in a patient who had hypermature lenses and diabetic retinitis proliferans. Vision was not improved in either eye. In each extracapsular extraction, an attempt was made to remove all of the capsular and cortical material. Two cases were noted in which vitreous was lost (1.4 per cent). The patient with preoperative-lens-induced uveitis and glaucoma had a hypermature lens and the capsule was ruptured. It was deemed essential to remove as much lens material as possible. In so doing, the hyaloid face was ruptured and vitreous was lost. Final vision was 20/50 forty-six months postoperatively. In the second case, vitreous appeared on completion of the corneal section. Final vision was 20/20 twenty months postoperatively. This patient had an apparent rise of intraocular pressure with general anesthesia. Another patient, who had a rise of intraocular pressure with general anesthesia, did not lose vitreous during the operation but postoperatively does have vitreous in the anterior chamber and some corneal edema has developed.

POSTOPERATIVE COMPLICATIONS Iris Prolapse. Iris prolapse developed in 2 patients, both females nearly eighty years of age at the time of operation. In 1 it developed seven days postoperatively with notable increase in intraocular pressure. This patient had a preoperative record of glaucoma. The iris was excised with a slight vitreous loss. Vision was 20/30 fifteen months postoperatively. The second case had an iris prolapse four days postoperatively with a severe hemorrhage and rise in intraocular pressure. The anterior chamber was irrigated, the prolapse replaced, and the final vision was 20/20 twenty-three months postoperatively. Both patients had a postoperative astigmatism of less than two diopters. The repair of an iris prolapse when a running suture has been used is not a difficult procedure. Under local anesthesia, the two loose ends of the suture are grasped by an assistant using tying forceps. The suture ends are pulled up, tightening the wound; the prolapsed iris is 154 A. D. Ruedemann, Jr., and A. D. Ruedemann, Sr. then either replaced or excised, the wound is dressed, and air is replaced in the anterior chamber. Glaucoma. Of the 12 cases that had glaucoma preoperatively, in 11 glaucoma was controlled, 8 required drops or some medical therapy, 3 required no therapy, and 1 patient required postoperative glaucoma surgery (a discission for pupillary block). Glaucoma developed in 4 patients postoperatively; all 4 were controlled medically. A pupillary membrane developed in 3 patients. One was the post-detachment case mentioned above, in whom a pupillary block developed during his postoperative course, requiring a discission. This patient now has 20/20 vision. The other 2 patients, who were diabetic, had no improvement in vision. Postoperative Astigmatism. An average figure of 1.35 diopters was obtained from the refractions taken three or more months postoperatively.

TABLE 2. FINAL VISION 20/20 89 20/30 14 20/40 4 20/50 7 20/70 1 20/100 5 20/200 5 N.I. 11 TOTAL EYES 136

TABLE 3. FINAL VISION Improved but less than 20/40 1 20/70 Glaucoma 7 20/50 Uveitis, lens-induced uveitis, senile macular degeneration, old injury, diabetes 5 20/100 Glaucoma, uveitis, corneal edema 5 20/200 Central hemorrhage (diabetes and retinitis pigmentosa), central chorioretinitis (myopia), amblyopia with esotropia, senile macular degeneration. No improvement in final vision 5 Detachment 2 Diabetic proliferans 1 Central hemorrhage 1 Uveitis 1 Glaucoma 1 Diabetic with glaucoma and hemorrhage Running Suture in Cataract Surgery 155 Contact Lenses. Thirteen patients were fitted with contact lenses six or more weeks postoperatively; 11 monocular, 2 binocular. None complained of diplopia. Final Vision. The final vision obtained may be noted in Tables 2 and 3. The results are self-explanatory.

SUMMARY A suture technique used in cataract surgery for over thirty years has been presented. An unselected but representative series of cases using this technique has been included. All of the operations were performed by the same surgeon. The results obtained would indicate that the suture technique utilized in routine cataract surgery affords reasonable and consistent results as have been noted over an extended period of time. REFERENCE 1. Olmos, E. S., Surjete esclero-corneal en la operacion de la cataract. An. Soc. mex. de oftal. y oto-rino-laring., 14:153-8, 1939.