This document provides information on surgical instruments and sutures used for ophthalmic procedures. It describes the characteristics and appropriate uses of different types of sutures including absorbable and non-absorbable sutures. The document also outlines the basic technique for suturing, including grasping the needle, advancing it through tissue, tying knots, cutting excess suture, and burying knots. Key steps and considerations for each part of the suturing process are described.
3. Material
1. Suture
• Absorbable suture
– Loses most of tensile strength < 2 months
– Polyglactin (Vicryl), collagen, gut, chromic gut,
polyglycolic acid (Dexon)
• Ideal characteristics vary depending on tissue and purpose for suture
• Nonabsorbable suture
– More slowly broken down
– Nylon, Poly-ester (Mersilene), polypropylene
(Prolene), silk and steel
Cornea or limbus (avascular) Nylon 10-0 Strong and long-lasting
Iris or transscleral fixation IOL Prolene 10-0 Permanent
Conjunctiva (vascular and thin) Collagen or Vicryl 8-0 Absorbable
Sclera Vicryl 8-0 or 9-0 Absorbable
4. Material
1. Suture + needle
2. Needle holder
• Non-locking needle holder
• Never grasp surgical instrument like pencil, but rest it against 1st
metacarpophalangeal joint with thumb and first 2 fingers encircling
handle for rotation and stability
✗ ✓
5. Material
1. Suture + needle
2. Needle holder
3. Tissue forceps (0.12mm forceps)
Smooth forceps Toothed forceps
• Without theeth
• +/_ serration of grasping surface ( friction)
• Teeth @ 90° angle (surgical forceps)
or angled teeth (mouse-tooth forceps)
Use:
• Soft, delicate tissue: iris and conjunctiva
• Tying platform for handling suture
Use:
• Tough tissue: cornea and sclera
• Never be used to directly handle needle as
suture can be cut
6. 1. Suture + needle
2. Needle holder
3. Tissue forceps (0.12mm forceps)
4. Tying forceps
• No teeth - smooth tips (no ridges, no serrations)
• Use
– suture tying
– suture rotation
– various handling of suture
Material
10. Basic technique of suturing
1. Dangling/Grasping the needle
2. Advancing the needle through tissue
3. Tying the suture
4. Cutting the suture
5. Burying the knot
11. 1. Dangling & Grasping the needle
1. Hold the suture with the forceps +/- 2 cm above the needle
2. Let the needle dangle and lower the needle until when it touches the
surface
3. Grasp the needle with the needle holder 2/3 away from the tip
3. Avoid gripping needle too close to swage end
• Cross section of needle is round in area of swage!
• Suture can be inadvertently detached from needle swage
4. Hold the needle @ 90° from the needle holder
5. Never grasp the needle with the forceps
26. B
A <
B
A =
Closure of perpendicular incision (vertical = linear laceration)
Distance from entry point of suture to wound = distance from
wound to point of exit (same for ant and post part of cornea)
Any of the limbs of suture is longer than other
override of wound edge on longest side
✗
✓
28. Closure of oblique wound (shelved or beveled) Needle pass
should be equidistant to deepest part of wound. Distance from
entry point of suture to point of exit should be measured from
posterior aspect of cornea
✗
✓
31. Closure of perpendicular incision (vertical = linear
laceration) Distance from entry point of suture to
wound = distance from wound to point of exit
(same for ant and post part of cornea)
35. Zone of compression
• Width of compression zones depends on
3. Degree of suture tension after tightening
2. Thickness of suture material
thick suture greater distance between sutures
1. Length of suture bites
long suture bites greater distance between sutures
Hugo Van Cleynenbreugel, MD - Belgium
36. - Compressive effect maximal in plane
between point of suture entry and suture exit
and falls off laterally
- Zones of compression of each interrupted suture
should overlap
✓
✗
Wound leak
Wound leak
43. 3. Tying the suture
• Pressurize globe before tying suture
• Load suture longitudinally
suture becomes extension of forceps
eases wrapping suture around second instrument
• Knot
– Approximation loop
= first knotting loop: performs suturing function
apposes and fixes wound edges in desired position
– Securing loop(s)
= 2nd and or 3rd loop to secure approximating loop
• Extra throws do not add strength to a properly tied knot,
but only contribute to its bulk (difficult to bury)
44. 3. Tying the suture
• Surgeon’s knot
= ligature knot (3-1-1)
Use: corneal wounds under tension
1. First approximating loop = 3 throws = adaption loop
2. Reinforcing knot with 1 throw = first securing loop
3. Second securing loop with 1 throw
45.
46. 4. Cutting the suture
• With scisors (tips curving upwards!) or single cutting blade
5. Burying the knot
• Suture knot burial
– Trim knot short
– Rotate knot beneath the corneal surface using smooth forceps
47. - Practice -
• Dange the needle
• Grasp it “forehand and backhand”
• Advance the needle through the tissue
• Use variable length
• Use variable depth
• Use variable compression
• Tie the suture
• Cut the suture
• Use different materials
• Suture in 16 directions
• Bury the knot
