Canaloplasty Glaucoma Surgery Using Mastel Instruments: Part 5 – Closure

Canaloplasty Glaucoma Surgery Using Mastel Instruments: Part 5 – Closure

So I do close the flap with 10 0 vicryl. I know others use nylon. I prefer vicryl because one of the things that you can run into with canaloplasty is the possibility of induced astigmatism.

Now here I’m using some Mastel needle drivers which are specially coated. And this coating just gives you wonderful grip and great control. In fact, I actually find many times I’ll just use these needle drivers and continue the tying process with them. So generally when I am suturing the superficial flap down, what I’ll do is I’ll suture the apex, and I’ll leave the first suture pretty loose. Because, remember, the eye is hypotenuse right now, and once I do bring the pressure up then these sutures will tighten. So I leave the apex pretty loose. But I do prefer not to inflate the anterior chamber until after I put down at least the apex suture. Just because until there’s something up against the trabeculo descemetic window, it’s very easy to blow out the window by inadvertently overfilling the anterior chamber. That’s why I just prefer to have the flap down before I fill the anterior chamber. And so you can either put one suture in, and then fill the anterior chamber, and then suture it through additional sutures if you want. Some people just throw one or three sutures; I tend to throw three to five. I’m actually holding onto the bridle suture, as I do think that that gives me a nice amount of control over the position of the eye as well as gives me good counter-traction against the throwing of the suture.

OK. So I’ve applied sutures here, which is just what I do. I wouldn’t say that you have to. I tend to throw three to five. What I’m doing here is I’m going to go ahead and check that the incision is indeed water tight using the fluorescence. I’ve already hydrated, already filled the anterior chamber with BSS, so the anterior chamber is fully formed. The pressure is between 16 and 20 millimeters of mercury. I just painted the superficial flap with fluorescence, and it is watertight with no leakage showing. So now we’re pretty much done here.

At this point all that’s left is closing up the conjunctiva. And there are a number of ways that one could do this. It varies greatly. There are those who just tack the two corners and are done with it. Again, if you’ve got watertight flap, that’s perfectly appropriate. There are those who take more of the approach that you would with a trabeculectomy, and will actually throw a running suture or a mattress. Both appropriate, although time consuming.

I’m fortunate in the sense that my surgery center gives me some leeway, because I’ve saved them so much money in terms of having my own instruments, they actually allow me to use TISSEEL. So what I’m going to do is I’m simply going to first make sure that I can approximate the edges without any tension. And then I’m going to place two drops of TISSEEL. So there’s the first. And as you know TISSEEL, it’s an epoxy. There’s the second. Now I’m simply going to place the conjunctiva where I would like it to be, I do make sure that the conjunctiva is over the exposed corneal incision. And I simply use my tying forceps to approximate the edges of the conjunctiva. So I will place a little pressure down at the limbus to make sure the conjunctiva is going to give me a watertight closure there. And the radial aspect of the conjunctival incision, the edges are approximated with the forceps. And I just patiently hold it there for a couple of minutes. I find it takes less time than actually suturing.

I do remove the extra TISSEEL, because I have found that it can be a little irritating. Although you do want to make sure that as you’re removing that extra TISSEEL, if you do use TISSEEL, that you don’t inadvertently remove the TISSEEL that’s holding the approximated edges together. And that’s it for the surgery. So the only part that’s left here is I do actually hydrate my corneal incisions, since this patient did have phaco emulsification prior. I do hydrate my corneal incisions with vancomycin. And we’ll end it here, there’s really no point to continue with that. So we’ll just say that’s it. Surgery’s done. After this I’ll go ahead and give subconjunctival injections of vancomycin. All right that’s it. Thanks.

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Author: Dr David Richardson

​David Richardson, M.D. is widely recognized as one of the top cataract and glaucoma surgeons in the US and is among an elite group of glaucoma surgeons in the country performing the highly specialized canaloplasty procedure. Dr. Richardson graduated Magna Cum Laude from University of Southern California and earned his Medical Degree from Harvard Medical School with scholarships from Phi Beta Kappa, Phi Kappa Phi, Harvard Medical Linnane and Harvard National. He completed his ophthalmology residency at the LAC+USC Medical Center/ Doheny Institute. Dr. David Richardson is also an Adjunct Assistant Professor of Clinical Ophthalmology at Keck School of Medicine of University of Southern California.​​

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