54.4.2.5 Suturing

The traction sutures are ideal for rotating the eyeball and provide access, but they do not Þxate the globe sufÞciently so as to allow needle insertion into the sclera, which has signiÞcant resistance against the passage of the needle.

¥Always hold the eyeball Þrmly by grabbing the sclera with tooth forceps, and choose a location close to where the needle is supposed to enter the sclera.

ÐIf possible, grab the sclera behind the needle (the needleÕs direction is away from the grabbing point). This gives you more control than grabbing the sclera beyond the needleÕs exit point and does not interfere with the local anatomy (see Fig. 54.6).

Fig. 54.6 Securely holding the sclera and the introduction of scleral sutures. The ideal site of grabbing the sclera is behind the entry of the needle (thick black arrow), not in front of the exit point (thin black arrow; the grey arrows show the direction of the needle). This allows the surgeon to apply proper counterforce without changing the scleral contour Ð especially important if the sclera is thin. The needle is inserted at an acute angle, which helps advancing it intrasclerally, along 2, separately applied vectors: slightly forward and up (outward) and then slightly forward and down (inward)54. In principle, the longer the intrascleral path of the needle, the more secure it is, reducing the risk of tearing the sclera when the suture is tightened

¥When working anteriorly, the surgeon has easy access to the Þeld. The more posterior he works, such as with a long radial buckle, however, the more difÞcult it becomes, and the nurse must be able to act as a third (and fourth) hand.

Ð The nurse uses one hand to rotate the eye with the traction suture.53

¥Her second hand holds the orbital spatula to keep the orbital fat away from the sclera. The spatula must not interfere with suture introduction. As the surgeon advances the needle, the spatula must be moved so that the needle can be extracted at its exit point. All this requires coordination between the surgeon and nurse Ð the nurse must be able to see what the surgeon is actually doing.55

53This may occasionally be substituted by clamping the two adjacent hemostats to the drape.

54In this schematic drawing reality is distorted to help illustrate the movement and path of the needle. (The intrascleral channel created by the needle obviously cannot exceed the length of the needle.)

55Another reason why SB is best viewed through the microscope and why the nurse should have her own ocular.

a

3 2

4

1

2 3

L

b

2 3

1 4

Fig. 54.7 Placing the mattress suture in SB. (a) In a limbus-parallel, segmental buckle the scleral entry (1, 3) and exit (2, 4) points by the needle on each side of the buckle are parallel to the limbus. It makes no difference whether the suturing is started on the anterior or posterior side of the buckle57 (i.e., points 2 and 3 are interchangeable); neither does it make a difference whether the initial suture is away or toward the surgeon58. The same type of suture is used to secure an encircling band. (b) In a radial buckle, it also makes no difference on which side of the buckle the surgeon starts (1 and 4 are interchangeable). However, the surgeon should always start at the limbal end so that when he ties the knot, it is closer to him59 (this is less important when working anteriorly but becomes very important when the furthest-away knot is tied). L limbus

54.4.2.6 Alternative Methods to Secure the Buckle

Scleral pockets and tunnels can also be used to hold the buckle. Their sole advantage is that no suturing is needed.60 This is, however, more than offset by several disadvantages.

57I.e., points 2 and 3 are interchangeable.

58The latter is important, though, for the nurse to know: she has to hand over the needle-holder accordingly. Typically a suture is introduced toward the surgeon (right-hand side on the image); if the initial entry is at point 1 (left-hand side on the image), the surgeon should ask the nurse to hand him the needle holder in the away position.

59This is less important when working anteriorly, but becomes very important when the furthestaway knot is tied.

60No risk that the suture releases in the coming months or years (this very rarely happens). However, even if this does occur with the traditional technique described above, the indentation