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162 J. Heichel et al.
Fig. 14.17 Eyelid margin suture in schematic representation and patient example. (Blue: posterior eyelid layer; pink:
anterior eyelid layer; red suture fixes the intermarginal sutures)
Fig. 14.18 Canthotomy and Cantholysis
14.5 Minor Lacrimal Surgery
Before treating a disease of the lacrimal
drainage system, a thorough medical history and
The goal of lacrimal surgery is to improve tear
drainage and to treat chronic inflammations. It is
generally very complex and can only be partially
presented here.
clinical examination must be conducted. The
latter includes special test procedures and also
involves a diagnostic irrigation of the lacrimal
drainage system. The goal is to classify the tear
Fig. 14.19 Semicircle Flap Technique (A = 2 x C; B ≥ A)
16314 Minor Eyelid and Lacrimal Duct Surgery
Tab. 14.1
Criterion Classification
Degree of stenosis Absolute
Type of stenosis Mechanical
Localization of
stenosis
Time of
manifestation
PANDO - primary acquired nasolacrimal duct
obstruction
SALDO - secondary acquired lacrimal drainage
obstruction
Classification of lacrimal duct stenosis
Relative
Functional
Presaccal
Intrasaccal
Postsaccal
Congenital
Acquired
- primary (PANDO)
- secondary (SALDO)
drainage disorder as accurately as possible (Tab.
14.1).
The basic diagnostics in the area of the lac-
rimal drainage system include the inspection
and palpation of the eyelids and the lacrimal sac
region, the examination of eyelid tension, the
conjunctival dye test, the manual compression of
the lacrimal sac, and the diagnostic irrigation of
the lacrimal drainage system. To rule out reflex
hypersecretion, a Schirmer test and the determination of the tear film break-up time should
be performed. If a mechanical tear drainage
disorder can be detected, an Ear Nose Throat
(ENT) consultation must be initiated to exclude
a possible causative pathology in this region.
14.5.1 Correction of the Position of the Lacrimal Punctum
An outward tilting of the lacrimal punctum prevents adequate immersion in the tear lake. This
results in a functional disorder. Through a diamond-shaped excision in the area of the inner
eyelid below the lacrimal punctum, an Eversio
puncti lacrimalis can usually be very effectively
corrected (Fig. 14.20). The highest point should
be at least 3 mm away from the eyelid margin to
avoid injury to the lacrimal punctum ampulla.
14.5.2 Therapeutic Irrigation of the Lacrimal Ducts
A classic indication for therapeutic lacrimal
duct irrigation is congenital dacryostenosis with
persistence of the Hasner membrane. Within
the first year of life, the intervention can be
performed under local anesthesia (anesthetic
eye drops; 40% glucose solution orally) on the
changing table. The child is wrapped in a cloth
("swaddling") and held by an assistant. This
allows approximately 90% of children to be successfully treated.
The therapeutic lacrimal duct irrigation
involves the following steps (Fig. 14.21):
• Dilation of the upper lacrimal punctum (alter-
natively, the lower one can also be used,
although the angle of entry into the lacrimal
sac is less favorable);
164 J. Heichel et al.
Fig. 14.20 Oval or diamondshaped excision below the
lacrimal punctum. The excision
is performed only on the inner
eyelid
Fig. 14.21 Therapeutic lacrimal duct irrigation in childhood and required instruments. (Bangerter cannula and conical probe, 2-ml syringe, physiological saline solution, anesthetic eye drops, swabs)
• Horizontal probing up to the periosteal stop
(hard stop);
14.5.3 Relief of a Lacrimal Sac Empyema
• Positioning of the lacrimal duct irrigation
cannula and further probing towards the nose
under slight irrigation pressure.
As a result of a postsaccal lacrimal duct stenosis, there is a retention of secretions in the lacrimal sac. This usually leads to chronic, often
mild, dacryocystitis. However, during acute
Therapeutic lacrimal duct irrigation in child-
hood under local anesthesia requires experience. Lacrimal duct irrigation purely for
diagnostic purposes is contraindicated in young
children, as it can lead to injuries and iatrogenic lacrimal duct stenosis.
exacerbations, the full picture of acute dacryocystitis can develop, characterized by severe
pain and swelling in the lacrimal sac region. In
addition to systemic intravenous antibiotic therapy, incision of the lacrimal sac is an effective
means to manage this life-threatening situation
16514 Minor Eyelid and Lacrimal Duct Surgery
(caution: sinus vein thrombosis). The procedure
for a stab incision of the lacrimal sac is shown in
Fig. 14.22.
Acute dacryocystitis with abscess is an oph-
thalmological emergency. Patients must be
admitted for inpatient treatment. In the course
Fig. 14.22 Stab incision of the lacrimal sac, swab collection, and loop drainage (povidone-iodine 7.5%) in acute
dacryocystitis
166 J. Heichel et al.
of treatment, almost always a restoration of
the lacrimal ducts through dacryocystorhinostomy is necessary.
14.5.4 Intubation of the Lacrimal Ducts
The temporary splinting of the lacrimal drainage system aims to bridge the opened passageway and thus keep it open during wound
healing, ultimately increasing the success rate
of the surgery. Indications for lacrimal drainage system intubation include trauma, lid and
tumor surgery affecting the lacrimal drainage
system, as well as stenosis recurrences or situations associated with a high recurrence rate for
lacrimal drainage system stenoses (e.g., narrow anatomical conditions, previous surgeries,
ENT pathologies, etc.). The variety of possible
intubation techniques for the lacrimal drainage
system is very large (Table 14.2). The ring intubation according to Murube del Castillo and the
technique according to Ritleng will be discussed
in more detail here.
Ring Intubation according to Murube del Castillo
The splinting of the tear ducts is primarily used
for stabilization after tear duct injuries. After retrograde probing of the injured canaliculus stump
using a special probe (e.g., pigtail probe according to Worst), a guide thread (Polypropylene
6-0) is inserted. Over this, a silicone tube can
now be threaded and pulled into the TNW. After
shortening the tube, the thread is tied, forming a
ring (Fig. 14.23). The intubation is usually left
in the TNW for three months (Chap. 2).
The primary reconstruction of a tear duct
injury requires intubation of the efferent tear
ducts to bridge the injured mucosal portion.
Monocanalicular Nasal Intubation according to Ritleng
As a very versatile intubation technique, the
monocanalicular nasal procedure according to
Ritleng can be applied. Using a special probe,
which has a lateral slit, a TNW probing is performed starting from the tear duct, through the
lacrimal sac to the nasolacrimal duct or the
Tab. 14.2 Intubation techniques for splinting the lacrimal drainage system. (Selection)
Location of the stenosis monocanalicular/monocanaliculonasal bicanalicular/
Canaliculi Minimonoka
Lacrijet
Lacrimal sac and/or Monoka® (Ritleng) bicanaliculonasal intuba-
Nasolacrimal duct Masterka
Lacrijet
Osteotomy as part of Minimonoka® (Fayet & Bernard) bicanaliculonasal
a DCR Monoka
Mono-Crawford
Conjunctiva/nose as part of Lester-Jones tube (StopLossTM tube)
a conjunctivorhinostomy Tube de Metaireau
DCR dacryocystorhinostomy
®
FCI, Paris, France
®
(Fayet & Bernard) Ring intubation (Murube
®
for tear duct injuries Ring intubation set
®
®
®
(Ritleng) Nunchaku
®
®
bicanaliculonasal
del Castillo)
("Erlangen model")
bicanalicular self-stabilizing set
tion (Jünemann)
BIKA intubation set
Intubation set Ritleng+
Nunchaku
intubation (Crawford,
O'Donoghue)
®
®
®
®
®
Fig. 14.23 Ring intubation of the TNW according to Murube del Castillo
16714 Minor Eyelid and Lacrimal Duct Surgery
Fig. 14.24 Lacrimal duct intubation using Ritleng technique in an 18-month-old child with congenital dacryostenosis. (Left eye)
168 J. Heichel et al.
lower nasal passage. Subsequently, a guide
thread is inserted at the end of which the silicone part is already attached. The guide thread
rolls up in the nasal cavity and can now be
extracted from the nostril with a hook. Since the
guide thread tapers after about 30 cm, this thin
part allows for lateral separation from the lacrimal drainage system probe through the slit. The
silicone part is then pulled in over the thread
remaining in the lacrimal drainage system until
it snaps into place with its shoe in the lacrimal punctum. The excess part of the intubation
can be shortened through the nostril (Chap. 2)
(Fig. 14.24).
References and Further Reading
1. Anderson R, Dixon R (1979) Aponeurotic ptosis surgery. Arch Ophthalmol 97:1123–1128
2. Anderson R, Gordy D (1979) The tarsal strip procedure. Arch Ophthalmol 97:2192–2196
3. Blaskovics L v, Kettesy A (1970) In: Vörösmarthy D
(Hrsg) Eingriffe am Auge. 4. Aufl. Enke, Stuttgart, p
176
4. Collin JRO, Rathbun JE (1978) Involutional entropion: a review with evaluation of a procedure. Arch
Ophthalmol 96:1058–1064
5. Frueh BR, Schoengarth LD (1982) Evaluation
and treatment of the patient with ectropion.
Ophthalmology 89:1049–1054
6. Heichel J (2017) Stufenkonzept zur Therapie
der konnatalen Dakryostenose. Klin Monatsbl
Augenheilkd 234:1250–1258
7. Heichel J, Reich W, Stadie V, Viestenz A, Eckert
A (2020 Jan) Interdisziplinäres Management von
Tumoren der Lid- und Periorbitalregion. Klin
Monatsbl Augenheilkd 237(1):46–56
8. Heichel J, Struck HG, Viestenz A, Glien A, Plontke
S (2020) Erkrankungen des Tränenapparats, Teil
1: Anatomie. Physiol Diagn Laryngorhinootol
99:112–125
9. Heichel J, Struck HG, Viestenz A, Glien A, Plontke
S (2020) Erkrankungen des Tränenapparats, Teil
2: Grundlagen der Therapie. Laryngorhinootologie
99:247–261
10. Jindal K, Sarcia M, Codner MA (2014) Functional
Considerations in Aesthetic Eyelid Surgery. Plast
Reconstr Surg 134:1154–1170
11. Jones LT, Reeh MJ, Wobig JL (1972) Senile
Entropion: A New Concept for Correction. Am J
Ophthalmol 74:327–329
12. Klingenstein A, Hintschich C (2018) Update
Oberlidblepharoplastik. Ophthalmologe 115:266–274
13. Lee OS (1951) Operation for correction of everted
lacrimal puncta. Am J Ophthalmol 34:575
14. Lew HR (1995) Suture repair of involutional entropion. Aus New Zealand J Ophthalmol 23:247–248
15. Müllner K (1998) Ritleng-Intubationsset zur
Schienung verletzter Tränenwege. Klin Monatsbl
Augenheilkd 213:238–240
16. Olver JM (1998) Surgical tips on the lateral tarsal
strip. Eye (Lond) 12:1007–1012
17. Pitz S (2010) Stellenwert der horizontalen
Lidspaltung nach Wies in der Entropiumchirurgie.
Klin Monatsbl Augenheilkd 227:26–28
18. Riedel KG, Beyer-Machule CK (1991) Die temporale Tarsalzungenplastik zur Korrektur von
Unterlidfehlstellungen. Forstchr Ophthalmol
88:569–573
19. Rokohl AC, Guo Y, Mor JM, Loreck N, Koch
KR, Heindl LM (2020) Intubationssysteme in der
Tränenwegchirurgie – eine aktuelle Übersicht. Klin
Monatsbl Augenheilkd 237:20–28
20. Rokohl AC, Kopecky A, Guo Y, Kakkassery V,
Mor JM, Loreck N, Koch KR, Heindl LM (2020)
Chirurgische Resektion mit ophthalmoplastischer
Rekonstruktion. Goldstandard beim periokulären
Basalzellkarzinom Ophthalmologe 117:95–105
21. Schaudig U, Heidari P, Schumacher S (2012)
Ektropium und Entropium des Unterlids.
Ophthalmologe 109:443–449
22. Schöpfer O (1949) Über einen einfachen Eingriff
zur Behandlung des Entropiums. Klin Monatsbl
Augenheilkd 115:40–42
23. Sommer F (2010) Operative Ektropium- und
Entropiumkorrektur. Ophthalmologe 107:897–904
24. Struck HG (2009) Tränenwegsverletzungen und
ihre chirurgische Versorgung. Ophthalmologe
106:223–228
25. Wabbels B (2019) Botulinumtoxin in der Augenheil
kunde. Klin Monatsbl Augenheilkd 236:825–836
Procedures on Conjunctiva and Cornea
Martin Miertsch, Frank Wilhelm, Christoph Schmidt,
Anja Viestenz and Erik Chankiewitz
Contents
15.1 Cornea......................................................... 169
15.2 Conjunctiva..................................................... 170
15.3 Amniotic Membrane Transplantation ................................. 173
15.4 EDTA Abrasion for Band Keratopathy................................ 175
References and Further Reading .......................................... 176
15
Practicing operations on the conjunctiva and
cornea is of particular value for beginners in
ophthalmic surgery. These are usually performed exclusively extraocularly and involve
suturing and knotting.
M. Miertsch ()
Greifswald, Germany
C. Schmidt
Augenärztliche Gemeinschaftspraxis „Augen im
Zentrum“, Greifswald, Germany
e-mail: c.schmidt@augen-im-zentrum.de
A. Viestenz
Klinik und Poliklinik für Augenheilkunde,
Universitätsklinikum Halle/Saale, Halle/Saale,
Germany
e-mail: sekretariat.augenklinik@uk-halle.de
E. Chankiewitz
Augenklinik, Städtisches Klinikum Braunschweig
gGmbH, Braunschweig, Germany
e-mail: erik@chankiewitz.de
F. Wilhelm
Universitätsklinikum Halle Saale, Greifswald,
Germany
15.1 Cornea
The most common procedures on the cornea
involve placing and removing sutures, which
will be exemplarily addressed here.
Corneal sutures are necessary after injuries to
the eyeball and in the context of intraocular procedures. Individual sutures, such as those placed
as tunnel sutures or for the treatment of small
perforating injuries of the cornea, are particularly suitable for beginners, as the risk of anterior chamber flattening or tissue prolapse during
manipulation is low in these cases.
There are rules that make it easier for begin-
ners in ophthalmic surgery to perform single
button sutures. It should be ensured that:
An operating microscope is used in principle,
non-absorbable suture material Nylon 10-0 is
used (see Fig. 15.1),
The needle is inserted perpendicular to the
wound edge,
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer Nature 2025
F. Wilhelm (ed.), Ophthalmic Surgery for Beginners, https://doi.org/10.1007/978-3-662-70287-1_15
169
170 M. Miertsch et al.
It is important to ensure that:
the suture is cut in such a way that the end
in the direction to be pulled is left as long as
possible to securely grasp it with the forceps
or fine needle holder,
The pull is directed towards the adapted
wound so that the opening of the wound is
not provoked and the wound edges do not
gape apart.
After suture removal, it is recommended to check
Fig. 15.1 Performing a single button suture on a corneal
tunnel after cataract surgery (Technical details are discussed in detail in Chap. 12.)
the condition at the slit lamp. Depending on
the extent of the primary wound, the number of
removed sutures, and the epithelial lesions caused
by the procedure, the use of topical antibiotics and
Opposite wound edges are precisely apposed
epithelializing eye ointments should be considered.
(deep lamellar),
The suture movement follows the curvature
of the needle,
The monofilament suture is cut close to the
knot,
The knot is tightened and rotated into the cor-
neal stroma,
The induced astigmatism is considered when
aligning and adjusting the suture tension.
The removal of individual corneal sutures is
possible for the experienced surgeon at the slit
lamp. If there are multiple single button sutures
after the treatment of extensive corneal wounds
or continuous sutures, for example, in the context of a corneal transplant, removal in the operating room under the microscope is advisable.
In addition to a suitable lid speculum for pulling the threads, a suture forceps or a fine needle
holder is required as instrumentation. A micro
knife (Chap. 13) can be used for cutting. A fine
needle is also possible and more cost-effective.
Just like with the blade of the micro knife, the
suture can be cut with the lateral edge of the
needle. The flat part of the instrument is then
used to lift the suture end over the epithelium,
which can then be grasped with the forceps.
15.2 Conjunctiva
The removal of a pterygium is the most common
procedure on the conjunctiva and is therefore
often assigned to beginners. This operation will
be exemplarily presented here, as the approach
in many individual steps is comparable to other
procedures on the conjunctiva, such as the treatment of wounds or the removal of small tumors.
15.2.1 Operative Procedure
After skin disinfection, taping the eyelid margins
with incision foil, and inserting the lid speculum,
local sub-conjunctival infiltration anesthesia with
Xylocaine follows. The body of the pterygium
is undermined with a probe, and the head is
partially bluntly detached and partially sharply
separated from the cornea with a 30° knife. The
base of the excision site is cleaned and smoothed
with the hockey knife and, if necessary, with
small scissors. Then, the triangular excision of
the pterygium is performed depending on the
extent up to the plica semilunaris. Hemostasis is
achieved using diathermy if needed. The use of
antimetabolites such as Mitomycin C to reduce
the recurrence rate should be handled restrictively, as the data on this is inconsistent [6].
Fig. 15.2 Inclusion of deeply located limbal stem cells at the excision site
17115 Procedures on Conjunctiva and Cornea
A conjunctival flap of appropriate size with
limbal stem cells is obtained from the upper
temporal area.
Since the limbal stem cells are not found
superficially at the limbus but several hundred
micrometers deep, the conjunctival flap should
not be prepared too thinly at the limbus!
As shown in Fig. 15.2, an appropriate micro
knife (here a 30° knife) is used to include the
deeply corneal limbal stem cells.
Additionally, the orientation of the conjunctival graft must be clear to the surgeon at
all times during the procedure. A spontaneous
movement of the patient or strong squeezing of
the eyelids can lead to displacement of the free
graft. Also, during this phase of the operation,
dabbing should generally be avoided (or done
only by the surgeon) as the graft may otherwise
adhere to it. If the conjunctival graft were to be
implanted in the wrong orientation, i.e., not with
the limbal stem cells at the corneal edge, the
likelihood of recurrence is very high.
The authors therefore recommend leaving
the conjunctival graft fixed at the limbus in an
area of about ½ hour during preparation. A correspondingly long 10–0 nylon suture is anchored
intrasklerally at the limbus at the lower corner
of the excision site and led to the corresponding limbal edge of the conjunctival graft. The
suture ends are left long (Fig. 15.3). Only then is
the final severing of the remaining bridge at the
upper limbus performed (Figs. 15.4 and 15.5).
Fig. 15.3 Placing a long suture from the excision site to the graft corner