SUTURES AND NEEDLES IN OPHTHALMOLOGY

SUTURES AND NEEDLES IN OPHTHALMOLOGYPresenter:Dr.Indu Ananthoju

DefinitionSuture means to sew or seam. In surgery suture is the act of sewing or bringing tissue together and holding them in apposition until healing has taken place.

A suture is a strand of material used to ligate blood vessels and to approximate tissues together.

REQUISITES OF AN IDEAL SUTURE

Tensile strength adequate material strength will prevent suture breakdown.

Tissue biocompatibility: sutures made from organic material will evoke a higher tissue response than synthetic sutures. tissue reaction is proportional to amount & size of suture material.

Low capillarity: multifilament type soak up tissue fluid by capillary action providing a rich medium for microbes increasing chances of inflammation & infection.Good handling & knotting properties: ease of tying & a thread type that permits minimal knot slippage also influence thread selection.Sterilization without deterioration of properties: dry heat & ethylene oxide gas.

Non allergic, non electrolytic and non carcinognic

Its use should be possible in any operation.

Low cost

It should not fray, should slide through tissues readily & knot should not slip after tying.

It should be readily visualized.

It should not shrink. It should not be extruded from the wound.

On break down ,it should not release toxic agents.

It should dissapear without any tissue reaction.

classification

Natural suture materials

SYNTETIC ABSORBABLESYNTHETIC NON-ABSORBABLEPOLYGLYCOLIC ACID(DEXON)

POLYGLACTIN(VICRYL)

POLYGLYCONATE(MAXON)

POLYDIAXANONE(PDS)

POLYGLYCAPRONE

BIOSYN(GLYCOMER 361)

CAPROSYNPOLYAMIDE(NYLON)

POLYESTER(DACRON)

POLYPROPYLENE(PROLENE)

POLYBUTESTER

Non absorbable sutures are categorized by the United States Pharmacopeia (USP) as

Class 1- Silk or synthetic fibers with twisted or braided construction

Class II- Cotton or linen fibers, coated natural or synthetic fibers in which the coating does not contribute to T.S

Class III- Metal wire of monofilament or multifilament construction.

ABSORBABLENON-ABSORBABLELoss tensile strength60daysenzymatic/hydrolytic degradationReduced/absent degradationNo foreign body reactionElicit foreign body reactionMarked inflammatory reactionInert

monofilamentmultifilamentHandling difficult

No wicking

Smooth and strong

Thinner

Easy passage through tissue

stick well in tissue

May fractureHandling easy

Wicking is a problem

Capillarity and infectivity moreThicker

Knot well

SUTURE PACKAGINGSealed in a primary inner packet with inside dry and outer, see-through peel-back packet sterilized Sterility maintained until opened or date of expiry arrived

NATURAL ABSORBABLE SUTURESMonofilament,derived from highly purified connective tissue from submucosa of cattle intestine.Moderate tissue reactionEnzymatic degradationNot used in slow healing tissuesAbsorbs rapidly in inflamed tissuesTies securely ,holds uniformly

plain catgutchromic catgutDerived from submucosa of cattle intestine

Tensile strength 7-10 days

Ligate superficial vessels,oral mucosa,sc tissue,ophthalmology casescoated with chromiumImproved handlingResist degradation in tissuesDecreased tissue reaction

Tensile strength 10-14days

Fascia,peritoneum,large vessels,mucosa,muscle

PLAIN CATGUT:YELLOW

CHROMIC CATGUTBROWN IF DYED BLUE

Usage of chromic4-0 chromic short half circle needle for suturing flaps in dacryocystorhinostomy5-0 chromic double armed for medial spindle operations

SilkBraided or twistedMultifilament dyed or undyedCoated with wax/silicone or uncoatedModerate to high tissue reactionTensile strength lost in 1 yearRisk of infection and tissue reactionAcute inflammatory reaction followed by encapsulation with fibrous tissue

Usage of silk3-0silk to loop rectus muscles in scleral buckle surgery4-0silk reverse cutting needle for traction suture4-0silk taper needle for bridle suture under extraocular muscles8-0silk for scleral closure in open globes

LinenTwisted(multifilament)Moderate tissue reactionRemains encapsulated in tissuesSurgical steel wireHigh quality stainless steelMono/multifilamentAlloy of iron,nickel,chromiumRemain encapsulated in body tissues

SYNTHETIC MATERIALCOMPOSITIONPOLYGLYCOLIC ACID(DEXON)100%GLYCOLIDEPOLYGLACTIN(VICRYL)90%GLYCOLIDE,10%LACTIDE IN CALCIUM STEARATEPOLYDIAXONE(PDS)POLYETHYLENE TEREPHTHALATEPOLYGLYCONATEGLYCOLIC ACIDTRIMETHYLENE CARBONATEPOLYGLYCAPRONEGLYCOLATE, LACTONEBIOSYNGLYCOLIDE,DIAXANONETRIMETHYLENE CARBONATEPOLYAMIDE(NYLON)ALIPHATIC POLYMERSPOLYESTER(DACRON)POLYETHYLENE TEREPHTHALATEPOLYPROPYLENE(PROLENE)LINEAR POLYOLEFIN

Polyglycolic acid(dexon)100%glycolide,braided multifilamentDye/undyed,coated/uncoatedGreen Mild tissue reactionT.S-84% at 2weeks, 23% at 4weeksComplete absorption 60-90daysHydrolytic degradation

Vicryl(polyglactic acid)Mixture of lactic and glycolic acid and calcium stearateAbsorbs in 2-3wksTensile strength75% at 14days,5% at 30 daysComplete absorption 60-90daysMono/multifilament

Usage of vicryl4-0 vicryl short half circle reverse cutting needle for lateral tarsal strip procedure5-0 vicryl for subcutaneous and orbicularis muscle closure6-0 vicryl double armed for tarsal fracture operation and jones tube anchoring suture7-0 vicryl for closure of conjunctiva and skin8-0 vicryl taper point needle for conjunctiva closure in trabeculectomy9-0 vicryl suture on a needle for bleb revision and conjunctival defects

Polydiaxone(PDS)clearDyed/undyedMinimal tissue reactionT.S-70% at 2weeks,50% at 4weeks,14% at 8weeks hydrolytic degradationComplete absorption 180days

PolyglyconateMonofilamentDyed/undyedCopolymer of glycolic acid& trimethylene carbonateMild tissue reactionT.S-70% at 2weeks,8% at 3weeksComplete absorption 180days

Polyglycaprone(monocryl)MonofilamentCopolymer of glycolate and lactoneMinimal tissue reactionT.S-21days maximumAbsorption 90-120days

Polyamide(nylon)Mono/multifilamentundyed/dyedBlack/blueMinimal tissue reactionTensile strength 15-20%lost per yearDegradation is none

Usage of nylon5-0 nylon for skin 6-0 nylon for skin closure of eyelid and periocular skin to intubate &tie stent used with pigtail probe in repair of canalicular lacerations9-0 nylon for scleral closure near the limbus10-0 nylon for closure of corneal lacerations penetrating keratoplasty flap of trabeculectomy

Polyester(dacron)Uncoated(mersilene), coated(ethibond)Ethibond(green/white)Braided,composed of polyethylene terephthalateTensile strength>1yearExtremely strong not weakened by wettingKnot holds securelyExcellent handlingMersilene-Minimal tissue reactionEthibond-no tissue reactionUsed for scleral buckle attachment to the sclera,superior oblique tuck or posterior fixation suture in strabismus

Polypropylene(prolene)Composed of synthetic linear polyolefinBlue,monofilamentNo tissue reactionTensile strength upto 2yearsMinimal acute inflammatory reaction in tissue followed by gradual encapsulationResists infection

Usage of prolene5-0 prolene:blue coloured useful in repair of lacerations in brow hair9-0 prolene:iridodialysis repair with a straight and large curved needle10-0 prolene:iris or scleral fixation suture of intraocular lens

Polybutester

Greater degree of elasticityTensile strength infinite>1yearNo tissue reaction

Absorption time of absorbable sutures

Suture TypesKnot pull strengthKnot securityHandlingTissue reactivityIn vivo strength lossCatgutPoorPoor (plain)Fair (chromic)FairHigh7-10 days (plain), 21-28 days (chromic)SilkFairGoodVery goodHigh1 yearPolypropyleneFairPoorPoorLowIndefinitePolyamideFairFairGoodLow1.5 2.5% /yearStainless steelHighGoodPoorLowIndefinitePGA/PLLAGoodFair -goodGoodLow10 days 4 weeksPolydioxanoneFair -goodPoor-fairFair-goodLow10 days 6 weeks

Parts of surgical needle

SWAGED NEEDLE AND EYED NEEDLE

Swaged Needles

Sharp Sterile New Needle each time.Ready for immediate use.Saves time.No unthreading.Less tissue damage The gap is fully plugged by the diameter of the suture strand.Chances of leakage Less

Curvature of needle1/4circle and 3/8 circle commonly used. 5/8 circle used in DCR

,BODY SHAPECOMMON USAGE

Straight Flat or shallow depth of skin woundCircle 3/8Shallow depth of skin woundCircle General purposes, interior of any woundCircle 5/8Deepest, smallest maneuvering room wounds such as DCRCircle 1/4Same as 1/2 circle,Squint surgeryJ CurveDeep inaccessible wound or flat wound

END OF NEEDLE

Round body needleSeperates rather than cutsAfter passage tissue closes tightly around itLeak proof suture lineUsed for soft,easily penetrable tissues

Trocar pointCutting head merging with round bodyProduces smallest holes of all needlesLeak proof suture line Taper cutInitial reverse cutting tip with round bodyPenetrates with minimum resistance both have leak proof suture line,cut at tip only so atraumatic both used in iris repair,tough tissues like fascia,calcific or sclerotic tissue

Conventional cutting needleTriangular cross section with apex on inside of needle curvature upto half length of needleCut at tip and edges of needleSuture canal extends superficial to path of needle tip,may pull out tissue during needle passageUsed for skin,fascia and aponeurosis

Reverse cutting needleTriangular in cross section, apex cutting edge on outside of needleCut at tip and edges of needleSuture canal extends deep to the path of needle tip, accidental perforation may occurOcculoplastic surgeries,suturing skin grafts

Slim blade needleA small conventional cutting needle elongated cutting blade smooth controlled penetration

Micropoint needles(reverse cutting and spatula needle)Thin flat profileCut at tip and sides parrallel to tissue planeNeedle splits the tissue avoiding accidental perforationUsed for ophthalmic anterior segment surgeries

Cataract3/8 circle,spatulated needle nylon

Corneal laceration and penetrating keratoplasty10-0 nylon black colour is used

Squint1/4circle,conventional cutting/spatulated,micropoint coated vicryl

DCR5/8 circle,taper cut ,5-0 chromic catgut

Scleral fixation10-0 prolene 16mm straight needle,double armed needle

Scleral buckling/encirclage: 4-0 ethibond 1/4circle needle spatulated

Iris repair 10-0 prolene ,double armed one straight needle second needle curved micropoint/round bodies 3/8 circle needle

Hold needle at junction of 1/3rd swaged side and 2/3rd pointed side of body

References1.Roper Hall MJ.Stallards Eye Surgery.7th ed:10-14.2.Yanoff M,Duker J.Ophthalmology.3rd ed:1492-1493.3.Krachmer JH,Mannis MJ,Holland EJ.Cornea.2nd ed(1):1481-1493.4.Internet.

THANK YOU