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Should corneal wounds be hydrated?

Stromal hydration of corneal incisions is a technique commonly employed at the end of phacoemulsification surgery. The benefit of this manoeuvre is equivocal, but evidence is mounting. 

Many argue that stromal oedema is so rapidly cleared that there is no lasting physical effect. Certainly within a few hours after surgery, focal oedema is no longer visible when examined with a slit lamp. Fine and colleagues [1] performed anterior segment OCT imaging of clear corneal incisions, comparing the configuration of wounds with and without hydration at 24 hours post-op. They argue that there is a visible difference even at this late time point and stimulation of endothelial pump function increases the security of wound closure.

Vasavada et al [2] studied 80 patients, half of whom had stromal wound hydration with BSS plus. The speculum was then removed and Trypan blue instilled into the conjunctival sac for two minutes. After irrigation an aqueous sample was taken and the degree of contamination quantified by UV spectrophotometry. There was a statistically significant reduction in the group receiving corneal hydration.

Michael Wong has argued that hydration of a supraincisional pocket persists for up to 36 hours and is more effective at reducing early ingress of periocular fluid, postulated to cause endophthalmitis [3] Using his technique, a stab incision is made in the cornea above the main wound. Theoretically, when this is hydrated, it exerts downwards pressure to close the wound without using a large amount of fluid. He argues that the increased distance from the endothelium slows the rate of resolution.

Stromal hydration in one study was not rated as even in the top three of the more painful stages of routine cataract surgery [4] but there are reported complications of wound hydration. These range from Descemet’s membrane detatachment [5] to even vitreous loss from ejection of the cannula into the eye. [6]

All advocates of this technique however, emphasise that it is no substitute for well constructed sections and the use of sutures where required.

References

[1] Fine IH, Hoffman RS, Packer M. Profile of clear corneal cataract incisions demonstrated by ocular coherence tomography. J Cataract Refract Surg. 2007 33(1): 94-7.

[2] Vasavada et al. Effect of stromal hydration of clear corneal incisions: quantifying ingress of trypan blue into the anterior chamber after phacoemulsification. J Cataract Refract Surg. 2007 33(4): 623-7.

[3] Wong MY. Securing clear corneal incisions. Cataract & Refractive Surgery Today. 2003 March.

[4] Yaylali et al. Subjective visual experience and pain level during phacoemulsification and intraocular lens implantation under topical anesthesia. Ophthalmologica. 2003 217(6): 413-6.

[5] Zafar SN, Khan A. Detachment of Descemet's membrane following stromal hydration in phacoemulsification surgery. J Coll Physicians Surg Pak. 2008 18(3): 179-80.

[6] Bradshaw SE, Shankar P, Maini R, Ragheb S. Ocular trauma caused by a loose slip-lock cannula during corneal hydration. Eye (Lond). 2006 20(12): 1432-4.

Dr Colin Chu

 

 

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