Scleral Flap Closure

The scleral flap should be gently replaced to its normal anatomical position. After releasing the traction suture, a single 10-0 nylon suture is placed in the middle of the apical edge and tied at the desired tightness (figure 8a).

Figure 8 (a). Scleral flap suture

The suture ends are cut and the knot is gently rotated into the scleral channel to prevent the suture tips from eroding the conjunctiva. Experienced surgeons learn to titrate suturing the scleral flap to their own technical experience. I titrate the filtering effect through the optimum tightness of the scleral flap suture. The anterior chamber is reformed by injecting the balanced salt solution (BSS) through the paracentesis site until the BSS is seeping out of the eye through the scleral flap. While the injection is withheld, the anterior chamber should become shallow but can maintain about two-thirds to three-quarters of the original depth before stopping the injection (figure 8b).

Figure 8 (b) Titrating for optimal filtration

If the anterior chamber becomes flat, filtration is too excessive and the additional external scleral flap sutures should be placed one by one, then retested to achieve the expected outcome. If the anterior chamber is too deep and the intraocular pressure is tense, the scleral flap suture should be loosened. Conjunctival Wound Closure The conjunctiva/Tenon's capsule flap is replaced to the normal position. I prefer to close the conjunctiva/Tenon's capsule flap with a 10-0 nylon running horizontal mattress suture (figures 9a and b). If the conjunctiva is fragile and easily cut, a small microtip atraumatic needle should be used, for example, the 10-0 Ethicon 2870 or 10-0 Alcon Biosorb needles. At the conclusion of surgery, atropine 1% eyedrops and an antibiotic/steroid eye ointment are instilled in the palpebral fissure. The eye is dressed with a dry sterile patch and a shield.

Figure 9 (a). Schematic of a horizontal mattress suture

Figure 9 (b). Sutured conjunctiva