How to suture the Phaco Incision with 10-0 Nylon

This video is special because we have two different camera angles: the view through the operating microscope as well as a tangential view showing the hand movements. These two video streams are shown synchronized picture-in-picture with my voiceover giving the pertinent teaching points.

To our junior residents and beginning doctors in training: No one is born knowing how to suture with 10-0 nylon under an operating microscope. This is a learned skill and you owe it to yourself to spend a considerable amount of time honing your skills. Your goal should be to place a 10-0 nylon suture in about 3 minutes, just like the resident surgeon in this case. The most dextrous residents can learn this after 100-200 practice sutures in the wet lab, average residents require about 400-500 sutures, and those who struggle will require 800-1000 sutures.

The 10-0 nylon suture in the phaco incision should have these qualities:

• about 70 to 80% corneal depth (never 100%, never piercing Descemet’s)
• radial like the spokes of a bicycle wheel (not tangential)
• bisecting the incision (in the case of a single suture)
• sufficient tissue bites on both sides of the incision line
• appropriate tension of the suture to keep the incision closed without inducing astigmatism

In this video, you will notice a few key points:

• Before tying the suture, the anterior chamber pressure is brought to a normal, physiologic level. This is important to get the appropriate suture tension.
• There are three throws: 3-1-1, so three loops, then one, and then one more. Note that for the second throw the suture ends are turned 90 degrees because this allows the suture to cinch down a little tighter if needed.
• To judge the correct tension, after throwing the second throw, the knot can be pulled side-to-side to see the overall tension of the suture. This method will allow you to throw many sutures in a row (for a larger incision) while keeping them all at about the same tension.

Click below to learn valuable pearls for suturing with 10-0 nylon: