Cherry Eye Surgery Technique

Re: Cherry Eye Surgery Technique

Anonymous — Tue, 25 Oct 2011 08:22:48 GMT

[quote user="Robert Lowe"]using the Yates corrected value (itself a test that is likely to overcorrect and therefore reject the null hypothesis) while not reporting the other tests suggests a selective use of statistics to reinforce your own hypothesis.[/quote]

I felt that relative risk (with confidence intervals) and Yates corrected Chi-square were the results I was looking for (obviously deciding on your statistical testing after you have the data in front of you and a hypothesis in mind, or axe-to-grind, is indeed likely to result in reporting bias, a point that I feel applies to this paper also). My selection of the Yates corrected Chi square was based on a value less than 5 in one square of the 2x2 table, and I felt this to be appropriate due to the small sample size. I appreciate this may be overly conservative (and quite possibly an out-dated thing to do?), but that would be my preferred approach and fits with my philosophy of study design (I'm quite a skeptic, so want to be pretty convinced before rejecting my null hypothesis). Thanks for pointing out my own tendency to bias!

[quote user="Robert Lowe"]I suspect that you may never be convinced but if we are to looked at this from an evidence point of view, the best evidence (and whatever the issues with it are, it is the best available) points to replacement as the desired treatment. There is no published data to suggest that removal (complete or partial) is an acceptable treatment. This combined with the weight of specialist opinion takes me back to my original point that I could not defend someone in front of the PIC for performing a removal as a first line treatment in normal circumstances.[/quote]

Fair enough. If that's all the data we'll ever have on the matter, then I guess I'll just have to return to knowing that TEG excision is regarded an inappropriate technique and leave it at that. Thanks again for bringing this matter to mind and hope generate more light than heat

Re: Cherry Eye Surgery Technique

Robert Lowe — Mon, 24 Oct 2011 23:17:18 GMT

David

I have also plugged the figures into Epi-info

Results below. Like you I am no statistician, however using the Yates corrected value (itself a test that is likely to overcorrect and therefore reject the null hypothesis) while not reporting the other tests suggests a selective use of statistics to reinforce your own hypothesis. However, I agree that raw data would have been useful in the paper and make this an easier assessment.

I suspect that you may never be convinced but if we are to looked at this from an evidence point of view, the best evidence (and whatever the issues with it are, it is the best available) points to replacement as the desired treatment. There is no published data to suggest that removal (complete or partial) is an acceptable treatment. This combined with the weight of specialist opinion takes me back to my original point that I could not defend someone in front of the PIC for performing a removal as a first line treatment in normal circumstances.

Single Table Analysis

	Point	95% Confidence Interval
	Estimate	Lower	Upper
PARAMETERS: Odds-based
Odds Ratio (cross product)	5.5714	1.0420	29.7910 `(T)`
Odds Ratio (MLE)	5.3542	1.0851	41.1479 `(M)`
		0.9168	58.3484 `(F)`
PARAMETERS: Risk-based
Risk Ratio (RR)	3.3704	0.8812	12.8909 `(T)`
Risk Difference (RD%)	33.8624	7.5715	60.1534 `(T)`
`(T=Taylor series; C=Cornfield; M=Mid-P; F=Fisher Exact)`
STATISTICAL TESTS	Chi-square	1-tailed p	2-tailed p
Chi-square - uncorrected	4.5567		0.0327919396
Chi-square - Mantel-Haenszel	4.4455		0.0349938598
Chi-square - corrected (Yates)	3.2140		0.0730123684
Mid-p exact		0.0190889056
Fisher exact		0.0334767335

Re: Cherry Eye Surgery Technique

Anonymous — Mon, 24 Oct 2011 19:53:05 GMT

Many thanks to the thoughtful colleague who loaned me a copy of the Morgan's paper to read

[quote user="Robert Lowe"]I don't as the beagle is not a dog that is predisposed to KCS and I suspect that the lacrimal gland hypertrophied to accommodate the loss of the nictitans gland. However in breeds predisposed, I suspect that the loss of nictitans cannot be made up and it pushes them over the edge sooner into clinical KCS.[/quote]

Makes sense. This suggests that the risk of KCS post TEG excision may well be breed-dependent. A study of 33 dogs, of which 15 are American Cocker Spaniels, is somewhat biased from this viewpoint. Can we really extrapolate from this data to other breeds (especially if not majorly predisposed to KCS) with high levels of confidence? The 13 dogs with TEG excision that went on to develop KCS were American Cocker Spaniels, English Bulldogs or Lhasa Apso's, indeed there were only 5 dogs that had TEG excision that weren't one of these breeds and none of them developed KCS during follow-up. (I'll confess to a lack of knowledge on breed predispositions of KCS, and suspect there will be significant common ground with breed predispositions for TEG prolapse)

[quote user="Robert Lowe"]Thanks for making me think about this[/quote]

Ditto. I'd be delighted to be able to batter a TEG excising (hypothetical) colleague with this paper until they yield to the powers of EBM, but I don't think it's strong enough evidence to do so. I think it's a fine pilot study and supports the hypothesis that TEG excision is a significant risk factor for development of KCS, but I don't see it as that conclusive.

I'm no statistician, and am going to expose further ignorances in another subject matter I have extremely limited experience of, but I have problems with the statistical analysis presented in the paper also. I think there is a danger in a non-concurrent, cohort study without a clear null hypothesis of post-hoc analysis (i.e. plugging data into formulae until hit a magic "statistically significant" result), although there is obviously no way of knowing if this occurred.

If, however, I wished to analyse the data available (raw data not present to do more meaningful assessments) with a Chi-square test, as the author chose to, I would compare excised and replaced TEG's as risk factors for the develeopment of KCS, and use a Yates correction. The relevant data being:

TEG excision + KCS = 13

TEG excision + no KCS = 14

TEG replaced + KCS = 2

TEG replaced + no KCS = 12

Inserting that data into a 2 x 2 table with TEG excision as risk factor and KCS as disease Epi Info (v3.5 available from CDC website), gives the following results:

Relative risk = 3.37 (Taylor Series 95% confidence intervals 0.89 to 12.89)

Yates corrected Chi square p-value = 0.073

i.e. there is a 7.3% probability that the difference in levels of KCS between the groups with TEG excision and those with replacement is simply due to chance.

So my problems with considering this paper in any way conclusive are:

A very limited breed representation.
The absence of raw data to spot trends or confounding factors that might have skewed results.
Unconvincing statistical analysis of results.
Only total TEG excision considered (cf partial TEG excision).

Re: Cherry Eye Surgery Technique

Robert Lowe — Fri, 21 Oct 2011 15:08:28 GMT

[quote user="David Beattie"]

but would be interested in what the definition of KCS is in this paper - I may be totally wrong, but am guessing is not clinical KCS, but a measurement of tear production (which obviously will be decreased after gland excision)?[/quote]

The definition is STT1<10 and mucopurlent discharge +/- corneal vascularisation +/- pigmentation

The mean follow up was 4.8 years (2-10) but it doesn't give CI for development of KCS

[quote user="David Beattie"]In the other paper you mentioned, the entire third eyelid was removed and at one year follow on there was near normal STT-1 and PRT and no clinical disease - I find it hard to reconcile this data with that in the table from Morgan's paper.[/quote]

I don't as the beagle is not a dog that is predisposed to KCS and I suspect that the lacrimal gland hypertrophied to accommodate the loss of the nictitans gland. However in breeds predisposed, I suspect that the loss of nictitans cannot be made up and it pushes them over the edge sooner into clinical KCS.

Thanks for making me think about this - bizarrely I have just had a client in who wasn't sure that replacement was the right thing so I was able to dazzle them with precise figures in front of me.

Re: Cherry Eye Surgery Technique

Anonymous — Fri, 21 Oct 2011 13:18:29 GMT

That table definitely looks conclusive - agreed.

Perhaps that's my problem. I find it hard to believe that practitioners don't notice a near 50% incidence of KCS within 2yrs of Sx on dozens of cases over a lifetime (although it's obviously quite possible). In the other paper you mentioned, the entire third eyelid was removed and at one year follow on there was near normal STT-1 and PRT and no clinical disease - I find it hard to reconcile this data with that in the table from Morgan's paper.

I've never read the paper (really should do before commenting further...), but would be interested in what the definition of KCS is in this paper - I may be totally wrong, but am guessing is not clinical KCS, but a measurement of tear production (which obviously will be decreased after gland excision)?

27 glands excised, 13 developed KCS (as yet I'm not sure of definition here in paper): what are confidence intervals for 48% prevalence of KCS at 2yrs in excised gland eyes?

14 glands excised, 2 developed KCS: what are confidence intervals for prevalence of KCS at 2yrs in replaced TEG eyes?

I'm also confused about what figures in last column relate to.

100's of cases would be great, but the results of this paper could be backed up with less.

What about partial excision of TEG?

Thanks for interest and posting that data.

Re: Cherry Eye Surgery Technique

Robert Lowe — Fri, 21 Oct 2011 12:52:43 GMT

That didn't work but hopefully understandable

Re: Cherry Eye Surgery Technique

Robert Lowe — Fri, 21 Oct 2011 12:51:56 GMT

Summary table from Morgan et Jaaha 1993

All dogs monitored for a least 2 years for KCS (mean 4.8 years)

Total eyes * Eyes with KCS * % of group with KCS * % of total KCS eyes

Excised gland 27 13 48.1 68.4

Replaced Gland 14 2 14.2 10.5

Gland remained prolapsed 7 3 42.8 1

Normal non prolapsed gland 18 1 5.5 5.3

Significant difference between gland replacement and untried / excised (chi squared p<0.008)

I can't see a lot wrong with the paper and it looks pretty conclusive to me.

However I would love to look at histories for animals that have had excisions. Numbers would need to be in 100's to improve on above and eliminate breed differences etc.

Re: Cherry Eye Surgery Technique

Anonymous — Fri, 21 Oct 2011 12:26:38 GMT

[quote user="Robert Lowe"]KCS may be one of the issues caused by removal but there are other effects as well and in an ideal scenario (i.e. finance, patient behaviour etc removed from the equation) it is difficult to defend removal.[/quote]

I agree so far as it is difficult to defend amputation on a fracture that would have a >95% success with surgery. I've probably been playing devil's advocate a little - as I said, I've never excised a TEG myself and have not knowingly personally had one re-prolapse (though I've done less than a dozen myself) - indeed I would question the approach of some practioners to excising a prolapsed but healthy looking TEG as cosmetic surgery unless vision is affected (the whole point of surgery arguably being to preserve function of the TEG which can become traumatised when exposed - hence tucking it back in again).

[quote user="Robert Lowe"]The evidence is a bit weak but the pocket technique if done correctly carries a very high success rate and the only other paper (Morgan et al JAAHA 1993) that I can think of does highlight a reduced risk of KCS with this technique compared to excision. Unfortunately I don't have it to hand so I can't give you the exact figures.[/quote]

I think we probably agree here also, both in reference to the link between TEG excision and KCS: "the evidence is a bit weak" and also that "the pocket technique if done correctly carries a very high success rate". Rhea Morgan's 1993 paper is the one usually quoted (the only paper comparing TEG excision with replacement that I'm aware of). I think from memory she claims a 40% incidence of KCS after complete TEG excision. Have never read the entire paper as not JAAHA archives don't go back that far online - but I'll maybe see if I can dig up a paper copy at some point. There appear to be a number of issues with both the study and the way in which the results are often quoted, and suffice to say that I don't feel this paper should have been the final word on the matter - I would like to see a clinical comparisson between partial TEG excision (about 2/3rds I'm told is ideal and apparently never causes a problem with clinical KCS alter in life) as still practised by some more senior practioners whose number is rapidly dwindling and pocket-replacement as developed by Morgan with regard to clinical ocular complications.

If there's any (partial or complete) TEG excision practitioners out there, I really think it would be good to get some proper data out there - I'm sure something comparable to the 5 Beagle study quoted above would be pretty easily achieved

Re: Cherry Eye Surgery Technique

Robert Lowe — Fri, 21 Oct 2011 11:44:03 GMT

[quote user="David Beattie"]

Sorry if sounds like I have a bee-in-my-bonnet, but I've had too many folk advise me that even partial TEG excision is negligent and I think that is a ridiculous statement like saying limb amputation is negligent and an orthopaedic surgeon wouldn't stand in front of the PIC and defend me if I amputated a limb.

[/quote]

Hi David

Sorry - I wasn't trying to get at you and I think we probably agree in the middle of all of this.

I was not saying it was negligent to remove it just that I wouldn't defend it. Equally in the example you gave, I would be hard pushed to disagree with the clients especially second time round but the example is different to what happens in some general practices where removal is advocated as a perfectly acceptable treatment as a first line approach.

The evidence is a bit weak but the pocket technique if done correctly carries a very high success rate and the only other paper (Morgan et al JAAHA 1993) that I can think of does highlight a reduced risk of KCS with this technique compared to excision. Unfortunately I don't have it to hand so I can't give you the exact figures.

As I said, KCS may be one of the issues caused by removal but there are other effects as well and in an ideal scenario (i.e. finance, patient behaviour etc removed from the equation) it is difficult to defend removal. In the real world other issues do apply but we should all be starting from best case scenarios and tailoring treatment accordingly.

It's a bit like saying you shouldn't use steroids in the face of ulceration - but I will leave that can of worms unopened for the present.

Re: Cherry Eye Surgery Technique

Anonymous — Fri, 21 Oct 2011 10:25:28 GMT

[quote user="Robert Lowe"]As to what I gain out of this - not a lot as a pocket surgery is something that can be done by anyone with general surgical experience. [/quote]

100% apologies - had meant that in jest, not as a genuine slur.

[quote user="Robert Lowe"] I wouldn't be standing up to defend you for gland removal in front of the PIC.[/quote]

For this reason I've never excised a TEG - in the UK at least it appears to have reached the dizzy heights of negligence - if this has been an informed client decision to have the TEG removed, should I really need defended? I think blanket negligence for TEG excision is too far.

An example:

When working at a charity clinic on one occasion I had a Neopolitan Mastiff with a prolapsed TEG. The owners requested the TEG be removed and advised me they had 'researched' the condition on the internet and were aware that if replaced there was a chance that the dog would need a second surgery if this failed. In the 5 minute consult available, I advised them that TEG removal was not advised as it produced a third of the tears and could predispose to problems like KCS later in life requiring regular eye medication. They insisted that they wanted the TEG excised. I booked the dog in for TEG excision.

The vet doing non-routine ops on the allocated day by chance happened to have a CertOphthal and went to some efforts taking a lot of time to insist that if the client wanted the TEG excised, they may pay to get that done elsewhere, as there was no way it was happening at this charity clinic - it would of course be professional negligence. The client eventually relented and the TEG was replaced by a perfectly competent vet who also happened to have an interest in eyes and a CertOphthal to prove it. The TEG re-prolapsed. This time the dog was suitably aggressive at the clinic that I had to book it in for sedation to examine the eye which was being held shut most of the time, and appeared to have become infected. The owners requested please could the gland (which certainly didn't look like it was in a fit state to be producing many tears by this stage) was removed. Again refused and replaced with pocket technique AND anchoring to orbital periosteum by same perfectly competent vet. Re-prolapse. Clients immensely frustrated and unable to afford further surgery (charity clinic was subsidised, not free). I finished locum position.

The amount of resources in terms of time dedicated to this case compared to the average charity case at the clinic were ridiculously disproportionate and needless if the TEG had been (partially) excised as the clients had wished in the first instance. I felt this was particularly ironic as to save resources the same CertOpthal used TMPS with abandon in skin cases and I had seen a KCS resulting from this in my 3mth locum stint. So is there a difference between TMPS use and KCS risk and TEG (partial) excision and KCS risk? I take it you would also not defend the use of TMPS in a dog in front of the PIC?

[quote user="Robert Lowe"]Probably the best reference for this is below. [/quote]

So the best reference for the fact that TEG (partial) excision is negligent is the fact that the excision of the entire third eyelid (a different procedure unless I've misunderstood) caused microinjury to the keratoconjunctival epithelium (not clinical disease) at one year and 40% decrease in STT-2, but near normal STT-1 and PRT at one year? I'm all for EBM - that is appraising the quality of the evidence and not just accepting expert opinion as totally correct - but I'm struggling to make the jump from that paper to TEG (partial) excision is an indefensible procedure?

My understanding of EBM would involve a clinical trial to answer the important questions and be able to give clients informed choice rather than speculate on the complication rate; is there an incease in clinical ocular disease after partial TEG excision compared to replacement with pocket technique by avergae general practitioner?; is that a 5% risk or 40% risk? etc. Because apparently it is negligent to (partially) excise the TEG in the UK or USA then it would be unethical to do such a clinical trial? Perhaps recruiting some of the seasoned practitioners who have done/do partial TEG excision (with promised anonymity and immunity from prosecution) and retrospectively assessing cases in case-control study for clinical ocular disease later in life and severity of this would be acceptable?

Re: Cherry Eye Surgery Technique

Robert Lowe — Thu, 20 Oct 2011 20:38:46 GMT

I leave it to your choice whether to follow the experienced practioner or EBM but I wouldn't be standing up to defend you for gland removal in front of the PIC.

As to what I gain out of this - not a lot as a pocket surgery is something that can be done by anyone with general surgical experience.

Probably the best reference for this is below. Rather than saying removal could induce KCS, I would be more comfortable saying it reduces ocular surface health and therefore a range of complications such as poor corneal healing post ulceration, chronic keratitis etc may occur if not replaced. The poor bulldogs with compromised eyelid anatomy are a classic example or why every bit of tear helps.

http://onlinelibrary.wiley.com/doi/10.1046/j.1463-5224.2001.00122.x/full

The effect of third eyelid gland removal on the ocular surface of dogs Akihiko Saito et al, Vet Ophthal 2001

To evaluate the effect of third eyelid removal on the ocular surface of dogs, we operated on five young Beagle dogs and observed changes to tear function using the following tests: phenol red thread test (PRT), Schirmer tear test (STT-1), modified Schirmer tear test (STT-2), pH and tear break-up time (BUT). There was a significant decrease (37%) in STT-2 within 2 weeks after the excision and this declined further to 60% at 1 year. The pH value increased after excision. Presurgical pH was 7.17 ± 0.20 (mean ± SD), which increased to 7.55 ± 0.24 in the 14–60 days following removal, and further increased to 7.77 ± 0.65 at 1 year. The PRT and STT-1 decreased by 26% within 3–7 months compared to pre-excision values, but by 1 year the values recovered to near normal. The BUT pre-excision value was 24.0 ± 8.1 s, which shortened to 13.5 ± 4.5 s after 5 months and continued to decrease further during the study. There were no overt visual signs of KCS during the observational period. However, microinjury of the keratoconjunctival epithelium was observed for all operated eyes when vital staining was used at 1 year post surgery. Surgical excision of the third eyelid in Beagle dogs influenced tear quality level and affected the stability of the tear layer, and at 1 year there was evidence of microinjury to the keratoconjunctival epithelium.

Re: Cherry Eye Surgery Technique

Hannah Wynne Richards — Thu, 20 Oct 2011 18:21:16 GMT

True KCS (I've now got the acronym bug) is auto-immune, but loss of Harderian gland leads to loss of loipid film in tears,and more rapid evaporation,so causes dry eye that way.Responds quite well to permanent application severaltimes a day of gel based eye ointment-but better toprevent by good technique in the 1st place

Wynne

Re: Cherry Eye Surgery Technique

Anonymous — Thu, 20 Oct 2011 17:40:25 GMT

I agree is very subjective, and having been educated in the absolute negligence of excising a third eyelid gland (TEG) due to increased risk of developing KCS, I've always replaced them myself so have no personal subjective info on the matter.

Let's look at it from the other side however:

It may be very subjective to note that dogs diagnosed with KCS had a TEG removal in the past and a biased link may be formed.

Unless I've missed something, there is a single study done in the early 90's and I can't access online, but I'm not sure if the outcome was clinical disease of KCS requiring treatment (I don't think it was) or reduced tear production as measured by STT (hardly surprising).

There are more than one technique for excision: many experienced practitioners who quote 'no problems' did/do partial exicision of the gland. Again most ophthalmology purists who condemn TEG excision as negligent (and in some instances may profit as a result - but obviously I'm not suggesting a conspiracy!) will point out that this removes the ducts for tears to drain or something and makes the gland dysfuntional - yet I've encountered at least one CertVetOpthal who is approved for eye scoring in UK who frequently excises a small amount of the tissue when replacing them.

If KCS is an immune-mediated condition that frequently responds to cyclosporin, then surely excision of the TEG is only a problem if this immune-mediated condition affects the other lacrimal glands later in life? If so, any reason to believe won't respond to cyclosporin in similar fashion?

I'll try to dig up the one study I know exists, but would be interested in hearing any other evidence on the matter - because I think the link between TEG excision (esp partial) as a treatment for 'Cherry Eye' and KCS could be equally subjective to the personal experience of clinicians who have not noted any link? I certainly would dispute a prevalence of 40% of KCS after TEG excision as I think most clinicians would spot something that common if do any number of procedures over a few decades?

Re: Cherry Eye Surgery Technique

Hannah Wynne Richards — Thu, 20 Oct 2011 17:17:50 GMT

But do the seasoned practitioners link up the gland removalwith the later developement of dry eye-or is that "just one of those things "?

Wynne

Re: Cherry Eye Surgery Technique

Niall Taylor — Thu, 20 Oct 2011 16:54:00 GMT

[quote user="David Beattie"]Anybody still cutting these out rather than replacing?[/quote]

We used to do a lot that way and "never seemed to get any problems" but that's very subjective, particularly when the alleged problems might only occur several years later (and in a breed (bulldog) which is prone to allsorts of other eye problems anyway). Also removing the gland tends to weaken the IIIrd eyelid and we would occasionally get adhesions forming in such a way that the eyelid became anchored at the medial canthus - again not a problem, but not ideal either.

All in all I'm happy to have found a technique for replacement which suits me.

Cheers,

Niall

Re: Cherry Eye Surgery Technique

Anonymous — Thu, 20 Oct 2011 14:38:04 GMT

Anybody still cutting these out rather than replacing? Have spoken to many seasoned practitioners who have done so for a large number of years without 'apparent' problems - kind of makes me wonder a little

Re: Cherry Eye Surgery Technique

Niall Taylor — Thu, 20 Oct 2011 12:18:06 GMT

[quote user="Niall Taylor"]I find it works very well and (touch wood) I have never had it fail yet.[/quote]

Aaaargh, talk about tempting fate - I've just had my first breakdown!!!

I'm going to have a second try, using vicryl 1.5 metric this time rather than 0.7 as previously.

Niall (crestfallen smartypants!)

Re: Cherry Eye Surgery Technique

emerald — Fri, 14 Oct 2011 15:46:31 GMT

Ame as Nial too

Re: Cherry Eye Surgery Technique

Mark Hedberg — Wed, 12 Oct 2011 22:37:02 GMT

[quote user="Niall Taylor"]

[quote user="Hannah Wynne Richards"]

Niall's explanation was brilliant-no need for a diagram That's how I do it as well

Niall -your explanation reminded me of Jim Pinsent's lectures-Evelyn will know how high that praise is

Wynne[/quote]

Aw shucks, now I'm blushing! Thanks Wynne

The reference is - King, M.C.A., 2000 Conditions of the third eyelid UK Vet Vol. 5 no. 1 pp. 17-21. I'm sure it won't be available on line but if anyone wants a copy I can forward a pdf.

Cheers,

Niall

[/quote]

Me, for one! Nice to check if any bad habits crept up on me the last few years! :)

Re: Cherry Eye Surgery Technique

Niall Taylor — Wed, 12 Oct 2011 19:00:03 GMT

[quote user="Hannah Wynne Richards"]

Niall's explanation was brilliant-no need for a diagram That's how I do it as well

Niall -your explanation reminded me of Jim Pinsent's lectures-Evelyn will know how high that praise is

Wynne[/quote]

Aw shucks, now I'm blushing! Thanks Wynne

The reference is - King, M.C.A., 2000 Conditions of the third eyelid UK Vet Vol. 5 no. 1 pp. 17-21. I'm sure it won't be available on line but if anyone wants a copy I can forward a pdf.

Cheers,

Niall

Re: Cherry Eye Surgery Technique

Hannah Wynne Richards — Wed, 12 Oct 2011 16:52:38 GMT

Niall's explanation was brilliant-no need for a diagram That's how I do it as well

Niall -your explanation reminded me of Jim Pinsent's lectures-Evelyn will know how high that praise is

Wynne

Re: Cherry Eye Surgery Technique

Evelyn Barbour-Hill — Wed, 12 Oct 2011 16:33:07 GMT

[quote user="Gerry Henry"] Annoying that the video can't be paused and watched in a oner, my broadband is glacially slow.[/quote]

It's not brilliant anyway. A case where three or four good diagrams would be worth a thousand words or millions of video Mb.

Re: Cherry Eye Surgery Technique

Gerry Henry — Wed, 12 Oct 2011 14:42:50 GMT

I prefer the tie down myself, I feel its a more permanent repair, also I use 1.5m or 2m mono nylon (prolene) as I've had post op breakdown in the past when I've used an absorbable suture. Annoying that the video can't be paused and watched in a oner, my broadband is glacially slow.

Re: Cherry Eye Surgery Technique

Alan Tevendale — Wed, 12 Oct 2011 07:12:56 GMT

Another one for exactly the same technique as Niall.

Re: Cherry Eye Surgery Technique

Mark Hedberg — Tue, 11 Oct 2011 22:31:25 GMT

edit: Niall types faster than I do and explains things better - I do it like he does! (I prefer vicryl, but nylon works just fine for those pesky times in the middle east when you don't have vicryl!)