Fig. 21. Fornix-based conjunctival closure. This is the author's preferred conjunctival closure for all fornix-based antimetabolite filtration procedures including combined procedures. The recurrent theme behind this closure is a conjunctivopexy approach. The conjunctiva must be tacked down to the limbus in an absolutely watertight fashion. The conjunctiva is brought forward onto the previously denuded limbus and sutured meticulously into place. This is a much more complicated time consuming closure than the usual hood technique. The wound is always closed from the surgeons' right to left for a right-handed surgeon. A. Use a 9-0 nylon Ethicon 2890 suture. First anchor the suture horizontally to epicornea beyond the conjunctival incision and trim the knot. B. Direct the needle across the limbus by first obtaining a limbal bite then impaling the underside of the conjunctiva and exit through the surface of the conjunctiva 1 mm from its edge. C. Redirect the needle back through the conjunctiva approximately 2 mm further to the left. This creates a suture loop over the conjunctiva. D. Tack down this loop of conjunctiva to the limbus by reintroducing the suture horizontally along the limbus 1 mm back toward the anchor bite. Follow the arc of the needle and exit the limbus. Pull to the left and tighten the suture while holding the edge of the conjunctiva encompassed by the conjunctival loop toward the cornea. This ensures the overlying suture loop is tacked directly down to the limbus. E. Direct the needle across the limbus again and pierce the underside of the conjunctiva approximately 1 mm back toward the anchor suture. Again, tack the conjunctiva down to the limbus in the same fashion by repeating steps C and D. F. It is especially important to tighten the suture loop-by-loop to make sure that the conjunctival edge (G) stays properly positioned beneath the loop. This constitutes a running vertical mattress suture and is repeated (H- J) until the wound is closed. K. Make a final epicorneal bite at the end of the incision, tie the suture to itself, and trim the knot. L. Final appearance of leak-free wound. In summary, this technique uses two ways to tack the conjunctiva down to the denuded limbus: First, directly as the suture loop compresses the conjunctiva down onto the limbus as in figure G much like a horizontal mattress suture. Second, the gap in the conjunctiva between the suture loops is normally the weak point in the wound. However with this particular wound closure, the conjunctiva between the tacked loops is stretched over the limbus due to the two adjacent conjunctival sutures (medial and lateral) that pull in opposite directions. This direct and indirect methodology ensures the best possible leak-free closure.