Double Running Suture Research Articles

V1243 LAPAROSCOPIC RESOLUTION OF COMPLICATIONS DURING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Oncology1 Apr 2012V1243 LAPAROSCOPIC RESOLUTION OF COMPLICATIONS DURING RADICAL PROSTATECTOMY Roberto Sanseverino, Giorgio Napodano, Olivier Intilla, Umberto Di Mauro, and Tommaso Realfonso Roberto SanseverinoRoberto Sanseverino Nocera Inferiore, Italy More articles by this author , Giorgio NapodanoGiorgio Napodano Nocera Inferiore, Italy More articles by this author , Olivier IntillaOlivier Intilla Nocera Inferiore, Italy More articles by this author , Umberto Di MauroUmberto Di Mauro Nocera Inferiore, Italy More articles by this author , and Tommaso RealfonsoTommaso Realfonso Nocera Inferiore, Italy More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1547AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Since its introduction, Laparoscopic preperitoneal radical prostatectomy (LPPRP) is undergoing continuous refinements which make it today a feasible, reproducible, and teachable operation. Nevertheless intraoperative complications require often conversion to open surgery. The video shows a laparoscopic resolution of a rectal injury and of an external iliac vein lesion during preperitoneal radical prostatectomy. METHODS After creating the preperitoneal space by balloon trocar dissection, five trocars (2 x 5mm and 3 x 10mm port) are placed in the hypogastrium. Bilateral pelvic lymphadenectomy is performed. Bilateral incision of endopelvic fascia anticipates haemostatic transacted suture of Santorini plexus with Vicryl™. Bladder neck dissection. Urethra is then transected. Vas deferens are isolated and then cutted; mobilization of seminal vesicles precedes incision of the Denonvilliers' fascia. Section of the prostatic pedicles is routinely realized with Ligasure™ or with Hem-O-lock and endoshears, when a nerve sparing technique is performed. Because of strong adhesion between prostate and rectum an injury of the anterior rectal wall occurs. After cutting Santorini plexus and urethra, the prostate is placed in endobag. The rectal lesion is repaired with Vicryl™ sutures. A sponge of Tachosil™ is applied on the repaired rectal wall using a laparoscopic dedicated device. In the second case the video shows a lesion of right external iliac vein occurred during removal of a needle from abdominal cavity. The vein is isolated and clamped by a self made tourniquet. The lesion is repaired with a Prolene suture. A Surgicel™ sheet is applied on the vein. Bladder neck biopsy and water-tight urethrovesical anastomosis with double running suture as described by van Velthoven are performed. RESULTS In both cases the laparoscopic surgical procedure is realized without any major consequences. CONCLUSIONS The LPPRP is feasible and reproducible technique that could be subject to intraopeative complications requiring conversion to open surgery. Nevertheless it is possible resolve, also during learning curve, major complications as rectal and vascular injuries without conversion to open surgery. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e502 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Roberto Sanseverino Nocera Inferiore, Italy More articles by this author Giorgio Napodano Nocera Inferiore, Italy More articles by this author Olivier Intilla Nocera Inferiore, Italy More articles by this author Umberto Di Mauro Nocera Inferiore, Italy More articles by this author Tommaso Realfonso Nocera Inferiore, Italy More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Intraoperative Videokeratography in Penetrating Keratoplasty and Excimer Laser-Assisted Lamellar Keratoplasty for Keratoconus

To evaluate the usefulness of intraoperative computerized corneal topographic data in excimer laser-assisted lamellar keratoplasty (ELLK) and penetrating keratoplasty (PK). Prospective, comparative, interventional case series. Intra- and postoperative videokeratography (Keratron Scout) evaluation was performed on 30 eyes of 30 consecutive patients affected by keratoconus (16 men and 14 women; mean age 32.63±8.02 years) submitted to ELLK (15 eyes) using 16 interrupted 10-0 nylon stitches or to PK (15 eyes) using a 12-bite 10-0 nylon double-running continuous suture. In the ELLK group, the mean intraoperative keratometric astigmatism was 12.06±4.86 diopters (D), which changed to 5.19±2.51 D after topography-guided intraoperative suture adjustment. In the PK group, intraoperative keratometric astigmatism was 10.18±3.88 D, which changed to 3.49±0.41 D. After 24 months (sutures out), the mean videokeratographic keratometric astigmatism was 3.35±1.96 D in the ELLK group and 3.37±0.92 D in the PK group. The Alpins method of vector analysis showed some significant changes especially in the ELLK group. In keratoplasty surgery, videokeratography is useful for suture adjustment. In the PK group, using a double-running suture technique, the postoperative astigmatism (after all sutures were removed) was similar to the astigmatism measured intraoperatively by videokeratography.

Timing of Suture Removal in Sequential Surgery: A Pilot Study

To study the appropriate timing of corneal suture removal in sequential surgery (penetrating keratoplasty [PK]-phacoemulsification [PE]) procedures. In a pilot study, patients with a PK double running suture in place requiring cataract surgery were randomized to suture removal 1 month before PE or during PE (n = 14; 7 in each group). Visual acuity, refraction, manual keratometry, Pentacam analysis, biomicroscopy, biometry, endothelial cell count, and funduscopy were determined before suture removal/PE and after PE (except biometry). Outcome measures at 6 months were corneal refractive change (induced by PE plus suture removal) analyzed by conversion to corneal power vector, index of surface variance change, and postoperative spherical equivalent, corrected, and uncorrected visual acuity. Average corneal refractive change induced was 1.63, -2.98 x 96 degrees in the preoperative suture removal group and 2.14, -2.84 x 90 degrees in the intraoperative suture removal group. Difference in parameters of the corneal power vector change were statistically significant but not clinically relevant (M, spherical component, 0.14 vs 0.72, P = 0.01, respectively; J, astigmatic component, 1.49 vs 1.42, P = 0.01, respectively). Postoperative spherical equivalent, index of surface variance change, and corrected and uncorrected visual acuity were not significantly different in the two groups. Differences in refractive state and visual acuity of the eye are not observed between patients with PK continuous suture removal (1 month) before PE and during PE.

Biomechanical study of four modified Kessler flexor tendon suture teclmiques

Objective To compare tensile strength of four different modified Kessler flexor tendon suture techniques. Methods Forty flexor digitorum profundus tendons of white pig hind limbs were transected and repaired using 4 suture techniques, with 10 tendons for each technique. The four suture techniques were Kessler, Double Kessler, Running suture and Kessler plus Running suture. After suturing, 2 mm gap formation force and failure load of the sutures were tested. One-way ANOVA was applied for statistic comparison of each technique. Results Double Kessler suture technique has the greatest tensile strength with its failure load, fonowed by Kessler plus Running suture, Kessler and Running suture. Kessler plus Running suture method had the greatest 2 mm gap formation force, followed by Double Kessler, Running suture and Kessler technique. Conclusion Kessler plus Running suture can better endure early finger active mobilization. Key words: Tendon injuries; Suture techniques; Biomechanics

Femtosecond laser‐assisted penetrating re‐keratoplasty

Editor, Penetrating keratoplasty has usually been performed taking a trephine for the sagittal excision of the corneal donor button and for the preparation of the recipient corneal bed. The disadvantages of this sagittal cutting technique are a lack of rotational stability and a lack of sagittal stability. With the introduction of the femtosecond laser into clinical ophthalmology (Jonas & Vossmerbaeumer 2004; Hoffart et al. 2008; Mastropasqua et al. 2008; Por et al. 2008; Price & Price 2008), a new cutting technique has emerged that offers the possibility of creating non-circular and angled incisions. According to preliminary results, this new technique can markedly reduce postoperative keratoplasty and enhance the overall stability of the wound because of the increased and angled surface of the interface between the graft and the host tissue. Because the femtosecond laser is based on an optical principle with the laser beam penetrating the corneal tissue, it necessitates sufficient transparency of the corneal stroma to allow the laser beam to penetrate to the deep corneal layer and Descemet’s membrane. Previous studies have shown that an intrastromal corneal oedema caused by a corneal endothelial insufficiency has not been an obstacle for the femtosecond laser beam (Hoffart et al. 2008; Por et al. 2008; Price & Price 2008). However, so far it has been unclear whether dense intracorneal scars, particularly after previous corneal surgery, may prevent the use of the femtosecond laser for keratoplasty. Therefore, in this article I report on the feasibility of the technique for a patient who underwent femtosecond laser keratoplasty after a previous keratoplasty had failed. A 48-year-old patient had undergone conventional trephine-guided penetrating keratoplasty as treatment of keratoconus in 1991. The diameter of the graft trephined from the endothelial side was 8.0 mm; the diameter of the excised corneal button in the host cornea was 7.8 mm. The graft was centred onto the optical axis. With an initially clear corneal graft, best-corrected visual acuity was 20/20. Seventeen years after the keratoplasty, the graft started to develop intrastromal oedema, particularly in the late afternoon, because of a progressive age-related insufficiency of the corneal endothelium of the graft. Using a commercially available femtosecond laser (Advanced Medical Optics; Intralase, Santa Ana, California, USA), a penetrating rekeratoplasty was carried out. A top-hat cutting configuration (Price & Price 2008) was chosen. The diameters of the superficial and deep parts were 7.0 mm and 8.5 mm, respectively; a lamellar cut was made at a depth of 250 μm. The lamellar overlapped the superficial part and the deep part by 0.3 mm, so that its outer diameter was 8.8 mm and its inner diameter was 6.7 mm. As per the previous corneal graft, the regraft was centred onto the optical axis. Despite the dense corneal opacities in the zone of the interface between the previous graft and the host cornea, the femtosecond laser was able to cut the corneal tissue unremarkably. The central corneal button precut by the laser could be removed without further use of a knife or scissors. The graft was fixated with a double running suture with buried knots in the interface (Fig. 1). Three months after the intervention, visual acuity was 20/20 with a regular corneal astigmatism of 2.0 dioptres (Fig. 1). Clinical photograph showing an eye 3 months after a femtosecond laser-assisted penetrating homologous keratoplasty 17 years after a previous penetrating keratoplasty. The scar of the interface between the former graft and the recipient cornea (remnants of the former scar: arrows) did not impede the femtosecond laser cutting of the cornea. These results suggest that the femtosecond laser is able to perform incisions in the superficial and deep corneal layers including Descemet’s membrane through dense intracorneal opacities such as scars in the interface after a previous penetrating keratoplasty. A previous keratoplasty is not a contradiction against a femtosecond laser-assisted keratoplasty.

Corneal Wavefront Errors 24 Months after Deep Lamellar Endothelial Keratoplasty and Penetrating Keratoplasty

To evaluate high-order aberrations (HOA) induced by the anterior corneal surface after deep lamellar endothelial keratoplasty (DLEK) and penetrating keratoplasty (PK). Prospective, randomized clinical trial. Twenty-eight eyes of 25 patients with corneal edema resulting from Fuchs dystrophy underwent DLEK with a 9- to 10-mm incision (n = 13) or PK with double-running sutures (n = 15) at the Cornea Service, Mayo Clinic Department of Ophthalmology, Rochester, Minnesota. The main outcome measures were HOA from the anterior corneal surface calculated from corneal topography and decomposed into Zernike polynomials to the sixth order, high- and low-contrast visual acuity (VA), and contrast sensitivity. Variables after surgery were compared with those before surgery and between treatments by using generalized estimating equation models with Bonferroni adjustment. Total HOA through 24 months (0.48 +/- 0.15 microm) after DLEK was similar to total aberration before surgery (0.44 +/- 0.23 microm; P = .10). After PK, total HOA remained elevated through 24 months (1.68 +/- 0.58 microm) compared with that before surgery (0.49 +/- 0.27 microm; P < .005) and compared with that after DLEK (P < .006). At 24 months after PK, corneas with sutures removed had greater total HOAs than corneas with sutures intact (1.90 +/- 0.52 microm vs 1.18 +/- 0.33 microm; P = .001). High- and low-contrast VA and contrast sensitivity at 24 months after PK did not correlate with any HOA. HOAs from the anterior corneal surface were higher after PK compared with after DLEK but did not correlate with visual function after PK.

A New Technique for Laparoscopic Vesicourethral Anastomosis: Preliminary Report

To introduce a new and easy technique to perform laparoscopic vesicourethral anastomosis with a single-suture, single-knot, running procedure. We have performed 350 laparoscopic radical prostatectomies. In a prospective study, we evaluated a new anastomosis technique in 50 consecutive cases. A multiple knot is prepared at 4 cm from the end of a suture. Then the running suture is started at the bladder neck at 4 o'clock. The posterior plate is maintained open for the first throws, and the suture is pulled only after the third passage at the bladder neck. Then the running suture is completed clockwise and finally tied to the 4-cm tail. Use of this technique in 50 patients was compared with use of a double running suture in 50 other patients. The 2 groups were comparable. The new procedure was related to a decreased anastomotic time, without complications, with no leak at catheter removal at postoperative day 5 or 6. The experience with this original anastomosis is still preliminary, but the results are very promising, and we would like to propose it to laparoscopic urologists.

The Effect of Different Suturing Techniques on Astigmatism after Penetrating Keratoplasty

The purpose of this study was to compare the effects on astigmatism after penetrating keratoplasty with three different suture techniques. In this prospective study, 38 eyes of 38 patients underwent penetrating keratoplasty with three suturing techniques: interrupted, single running, and double running. Topographic astigmatism was measured at 2, 6, 12, and 18 months after keratoplasty. During 18 months after surgery, the interrupted suture group had higher astigmatism than the double running suture group. There was no significant difference in the amounts of astigmatism during the first year after keratoplasty between the single running and the double running suture group. However, at 18 months after surgery, when all sutures were out, the double running suture group (3.60±1.58 diopters) showed significantly less astigmatism than the single running group (5.65±1.61 diopters). In conclusion, post-keratoplasty astigmatism was the least in the double running suture group of the three suturing techniques at 18 months after penetrating keratoplasty.

Laparoscopic Leak-Free Technique for the Treatment of Choledochal Cysts

The aim of this report was to present our experience with a modified surgical technique designed for the treatment of choledochal cysts (CC) in children. Between June 2004 and February 2005, we operated on 6 patients with a diagnosis of type I CC by means of a "leak-free" technique that consists of a transient complete sealing of the hepatic duct for the duration of the dissection, and a single- or double laparoscopic running suture to build the end-to-side hepatico-jejuno anastomosis. There were 4 females and 2 males, whose age ranged between 45 days and 7 years (median, 45 months). All cases were performed with three trocars plus the scope, and two or three percutaneous stay-stitches to retract the liver. The end-to-side hepatico-jejuno anastomoses were done with 5.0 or 6.0 PDS. We left no drains. The mean operative time was 335 minutes, and mean postoperative time to oral feeding was 44 hours. The mean hospital stay was 6 days (range, 5-10). No postoperative biliary leak was observed. A cosmetic result was excellent in all patients. In the follow-up (mean, 12 months), all patients were asymptomatic, had no intrahepatic biliary tree dilation, and had normal liver function tests. Based on the results of our series, we think that the laparoscopic approach is suitable for these patients, but some surgical details should be followed to lower the complication rate. First, a temporary closure of the hepatic duct to prevent bile spillage during the dissection is important for keeping the area clean and thus reducing the operative time. Second, the use of a running suture for the hepatico-jejunostomy, even though it may be technically challenging, should always be attempted to avoid postoperative bile leaks in these high-flow anastomoses.

Changes in Corneal Power and Refraction Due to Sequential Suture Removal Following Nonmechanical Penetrating Keratoplasty in Eyes With Keratoconus

To assess the changes in corneal power and refraction due to sequential suture removal after penetrating keratoplasty (PK). Retrospective consecutive case series. setting: Clinical practice. study population: We studied 67 phakic keratoconus eyes (central excimer laser trephination, primary keratoplasty, graft/recipient diameter 8.1/8.0 mm; double running suture) in this longitudinal study. main outcome measures: Zeiss keratometry (equivalent power (KEQ), astigmatism (KAST)), corneal topography (equivalent power (TEQ), astigmatism (TAST)) and subjective refractometry (spherical equivalent (SEQ), refractive cylinder (RAST)) were assessed with sutures in place (interval 1), with one suture out (interval 2), and with all sutures out (interval 3). observation procedure: Corneal power and refraction was decomposed into vector components and the changes were derived between time stages. The mean follow-up period was 3.9+/-1.7 years. At interval 1, the axes of KAST/TAST/RAST were almost randomly distributed. At interval 2, the with/against the rule component of KAST/TAST/RAST decreased slightly and the oblique component increased significantly, so that the axes tended to have a preferred oblique direction. At interval 3, the with/against the rule component of KAST/TAST/RAST increased slightly and the oblique component decreased significantly, so that the with/against the rule component exceeded the oblique component by approximately 23%/28%/25%. Median KEQ/TEQ/SEQ changed by 0.64/0.62/-1.11 diopters (interval 1 to interval 2) and by -0.85/-0.90/1.56 diopters (interval 2 to interval 3). As a result of removal of the first running suture, corneal astigmatism as well as the refractive cylinder tend to oblique axes. As a result of removal of the second running suture, the final corneal astigmatism and refractive cylinder tend to orientation axes with/against the rule.

Repeat Keratoplasty for Correction of High or Irregular Postkeratoplasty Astigmatism in Clear Corneal Grafts

To evaluate the functional results of repeat penetrating keratoplasty in clear corneal grafts with high/irregular postkeratoplasty astigmatism. Retrospective, longitudinal, single-center, consecutive clinical case series. We studied 17 eyes (16 keratoconus, 1 Fuchs' dystrophy) of 16 patients (age, 54.9 +/- 12.6 years). They were treated with repeat PK, performed using the 193-nm Zeiss-Meditec MEL-60 excimer laser using round metal masks (diameter, 7.5-8.0 mm), and employing double running sutures. main outcome measures: Subjective refractometry, standard keratometry, and corneal topography (Tomey TMS-1) were used to assess best-corrected visual acuity (BCVA), spherical equivalent (SEQ), keratometric and topographic central corneal power (CP), refractive, keratometric and topographic astigmatism, surface regularity index (SRI), surface asymmetry index (SAI), and potential visual acuity (PVA) preoperatively, before and after first suture removal (1.1 year), and after second suture removal (1.8 years). Visual acuity improved significantly (BCVA from 0.2-0.5, P = .04 or better) for all postoperative measurements. CP decreased significantly, but SEQ did not change. All measures of astigmatism and SRI and SAI values showed postoperative improvement with sutures in place; however, astigmatism increased significantly after second suture removal. With all-sutures-in, BCVA and astigmatism improve significantly after repeat PK for high/irregular astigmatism. However, to present significant increase in astigmatism, final suture removal should be postponed as long as possible in such eyes.

Langzeitergebnisse der perforierenden Keratoplastik mit verschiedenen Trepansystemen - Eine klinische Studie aus der Universitätsaugenklinik Halle/Saale und der Augenklinik des Helios Klinikums Aue

The results of penetrating keratoplasty in two centres for cornea transplantation were investigated with regard to the following parameters: the trephine system used, the origin of the donor cornea, the influence on the postoperative astigmatism and other aspects. The retrospective clinical investigation reports about the results of 186 patients with penetrating keratoplasty from the University Eye Hospital of Halle and 204 patients from the Eye Clinic of the Helios hospital Aue. Three trephine systems have been used: the Hessburg-Barron trephine, the guided trephine system (GTS) and the Asmotom device. There were no significant differences between them concerning visual acuity after 12 months postoperatively. The results were highly significantly better (p = 0.003 Halle; p = 0.001 Aue) when using larger diameters of the trephine (7.5 mm and 8.0 mm). The origin of the donor cornea ("fresh" cornea from a deceased subject or organ cultivated cornea from a cornea bank) had no influence on visual outcome after twelve months (p > 0.8). There were less wound dehiscences using the double running suture in comparison with other techniques (p = 0.05). The removal of suturing material was not effective in reducing postoperative astigmatism (p > 0.11). There was no increase in astigmatism when leaving the sutures in situ (p > 0.25). Generally, each of the three trephine systems can be recommended for clinical use. The trephination should be done with trephine diameters of 7.5 mm or 8.0 mm. A timely operation guarantees better visual acuity at one year postoperatively.

Keratometric astigmatism after suture removal in penetrating keratoplasty: double running versus single running suture techniques

AbstractBackground and ObjectiveTo compare astigmatism after suture removal in a retrospective sequential series of patients who had penetrating keratoplasty with either a double running suture technique or an adjustable single running suture technique. During the first year postkeratoplasty, when s

Shortterm and longterm visual and astigmatic results of an opposing 10-0 nylon double running suture technique for penetrating keratoplasty.

In ophthalmic surgery, corneal transplantation (penetrating keratoplasty) may be employed when the clarity of the cornea has been significantly compromised by conditions such as scarring, edema, and variable corneal thickness. Irregularities in corneal curvature can occur postoperatively. This astigmatism is of concern, because it can impair visual acuity despite an otherwise good surgical result. Different suturing techniques have been developed to minimize astigmatism. The purpose of this study was to evaluate an opposing 10-0 nylon double running suture technique for penetrating keratoplasty. A retrospective study was undertaken of 91 records of patients who underwent penetrating keratoplasty performed by one surgeon (RNG). This represents 54.8% of 166 consecutive cases. Every eye with an opposing double running suture and a 1- to 3-month postsuture removal followup was selected and evaluated for best corrected visual acuity and astigmatism, excluding eyes that developed graft failure or corneal ulcer or that had lack of adequate followup. The cases were divided into five groups by preoperative diagnosis: pseudophakic bullous keratopathy (n = 43), aphakic bullous keratopathy (n = 5), keratoconus (n = 17), Fuchs dystrophy (n = 12), and miscellaneous (n = 14). The mean standard followup period was 13.7 months after penetrating keratoplasty. Thirty percent of the eyes had an extensive followup, with a mean of 33 months after penetrating keratoplasty. Eighty-two percent of the patients had a significant improvement of their visual acuity postoperatively, defined by a five-line improvement of best corrected visual acuity or a best corrected visual acuity of 20/40 or better. The mean astigmatic keratometric reading was 3.98 diopters, with a manifest refraction cylinder of 3.42 diopters at the 1- to 3-month postsuture removal visit. This study also shows that there is no statistically significant change in keratometric astigmatism or manifest refraction cylinder from the 1- to 3-month postsuture removal measurements to the more extensive followup of 18 to 66 months after penetrating keratoplasty (p > 0.10). This suture technique allows for excellent longterm stability of the wound with visual and astigmatic results that are comparable to those of previous studies. The use of the opposing double running suture is a viable alternative to some of the other widely used techniques and may be considered more stable and secure.

Keratometric astigmatism after suture removal in penetrating keratoplasty: double running versus single running suture techniques.

To compare astigmatism after suture removal in a retrospective sequential series of patients who had penetrating keratoplasty with either a double running suture technique or an adjustable single running suture technique. During the first year postkeratoplasty, when sutures were in place, the latter technique had produced less astigmatism. Keratometry and keratometric astigmatism were measured before and after suture removal. We compared these variables in 30 grafts with the double running suture technique to the same variables in 24 grafts with the single running suture technique. The final portion of the double running suture was removed 408 +/- 177 (mean +/- SD) days after keratoplasty, whereas the single running suture was removed 611 +/- 224 days after keratoplasty (P<0.001). After suture removal, there was no difference between the double running and single running groups in either mean keratometry [46.5 +/- 1.8 diopters (D) versus 45.6 +/- 2.0 D, P=0.09, minimum detectable difference (MDD)=1.5D] or mean astigmatism (4.6 +/- 2.7 D versus 5.2 +/- 3.2D, P=0.72, MDD=2.3). In this consecutive series of corneal transplants performed by one surgeon, the results suggest no difference in astigmatism between the two suturing techniques after all sutures have been removed.

Impact of graft diameter on corneal power and the regularity of postkeratoplasty astigmatism before and after suture removal

Objective To assess the impact of graft diameter on corneal curvature before and after removal of a double-running suture after nonmechanical penetrating keratoplasty (PK). Design Prospective, nonrandomized, comparative (self-controlled) single-center clinical trial. Patients Four hundred eighty-nine eyes with “two sutures in” and 308 eyes with “all sutures out” (mean age, 52±19 years) were included. The diagnoses were keratoconus (48%), Fuchs' and stromal dystrophies (31%), aphakic or pseudophakic bullous keratopathy (11%), and scars (10%). Interventions In all eyes, a central trephination was performed (donor trephination from the epithelial side) using the 193-nm Meditec excimer laser (Carl Zeiss Meditec, Jena, Germany) along metal masks with eight “orientation teeth/notches.” Diameters were 8.0 mm, 7.5 mm, and 7.0 mm with a graft oversize of 0.1 mm. In 29% of eyes, additional cataract, intraocular lens surgery, or both were performed simultaneously. In all eyes, a double-running 10-0 nylon suture was applied. Zeiss keratometry and TMS-1 topography analysis were performed before removal of the first suture (14±4 months) and at least 6 weeks after removal of the second suture (20±4 months), but before any additional surgery, such as cataract extraction or refractive keratotomies. Main outcome measures Topographic central corneal power (CP; keratometric diopters), keratometric astigmatism (KA), surface regularity index (SRI), and surface asymmetry index (SAI). The regularity of keratometry mires was recorded semiquantitatively from 0 = regular to 3 = not measurable (as published earlier). Results With both sutures in, median CP in 7.0-mm (42.0 diopters [D]; P = 0.04) and in 7.5-mm grafts (42.3 D; P = 0.007) was significantly lower than in 8.0-mm grafts (43.0 D). Keratometric astigmatism did not differ between groups (3.0 D vs. 3.0 D vs. 2.7 D). The SRI (1.66 vs. 1.43 vs. 1.11) and SAI (1.55 vs. 1.24 vs. 0.85) decreased significantly with increasing diameter. The proportion of regular keratometry mires (13% vs. 17% vs. 29%) increased, and the proportion of not measurable keratometries (45% vs. 18% vs. 9%) decreased with increasing diameter. With all sutures out, CP in 7.0-mm grafts (40.4 D) was significantly smaller than in 7.5-mm (43.6 D; P = 0.04) and 8.0-mm grafts (43.3 D; P = 0.04). Again, KA did not differ between groups (3.0 D vs. 3.2 D vs. 3.0 D). The SRI (1.40 vs. 1.09 vs. 0.84) and SAI (1.24 vs. 0.83 vs. 0.62) decreased significantly with increasing diameter. The proportion of regular keratometry mires (5% vs. 31% vs. 52%) increased, and the proportion of not measurable keratometries (42% vs. 11% vs. 4%) decreased with increasing diameter. Conclusions After PK, a smaller graft diameter results in a flatter curvature and a higher degree of topographic irregularity, but not in higher net astigmatism. After suture removal, graft topography tends to regularize, whereas the principal differences between diameters do persist.

Impact of preoperative corneal curvature on the outcome of penetrating keratoplasty in keratoconus.

To assess the impact of the patient's preoperative corneal curvature on the refractive outcome after penetrating keratoplasty (PK) in keratoconus before and after suture removal. In this retrospective cross-sectional clinical study, 236 keratoconus patients (mean age 37 +/- 11 years) were divided into four groups based on their preoperative keratometric (K-) readings: group 1, <50 diopters (D) (n = 24); group 2, <60 D (n = 52); group 3, > or =60 D (n = 101); group 4, irregular corneal shape with unmeasurable K-reading (n = 59). An 8.0/8.1-mm central round PK was performed using 193 nm Meditec excimer laser trephination along metal masks with eight "orientation teeth/notches." A 16-bite double running cross-stitch suture was applied in all cases. Postoperative examinations were performed before removal of the first suture (ie, 12 months) and after removal of the second suture (ie, 18 months). The outcome measures included central power (C-power), keratometric astigmatism (AST), surface regularity index (SRI), surface asymmetry index (SAI), spherical equivalent (SEQ), refractive cylinder (Cyl), and best corrected visual acuity (BCVA). In addition, the regularity of Zeiss keratometry mires was classified semiquantitatively (0, regular; 1, mildly irregular; 2, moderately irregular; 3, unmeasurable). RESULTS Before/after suture removal, median C-power was 43.4/43.3 D; AST was 3.0/3.0 D; SAI was 0.6/0.6; SRI was 0.9/0.9; Cyl was 2.5/2.5 D; BCVA was 0.7/0.7. After suture removal, the percentage of regular keratometry mires increased from 37% to 61%. Comparisons among the four groups revealed no significant differences for any parameters tested either before or after suture removal. CONCLUSIONS With laser trephination and a double running suture, the refractive and visual outcome of PK for keratoconus seems to be independent on the patient's preoperative corneal curvature or irregularity. Suture removal did not effect an increase of corneal astigmatism but did increase the proportion of regular keratometry mires. Thus, our policy of not performing PK in keratoconus eyes before the patient becomes contact lens intolerant is well supported.

Keratometric Results During the First Year After Keratoplasty: Adjustable Single Running Suture Technique Versus Double Running Suture Technique

To compare the 3-month and 1-year postoperative keratometric results in a retrospective sequential series of corneal grafts performed with either a double running suture technique or an adjustable single running suture technique. Keratometry values obtained 3 months and 1 year after penetrating keratoplasty, when sutures were still present, were compared between 31 grafts with double running sutures and 27 grafts with single running sutures, 15 of which had been adjusted postoperatively. No significant difference in mean keratometry between the 2 groups was found either 3 months or 12 months after keratoplasty. Mean keratometric astigmatism was significantly less in the single running group at both 3 months (2.2 +/- 1.9 vs 4.5 +/- 2.8, mean +/- SD, P <0.001) and 12 months (3.0 +/- 2.2 vs 4.2 +/- 2.1, P = 0.03). Within groups, there was no significant change from 3 months to 12 months in either mean keratometry or keratometric astigmatism. The single running suture technique, with postoperative adjustments, produced less keratometric astigmatism during the first postoperative year, when sutures were still in place.

Different suturing techniques variously affect the regularity of postkeratoplasty astigmatism

Objective This study aimed to determine the effect of various suturing techniques on the regularity of postkeratoplasty astigmatism. Design A prospective clinical trial. Participants Sixty-two consecutive patients undergoing penetrating keratoplasty by the same surgeon (MB) participated. Intervention Each patient was assigned to one of four groups according to the suturing technique used (a = 16 interrupted 10-0 nylon sutures; b = 2 running 10-0 nylon sutures, each with 8 bites; c = 2 running 10-0 nylon sutures, each with 12 bites; d = 2 running 10-0 nylon sutures, each with 16 bites). This was the only parameter permitted to be changed in the standard keratoplasty procedure used for all cases. Corneal topography was performed 1, 3, and 6 months after surgery. The astigmatic patterns seen on the corneal maps then were classified into regular (symmetric or asymmetric bowtie patterns) or irregular (distorted bowtie, multiaxial, or other patterns). Main outcome measures Regularity of postkeratoplasty corneal astigmatism was measured. Results At all postoperative examination times, the percentage of irregular astigmatic patterns was highest in group a and lowest in group d (chi-square test: P < 0.005). Groups b and c showed intermediate values. The entity of the astigmatic error as measured by the simulated K-readings of the topographic maps did not differ significantly in the four groups. Conclusions A suturing technique using 2 running sutures with 16 bites each can minimize irregular postkeratoplasty astigmatism as long as sutures are in place, when compared with interrupted sutures or double-running sutures of less than 16 bites.

Keratometric Results of Penetrating Keratoplasty with the Hessburg-Barron and Hanna Trephine Systems Using a Standard Double-Running Suture Technique

To compare final, sutures-out, keratometric results of penetrating keratoplasty using two different suction trephine systems and a standard double-running suture technique. Keratometric data after final suture removal were compared retrospectively for three groups of transplants: Group 1, 7.50-mm Hessburg-Barron recipient trephine and 7.70-mm modified Lieberman donor punch (n = 70); Group 2, 7.50-mm Hessburg-Barron recipient trephine and 8.00-mm modified Lieberman donor punch (n = 18); Group 3, 7.50-mm Hanna recipient trephine and 7.75-mm Hanna donor punch (n = 68). Final average keratometry was 46.7 +/- 2.4 D (mean +/- SD, diopters), and final median keratometric astigmatism was 4.6 D (2.6-7.4 D, interquartile range), with no significant difference between groups. Final average keratometry values increased from preoperative values by 3.3 +/- 2.7 D. The correlation between preoperative average keratometry values and final values was low (rs = 0.2; p = 0.07). Average keratometry values increased by 2.3 D (median) after 10/ 0 suture removal (p < 0.0001) and by 0.2 D (median) after 11/0 suture removal (p = 0.09), with no significant difference between groups. There was a negative correlation between donor age and overall change in average keratometry (rs = -0.3; p = 0.002). Visual acuity improved by a median of 5 lines, with no significant difference between trephine systems. There was no statistically significant difference in keratometric results using these two suction trephines with a standard suture technique. Final graft curvature was greater with both suction trephines compared with previously published results of transplants using hand-held trephines with the same suture technique.