Horizontal Sutures Research Articles

Ergonomic principles of task alignment, visual display, and direction of execution of laparoscopic bowel suturing.

Laparoscopic suturing is technically a demanding skill in laparoscopic surgery. Ergonomic experimental studies provide objective information on the important factors and variables that govern optimal endoscopic suturing. Our objective was to determine the optimum physical alignment, visual display, and direction of intracorporeal laparoscopic bowel suturing using infrared motion analysis and telemetric electromyography (EMG) systems. Ten surgeons participated in the study; each sutured 50-mm porcine small bowel enterotomies toward and away from the surgeon in the vertical and horizontal bowel plane with either isoplanar (image display corresponds with actual lie of the bowel) or nonisoplanar (bowel displayed horizontally but mounted vertically in the trainer and vice versa) display. The end points were the placement error score, execution time, leakage pressure, motion analysis, and telemetric EMG parameters of the surgeon's dominant upper limb. Suturing was demonstrably easier in the vertical than in the horizontal plane, resulting in a better task quality (placement error score, p < 0.0001; leakage pressure, p < 0.005) and shorter execution time (p < 0.05). Nonisoplanar display of the surgical anatomy degrades performance in terms of both task efficiency and task quality. On motion analysis, a wider angle of excursion and lower angular velocity were observed during the vertical suturing with isoplaner display. Compared to horizontal suturing, supination at the wrist was significantly greater during vertical than horizontal suturing (p < 0.05). Within each category (vertical vs horizontal suturing), the direction of suturing (toward/away from the surgeon) did not influence the extent of pronation/ supination at the wrist. In line with the degraded performance, significantly more muscle work was expended during horizontal suturing. This affected the forearm flexors (p < 0.05), arm flexors and extensors (p < 0.005 and p < 0.05, respectively), and deltoid muscles (p < 0.005) and was accompanied by significantly more fatigue in the related muscles. Small bowel enterotomies sutured toward the surgeon in both the vertical and the horizontal planes exhibited less placement error score than when sutured away from the surgeon, with no significant difference in the motion analysis and EMG parameters. Optimal laparoscopic suturing (better task quality and reduced execution time) is achieved with vertical suturing toward the surgeon with isoplanar monitor display of the operative field. The poorer task performance observed during horizontal suturing is accompanied by more muscle work and fatigue, and it is not improved by monitor display of the enterotomy in the vertical plane.

A new technique of arthroscopic capsular shift in anterior shoulder instability

We describe a new arthroscopic technique to reinforce the torn inferior glenohumeral ligament (IGHL) and the elongated capsule to the glenoid rim. The arthroscope is inserted over the superior portal and, after the insertion of a suture anchor, both limbs are pulled out over the posterior portal. The IGHL is grasped and pulled upward onto the glenoid rim using a suture retriever clamp inserted over the posterior portal. A 45° curved blunt clamp (Sidewinder; Arthrex, Naples, FL) coming from the anterior penetrates the IGHL, and 1 end of the suture limb is given into the branches of the clamp and pulled out anteriorly. After a second perforation of the capsule, a horizontal suture creating a neolabrum can be placed. This technique allows a suitable reinforcement of the capsule without intraoperative complications. In cases of capsular elongation, especially a torn IGHL, the capsular instability can be addressed by the described Sidewinder technique. More sophisticated arthroscopic techniques such as this will increase the indication for arthroscopic shoulder stabilization.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 4 (April), 2001: pp 426–429

Cyclic testing of meniscal sutures

Summary: Suturing the meniscus has become a standard procedure for repairable tears. Studies investigating the outcome of meniscal sutures report a considerable rate of failures. Regarding the indications, which have been extended to the avascular zones, and regarding some accelerated rehabilitation protocols, the need for further in vitro investigations has become obvious. The aim of this study was to compare different meniscal suture types (vertical and horizontal mattress sutures) and materials (absorbable monofilament PDS 2-0, and nonabsorbable braided Ethibond 2-0 [Ethicon, Somerville, NJ]) under standard and cyclic loading conditions. Testing was performed on medial porcine menisci. In group A, specimens were tested to failure at a cross-head speed of 50 mm/minute. In group B, cyclic testing (100 cycles) was performed first within different load intervals (5 to 20 N and 5 to 40 N). Finally, the specimens were loaded until failure. In both groups, the failure loads were recorded and the failure modes were analyzed. In group A, there was no difference between suture type or suture material, with a mean failure load of 60 N. The failure modes were significantly different for vertical (100% suture failure) and horizontal sutures (50% suture failure) (P <.0001). In group B, 13% of the sutures failed under cyclic loading (7 with 40-N load, 1 with 20-N load). The gap of the sutured tear that appeared within the first load cycles was broader in horizontal sutures (P <.001). During the first cycles, the thread cut through the meniscus tissue and disappeared from the surface (partial tissue failure). There was no difference according to suture material. The ultimate failure loads after cyclic loading did not differ from the values of group A. These results show that meniscal sutures may fail under repetitive loading conditions and that a gap appears between the meniscal margins within the first loading cycles irrespective of the suture type and suture material used. The appearance of the gap and suture disappearance on the meniscal surface because of partial tissue failures (which were more pronounced in the horizontal sutures) confirmed the superior resistance of meniscal tissue to vertical sutures.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 16, No 5 (July), 2000: pp 505–510

Biomechanical Test Comparing the Load to Failure of the Biodegradable Meniscus Arrow Versus Meniscal Suture

Summary: The biodegradable Meniscus Arrow (Bionx, Blue Bell, PA) is a newly introduced method for repair of meniscal injury. However, because of a lack of studies, there is still little understanding of its biomechanical behavior. Biomechanical test was carried out to evaluate the load to failure and failure modes of the Meniscus Arrow and to compare the results with those of three traditionally used methods. Thirty-five lateral menisci obtained from Yorkshire pigs were incised longitudinally, simulating a peripheral longitudinal tear, and were repaired by means of Meniscus Arrows (one-point and two-point fixation), as well as with the techniques of knot-end, horizontal, and vertical suture using No. 1 PDS II monofilament suture. Tensile strength testing was performed according to each repair method with the Instron tensometer (Model No. 5569; Instron, Canton, MA) and its results were analyzed using a computerized statistical program. The average maximal tensile strengths were 113.9 ± 14.6 N in vertical suture, 75.1 ± 18.4 N in horizontal suture, 53.9 ± 6.4 N in knot-end suture, 38.3 ± 4.3 N in one-point fixation Meniscus Arrow repair, and 56.5 ± 3.5 N in two-point fixation Meniscus Arrow repair. The initial failure strength for two-point fixation Meniscus Arrow repair is comparable to that of a knot-end suture. Following the results of this study, meticulous caution should be taken when meniscal tears are repaired with Meniscus Arrows. Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 7 (October), 1999: pp 726–732

Intracutaneous butterfly suture - a horizontal buried interrupted suture for high tension

Background: Tension on surgical wound margins frequently results following the excision of skin lesions such as tumors, naevi or scars. This tension is commonly counteracted with buried, intracutaneous, interrupted sutures of absorbable or non-absorbable material anchored vertically in the corium. Method: A horizontal, buried, intracutaneous suture has now been developed which can be more firmly anchored in the corium. It adapts and everts wound margins nearly as broadly as two vertical sutures, particularly, when the wound edges are cut obliquely with a longer rim of epidermis. When finished, the suture has a butterfly shape, whence its name. It can also be laid as a double suture (double butterfly suture). In creating this sutures, the surgeon changes the customary direction of the needle holder from horizontal to vertical. Materials: Since 1985, this suture has been made with polydioxanon in more than 30000 skin lesion excisions with very good results. In most cases the resulting narrow and smoth scars were narrow and flat in the most cases. During the study, the following suture materials were tested prospectively in 1325 patients: polyglactin 910 (Vicryl®) (n=390), polytrimethylcarbonate (Maxon®) (n=95), poliglecaprone 25 (Monocryl®) (n=175), and (PDS®) (n=665). Results: The results were unsatisfactory in only 8% of procedures. Polyglactin 910 was accompanied by somewhat more inflammation and scar dehiscence, poliglecaprone 25 by a high rate of scar dehiscence. Polytrimethylcarbonate caused skin reactions in 23% and was discontinued. Suture perforation occurred in 9%. Polydioxanon yielded the best results (p-value of the difference <0.05). Conclusions: The butterfly suture has the advantages of withstanding tension better while everting wound margins and requiring fewer stitches for wound closure. However, it is important that the suture knot be deeply anchored beneath the corium.

End-on-Side Microvascular Anastomosis: An Experimental Study

A new method, the end-on-side microanastomotic technique, is presented and also compared with the conventional end-to-side technique. The technique can be summarized as follows: The proximal end of the donor vessel is incised bilaterally at midlateral points. Thus it is separated into inferior and superior segments. These segments are placed to overlap the posterior and anterior walls of the recipient artery by using two vertical sutures. Two additional horizontal sutures are placed between the apexes of the midlateral incisions and the apexes of the arteriotomy on the recipient artery. Eventually the microanastomosis is totally completed with four sutures lying at the intramural position in the recipient artery. Twenty rabbits were equally divided into two groups. The femoral and the profunda femoris arteries were used bilaterally to investigate applicability of the end-on-side technique in the first 10 rabbits. Eighteen end-on-side anastomoses were observed to be patent in the first stage. Subsequently the end-on-side technique was compared with the conventional end-to-side technique in the other 10 rabbits. All anastomoses, both end on side and end to side, were patient. Four end-on-side microanastomoses were histologically evaluated. It was proved that the end-on-side technique is a feasible and experimentally reliable method.

Failure strength of a new meniscus arrow repair technique: Biomechanical comparison with horizontal suture

A new method for arthroscopic all-inside repair of vertical meniscus lesions by use of a biodegradable fixation device (“meniscus arrow”) has been developed, including a set of cannulas for easy insertion via standard arthroscopic portals. The technique is described. A study to test the fixation properties was performed in the laboratory. Twenty-four fresh frozen bovine medial menisci were defreezed and devided into three groups. In all menisci an artificial vertical lesion was created with a scalpel 3 mm from the peripheral rim. Repair in group I was done with a single horizontal Maxon-0 suture using an Acufex double-barrel cannula (Acufex Meniscal Stitcher; Acufex Microsurgical, Norwood, MA). A knot was tied on the capsular side. Repair in group II was made with one 13 mm Biofix Meniscus arrow (Bioscience Ltd, Tampere, Finland). In group III repair was performed like in group II but the menisci were incubated in isotonic saline at 21°C for 24 hours before testing. Menisci in group I and II were tested within 3 hours after defreezing. Prior to testing total separation of central and peripheral part of meniscus was performed. Thus only the repair site was tested. Pull-out tests to failure were made in a computer-based Nene M5 testing maschine with a cross-head speed of 5 mm/min. Median failure load in group I: 49 N (range 43 to 77 N), in group II: 53 N (range 42 to 65 N) and in group III: 54 N (range 35 to 74 N). No statistically significant difference in failure load was found between the groups. Thus initial failure strength for arrow-repaired bovine menisci is comparable to that of a horizontal suture

Prevention and Management of Complications Associated with the Hydroxyapatite Implant

The hydroxyapatite orbital implant offers many advantages compared to conventional implants; however, its use is not entirely free of complications. The objectives of this study are to review the complications encountered with the hydroxyapatite orbital implant, suggest mechanisms contributing to the development of these complications, and emphasize aspects of surgical technique that will minimize the risk of the most frequent complication, implant exposure. Preoperative, operative, and postoperative records of 154 patients receiving primary and secondary hydroxyapatite implants were studied retrospectively. Three clinical types of exposure defects were observed; dehiscences along the horizontal suture line, defects over holes in the hydroxyapatite, and a defect adjacent to the site of radiation plaque therapy. Most small exposures healed spontaneously. Medium and large defects were associated with anteriorly malpositioned implants, most often required surgical intervention, and were successfully managed with one or a combination of techniques including flaps, mucous membrane grafts, or repositioning of the implant more posteriorly. Placing the hydroxyapatite implant as far posteriorly as possible and advancing the extraocular muscles 3-5 mm from the apex of the implant will prevent most exposures. Unlike other types of implants, the hydroxyapatite implant does not migrate or extrude, and when exposed, usually does not require removal.

Acquired benign esophago-airway fistulas.

Over a period of 25 years, 35 patients with acquired benign esophago-airway fistulas were treated. Only two of them were female. The etiology of the communications was corrosive burns, penetrating wounds, postoperative and endoscopic lesions, esophageal diverticula, prolonged ventilatory assistance, pleural empyema and foreign bodies. Radical operative treatment was performed in 31 cases. In four of these the procedure was palliative, because of poor general condition and lung complications. The operative approach was chosen after precise endoscopic and contrast X-ray examinations. A cervical approach with partial median sternotomy to the third intercostal space was performed in 19 patients. In the rest of the patients a thoracotomy was performed. Simple excision of the fistula, longitudinal suture of the trachea and horizontal suture of the esophagus was the method of choice in nine patients. A flap from the left sternocleidomastoid was additionally interposed in front of the esophagus in 12 patients. In six cases circular resection, reconstruction of the trachea and plastic suture of the esophagus were performed. Esophagectomy with ensuing colon substitution was necessary in four patients. Excellent or good results were obtained in 29 of the 31 patients operated on. We had two deaths in the early postoperative period (6.8%) due to lung complications in patients with chemical burns of the esophagus. The operated patients were followed up for period ranging from 3 to 20 years. Acquired esophago-respiratory fistulas require emergency surgical treatment. The proper choice of operative approach is largely dependent on the precise diagnosis. Preoperative intensive care and metabolic balance are important factors in this report. Radical operative treatment depends on the basic disease, local inflammation and lung complications.

Effects of Wound Architecture and Suture Technique on Postoperative Astigmatism

A prospective randomized investigation was performed to evaluate the effects of wound architecture and suture techniques on postoperative astigmatism after phacoemulsification and intraocular lens implantation. Two hundred eyes with preexisting with-the-rule astigmatism were randomized into four groups: (1) sutureless scleral tunnel frown incision, (2) scleral tunnel frown incision with a horizontal suture, (3) scleral tunnel frown incision with both a horizontal and a running suture, and (4) posterior limbal acute beveled cataract incision with a running suture. All the incisions were placed in the vertical steep meridian. Data were analyzed from 128 cases with 1-year follow-up. The results revealed that at the 2-month postoperative visit, preexisting astigmatism was significantly reduced in group 1 (P = .029) and significantly increased in groups 3 (P = .020) and 4 (P = .005). There was no significant change in group 2 (P = .06). By the 1-year postoperative visit, there was no significant difference in astigmatism from preoperative levels for all four groups. Vector analysis revealed no significant difference in the mean surgically induced cylinder at 1 year in all four groups. The number of eyes with induced against-the-rule astigmatism, however, was significantly higher than the number of eyes with induced with-the-rule astigmatism in all four groups (P <.01). The authors found that sutured wounds placed in the vertical steep meridian may initially increase with-the-rule astigmatism, whereas nonsutured wounds placed in the vertical steep meridian may initially reduce with-the-rule astigmatism. By 1 year, however, a mean flattening of the vertical steep meridian was observed in the three groups with sutures as well as in the group without sutures.

Combined phacoemulsification, intraocular lens implantation, and trabeculectomy with a modified scleral tunnel and single-stitch closure

In most combined phacoemulsification and filtration surgery, the standard tunnel incision is altered to create a scleral flap, usually a limbal-based scleral flap with radial suture closure. We describe a new technique that has the advantages of both scleral tunnel architecture and horizontal suture closure. It creates a scleral groove tangential to the limbus and a standard scleral tunnel. Phacoemulsification and intraocular lens implantation are performed under the scleral tunnel. A 10-0 nylon horizontal suture is positioned for scleral tunnel closure and looped aside. A central “T” relaxing incision is made at the midpoint of the scleral tunnel up to the posterior insertion of conjunctiva. A punch sclerectomy is performed. The 10-0 nylon horizontal suture is tied. The conjunctiva is closed and bleb elevation is confirmed via deepening through a corneal paracentesis incision. The results in an initial series of 24 consecutive eyes followed for a mean of seven months are presented: Mean visual acuity improved from 20/70 to 20/30 and mean intraocular pressure reduction was 5.0 ± 2.4 mm Hg (standard deviation). By preserving standard scleral tunnel architecture and single horizontal suture closure, this technique permits rapid visual recovery and accelerated return to full activity. It also permits postoperative titration of aqueous outflow by laser suture lysis, if indicated. Against-the-rule astigmatic drift associated with limbal-based scleral flaps and antimetabolite therapy may be minimized.

Astigmatic and Refractive Stabilization After Cataract Surgery

We assessed the timing of astigmatic and refractive stabilization following six cataract surgery procedures with intraocular lens implantation in 229 eyes divided into six groups in the following incision sizes and methods of wound closure: 11-mm incision with running suture closure (26 eyes) 6.5-mm incision with running suture closure (29 eyes) 6.5-mm incision with single horizontal suture closure (25 eyes) 6.5-mm incision without suture closure (46 eyes) 5.5-mm incision without suture closure (51 eyes) 3.2-mm incision without suture closure (52 eyes) Analyzed up to 6 months postoperatively were: the mean and standard deviation of axis-based keratometric cylinders the absolute value of the induced-cylinder vector the spherical equivalent of the refractive power. In the 11- and 6.5-mm incision running suture groups, these parameters did not stabilize during the study period. In the 6.5-mm incision horizontal suture and sutureless groups, the values stabilized at 3 months postoperatively; in the 5.5-mm incision group, at 1 month; and in the 3.2-mm incision group, at 2 weeks. These results indicate that the appropriate point at which to prescribe postoperative correction spectacles differs significantly depending on the procedure, and that smaller incisions with wound-closure methods that do not exert vertical force are associated with fewer postoperative refractive changes.

Long-term astigmatic changes after phacoemulsification with single-stitch, horizontal suture closure

We analyzed postoperative corneal astigmatism in 32 eyes followed for three years after small incision phacoemulsification with a 4 mm scleral tunnel incision and a single-stitch, horizontal suture technique. Sutures were left intact postoperatively. Mean surgically induced cylinder was 0.63 diopters (D) at one day postoperatively, −0.01 D at one year, and −0.07 D at three years. A significant number of eyes showed an initial shift toward with-the-rule astigmatism. At one year, the axis had nearly returned to preoperative orientation without further against-the-rule shift after three years. An uncorrected visual acuity of 20/40 or better was found in 43.8% of the patients at one week postoperatively and in 62.5% at one and three years. Best corrected visual acuity of 20/40 or better was found in 62.5%, 90.6%, and 93.7%, respectively.

Failure strengths of different meniscal suturing techniques

The aim of this study was to measure the failure strengths of three arthroscopic meniscal suturing methods. The techniques investigated were a single horizontal loop, a double vertical loop, and a single vertical loop. Eleven human, lateral menisci obtained at autopsy were cut with a scalpel to simulate peripheral longitudinal tears. The menisci were then repaired with one suture at a time, using each of the three methods in turn. The two parts of the meniscus were then pulled apart using a computer-controlled materials testing machine until failure occurred, either by the suture itself failing or by the suture pulling out because of tearing of the meniscus. The horizontal sutures had a mean failure strength of 29.3 N, whereas the double vertical loop failed at 63.2 N and the single vertical loop at 67.3 N. The horizontal loop sutures and the double vertical loop sutures all failed by pulling out of the meniscus. The single vertical loop sutures failed by rupture of the suture itself. This study showed the superior mechanical characteristics of the single vertical loop suturing system over the other techniques tested. Owing to the more consistent failure strength, decreased costs, and shorter surgical time over the double vertical loop system, the single vertical loop technique is recommended for arthroscopic meniscal repair.

No Stitch Compared to Single Stitch Closure after Phacoemulsification

OBJECTIVE: Evaluation of the clinical outcome, especially surgically induced astigmatism, after 5.2 mm scleral tunnel incision, phacoemulsification and posterior chamber lens implantation, comparing one horizontal suture and no stitch closure. STUDY DESIGN AND PATIENTS: 40 patients admitted for cataract surgery were enrolled in the study. A single stitch was used to close the wound in the first 20 eyes, while in the latter 20 cases no stitch was placed. The patients were examined before surgery and one day, one week, two and eight months postoperatively. MAIN OUTCOME MEASURES: Keratometric astigmatism, postoperative visual acuity and intraocular pressure. RESULTS: No statistically significant differences in surgically induced astigmatism were found between the two groups. There were no complications in the no stitch group but a few suture related ones in the single stitch group. CONCLUSION: The induced keratometric astigmatism after phacoemulsification using a 5.2 mm incision is the same whether a horizontal suture or no suture is used. Suturing seems to be unnecessary, provided that a self-sealing incision is created.

Meniscal repair enhanced by an interpositional free synovial autograft: An experimental study in rabbits

This report describes the methods and effectiveness of interpositional free synovial autografts (IPFSAs) in promoting the healing of lesions in the avascular portion of the knee joint meniscus in rabbits. Thirty-four specimens were divided into two groups: 17 in the study group and 17 in the control group. The medial meniscus of the left knee joint was excised in each rabbit, and an artificial longitudinal tear was created in the avascular zone of the meniscus. In the study group, an IPFSA was sewn into the tear with a single horizontal suture. In the control group, the tear was repaired without synovium in the same manner. The menisci were then implanted into the right knee joint in the respective animals. At intervals the animals were killed, and the menisci were examined grossly and microscopically. Three menisci were eliminated because they had become attached to the synovial wall. In the study group, the lesion completely healed by 4 weeks, except for one. The menisci in the control group never completely healed, particularly at the deeper levels of the lesion. At 8-16 weeks, autolysis of the specimens made microscopic examination difficult and unreliable in both groups. Based on these results, it has been concluded that an IPFSA can promote the healing process in the avascular zone of a torn meniscus in rabbits and that systemic vascularity to the synovium or the meniscus is not essential for healing to occur.

Refractive Stability After Cataract Extraction Using a 6.5-Millimeter Scleral Pocket Incision With Horizontal or Radial Sutures

Radial suturing of 6.5-millimeter scleral tunnel incisions following cataract surgery can create significant with-the-rule astigmatism in the immediate postoperative period. Because of the significant visual distortion and slow visual recovery seen with radial suturing, this study was undertaken to compare two other suturing techniques which induce lesser amounts of with-the-rule astigmatism in the immediate postoperative period. The refractive behavior of eyes closed with loose radial sutures and with horizontal sutures was compared to the behavior of eyes closed with the more traditional "tight" radial sutures following phacoemulsification surgery. Eyes sutured with loosely tied radial sutures demonstrated minimal with-the-rule cylinder immediately following surgery (1.25 D) and showed a more rapid stabilization of astigmatism than did the eyes tied with tight radial sutures, 2 months versus up to 6 months. However, the eyes tied with horizontal sutures, which showed no induced with-the-rule astigmatism at the time of surgery, showed even more rapid stabilization between 5 days and 1 month from the time of surgery. To get the most rapid visual rehabilitation following cataract surgery, a wound closure which generates no induced with-the-rule cylinder such as horizontal sutures would be required.

Scleral-Flap Incision for Cataract Surgery

I present a technique for creating a three-stage scleral incision for extracapsular cataract extraction and intraocular lens (IOL) implantation, especially useful for cases in which phacoemulsification is contraindicated or aborted. The incision is 5 to 10 mm wide, and the scleral flap is trapezoidal and requires one to three horizontal sutures for closure. The technique was used in 364 consecutive eyes; follow up was 6 months. After 1 week, 80% of these eyes had 1.50 diopters or less of induced keratometric cylinder; at 1 month, 70% had less than 1.00 D. At 6 months, 87% had 0.50 D of against-the-rule cylinder. Less than 6% had elevated intraocular pressure (22 to 28 mm Hg); hyphema developed in 7%. Forty-nine percent had 20/40 or better vision in 1 week; 75% achieved this acuity at 1 month. Final refractions in 87% of the eyes at 6 months were -1.00 (+/- 0.75) + (+/- 1.00) x 180 degrees. This technique provides most of the benefits of small-incision cataract surgery, including rapid, stable visual recovery. IOLs of any optical size can be implanted.

Surgically Induced Astigmatism after Small Scleral Pocket Incision in Phacoemulsification: Horizontal vs Radial Suture Closure

Objective: To evaluate the difference in surgically induced astigmatism between two types of suture technique after phacoemulsification with a 4mm incision. Study Design: Retrospective study with a minimum follow-up of 12 months. Setting: Teaching university hospital. Patients: Ninety-five patients divided into two groups. Forty-three eyes were closed with two interrupted radial 10-0 Nylon sutures, and 52 were closed with a single stitch horizontal 10-0 Nylon suture. Mean Outcome Measures: Changes in the keratometric cylinder, surgically induced astigmatism, best corrected visual acuity and IOP. Results: The horizontal group showed no significant change in surgically induced astigmatism, at either 1 week or 1 year ( P >0.05). The radial group showed a significant increase in astigmatism with-the-rule (WTR) 1 week postoperatively, followed by an insignificant change against-the-rule (ATR) after 1 year. There was no significant difference in astigmatism between the two groups preoperatively. At 1 week postoperatively the difference between the two groups was significant ( P P >0.05). Conclusion: A single stitch horizontal 10-0 Nylon suture induces less surgical astigmatism than two interrupted radial sutures after small incision phacoemulsification. The horizontal suture technique shows an exceptionally small and stable surgically induced astigmatism.

Astigmatism after a large scleral pocket incision in extracapsular cataract extraction

In this four-month prospective study, we measured astigmatism in 116 patients who had extracapsular cataract extraction through a 13 mm scleral pocket incision. In one group, the wound was closed with five radial 10-0 polypropylene sutures. Early and late postoperative astigmatism in this group was approximately 2 diopters (D), but a significant shift to against-the-rule astigmatism occurred. In a second group, an additional 10-0 polypropylene horizontal suture was placed anteriorly to the radial suture at the 12 o'clock meridian. This reduced the against-the-rule astigmatic decay. Moreover, this group had less postoperative astigmatism. Mean corneal astigmatism was 2.27 D at one week, 1.76 D at one month, 1.37 D at two months, and 1.70 D at four months. In neither group was cutting the sutures necessary.