Intraoperative Suture Adjustment Research Articles

Strabismus surgery in topical anaesthesia with intraoperative suture adjustment in Graves' orbitopathy.

To report the results of strabismus surgery in a series of patients with Graves' orbitopathy (GO), using topical anaesthesia with intraoperative suture adjustment. All first-time strabismus surgeries in patients with GO in our department during the years 2014-2021 (n = 45) were assessed retrospectively. Among these, 31% came from outside our health region due to increased complexity of the strabismus condition. Orbital decompression surgery had been carried out in 58% of the patients prior to strabismus surgery. Patients with less than 2 months of follow-up were excluded from the study. Median follow-up time was 22 months. Among the total patient material, 37 (82%) could be operated with topical anaesthesia with intraoperative suture adjustment. There were no cases with triggering of the oculo-cardiac reflex during the procedure. Among the 36 patients operated with topical anaesthesia and follow-up time ≥2 months, 11 (31%) needed further surgery. Late overcorrection after recession of the inferior rectus was seen in 19%. At the last control examination, 32 (89%) were diplopia-free in primary and down-gaze position, either with or without weak prisms. Strabismus surgery in topical anaesthesia with intraoperative suture adjustment appears to be a suitable and safe procedure in most patients with GO, including difficult and complex cases. The patients should be informed about the possibility of additional surgery and/or post-operative need for prism glasses.

A novel suture: adjustable superior oblique spacer with optional 7 days delayed adjustment

Superior oblique (SO) spacer sutures may correct tight SO incomitant strabismus. Suh described SO spacer for optional intraoperative suture adjustment. To our knowledge, no former technique describes adjustable SO spacer with optional delayed suture adjustment.

Single-stage superior oblique tendon recession with suture adjustment under topical anesthesia and sedation for A-pattern strabismus with superior oblique overaction

To assess the surgical effect of single-stage superior oblique recession with intraoperative suture adjustment under topical anesthesia and sedation in terms of A-pattern correction, vertical alignment, and superior oblique overaction. The medical records of patients who underwent superior oblique weakening (recession with adjustable suture) for superior oblique overaction from 2015 to 2018 were reviewed retrospectively. Preoperative, pre- and postadjustment, and 6-week follow-up data were assessed and compared for A pattern, primary position hypertropia, superior oblique overaction scale and objective fundus torsion. A total of 29 patients (17-42years of age) were included. Of 51 operated eyes, 37 underwent intraoperative adjustment (further recession of 1-4mm) after superior oblique recession of 8mm. Mean decrease in primary position hyperdeviation after adjustment was 3.6Δ ± 2.7Δ (range, 0Δ-8Δ); in A-pattern deviation, 5.5Δ±4.8Δ (range, 0Δ-16Δ). At 6weeks' follow-up, A pattern had either resolved completely or became clinically insignificant (<10Δ) in 23 of 29 patients (79%); 24 (83%) patients had hyperdeviation in primary position of ≤5Δ. Of the 5 patients with preoperative primary position hyperdeviation of 15Δ-30Δ, 2 had residual primary position hyperdeviation of >10Δ. In our study cohort, single-stage, unilateral superior oblique tendon recession with adjustable suture under topical anesthesia and sedation was well tolerated and resulted in good postoperative outcomes at 6weeks' follow-up, effectively correcting primary position vertical deviation of <15Δ.

The surgical effect of secondary esotropia with diplopia after orbital decompression for thyroid-associated ophthalmopathy

Objective: To evaluate the effect of extraocular muscle surgery in treating secondary esotropia with diplopia after orbital decompression for thyroid-associated ophthalmopathy (TAO). Methods: Retrospective case series study. Eleven secondary esotropic patients with diplopia after orbital decompression for TAO who underwent extraocular muscle surgery during March 2016 and October 2018 in Tianjin Eye Hospital were included. All patients had new onset esotropia after decompression surgery and underwent strabismus surgery. Deviation angle, diplopia, and ocular movement were observed preoperatively and postoperatively. Surgeries were carried out under the monitored anesthesia care combined with local anesthesia, and the eye alignment was adjusted to orthotropia with no diplopia in the operation with the technique of intraoperative adjustable suture and forced duction test results. All the patients were followed up. Results: The ages of the patients were from 26 to 42 years (1 male and 10 females). The deviation angles were 10-98 prism diopter. Orbital CT scan showed that the horizontal rectus thickness was increased at different levels, and the thickness of the medial rectus was increased more than that of the lateral rectus. Two patients had monocular medial rectus recession only, 2 had bilateral medial rectus recession only, 2 had monocular medial rectus recession combined with lateral rectus resection, and the other 5 had bilateral medial rectus recession with monocular lateral rectus resection. The recession of medial rectus muscle was 3.5 to 7.5 mm in 11 patients and 2.0 to 6.0 mm in 7 patients with the resection of lateral rectus muscle. Diplopia of the 11 patients disappeared with orthotropia at primary gaze position after the extraocular muscle surgery. The limitation of abduction changed from preoperative (-1.91±1.04) to postoperative (-0.64±0.81). All the patients were satisfied with the surgical results. At the end of the follow-up (6 to 24 months), the results of the patients were stable, and no over-correction was found. Conclusion: Extraocular muscle surgery with intraoperative adjustable suture technique can effectively treat TAO patients with secondary esotropia with diplopia after orbital decompression. (Chin J Ophthalmol, 2020, 56: 183-188).

External levator resection for involutional ptosis: is intraoperative suture adjustment necessary for good outcomes?

ABSTRACT Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann–Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19–84) and 59.3 years (range 24–83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was −0.1 mm (95% CI −0.3–0.1) and −0.2 mm (95% −0.5–0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6–15.1) and 9.5 min (95% CI 9.0–10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.

Topical Anesthesia in Children With Intraoperative Adjustable Strabismus Surgery.

To evaluate strabismus surgery with intraoperative adjustment of sutures under topical anesthesia in children. Nineteen children with horizontal deviation underwent a one-stage surgical technique performed under topical anesthesia. Surgery consisted of unilateral or bilateral recession and/or resection of horizontal muscles or the medial or lateral rectus muscles, with intraoperative adjustment of sutures based on alternate prism cover test. Follow-up was done at 1 day and 1, 3, and 6 months postoperatively. Mean age at surgery was 12.68 ± 2.50 years (range: 8 to 16 years). Mean preoperative angle of deviation was 24.21 ± 11.20 prism diopters (PD) (range: -50 to +30 PD) at distance. Mean postoperative angle of deviation at 6 months was 4.11 ± 2.87 PD (range: -10 to +10 PD) at distance. In esotropic patients, the average angle of deviation decreased from +23.80 ± 5.89 PD preoperatively to +4.80 ± 3.35 PD at 6 months, whereas in exotropic patients it decreased from -24.36 ± 12.76 to -3.86 ± 2.77 PD. Seventeen of 19 patients (89%) remained comfortable during surgery, whereas 2 needed an intravenous injection of propofol. The success rate, defined by a postoperative residual angle of deviation of ±8 PD or less, was 89% at 6 months. Strabismus surgery with intraoperative suture adjustment under topical anesthesia in children is a tolerable procedure with encouraging outcomes, representing an alternative to general anesthesia in well-selected children. Clinical evaluation of children and parents is fundamental to predict a likely poor collaboration of the child during surgery, which, if present, would require surgery under general anesthesia. [J Pediatr Ophthalmol Strabismus. 2019;56(3):173-177.].

Modified Y-splitting Procedure for the Treatment of Duane Retraction Syndrome.

Objectives:To present the outcomes of modified lateral rectus Y-splitting combined with either unilateral or bilateral horizontal rectus recession in Duane Retraction Syndrome (DRS) with significant upshoot or downshoot.Ma­te­ri­als and Met­hods:A total of 12 patients including 10 patients with Type I DRS and 2 with Type III DRS underwent modified Y-splitting surgery. Amount of additional recessions varied with the degree of preoperative deviation by intraoperative adjustable suture technique. Preoperatively 3 patients had esotropia (ET), 6 had exotropia (XT), and 3 patients had orthotropia. The mean preoperative deviation was 19.3 prism diopters (PD) (range, 18-20 PD) in ET patients and 19.2 PD (range, 16-20 PD) in XT patients.Re­sults:Postoperatively, all patients had significant correction in horizontal deviation and aligned within 4 PD of orthotropia, and no patients exhibited abnormal head posture. Co-contraction and globe retraction were markedly reduced and abnormal ocular vertical movement disappeared or significantly decreased in all cases. No patients experienced recurrence of ocular motility disorders in the mean 26-month (range, 13-66 months) follow-up period.Conclusion:Modified Y-splitting surgery combined with co-contracting horizontal muscle recession technique seems to be a safe and effective treatment in DRS.

Effectivity of intraoperative adjustable suture technique in horizontal strabismus.

To compare the long-term effectivity of intraoperative adjustable suture technique with traditional non-adjustable strabismus surgery. Two hundred and thirty-three patients, who underwent strabismus surgery either with traditional procedures or one-stage intraoperative adjustable suture technique, were included in our long-term follow-up study. One hundred and eighteen patients were evaluated in traditional surgery group (TSG) and 115 who underwent adjustable suture were in the one-stage intraoperative adjustable surgery group (ASG). In this group 9 patients had paralytic strabismus and 16 had reoperations, 2 patients had restrictive strabismus related to thyroid eye disease. The mean follow up in the TSG was 26.2 months and it was 24.8 months in the ASG group. In patients with exotropia (XT) the mean correction of deviation for near fixation in ASG (32.4±13.2PD) and in TSG (26.4±8.2PD) were similar (P=0.112). The correction for distant fixation in ASG (33.2±11.4PD) and TSG (30.9±7.2PD) were not significantly different (P=0.321). In patients with esotropia (ET) even the mean correction of deviation for both near (31±12PD) and distant (30.6±12.8PD) fixations were higher in ASG than in TSG, for both near (28.27±14.2PD) and distant (28.9±12.9PD) fixations, the differences were not significant (P=0.346, 0.824 respectively). The overall success rate of XT patient was 78.9% in TSG and 78.78% in ASG, the difference was not significant (P=0.629). The success rates were 78.75% in TSG and 75.51% in ASG in ET patient, which was also not significantly different (P=0.821). Although patients in ASG had more complex deviation such as paralysis, reoperations and restrictive strabismus, success rates of this tecnique was as high as TSG which did not contain complicated deviation. One-stage intraoperative adjustable suture technique is a safe and effective method for cooperative patient who has complex deviation.

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.

Intraoperative Adjustable Suture Surgery for Excyclotorsion: A Modification of the Harada-Ito Procedure

This study evaluated the surgical results of intraoperative adjustable tucking of the anterior portion of the superior oblique tendon for treatment of excyclotorsion. Two cases of acquired bilateral superior oblique palsy with symptomatic excyclotorsion and minimal vertical deviation in primary position were considered. Tucking of the anterior one-third of the superior oblique tendon was performed with a nonabsorbable suture. The amount of tuck was adjusted until the fovea was at the level of the superior one-third of the disc through indirect ophthalmoscopy. In the patient with local anesthesia, a double Maddox rod test was used to evaluate subjective cyclotorsion intraoperatively. After surgery, the patients became symptom-free. No regression toward excyclotorsion was noted during 18 months of follow-up. Tucking of the anterior portion of the superior oblique tendon is an effective procedure for improving symptomatic excyclotorsion in patients with bilateral superior oblique palsy without significant vertical deviation in primary position.

Intraoperative Adjustable Suture Strabismus Surgery Under Topical and Subconjunctival Anesthesia

To assess the postoperative surgical results of intraoperative adjustable suture strabismus surgery under topical and subconjunctival anesthesia. For 44 patients who had undergone intraoperative adjustable suture technique under topical anesthesia, the deviations were measured preoperatively, at 1 day, 1 month, and 3 months postoperatively, and at the last postoperative follow-up visit. The mean follow-up period was 7.8 months. Thirty-three patients had exotropia and 11 had esotropia. Mean age was 28.8 years. The success rates for exotropia and esotropia at the last follow-up visit were 81.8%. Intraoperative adjustable suture strabismus surgery under topical and subconjunctival anesthesia is the recommended surgical technique due to the successful results and various advantages compared with non-adjustable surgery, including the decreased rates of overcorrection or undercorrection that appear immediately after surgery and reoperation. Postoperative "drift" toward the original deviation was observed under longer follow-up periods than other studies.

Técnica de sutura ajustável per-operatória simplificada para a correção de desvios horizontais: estudo de 153 casos

To evaluate the simplified intraoperative adjustable suture technique for horizontal strabismus surgery. Data charts of all patients who underwent horizontal strabismus surgery by the simplified intraoperative adjustable suture technique at the Strabismus Department of the "Hospital das Clínicas" of the University of São Paulo in the period from January 2001 to November 2005 were evaluated retrospectively. Using this technique, the adjustment was calculated based on the corneal light reflection, having considered the difference between the measures in the awake state and with the anesthetized patient. One hundred fifty-three patients were operated on, 73 (47.8%) cases of esotropia (ET) and 80 (52.2%) of exotropia (XT). Under anesthesia, 123 (80.4%) patients had the eye position modified: 69 (56.1%) were less esotropic, 51 (41.5%) were more exotropic and 3 (2.4%) were less exotropic. Surgery was adjusted in 60 (39.2%) patients: 30 were esotropia and 30 were exotropia. Surgical success was defined as an eso- or exodeviation within 10 prism diopters, in a follow-up period of at least 180 days. The overall success rate was 71.6%. The simplified intraoperative adjustable suture technique, described in 2003 in a study performed on 49 patients operated on by the same surgeon, was shown to be efficient in this larger series of patients operated on by different surgeons. This technique should be considered in patients who do not cooperate in other adjustment techniques, aiming at improved success rates.

Competitive analysis of intraoperative adjustable suture with conventional suture technique in strabismus surgery

We compared the effectiveness of fixed conventional strabismus surgery (CSG) with a one-stage intraoperative adjustable suture technique in 88 patients undergoing strabismus surgery (ASG) either with fixed conventional (38) or intraoperative adjustable suture (50) technique. The mean correction of deviation with both near-fixation and distant-fixation for the ASG and CSG were not different. One-stage intraoperative adjustable suture technique is safe and effective method for strabismus surgery for cooperative patients.

The study of intraoperative adjustable suture Harada-Ito procedure for excyclotorsion of superior oblique palsy

目的 观察术中可调整缝线的上斜肌前部前徙术治疗上斜肌麻痹的外旋斜的效果.方法对6例(9眼)外旋斜患者(其中双眼外旋斜和单眼外旋斜各3例)行此术式,在术前、术中、术后1周分别行双马多氏杆检查第一眼位的主观旋转斜.分析旋转斜度与手术量的关系及治疗效果.结果6例患者术前都存在正前方及下方双眼复视症状,第一眼位的外旋斜5～15°,平均10.5°.术毕双马多氏杆检查第一眼位为0°～内旋斜5°,平均内旋斜3.7°.术后所有患者正前方及向下看复视症状消失,术后1周为外旋2°～内旋4°,平均内旋1.4°.其中2例患者术后7个月复诊,一例外旋斜3°;另一例为旋转斜0°,都未出现明显复视症状.结论术中可调整缝线的上斜肌前部前徙术是一种安全可靠的矫正上斜肌麻痹的外旋斜的手术方式,常需要过矫至内旋5°左右来代偿术后出现的回退。

Eficácia da técnica de sutura ajustável per-operatória simplificada para a correção de desvios horizontais: estudo prospectivo de 49 pacientes

PURPOSE: To evaluate the efficacy of a simplified intraoperative adjustable suture technique, under general anesthesia (GA) proposed by the authors. METHODS: A prospective study of 49 patients with horizontal strabismus, 22 esotropes and 27 exotropes. The same surgeon (MP) operated on all of the patients. The corneal light reflection was measured in millimeters (mm) from the limbus preoperatively and under GA: the esotropes from the temporal border and the exotropes from the nasal border. The adjustment was made or not based on these two measures if there was or not a difference between them. The authors calculated the adjustment on the measures in mm, not converting them in to prism diopters (PD) or taking the pupil as a reference point. RESULTS: 28 patients (57.1%) had the eye position modified under GA. In 25 of all of them (51.0%) surgery was adjusted. Surgical success was defined as orthotropia, eso- or exodeviation up to 10 PD, in a follow-up period of at least 6 months. The overall success rate was 75.6%. CONCLUSION: Results suggested this simplified procedure is effective. As an adjustable technique can conduct to more predictable outcomes, and being a simplified technique it can be employed in more cases, specially because it can be carried out by surgeons not used to the adjustable suture techniques.

Combined superior oblique tuck and adjustable suture recession of the ipsilateral superior rectus for long-standing superior oblique palsy

Purpose Unilateral long-standing superior oblique palsy may lead to superior rectus overaction/contracture requiring surgery of multiple extraocular muscles to correct the hypertropia. We review our technique of tucking the superior oblique combined with immediate postoperative adjustable suture recession of the ipsilateral superior rectus. Methods Twelve patients during the course of 2.5 years with longstanding vertical diplopia unrelated to closed head trauma or systemic disease who underwent our surgical technique were identified. The hypertropia in all patients was largest across the lower field (Knapp class 5) or nasal and lower fields (Knapp class 4). Outcome measures were primary-position hypertropia and vertical diplopia. Results The mean preoperative hypertropia in primary gaze measured 17.8 PD (range, 4 to 30). The mean 2-week postoperative vertical deviation was 1.3 PD (range, 4 PD hypotropic to 6 PD hypertrophic). The mean 6-week postoperative vertical deviation was 1.9 PD (range, 2 PD hypotropic to 12 PD hypertrophic). Diplopia in primary and down gaze, which was universally present before surgery, resolved in 11 of the 12 patients (92%). Conclusions This combination of procedures appears to be a highly successful choice for treatment of unilateral long-standing superior oblique palsy. Advantages for both patient and surgeon include adequate exposure through a single conjunctival incision, elimination of risks to the contralateral eye, and immediate intraoperative suture adjustment of the ipsilateral superior rectus.

Strabismus Surgery Using the Intraoperative Adjustable Suture Method Under Anesthesia With Propofol

Purpose: To evaluate the feasibility and efficacy of using the intraoperative adjustable suture method with anesthesia induced by intravenously administered propofol for strabismus surgery. Methods: Seven adult patients (mean age, 29.7 ± 18.5 years) with different types of strabismus were enrolled in this study. All patients underwent full ophthalmological and general medical examinations before surgery. Surgery was performed after induction of anesthesia using intravenously administered propofol that was titrated to control consciousness. Results: Arousal of consciousness was observed at approximately 2 minutes after discontinuation of the propofol infusion in each case, and the consciousness level was sufficient to allow accurate cover-uncover testing and intraoperative adjustment of sutures. Minor complications of nausea in three patients and vomiting in one patient were noted after surgery. Conclusions: Strabismus surgery using the adjustable suture method with propofol intravenous anesthesia appears to be safe and useful for the treatment of adult strabismus.

Comparison of Astigmatism After Penetrating Keratoplasty by Experienced Cornea Surgeons and Cornea Fellows

We compared surgically induced astigmatism after penetrating keratoplasty performed by supervised cornea fellows and experienced cornea surgeons. Data were collected by retrospective chart review of 166 cases (166 eyes) of penetrating keratoplasty: 63 performed by two cornea surgeons and 103 by four cornea fellows. Astigmatism was calculated using scalar and vector methods. Vector analysis was performed on 109 of 166 eyes. Two techniques were compared: intraoperative keratometry and suture adjustment and the torque-antitorque running suture technique with no intraoperative keratometry or suture adjustment. Mean surgically induced scalar astigmatism changed from preoperative astigmatism by 3.27 diopters (fellows) and 2.94 diopters (attending surgeons). In 109 cases, surgically induced vector cylinder changed from peroperative astigmatism by 4.21 diopters at 98 degrees (fellows) and 4.25 diopters at 114 degrees (surgeons). Surgically induced vector astigmatism changed from preoperative astigmatism by 4.67 diopters at 93 degrees in the first 6 months (fellows) and by 3.79 diopters at 103 degrees in the second 6 months. Analysis of x-axis and y-axis components of the surgically induced vector cylinder showed that the majority of the astigmatism was induced in the y-axis and that this difference was significant (P < .001) in all comparisons, independent of technique or surgeon group. Penetrating keratoplasty performed by supervised cornea fellows resulted in similar rates of surgically induced vector astigmatism, surface asymmetry, and surface regularity as that by experienced surgeons. Fellows induced significantly more with-the-rule astigmatism, but this tendency decreased with further training. Penetrating keratoplasty astigmatic outcomes were not significantly different whether or not intraopertive keratometry and suture adjustment were utilized. This study supports the concept that increased experience with corneal transplantation improves the outcome of penetrating keratoplasty by using the criterion of postoperative astigmatism as a measures.

Randomized Clinical Trial of Penetrating Keratoplasty: Before and after Suture Removal Comparison of Intrapperative and Postoperative Suture Adjustment

The authors performed a prospective, randomized clinical trial of penetrating keratoplasty and compared visual acuity, refraction, and topography up to 15 months postoperatively (3 months after suture removal) after intraoperative and postoperative suture adjustment. Twenty-five patients undergoing penetrating keratoplasty for avascular corneal pathology were randomly assigned to two groups. All surgery was done by one surgeon using the same technique (except for intraoperative suture adjustment) with suction trephination (8 mm) and a running 10-0 nylon suture. Intraoperative suture adjustment was performed in the test group and was not performed in the control group. Postoperative suture adjustment was done during the first postoperative month and up to 4 months postoperatively in all patients who had more than 3.5 diopters (D) of astigmatism. The running suture was removed at approximately 12 months postoperatively. Refraction and computed topographic analysis to compare patients with intraoperative and postoperative suture adjustment were performed at 1, 3, 6, 9, 12 (before suture removal), and 15 (after suture removal) months. There was less (P = 0.004) topographic astigmatism up to 12 months postoperatively (pre-suture removal) in patients adjusted intraoperatively (mean +/- standard deviation, 1.53 +/- 0.72 D) than in patients adjusted postoperatively (2.83 +/- 1.19 D). After suture removal, at 15 months postoperatively, astigmatism was still less in the intraoperative adjustment group (1.75 +/- 1.04 D) than in the postoperative adjustment group (2.23 +/- 17.2 D), but the authors could not demonstrate statistical significance. After intraoperative adjustment, no significant change in mean astigmatism occurred, and no patient had more than a 1.18-D change in the amount of astigmatism or more than a 22 degrees change in axis (75% < 10 degrees change) after suture removal. Corneas were more regular until suture removal in the group with intraoperative adjustment, but differences decreased after suture removal. Best spectacle-corrected visual acuity was better in the intraoperatively adjusted group until suture removal with no significant changes in best spectacle-corrected visual acuity between 1 and 15 months. Best spectacle-corrected visual acuity improved more slowly after postoperative adjustment and was different at 1 and 15 months (P = 0.0005). The authors demonstrated low astigmatism and good visual results at 15 months postoperatively after either intraoperative or postoperative running suture adjustment, but intraoperative suture adjustment permitted more rapid visual rehabilitation, increased safety, and increased refractive stability.

Randomized Clinical Trial Comparing Astigmatism and Visual Rehabilitation after Penetrating Keratoplasty with and without Intraoperative Suture Adjustment

The authors performed a prospective, randomized clinical trial to compare postoperative astigmatism and visual rehabilitation after penetrating keratoplasty with and without intraoperative suture adjustment. Twenty-five patients undergoing penetrating keratoplasty for avascular corneal pathology randomly were assigned to two groups. All surgery was performed by one surgeon (ONS) using the same technique (except for intraoperative suture adjustment) with Hanna trephination (8 mm) and a running 10-0 nylon suture. Postoperative suture adjustment was done during the first postoperative month in all patients who had more than 3.5 diopters of astigmatism. Refraction and computerized topographic analysis were performed at 1 and 6 months postoperatively. Intraoperative suture adjustment significantly decreased postkeratoplasty topographic (P = 0.0001) and refractive (P = 0.0001) astigmatism and improved best spectacle-corrected visual acuity (P = 0.0019) during the first postoperative month. Seventy-seven percent of control patients (mean topographic astigmatism, 4.89 +/- 1.99 D at 1 month), but no patients who underwent intraoperative suture adjustment (mean topographic astigmatism, 1.50 +/- 0.74 D at 1 month), required at least one postoperative suture adjustment that delayed optical stability and increased postoperative complications. At 6 months postoperatively, mean topographic (P = 0.06) and refractive (P = 0.0001) astigmatism were smaller in the intraoperatively adjusted group than in the control group with postoperative suture adjustments. After intraoperative adjustment, best spectacle-corrected visual acuity was better (P = 0.0168, P = 0.0434) and corneal topography was more regular (P = 0.02, P = 0.07, NS) at 1 and 6 months, respectively, than after postoperative adjustment. Visual rehabilitation with decreased postkeratoplasty astigmatism and more regular corneal topography was attained more rapidly and safely with intraoperative suture adjustment.