Selective Suture Removal Research Articles

P.548: The effect of early selective suture removal on post-penetrating keratoplasty keratometry and refraction.

P.548: The effect of early selective suture removal on post-penetrating keratoplasty keratometry and refraction.

Outcomes of deep anterior lamellar keratoplasty in eyes with healed hydrops - A retrospective interventional analysis.

The aim of the study was to analyze the techniques and outcomes of deep anterior lamellar keratoplasty (DALK) done in eyes with healed hydrops. Thirty-one eyes with paracentral scars following acute hydrops underwent DALK and were included in the study. Manual layer-by-layer dissection with stromal air injection was done in all cases, keeping dissection of the site of preexisting perforation to the end. Out of the 31 eyes, in 28 eyes, DALK could be completed, and in 3 eyes, procedure had to be converted to penetrating keratoplasty. Visual outcomes in all cases were good, with 26 out of 28 eyes (92.8%) achieving a best-corrected visual acuity (BCVA) of 6/12 or better. Preoperative mean BCVA of LogMAR 1.19 ± 0.27 improved to a postoperative mean BCVA of LogMAR 0.23 ± 0.08 (P < 0.00001). Postoperative mean refractive astigmatism at the last follow-up was -2.69 ± 0.82 D with postoperative a spherical equivalent of -2.31 ± 0.7 D. Complications included double anterior chamber in one eye and secondary angle closure in two eyes. Stromal rejection in one eye was managed with steroids and one eye with suture infiltrate needed selective suture removal. Layer-by-layer dissection with limited air injection into the stroma has shown good visual outcomes in patients undergoing DALK following healed hydrops, and DALK can very well be the primary treatment option even in such cases with a paracentral posthydrops scar.

Selective suture removal for the management of buttock pain after uterosacral ligaments suspension.

Selective suture removal for the management of buttock pain after uterosacral ligaments suspension.

Selective suture removal in astigmatism after conventional cataract surgery

Selective suture removal in astigmatism after conventional cataract surgery

VISUAL REHABILITATION AFTER PENETRATING KERATOPLASTY

Introduction: Astigmatism is the most common cause of suboptimal vision after corneal transplantation despite a clear corneal graft.1 Based on several studies, 15–31% of patients undergoing penetrating keratoplasty (PK) may develop postoperative astigmatism greater than 5 diopters (D).2,3 Commonly practiced techniques for visual rehabilitation after PK consist of postoperative suture manipulation, optical correction consisting of spectacles and contact lenses, relaxing incisions, compression sutures, laser refractive surgery, insertion of intrastromal corneal ring segments, wedge resection, toric phakic intraocular lenses, and finally regrafting.4 The aim of this study was to report our management strategies and their results performed for visual rehabilitation and management of astigmatism after PK. Patients and Methods: The records of 104 eyes of 98 patients (54male/44 female) who underwent PK between January 2013 and January 2015 in Baskent University Faculty of Medicine, Department of Ophthalmology were reviewed. The age, the indication for PK, interventions performed for visual rehabilitation, the duration of follow-up, the topographic and refractive astigmatism at the end of follow-up and the final BCVA were recorded. Results: The mean age of the patients was 54±23 years. The indications for PK included keratoconus, Fuch’s endothelial dystrophy, pseudophakic bullous keratopathy and corneal scarring (Figure 1).Fig. 1. The mean duration of follow up was 23±11.5 months. Suture adjustment and selective suture removal were performed 2 to 6 weeks and after 3 months in eyes with more than 3 D of corneal astigmatism. Spectacle correction was performed in 86 eyes (83%) and contact lenses including rigid gas permeable and scleral lenses were fitted in 18 eyes (17%) who were unsatisfied with spectacle correction mostly due to higher order aberrations or high anisometropia (Figure 2).Fig. 2. Relaxing corneal incisions were performed in 23 eyes (22%) and toric intraocular lens implantation was performed in 34 eyes (33%) with cataracts. The mean topographic and absolute refractive astigmatism at the end of follow up was 3.4±2.6 D and 3.6± 1.9 D, respectively. Discussion: Intraoperative and postoperative suture manipulation have been described for minimising early postoperative astigmatism.5,6 After PK, sutures should be kept for at least one year. During this period, astigmatism >4 D can be reduced by suture manipulation consisting of selective interrupted suture removal and tension adjustment of running sutures.4 If significant astigmatism remains after suture removal, which cannot be corrected by optical means such as spectacle correction or contact lenses, surgical procedures can be performed.4 Conclusion: Although general guidelines are useful, it is important to individualize the management based on corneal topography and patient expectations for successful visual rehabilitation.

Graft-size selection and anisometropia reduction in penetrating keratoplasty (PKP).

PurposeTo compare the amount of myopia induced by same-size donor-to-host penetrating keratoplasty with that of the amount of myopia induced by over-sized donor-to-host penetrating keratoplasty.SettingTertiary referral academic center.DesignRetrospective cohort study.MethodsCharts from patients who underwent penetrating keratoplasty by the same technique at Bascom Palmer Eye Institute between Nov 1, 2002, and January 1, 2006, were reviewed. The patients underwent optical penetrating keratoplasty using 12 interrupted 10–0 nylon sutures and a 12-bite continuous 10–0 nylon suture by a single surgeon (R.K.F.). The surgical technique used would be considered standard of care at most institutions. The Institutional Review Board, University of Miami Human Subjects Research Office, approved the study protocol. The donor graft was over-sized by 0.25mm in eyes when the intended final refractive target was greater than -1.00 diopters spherical equivalent (SE). The same-size donor graft was used when the intended final refractive target was less than -1.00 diopters SE. The selection of donor graft size was entirely based upon clinical parameters, meaning that the intended final refractive target was determined per each patient’s fellow eye refraction, with the intention of reducing anisometropia. All patients received postoperative refraction and corneal topography. These measurements were performed at 6–8 weeks when the initial removal of sutures commenced, then at 6 months, then after completion of selective suture removal, then again at 12 months.ResultsAt 12 months, the over-sized group resulted in -1.35 diopters (SD = 2.25) SE of refraction, and the same-size group resulted in -0.14 diopters (SD = 2.42) SE. This approached statistical significance (p = 0.052) in comparison to -1.00 diopters spherical equivalent.ConclusionsUsing a donor graft that is over-sized by 0.25mm results in refraction of -1.00 diopters SE or more of myopia. Using a same-size donor-graft results in refraction of less than -1.00 diopters SE. Therefore, careful graft-size selection can result in a more favorable clinical outcome—namely, reduction in anisometropia—in patients undergoing penetrating keratoplasty.

Management of Reverse Pellucid Type Topography.

Evaluation of the etiopathogenesis and management of topographic reverse pellucid pattern after rigid intraocular lens (IOL) implantation with wide limbal clear corneal incision (CCI). Fifteen eyes with a history of gradual decrease in vision after IOL surgery with at least 6.5-mm CCI were diagnosed with wound dehiscence and were managed with tight resuturation, delayed, and selective suture removal. The improvement in uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively) and refractive errors were analyzed, at least 6 months postoperatively. Postoperatively, UDVA improved in 13/15 eyes (86.7%), whereas CDVA also improved for at least 2 Snellen lines in 11/15 eyes (73.3%) (P<0.01 for both). In all patients, against-the-rule astigmatism changed to with-the-rule astigmatism pattern and the amount of cylinder decreased as the sutures are removed progressively. Vector analysis of astigmatism showed an arithmetic mean of corrected amount of cylinder of 4.17±2.10 D using manifest refraction data and 4.90±2.83 D using keratometric data at the last follow-up. Low visual acuity together with high astigmatism after rigid IOL surgery should prompt the surgeon for considering wound dehiscence that could be managed by careful and deliberate wound revision.

Risk factors for necrosis of skin flap-like wounds after ED debridement and suture

BackgroundSkin flap-like wounds are common. These wound flaps are prone to avascular necrosis with simple debrided and sutured, and postoperative hyperplastic scarring and contracture of wound surfaces can adversely affect the patient's appearance. Here, we evaluate the data of cases with flap-like wounds to identify the causes of flap necrosis. MethodsSix hundred patients with skin flap-like wounds between January 1, 2013 and December 31, 2016 were retrospectively reviewed. Their age, sex, injury reason, size of flap, length-width ratio of wound, thickness of pedicle, operation time, injury site, direction of blood perfusion in the flap and operating methods were recorded. The risks for flap necrosis were analyzed with one-factor analysis. ResultsA total success rate of 92.5% (555/600) for flap-like wound reconstruction was obtained. Among 67 flaps with vascular crisis, 22 were salvaged by subcutaneous injection of anisodamine, selective suture removal, and pressure dressing with elastic bandages. For the 45 patients with flap necrosis, there was no significant difference from patients without necrosis in terms of sex, age, and size of flap (P > 0.05). The incidence of flap necrosis was significantly different in terms of injury reason, length-width ratio of wound, thickness of pedicle, operation time, injury site, direction of blood perfusion in the flap and operating methods (P < 0.05). ConclusionInjury reason, length-width ratio of wound, thickness of pedicle, operation time, injury site, direction of blood perfusion in the flap and operating methods, rather than age, sex and size of flap, were significant risk factors for necrosis of flap-like wounds.

Effect of Suture Removal on Refraction and Graft Curvature After Deep Anterior Lamellar Keratoplasty in Patients With Keratoconus.

To evaluate the effect of suture removal on refraction and keratometry measurements after deep anterior lamellar keratoplasty (DALK). This retrospective study enrolled 54 keratoconus-affected eyes that underwent DALK. A combined suturing technique consisting of a 16-bite single running and 8-bite interrupted 10-0 nylon sutures was used at the time of keratoplasty. Selective interrupted suture removal was performed in a subgroup of patients to reduce postkeratoplasty astigmatism. In another subgroup, all sutures were removed at a single session. Adjustment of the running suture tension was not performed in any case. The effect of suture removal on refractive outcomes was investigated in the entire study group, and the 2 subgroups were compared. Mean patient age was 26.6 ± 6.7 years at the time of keratoplasty. The mean interval from surgery to complete suture removal was 17.4 ± 5.9 months. Compared with the pre-suture removal values, there was a significant increase in the magnitude of myopia (-1.12 ± 1.73 D, P = 0.001), refractive astigmatism (-0.89 ± 2.47 D, P = 0.04), mean keratometry (1.39 ± 1.64 D, P = 0.001), and keratometric astigmatism (2.61 ± 2.43 D, P < 0.001) after complete suture removal. Subgroup analysis revealed that selective removal of interrupted sutures was effective as long as remaining interrupted and running sutures were left in place. Complete suture removal was followed by an unpredictable and significant increase in post-DALK refraction and keratometry readings. In the subgroup that underwent early selective removal of interrupted sutures before complete suture removal, the desirable effects of this procedure significantly diminished after all remaining sutures were completely removed.

Surgical outcome of deep anterior lamellar keratoplasty with air-assisted manual dissection for corneas with previous inflammation or fibrosis.

PURPOSE:To report our experience in air-assisted manual dissection deep anterior lamellar keratoplasty (DALK) for the treatment of corneal scar with previous inflammation and fibrosis.MATERIALS AND METHODS:We retrospectively reviewed the medical history of 21 patients (male:female = 13:8 mean age 41.9 years old) with corneal pathology from previous infection and inflammation. Trephination diameter ranged from 7.0 to 8.0 mm, and the graft was oversized by 0.25–0.50 mm. Debulking technique was performed to expose Descemet's membrane after filling stroma with air. Starting from postoperative 3 months, selective suture removal was performed to reduce corneal astigmatism.RESULTS:The mean follow-up period was 59.9 ± 19.8 (20–96) months. Intraoperative microperforation occurred in 2 eyes (9.5%); however, there was no shift to penetrating keratoplasty. Air-bubble tamponade was performed in 7 eyes (33.3%) for postoperative gapping of the graft. There were 2 failed grafts (9.5%) due to corneal ulcer while all the other grafts remained clear throughout follow-up. The mean preoperative best-corrected visual acuity (BCVA) was 1.84 ± 0.66 logMAR, which improved to 0.74 ± 0.63 (P < 0.01). The average sphere power was − 0.88 ± 3.88 diopter (D), average cylinder power 3.03 ± 1.46D, and average endothelial count 1877 ± 375 cells/mm2.CONCLUSION:In severe ocular surface diseases, big-bubble technique frequently failed to separate predescemtic plane; however, it effectively created air-filled stroma which was easier to remove. Although BCVA was suboptimal due to ocular surface disorders, graft survival and clarity rate is high, justifying the application of DALK in these cases.

DALK: Post operative management

SummarySuccess of DALK, like that of any other operation depends on good surgical technique, appropriate post‐operative examination, treatment, early detection of any problems and adequate management thereof.In the immediate post operative period eye pressure check is important especially if air is left in the anterior chamber. High pressure can cause Urrets‐Zavalia syndrome if not treated.Topical steroids, antibiotics, mydriatic and hypotensive medication if needed, are the mainstay postoperatively. Steroids can be tapered and discontinued earlier than for PK as there is no risk of endothelial rejection.In the early postoperative days, special attention should be paid to the sutures, epithelial defects, signs of inflammation and infection. A loose suture needs to be removed and replaced as soon as possible as it carried a high risk of infection and vascularization. The latter can be a precursor of stromal rejection. Epithelial rejection does occur and behaves exactly like in PK with an advancing epithelial line that stains with fluorescein.Astigmatism is a major problem, strategies for management include, selective suture removal, glasses, contact lenses, arcuate incisions, laser refractive surgery and toric intraocular implants.

Sequential selective same-day suture removal in the management of post-keratoplasty astigmatism

In a previous study, we proposed that corneal topography performed 30-40 min after the initial suture removal can identify the next set of sutures requiring removal, for the treatment of post-keratoplasty astigmatism. The aim of this study was to evaluate the effect of removing subsequent sets of sutures at the same sitting. 10/0 nylon interrupted sutures were placed, to secure the graft-host junction, at the time of keratoplasty. Topography was performed using Pentacam (Oculus) before suture removal. The sutures to be removed in the steep semi-meridians were identified and removed at the slit-lamp biomicroscope. Topography was repeated 30-40 min post suture removal, the new steep semi-meridians determined, and the next set of sutures to be removed were identified and removed accordingly. Topography was repeated 4-6 weeks later and the magnitude of topographic astigmatism was recorded. A paired-samples t-test was used to evaluate the impact of selective suture removal on reducing the magnitude of topographic and refractive astigmatism. Twenty eyes of 20 patients underwent sequential selective same-day suture removal (SSSS) after corneal transplantation. This study showed that the topographic astigmatism decreased by about 46.7% (3.68 D) and the refractive astigmatism decreased by about 37.7% (2.61 D) following SSSS. Vector calculations also show a significant reduction of both topographic and refractive astigmatism (P<0.001). SSSS may help patients to achieve satisfactory vision more quickly and reduce the number of follow-up visits required post keratoplasty.

Long-Term Outcomes of Femtosecond Laser–Assisted Mushroom Configuration Deep Anterior Lamellar Keratoplasty

To review the long-term outcomes after femtosecond laser (FSL)-assisted mushroom configuration deep anterior lamellar keratoplasty (DALK). Noncomparative case series of 19 eyes from 19 patients who underwent FSL-assisted mushroom configuration DALK. Data were available for 14 eyes at 1 month, for 14 at 3 months, for 16 at 6 months, for 10 at 9 months, and for 8 at 1 year. Preoperative mean best-corrected visual acuity was 20/108 (range: 20/30-20/400). At 3 months, the mean best-corrected visual acuity was 20/46 (range: 20/25-20/250), and at a mean final follow-up of 13 months (range: 6-29) it was 20/35 (range: 20/15-20/200). The greatest change in mean spherical equivalent was at 3 months [-2.29 diopters (D), range: -7.38 to +3.38 D; from -9.54 D, range: -20.00 to +3.38 D, preoperatively]. There was 56% reduction in mean keratometric cylinder at 6 months (4.00 D, range: 1.04-8.75 D; from 9.13 D, range: 0.50-18.75 D, preoperatively). Complications included 3 cases (15.8%) of small Descemet membrane perforation, none of which required conversion to penetrating keratoplasty; 3 cases (15.8%) of stromal rejection that resolved with topical steroids; and 6 cases (31.6%) of steroid-related intraocular pressure rise that were treated with topical medications. Selective suture removal was initiated a mean of 3.5 months (range: 1.5-6 months) after surgery. The use of the FSL to perform corneal cuts in a mushroom configuration for DALK is reliable and reproducible. Earlier visual rehabilitation may be possible because of the mechanical stability and wound healing advantages of stepped corneal wounds.

Femtosecond Laser–Assisted Keratoplasty in Failed Penetrating Keratoplasty and Globe Trauma

To demonstrate feasibility and present postoperative outcomes for femtosecond laser-assisted keratoplasty (FLAK) in the setting of previous failed conventional penetrating keratoplasty (PK) and previous open-globe trauma with corneal laceration. In this retrospective case series, data were collected for 12 consecutive patients at the Casey Eye Institute (Oregon Health and Science University, Portland, OR) with the primary diagnosis of either failed PK or open-globe trauma with corneal laceration that underwent zigzag incision FLAK. Outcome measures included topographic astigmatism, best spectacle-corrected visual acuity, uncorrected visual acuity, pinhole visual acuity, intraocular pressure, and timing of selective suture removal (or adjustment) over various follow-up intervals up to 18 months postoperatively. Mean follow-up was 10.42 months. Mean postoperative topographic astigmatism ranged between 3.56 and 6.81 diopters (D). Mean best spectacle-corrected visual acuity (BSCVA) in logarithm of minimal angle of resolution (logMAR) equivalents ranged between 0.18 and 0.61 as compared with 1.28 for preoperative BSCVA (P = 0.0064). Thirty-three percent (4 of 12) of patients had significantly increased intraocular pressure develop during the first year of follow-up that required glaucoma therapy. No adverse events or complications occurred as a result of either the femtosecond laser procedure itself or during the transportation of the patient from the laser suite to the operating room. FLAK is a feasible transplantation technique in the setting of previous failed PK and open-globe trauma with corneal laceration. Significant globe pressure associated with laser applanation did not cause rupture of old corneal wounds among our case series. Postoperative astigmatism is within previous reported limits in the literature under varying suturing techniques. Development of ocular hypertension within 1 year of follow-up was comparable with historically reported rates for PK in the setting of previous trauma and failed grafts.

Femtosecond Laser-Assisted Mushroom Configuration Deep Anterior Lamellar Keratoplasty

To review patient outcomes after femtosecond laser-assisted mushroom configuration deep anterior lamellar keratoplasty. Seven eyes of seven patients with a mean age of 30 years underwent femtosecond laser-assisted mushroom configuration deep anterior lamellar keratoplasty from April 2008 to September 2008. Patients had keratoconus, corneal ectasia or scarring. Set for 100 mum of residual cornea, the femtosecond laser was used to create a mushroom-shaped recipient bed and donor button (having a larger anterior than posterior diameter). The posterior central lamella was manually dissected using Melles technique. Mean follow up was 4 months (range, 3-6.5 months). Preoperative mean best-corrected visual acuity was 20/95 (range, 20/40-20/400). Intraoperative complications included two cases (28.6%) of small Descemet membrane perforation. Postoperatively, there was one case of stromal rejection that resolved with topical steroids and two cases of steroid-related intraocular pressure rise that were treated with a prostaglandin analog. At 3 months, mean best-corrected visual acuity was 20/40 (range, 20/25-20/60), mean spherical equivalent refraction was -3.21 D (range, -6.75 D to plano), mean cylindrical refractive error was 3.57 D (range, 1.5-7 D), and mean keratometric cylinder measured 5.56 D (range, 3.79-7.00 D). Selective suture removal occurred in six patients (86%) at a mean of 3.8 months (range, 2-6 months) postoperatively. This preliminary series demonstrates that the use of the femtosecond laser to perform corneal cuts in a mushroom configuration for deep anterior lamellar keratoplasty is feasible. The mechanical stability and wound healing advantages for stepped corneal wounds should be considered in lamellar surgery.

Relaxing Incisions Combined With Adjustment Sutures for Post-Deep Anterior Lamellar Keratoplasty Astigmatism in Keratoconus

To find an effective and reliable method to correct astigmatism after deep anterior lamellar keratoplasty (DALK) in patients with keratoconus. This interventional case series included 14 eyes of 14 patients with keratoconus (12 males) undergoing graft refractive surgery (GRS) for intolerable post-DALK astigmatism. The technique of GRS for the 5 initial cases consisted of only relaxing incisions at the steep meridian in the graft-host interface down to Descemet membrane. For the rest, the relaxing incisions at the steep meridian were accompanied by simultaneous suturing and the effect of the relaxing incisions was controlled through selective suture removal starting a few days after the operation. The main outcomes were uncorrected and corrected visual acuity and change in refractive and keratometric astigmatism using subtraction and vector analysis methods. Mean patient age was 29.36 +/- 6.2 years. Mean time interval from complete suture removal to GRS and follow-up period were 4.5 +/- 2.0 months and 12.0 +/- 7.4 months, respectively. Mean preoperative best-corrected visual acuity was 0.29 +/- 0.1, increasing to 0.22 +/- 0.1 logarithm of minimum angle of resolution after the operation (P = 0.007). Average keratometric astigmatism was reduced by 3.8 and 5.5 diopters measured with subtraction and vector analysis methods, respectively. Four of 5 eyes that had only relaxing incisions initially required suturing of the incisions because of overcorrection, whereas preliminary results showed none of the 9 patients undergoing simultaneous relaxing incisions and suturing required further intervention. Relaxing incisions and suturing at the steep meridian followed by selective suture removal can effectively and predictably reduce post-DALK astigmatism in patients with keratoconus.

Outcomes of Augmented Relaxing Incisions for Postpenetrating Keratoplasty Astigmatism in Keratoconus

To determine the outcomes of augmented relaxing incisions (relaxing incisions and counter-quadrant compression sutures) as graft refractive surgery (GRS) in keratoconic eyes. This interventional case series included keratoconic eyes undergoing GRS for intolerable amounts of postpenetrating keratoplasty (PKP) astigmatism. Relaxing incisions were made in the graft-host interface down to Descemet membrane on both sides of the steepest meridian. Interrupted 10-0 nylon compression sutures were added in the opposite meridian to overcorrect astigmatism. Selective suture removal was initiated after 3-6 weeks to achieve tolerable amounts of astigmatism. Best-corrected visual acuity and refractive and keratometric astigmatisms were compared before and after the operation using simple subtraction and vector analysis methods. Overall, 77 eyes of 77 patients including 51 (66.2%) male and 26 (33.8%) female subjects with mean age of 30.0 +/- 10.2 years at the time of PKP were studied. Average follow-up was 61.5 +/- 33.5 months after PKP and 40.8 +/- 29.3 months after GRS. Mean best-corrected visual acuity improved from 0.31 +/- 0.26 logMAR (20/40) before GRS to 0.18 +/- 0.12 logMAR (20/30) postoperatively (P < 0.001). Mean preoperative and postoperative values for refractive astigmatism, keratometric astigmatism, and spherical equivalent refractive error were 6.8 +/- 1.4 and 3.9 +/- 1.6 diopters (D) (P < 0.001), 7.9 +/- 1.9 and 4.5 +/- 2.2 D (P < 0.001), and -2.0 +/- 2.9 and -3.24 +/- 2.8 D (P < 0.001), respectively. Vector analysis demonstrated that refractive and keratometric astigmatisms were reduced by 4.8 and 5.9 D, respectively. GRS using augmented relaxing incisions reduces post-PKP astigmatism in keratoconic eyes; however, it causes a slight myopic shift.

Comparison of the Effect of Three Suturing Techniques on Postkeratoplasty Astigmatism in Keratoconus

To compare the effect of 3 common suturing techniques on postkeratoplasty astigmatism and final best corrected visual acuity (BCVA) in patients with keratoconus. In this randomized clinical trial, 103 eyes of 103 patients with advanced keratoconus, who were contact lens intolerant, or with contact lens-corrected visual acuity less than 20/80, underwent penetrating keratoplasty with 3 suturing techniques: interrupted (IR), single running (SR), and combined interrupted and running (CIR). Postkeratoplasty astigmatism and BCVA were evaluated during regular examinations 1.5, 3, 6, and 12 months postoperatively and 2 months after complete suture removal. Suture adjustment and selective suture removal were performed 2 to 6 weeks and after 3 months in eyes with more than 4 D of corneal astigmatism in the SR and IR/CIR groups, respectively. Of 87 patients who completed follow-up, 26 eyes underwent PK with interrupted suturing technique (IR), 26 eyes had single running sutures (SR), and in 35 eyes, the suturing technique was combined (interrupted + running sutures; CIR). Mean age was 27.2 +/- 8.4, 28.9 +/- 8.7, and 30.3 +/- 8.7 years, and postoperative astigmatism 1.5 months after surgery was 3.77 +/- 1.68, 5.48 +/- 2.09, and 4.10 +/- 1.79 D in the 3 groups, respectively (P = 0.015). However, 2 months after complete suture removal, final postoperative astigmatism was 3.83 +/- 1.65, 3.37 +/- 1.9, and 3.88 +/- 2.79 D (P = 0.851) and BCVA (log MAR) was 0.08 +/- 0.14, 0.13 +/- 0.23, and 0.09 +/- 0.16, respectively (P = 0.53). Immunologic endothelial rejection reactions were seen in 5 eyes (19.2%) in the IR group, 3 eyes (11.72%) in the SR group, and 6 eyes (17.64%) in the CIR group (P = 0.44). There was no case of graft failure during the follow-up period. Postkeratoplasty astigmatism and BCVA are comparable with the 3 common suturing techniques (IR, SR, and CIR) in patients with keratoconus, provided that regular postoperative examinations and topography-guided suture adjustment and/or removal are performed.

Surgical technique for control of postkeratoplasty myopia, astigmatism, and anisometropia

Purpose We previously demonstrated that selective suture removal reduces keratoplasty astigmatism; however, a myopic shift was induced with the increasing number of interrupted sutures removed. This study is an attempt to determine the effects of a modified surgical technique on postkeratoplasty myopia, astigmatism, and anisometropia. Design A cohort study compared with historical controls. Methods Optical penetrating keratoplasties were performed on 92 eyes of 84 patients. The study group consisted of 92 consecutive penetrating keratoplasties performed using 12 interrupted 10-0 nylon sutures and a tight 12-bite continuous suture and an average K reading of 46.00 diopters for eyes undergoing combined and intraocular lens exchange procedures. All patients had refraction, keratometry, and videokeratoscopy postoperatively starting at 6 weeks and at the completion of selective suture removal. Results Before suture removal, the average spherical equivalent was −0.160 ± 3.59 diopters; it was −1.58 ± 3.66 diopters at the completion of suture removal at 1 year and −1.44 ± 3.72 at the last follow-up visit, averaging 20.7 months. Final refractive, keratometric, and videokeratoscopy astigmatism was 2.81 ± 1.82, 4.19 ± 2.94, and 3.58 ± 2.03 diopters, respectively. Anisometropia, using the spherical equivalent of the operated and fellow eyes, was 2.49 ± 2.25 diopters at completion of the study. A best-corrected visual acuity of 20/50 or better was achieved in 59% of patients. Conclusions Low myopic spherical equivalent and anisometropia were achieved using a K reading of 46 diopters for calculation of intraocular lens power. The use of tighter continuous sutures and selective removal of fewer interrupted sutures only served to increase final astigmatism, with no significant effect on the final spherical equivalent.

Surgical treatment of advanced pellucid marginal degeneration

Purpose To determine the efficacy of simultaneous peripheral crescentic lamellar keratoplasty (LK) and central penetrating keratoplasty (PK) for advanced pellucid marginal degeneration (PMD). Design Retrospective, noncomparative, interventional case series. Participants Five patients with advanced PMD. Method Simultaneous peripheral crescentic LK and central PK followed by selective suture removal and astigmatic keratotomy in the postoperative period. Main outcome measures These included interval of time required for visual rehabilitation, best spectacle-corrected visual acuity achieved, and amount of corneal astigmatism, as measured by videokeratography. Measuring the change in corneal astigmatism by videokeratography over the subsequent follow-up period after spectacle correction had been prescribed assessed stability of the achieved refraction. Results Visual acuity results were 20/40 in three eyes, 20/80 in one eye, and 20/400 in one eye. The latter two had decreased acuity from posterior subcapsular cataract formation, which may have been caused by topical steroid use. The time required for visual rehabilitation ranged from 5.13 to 10.93 (mean, 9.92) months, and the amount of corneal astigmatism at the end of this period ranged from 0.3 diopters (D) to 5.3 D. A tendency for an increase in “with the rule astigmatism” after the rehabilitation period was noted. Two patients had elevations of intraocular pressure that responded to reduction in topical steroid dose. Conclusions The short-term results with this technique are excellent in that it provides early and stable visual rehabilitation in patients with advanced PMD. Low to moderate levels of postkeratoplasty astigmatism were achieved in all the eyes treated. The usual tendency of an increase in “against the rule astigmatism” that occurs when PK alone is done for PMD was eliminated.