Corneal sutures or methods which are more likely to reduce suture-related complication (review)

According to previous studies, we've described several advances in corneal surgery, that have brought enhanced results .They have also been associated with unwanted adverse events. Therefore, we conducted analysis to compare and estimate effectiveness of the treatments, diminishing post-surgical complications.

We searched PubMed, Lancet, for clinical trials, making an accent to the management or prevention of such complications as astigmatism and scarring.

According to our analysis of reviews, we highlighted such preventative measures like excimer laser keratoplasty method; collagen cross-linking which is beneficial for wound strengthening; AFG; X-pattern sutures and horizontal suture. Besides the last study showsmore safe and efficient way to reduce the risk of egress of fluid from the eye after wound leakage during cataract surgery .

Introduction.Corneas are the most commonly transplanted tissue worldwide, and the indications for transplantation cover a wide range of diseases (tables 1 and 2). In the USA, 42 642 corneal transplantations were done in 2010 [1] compared with 12 623 solid-organ transplantations in 2008, including kidney, liver, lung, pancreas, heart, and intestine.[2] In the UK in 2010 and 2011, there were 3565 corneal, 2671 kidney, and 689 liver transplantations”[3].

Corneal transplantation or keratoplasty has developed quickly within the previous 10 years. Penetrating keratoplasty, a technique comprising of full-thickness substitution of the cornea, has been the predominant methodology for more than 50 years, and effectively obliges most reasons for corneal visual impairment. The selection of fresher types of lamellar transplantation by specialist surgeons , which specifically substitute just affected layers of the cornea, has been a crucial change as of late. Deep anterior lamellar keratoplasty is substituting penetrating keratoplasty for disarranges affecting the corneal stromal layers, while eradication of the danger of endothelial rejection. Endothelial keratoplasty, which specifically replaces the corneal endothelium in patients with endothelial disease, has brought about more quick and unsurprising visual results. Other developing treatments are ocular surface reconstruction and artificial cornea (keratoprosthesis) surgery, which have turned out to be all the more broadly accessible as a result of fast advances in these systems [4].

On the whole, these advances have brought about enhanced results, and at the same time have extended the quantity of complications. This article was aimed to describe actual methods of avoidance of surgical-induced postoperative complications.

Methods. For this review, the authors searched PubMed ,The Lancet using the keywords “keratoplasty; corneal sutures;Amniotic membrane, astigmatism”. They also searched ophthalmology books about cornea and papers published in the last 5-10 years discussing the different steps of evolution of corneal surgeries and management of endothelial diseases. The authors used the statistics of the eye bank association of America. The abstract, the full article and references were obtained and references checked for additional material where appropriate.


The first relevant issue of nowadays to be discussed was estimation of excimer laser keratoplasty and motor trephination role in the post-surgery outcomes.

“Prospective clinical studies have shown that the technique of non-contact excimer laser PKP improves donor and recipient centration, reduces "vertical tilt" and "horizontal torsion" of the graft in the recipient bed, and thus results in significantly less "all-sutures-out" keratometric astigmatism (2.8 vs. 5.7 D), more regular topography (surface regularity index [SRI] 0.80 vs. 1.0) and better visual acuity (0.80 vs. 0.60), in comparison to the motor trephine. The stage of the disease does not influence functional outcome after excimer laser PKP” [18,19,20,21].

During this randomized, clinical study at the university eye hospital of Erlangen, Germany, 134 eyes of seventy six females and fifty eight males undergoing PK between 1992 and 1997 were haphazardly assigned to tissue layer surgical procedure. The inclusion criteria were physicist dystrophy (diameter seven.5 mm) or kHz (diameter eight.0 mm), graft large zero.1 mm, no previous intraocular surgery, and 16-bite double running diagonal suture in keeping with F. Hoffmann. Patients with any style of maculopathy (including high myopia), glaucoma, or visual defect were excluded. Surgical procedure was performed exploitation either a 193-nm excimer optical maser on metal masks with eightorientation teeth/ notches as delineate elsewhere [5,6] (excimer group: thirty seven kHz and twenty three or a Geuder motor trephine (control group: forty four kHz and thirty Fuchs dystrophy). In sixteen eyes within the excimer cluster and nineteen eyes within themanagement cluster, “open-sky” extracapsular cataract extraction and posterior chamber lens implantation were performed at the same time (triple procedure)[7].

In conclusion, after double running suture removal, astigmatism decreases or remains unchanged in 79% of patients after excimer laser keratoplasty and increases in 80% of patients after conventional motor trephination.

Collagen cross-linking as an adjunct for repair of corneal lacerations: A cadaveric study

A penetrating globe injury is a disease which causes loss of structure of eye, especially prolapsed or damage to the structures of the eye. The standard of the treatment of such kind of the injuries is to riposte the and close the wound with the suture.[8] Earlier treatment reduces the risk of the appearance of the complications: endophthalmitis, supachoroidal hemorrhage, epithelial ingrowth, tissue necrosis and loss of the eye [9.10].

In the experiment they conducted a cadaveric bench study to compare wound strength with and without CXL. For the corneal laceration they created a 5 mm wound in the center of the cornea. The placement of both 1 and 2 sutures in the wound resulted in a sealed wound that leaked without suture breakage when IOP was increased. Eyes were then randomized to receive 1 suture (n % 8 eyes), 2 sutures (n % 8 eyes), or 3 sutures (n % 4 eyes). Their technique was similar to previous reports in the ophthalmologic literature [11].

Then BSS was slowly injected into the anterior chamber via a 3 mL syringe. This was continued until fluid was seen from the wound [11] .The burst pressure was later determined by 2 blinded observers (Y.W. and M.X.). The burst pressure was easily identifiable as the highest point of a slow rise immediately before a precipitous drop. The mean between the 2 observers was used.

As an outcome of this experiment we can consider that CXL could be performed in an operating room to provide benefits for wound strengthening. This could help to prevent future formation of suture related astigmatism and scarring.

Comparison of autologous fibrin glue versus nylon sutures for securing conjunctivalautografting in pterygium surgery 

Pterygium is a fibrovascular mass which isnextending onto the corneal surface. Risk factors that can occur within usage are heredity, chronic ultraviolet radiation (UVR) exposure, chronic inflammation, vitamin A deficiency, tear film disturbances, micro trauma to the eyes and dusty, windy, dry, smoky environments [12].

Patients The study population consisted of 120 patients (120 eyes). People were randomly assigned to either the AFG (n = 60) or the NS (n = 60) group randomly. All patients who underwent surgery had a primary pterygium which had been injected the cornea more than 2 mm from limbus. Recurrence is defined as equal to or more than 1 mm fibrovascular growth over the peripheral cornea. All patients had a visiting to surgeon, and were then followed at 1 day, 1 week, 1, 3, and 6 months, and then every 6 months after surgery. Surgeon satisfaction was rated from 1 to 10, with 1 being least and 10 most satisfied with the surgery.

In conclusion, AFG is a safe and effective method for securing conjunctival wounds in pterygium surgery, and, in comparison to suturing, it can reduce the risk of the recurrence rate and the operating time of the surgery.

The Manual small incision cataract surgery(MSICS) is one of the effective techniques for cataract surgery.[14]The main incision of MSICS is the scleral tunnel, which can be sealed by two general sutures: horizontal and X-pattern sutures. This study compares the effectiveness of two suture types on surgically induced corneal astigmatism(SIA) in the scleral tunnel incisions for the MSICS.[13]

In a nonrandomized comparative trial, sixty four consecutive patients (64 eyes) diagnosed with a cataract within the Farabi Eye Hospital that needed surgery were enclosed. The patients with intraand post-operative complications, pediatric cataracts, traumatic cataracts, and previous ocular surgeries (were excluded from the study. The amount of corneal astigmatism was calculated by subtracting Sim K values, using the plus cylinder notation. The patients were divided randomly to one of the groups: Horizontal or Xpattern suture group. [15,16,17]

In this study, the patients were followed till three months after surgery. The astigmatism looks to be constant at 1.5 months after surgery, due to the small dissimilarity between 1.5 and 3 months postoperative and surgically persuaded astigmatism in both groups. So, the other managements of the astigmatism (such as glasses or refractive surgery) in the patients that underwent MSICS might be done at 1.5 months after the surgery.

In conclusion, in the MSICS the horizontal sutures induced against-the-rule astigmatism and the Xpattern sutures induced mild with-the-rule astigmatism. So, the X-pattern sutures were more suitable than the horizontal sutures in the patients without significant preoperative abrupting in line with the central meridian of the incision. In the cases with significant preoperative abrupting, sutureless surgery or horizontal sutures were preferred.

Most surgeons in the United States now plainly conduct cataract surgery using clear corneal indstons (CCIs).[22]StuСies have shewn that еѵеп weІІ-coпstгucteС іпсіяош! сап іeak wit^l ргоѵосаНоп [23] ог after iпtгaocuіaг pгessuгe (IOP) iпstabiІity.[24,25]SeaІiпg CCIs might геСисе the ргоЬаЬіііЬу ой Іeak-гeІateС surgtoal сотрПсайоп8. This pгospective гaпСomizeС рагаііеі-агт сопЬгоііеС muіticeпteг suЬject-maskeС stuСy evaІuateС the saйety апС еййісіасу ой а hyСгogeІ seaіaпt іп compaгisoп with а 10-0 пуіоп suture (попа^огЬаЬіе, ріасеС 90 Сegгees to the indston using а 3-1-1 ЬuгieС-kпot te^^que) йог guarting indston іeakage йгот CCIs in patieпts having uпeveпtйuі сіеаг согпеаі саЬагасЬ surgery after whtoh a wouпС іeak оссшггеС. The stuСy was coпСucteС at 24 sites in the U.S., with a maximumoй 96 patieпts епгоііеС at апу site. Of the 583 patieпts епгоііеС, eighty three weгe ехсішСеС toning scгeeпiпg ог iпtгaopeгativeіy йог гeasoпs uпгeІateС to wouпС іeakage, іeaviпg 500 һеаіЬһу patieпts having uпeveпtйuі сіеаг согпеаі indston (CCI) саЬагасЬ surgery weгe acceptaЬІe йог the stuСy. Spoпtaпeous апС іпСисеС АшС ошЬіеЬ йгот wouпСs was evaІuateС at the Ьіте ой surgery using а саііЬгаЬеС йогсе gauge.[25] Eyes with іeakage weгe гaпСomizeС to гесеіуе a hyСгogeІ seaіaпt (Resuгe) ог а пуіоп suture at the таіп indston site. Indston іeakage was гeevaІuateС 1, 3, 7, апС 28 Сays after surgery.

Oveгaіі, ой 500 eyes, 488 һаС leakage at the Ьіте ой саЬагасЬ surgery The leak was extempoгaпeous in 244 cases (48.8%), апС 488 (97.6%) ой all indstons ІeakeС with 1.0 ошпсе ог less ой аррііеС йогсе. АйЬег гaпСomizatioп, 12 (4.1%) ой 295 eyes in the sealant gгoup апС 60 (34.1%) ой 176 eyes in the suture gгoup һаС wouпС leakage with pгovocatioп (P<.0001). The oveгaіі іпсіСепсе ой averse осшіаг events was statisticaііy sigпiйicaпtіy tower in the sealant gгoup than in the suture gгoup (P<.05).

In summary, a high peгceпtage ой the single-ріапе CCIs in this stuСy showeС some level ой leakage after саЬагасЬ surgery апС Ьейоге interventton. Results s^w that the hyСгogeІ sealant is safe апС еййісіепЬ апС is ЬеЬЬег than sutures in pгeveпtiпg egress ой йішіС йгот the еуе after wouпС leakage toning саЬагасЬ surgery.


Initial^, we've СescгiЬeС several a^a^es in согпеаі surgery, that have Ью^Ы епһапсеС results [4]. Current staпСaгСs ой саге, sinh as stгomaі һуСгаЬіоп апС sutures, Со поЬ арреаг to pгoviСe suffident wouпС integrity to guarantee a tofinitive seal. ^еу have aіso Ьееп associateС with uпwaпteС averse eventstos we тепЬіопеС,Ьһе purpose ой this review artide was to estirnate the methoСs ой геСшсЬіоп ой these сотр^нНо^. Ассог^^ to ошг aпaіysis ой reviews, in the case ой гemovaі ой СошЬіе running suture, it ЬшгпеС ошЬ that ехсітег laser keгatopіasty теЬһоС is less іikeіy to саіпе astigmatism , in сопЬгагу to coпveпtioпaі тоЬог ЬгерһіпаЬіоп. АпоЬһег гесепЬ stutoes showeС the next теЬһоС, гeСuciпg йогтаЬіоп ой sutuгe-гeІateС astigmatism апС scaггiпg was ^Hagen cгoss-іiпkiпg whtoh is Ьепейісіаі йог wouпС strengthening. Moгeoveг, researehers таСе a compaгisoп ой AFG апС suturing in pterygium surgery, whtoh showeС pгevaіeпce ой AFG to the secoпС опе, Сие to it’s еййісіепсу апС аЬіііЬу to геСшсе гесшггепсе rate апС opeгatiпg Ьіте ой surgery. In MSICS its тоге арргоргіаЬе to use X-раЬЬегп sutures опіу in patieпts with signiftoant ргеорегаЬгее а^ирЬ^ in line wit^l the сепЬгаі тегіСіап ой the indston, while in the cases with signiftoant ргеорегаЬгее aЬгuptiпg, sutureless surgery ог hoгizoпtaі sutures were ргейеггеС. This issue пeeСs further researeh. The last stuСy slwws тоге safe апС еййісіепЬ way Ьо геСисе the risk ой egress ой йішіС йгот the еуе after wouпС leakage toning саЬагасЬ surgery is hyСгogeІ sealant in compaгisoп Ьо sutures.



  1. Еуе Banking Statisttoal RepoгЬ Еуе Bank AssociaЬioп ой Атегіса URL: hЬЬp://www.гesЬoгesighЬ.oгg
  2. OPTN / SRTR Аппшаі RepoгЬ: ^а^ріа^ Data 1999-2008: US DepaгЬmeпЬ ой Health апС Humaп Servtoes URL: hЬЬp://opЬп.ЬгaпspІaпЬ.hгг2009/ (дата обращения: 28.11.2011).
  3. Үга^ріапЬ АсЬМЬу in the UK: Nattonal Health Servtoe BІooС апС Үга^ріапЬ (NHSBT) Registry URL: hЬЬp://www.ukЬгaпspІaпЬ.oгЬ/sЬaЬisЬics/ЬгaпspІaпЬ_acЬiviЬy_гepoгЬ/ЬгaпspІaпЬ_acЬiviЬy_гepoгЬ.jsp (дата обращения: 28.11.2011).
  4. CtornealЬга^ріапЬаЬіоп URL: https://Сoi.oгg/10.1016/S0140-6736(12)60437-1 (дата обращения: 5.05.2012).
  5. Seitz B, LaпgeпЬucheг А, Kus MM, et al. Моптесһапісаі согпеаі ЬгерһіпаЬіоп with the ехсітег laser impгoves ошЬсоте after peпetгatiпg keгatopіsty / / Ophthaіmoіogy. 1999. №106. Р. 1156-1165.
  6. Eі-Husseiпy M, Seitz B, LaпgeпЬucheг А, et al. Ехсітег versus йemtosecoпС laser assisteС peпetгatiпg keгatopіasty in kerato^n^ апС FuAs Сystгophy: іпЬгаорегаЬгее Pitfalls / / J ОрһЬһаітоі. 2015. №64. Р. 46-59.
  7. Jaffe N. Postopeгative согпеаі astigmatism. Cataгact Surgery апС Its ^трИснНо^. St. Louis, MO: MosЬy, 1982. Р. 92-110.
  8. Mascai M. Surgical management and rehabilitation of anterior segment trauma. New York: Mosby-Elsevier, 2011. Р. 1655-1669.
  9. Essex RW, Yi Q, Charles PG, Allen PJ.Post-traumatic endophthalmitis // Ophthalmology. 2004. №111. Р. 2015-2022.
  10. Velazquez AJ, Carnahan MA, Kristinsson J, Stinnett S, Grinstaff MW, Kim T. New dendritic adhesives for sutureless ophthalmic surgical procedures: in vitro studies of corneal laceration repair // Arch Ophthalmol. 2004. №122. Р. 867-870.
  11. Portnoy SL, Insler MS, Kaufman HE. Surgical management of corneal ulceration and perforation // SurvOphthalmol. 1989. №34. Р. 47-58.
  12. Liu L, Wu J, Geng J, Yuan Z, Huang D Geographical prevalence and risk factors for pterygium: a systematic review and meta-analysis // BMJ Open. 2013. №3(11). Р. 77-87.
  13. Eslami Y, Mirmohammadsadeghi A. Comparison of surgically induced astigmatism between horizontal and Xpattern sutures in the scleral tunnel incisions for manual small incision cataract surgery // Indian J Ophthalmol. 2015. №63(7). Р. 606-610.
  14. Khanna RC, Kaza S, PalamanerSubashShantha G, Sangwan VS. Comparative outcomes of manual small incision cataract surgery and phacoemulsification performed by ophthalmology trainees in a tertiary eye care hospital in India: A retrospective cohort design / / BMJ Open. 2012. №2. Р. 159-168.
  15. Davison JA. Keratometric comparison of 4.0 mm and 5.5 mm scleral tunnel cataract incisions // J Cataract Refract Surg. 1993. №19. Р. 3-8.
  16. Storr-Paulsen A, Henning V. Long-term astigmatic changes after phacoemulsification with single-stitch, horizontal suture closure / / J Cataract Refract Surg. 1995. №21. Р. 429-432.
  17. Azar DT, Stark WJ, Dodick J, Khoury JM, Vitale S, Enger C, et al. Prospective, randomized vector analysis of astigmatism after three-, one-, and no-suture phacoemulsification / / J Cataract Refract Surg. 1997. №23. Р. 1164-1173.
  18. PKP for Keratoconus From Hand/Motor Trephine to Excimer Laser and Back to Femtosecond Laser // KlinMonblAugenheilkd. 2016. №233(6). Р. 727-736.
  19. Kluhspies U, Grunder A, Goebels S et al. Keratokonuslinse Das kleine Korrektionswunder / / Ophthalmologe. 2013. №110. Р. 830-883.
  20. El-Husseiny M, Tsintarakis T, Eppig T et al. Intrakorneale Ring segmente beim Keratokonus // Ophthalmologe. 2013. №110. Р. 823-829.
  21. Seitz B, Cursiefen C, El-Husseiny M et al. DALK und perforierende Laser keratoplastik beifortgeschrittenem Keratokonus // Ophthalmologe. 2013. №110. Р. 839-848.
  22. Leaming DV. Practice styles and preferences of ASCRS membersd2003 survey. J Cataract Refract Surg 2004; 30:892-900
  23. Taban M, Sarayba MA, Ignacio TS, Behrens A, McDonnell PJ. Ingress of India ink into the anterior chamber through sutureless clear corneal cataract wounds // Arch Ophthalmol. 2005. №123. Р. 643-648. Johnson CS, Wathier M, Grinstaff M, Kim T. In vitro sealing of clear corneal cataract incisions with a novel biodendrimer adhesive // Arch Ophthalmol. 2009. №127. Р. 430-434.
  24. Masket S, Hovanesian J, Raizman M, Wee D, Fram N. Use of a calibrated force gauge in clear corneal cataract surgery to quantify point-pressure manipulation // JCataract Refract Surg. 2013. №39. Р. 511-518.
Year: 2018
City: Almaty
Category: Medicine