Background: Visual acuity following penetrating keratoplasty is frequently limited by excessive astigmatism which cannot be compensated for with spectacles or contact lenses. The purpose of the study was to determine the effects of arcuate keratotomies and compression sutures on the amount and regularity of corneal astigmatism and on the visual acuity.
Patients and methods: Between June 1989 and August 1995, 56 eyes from 56 patients (30 women, 26 men, average age 53 +/- 16 years) with excessive post-penetrating keratoplasty astigmatism were treated with paired arcuate cuts and compression sutures 4.8 +/- 3.5 years after suture removal (45% keratoconus, 30% scars, 20% dystrophies). The incisions were made along the meridian of maximum dioptric power in a sector extending for 60 +/- 15 degrees (6 mm diameter). Incision depth was standardized at 450 microns. Compression sutures were placed 90 degrees away in the flat meridian. Eight patients required more than one procedure to obtain the desired effect. Best corrected visual acuity (VA), keratometric readings and topographic power maps were analyzed pre- and postoperatively. We categorized the topographic maps into six groups: from group 1 (regular) to group 6 (irregular). For description of the astigmatic change after surgery, the formulas by Naylor and Jaffe (vector-corrected astigmatism) were applied.
Results: The mean preoperative astigmatism was 10.8 +/- 3.1 (4.2 to 19.2) diopters (D). After a mean follow-up of 1.1 years, the mean net astigmatism was 5.8 +/- 3.2 (0 to 16) D. The mean preoperative visual acuity (VA) was 0.38 +/- 0.31 (from 0.03 to 1.0). At the end of follow-up, the mean VA was 0.43 +/- 0.25. Non-refractive reasons for poor visual acuity included amblyopia (n = 5), macular degeneration (n = 4), glaucoma (n = 4), cataract (n = 2), and others (n = 5). Twenty-seven percent of the preoperative topographic maps were categorized into groups 1 and 2 and only 10% into groups 5 and 6. At the end of the follow-up, none of the 53 available topographic maps was categorized into group 1, 7.5% into group 2 and 30% into groups 5 and 6. The mean astigmatic change (vector-corrected astigmatism) was 12.3 +/- 5.2 (1.0 to 29.8) D with a turn of the axes ranging from -39 to 44 degrees.
Conclusions: Arcuate incisions with compression sutures are easily performed and hold a low complication rate in comparison with other refractive operations. Definition of successful surgery is even broader when a significant reduction of astigmatism that usually allows the use of spectacles or contact lenses is considered. A disadvantage is that each particular case is unpredictable because of the tendency of the topography to irregularity and possible regression of the effect.