For penetrating keratoplasty, multiple suturing techniques have been described. Most often a combination of eight interrupted 10-0 nylon sutures and a running 11-0 suture is used, or a single or double running 10-0 nylon suture. The first technique may have the advantage that the astigmatism can be closely monitored by selective suture removal. In addition, suture loosening rarely requires secondary surgical intervention, since enough sutures are usually left for fixation of the transplant. Single or double running sutures have the advantages that suture placement is easier and can be performed faster, and that the astigmatism may be monitored by suture adjustment. However, suture loosening may then require additional surgical intervention.

In contrast to penetrating keratoplasty, that requires the sutures to be in-situ for at least one year, the sutures may be removed at 4 to 6 months after lamellar keratoplasty. It may therefore be considered to choose a suturing technique that requires the least surgical time, induces the least amount of astigmatism, and provides sufficient fixation of the graft in the event of inadvertent suture loosening. The suturing technique that fits these criteria best may be a double running 8-bite 10-0 nylon anti-torc suture (Figure 4.5 and 5.5).

In deep anterior lamellar keratoplasty, placement of a double running 8-bite 10-0 nylon anti-torc suture can be performed quickly and easily, without the need for cardinal fixation sutures. After marking four corneal meridians with an eight radial marker, the needle is placed obliquely in the donor button at an ink mark, then inserted into the dissection plane present in the peripheral recipient cornea, and moved upward. Care should be taken to burry the knots at the 12 o clock position, for unburried knots may cause continuing discomfort for the patient.

Theoretically, a double running 8-bite 10-0 nylon anti-torc suture may induce little astigmatism, because the forces exerted by each bite are counteracted by an opposing bite. If suture loosening occurs after surgery, the graft is usually fixated well by the remaining suture, and in our series secondary suture placement has not been neccessary. Finally, in contrast to a 24-bite running 11-0 suture, removal of a 8-bite running 10-0 suture is easily performed behind the slit-lamp.