Suturing technique remains one of the most vital skills in the art of contemporary corneal surgery. Although the main purpose of suture placement remains adequate wound apposition and closure, meticulous attention to appropriate suture placement cannot only minimize postoperative astigmatism, but also may facilitate more rapid visual recovery and lead to a more stable wound long term. A variety of factors remain critical for suture placement, including avoidance of mismatch between radial and nonradial suture bite placement, appropriate donor and recipient bite lengths, appropriate bite depth, and symmetrical and adequately dispersed suture tension in each quadrant of the cornea, with special care to prevent excessive tightening. Th e evolution of corneal suturing techniques from overlay sutures to direct appositional suture closure, along with the discovery of small, monofilament suture material has revolutionized suturing techniques and postoperative success. This chapter focuses on the suturing techniques in penetrating keratoplasty, including indications, instrumentation, various surgical techniques, complications, and future considerations. Corneal suturing in settings other than keratoplasty is discussed elsewhere in this book.
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