Transcript Technique - The Private Eye Clinic

Adjustable Sutures in
Strabismus Surgery
Why use adjustable sutures?
 Allows binocular alignment to be refined after
strabismus surgery
 Useful in patients in whom standard surgical dosages
may not apply i.e. complicated strabismus surgery
such as re-operations, orbital fracture, Graves
orbitopathy
Adjustable suture technique
• Advantages
– Reduce rate of re-operations
• Disadvantages
– Muscle slippage (7-41% when adjustable suture surgery
performed on IR)
•
–
Function of:
– Magnitude of recession performed
– Nature of strabismus (↑ with fibrotic muscles)
– Specific muscle (IR and MR)
Generally tied within 24 hours of initial procedure
Semi-adjustable suture procedure
• Co-developed by Spielmann & Campo
• 1st described in 1993
• Aim: decrease the incidence of postoperative muscle
slippage yet retain advantages of adjustable suture
surgery
• Involves suturing the corners of the muscle firmly to the
sclera at the desired recession point but also placing an
adjustable suture through the centre of the muscle
Kushner
 This study evaluates the procedure wrt muscle
slippage
 In 2000 it became his standard technique for:
 Recessing the IR in those patients who he wished to do an
adjustable suture
 If recessing MR > 12 mm from limbus
Method I
2 groups:
1. Primary treatment group= never undergone surgery
OR had but had not previously slipped muscle
–
–
57 patients on 61 muscles
55 IR and 6 MR
2. Secondary treatment group= semiadjustable suture
suture on muscles but had slipped muscle
–
7 patients
Primary outcome: occurrence of muscle slippage
within 6-months after surgery
Method II
• After the muscle was disinserted, the 2 corner
sutures were sewn through the sclera at desired
recession distance ~ 5mm apart with needle tracks
directed toward each other
–
–
Bunches muscle at new insertion
Permits centre of muscle to sag 1-2mm
• Double-armed suture securing centre of muscle was
brought out through insertion and secured with 6.0
polyglactin cinch & tightened to level of 2 corners
• Reference knot ~ 30-50 mm anterior to cinch
Method III
 Postoperative alignment performed on the morning
after surgery
 After adjustment, the distance between the cinch and
the knot is measured again, the difference
representing the amount of muscle adjustment
Criteria for muscle slippage
“Suspect” if:
1. Angle of misalignment changed by > 4 Δ in the
direction away from the field of action of the
muscle between the measurement taken
immediately after post operative suture adjustment
to 6 month outcome
2. Versions demonstrated > 1 unit of change in the
direction of ↑ underaction (5 point scale 0 to -4)
from the 1-week r/v to 6 month outcome
Surgically explored (n=4)
If not surgically explored, counted as slipped muscle
Results
 Primary treatment group
 n=0 had muscle slippage
 Secondary treatment group
 n=1 had muscle slippage
51 year old male
 Left orbital floor # with IR entrapment
 3 prior adjustable suture procedures on IR
 Found 13.5 mm from insertion
 Advanced using non-adjustable technique

Limitations of Semiadjustable suture
 Limited efficacy for ↑ recession, target an initial
overcorrection
Short Tag Noose Technique for Optional & Late
Suture Adjustment
 Aim: to evaluate a new technique which allows the
second-stage suture adjustment to be skipped or
delayed if the immediate postoperative alignment is
satisfactory
 Evaluate for:
1.
2.
3.
Alignment
Reoperation
Complications
Method
 Retrospective study
 Simple and complex strabismus surgery
 All patients treated by a single surgeon from 2005-
2008 were evaluated
Method II
 Fornix incision
 Recession: standard hang-back
 Resection: extra 1-3mm of muscle resected and
allowed to hang back by same amount to allow for an
↑ or ↓ at adjustment
 Standard adjustable-suture sliding noose
 Noose sutures were trimmed to 3mm (short tag
noose) and buried under conjunctiva
Method III
 Patient assessed in recovery room 1-2 hours ±
adjusted after procedure and > 24 hours
• Alignment success:
1.
2.
≤ 10 horizontal
≤ 6 Δ vertical
Alignment Results at 2 months
• 120 procedures
– Children n=27 (22.5%)
– Adults n=97 (80.8%)
 Post operative adjustment n=65
 Same day n=56 (46.7%)
 Performed or repeated after ≥ 2 days n=18 (15.0%)
Horizontal
Vertical
Alignment Success
81.0%
70.7%
Re-operation rate
10.0%
19.0%
Reoperation Results
 No statistical difference in:
 Success or re-operation rate for simple or complex strabismus
 Success rates in time patients adjusted
 Success or re-operation rate with children & adults
Complications
 Slipped muscle n=1
 Granuloma n=2
 Recurrence of diplopa n=1