adjustable suture strabismus surgery - overview part 1 - christolyn raj adjustable suture...
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Adjustable sutureAdjustable suturestrabismus surgerystrabismus surgery
- Overview Part 1 -- Overview Part 1 -
Christolyn Raj
Adjustable suture strabisumus surgery
Adjustable sutures Indications Patient selectionAnaesthetic considerations Techniques Complications
Adjustable suture strabisumus surgery
Overview Part 1Overview Part 1
Adjustable sutures in strabsmus surgery
• Principle : to secure EOM to sclera with a sliding knot , then when pt is awake , the length of suture b/w attachment site and muscle may be shortened or lengthened
First described by Claude Worth , first practised by Jampolsky 1975 No prospective RCTs to date on selective advantage of adjustable sutures Few reports on use of adjustable sutures on children
Adjustable sutures in strabismus surgery . Hunter, D. Dingeman RS et al. J Paed Opthal 2009. Number of surgeons decribe adjustable sutures in adults to improve immediate post-op
alignment [refs 3, 17, 22, 26, 30-32] Summary by Hunter, Dinegeman et al., promote use of adjustable sutures on ALL adults ,
including those with comitant strabismus & no prior surgery Authors also describe use in children who met select criteria
Adjustable suture strabisumus surgery
Standard indications for adjustable suture strabismus surgery
• Restrictive strabismus eg: TED• Previous trauma or surgery• Slipped, lost, disinserted muscles• Incomitant deviations eg : Duane’s syndrome ,
MG • Any longstanding, complex strabismus
Adjustable suture strabisumus surgery
Patient selection
Adjustable suture strabisumus surgery
Adjustable sutures can be used with recessed or resected muscles and also been successfully described on superior oblique tendon .
Goldenberg-Cohen N, et al. 2005. Strabismus 13;5-10. • Most surgeons advocate adjustable suture technique in children aged 12 yrs & older • and only younger if co-operative & may require two stages of anesthesia • Active participation of parents is a key factor (Dawson et al. 2001)
Can perfom “Q-tip” test to identify suitable pts – consists of touching a cotton tip to the MR or LR aspect of the unanesthetized bulbar conjunctiva as a pre- test tolerability
If patient fails Q-tip test : consider non-adjustable suture surgery or arrange for back-up sedation
Anaesthetic considerations
1). Recovery of extraocular muscle function-GA: EOM function recovers when pt awakes-LA: short acting agents require 5hrs minimum for motility to recover 2). Patient comfort & alertness in recovery-pre-medication: for post-op nausea-induction with propofol preferable , shorter acting muscle relaxants
preferable -avoid opiate analgesia which may cause sedation & nausea-topical tetracaine is often sufficient -ketorolac early intraop is another option /7 is m.effective
Adjustable suture strabisumus surgery
Anaesthetic considerations
3). Post-op nausea & vomiting-ondansetron is very effective & has few SE’s -use with dexamethasone may augment effects of
ondansetron 4). Sedation protocol for suture adjustment -mainly for unco-operative pts-inform anaethetist-should be monitored in recovery room setting to ensure
airway & basic monitoring equipment is readily available-may need propofol induction dose
Adjustable suture strabisumus surgery
Surgical techniques
Limbal vs fornix approacho Limbal appoach provides broad exposure but requires conjunctival closure post suture
adjustment o Fornix approach may be more comfortable as sutures are covered
TechniqueBow tie
o Sutures ae tied together in a single-loop bow-tie like a shoelace o At adjustment the bow is untied , muscle adjusted & re-tied, bow cut & converted to a
square knot
Adjustable suture strabisumus surgery
Sliding-noose o sutures are passed through scleral tunnels emerging <1mm apart , a noose is created by tying a separate piece of suture around the scleral sutures
Surgical techniquesSemi-adjustable sutures
o Described by (Kushner et al.) to reduce muscle slippage whilst preserving potential for adjustment o Involves suturing corners of muscle to sclera & placing centre of muscle on adjustable
Authors’ preferred technique o Describes “noose” suture o For adjustable recession standard hangback doses usedo For adjustable resection an extra 1-3mm muscle is resected , then muscle allowed to hang back by
same amt o After the sutures are passed , they are pulled to original insertion then these sutures are secured to
each other with an overhand knot- these joined sutures are ‘ple sutures’o For the adjustable noose , an absorbable suture is used , placed underneath the pole sutures &
wrapped around a second time, finally tying a square knot to prevent slippage o At adjustment the bow is untied , muscle adjusted & re-tied, bow cut & converted to a square knot
Adjustable suture strabisumus surgery
Complications
*Intra-adjustment complications : Nausea& vomiting oculucardiac reflex possible bradycardia Syncope
*Postoperative healing process may be very inflammatory : conjunctival suture granulomas etc Adhesions
Adjustable suture strabisumus surgery
Conclusion
• Adjustable sutures provide a second chance to improve outcomes of initial strabismus surgery
• However…. They can add to complexity of case Require appropriate patient selection Evidence to validate their advantage over convential surgery is still not
universally acknowledged Difficult learning curve involved
Adjustable suture strabisumus surgery