adjustable sutures in strabismus surgery. why use adjustable sutures? allows binocular alignment...
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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. Alignment2. Reoperation3. Complications
Method
Retrospective studySimple and complex strabismus surgeryAll patients treated by a single surgeon from
2005-2008 were evaluated
Method II
Fornix incisionRecession: standard hang-backResection: 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 nooseNoose 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. ≤ 10 horizontal2. ≤ 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 VerticalAlignment 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=1Granuloma n=2Recurrence of diplopa n=1
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