Adjustable suture strabismus surgery - Overview Part 2 -

1. Adjustable suturestrabismus surgery- Overview Part 2 - Fumitaka Nonaka Adjustable suture strabisumus surgery

2. Overview Part 2 • Adjustable sutures in children • Special circumstances • Postoperative drift • Complications • Future directions • Conclusion Adjustable suture strabisumus surgery

3. Adjustable sutures in children • very few reports: nonrandomized, retrospective studies • difficulty obtaining cooperation of children • often requires a second stage of anesthesia • Adjustable suture strabismus surgery in infants and children. Awadein A, Guyton DL, et al. J AAPOS 2008; 12: 585–590. • used topical proparacaine for the adjustment if children were able to cooperate • intravenous propofol, 3±1 mg/kg for those who could not • The mean age in the adjustable group: 4.7±2.5 years (range, 6 months–10 years) • The results were similar to those obtained by other authors in adults • better than the results obtained in their own non-adjustablepediatric control group. Adjustable suture strabisumus surgery

4. Special circumstances • Adjustable superior oblique (SO) surgery • Adjustable inferior oblique (IO) surgery • Adjustable posterior fixation sutures (Faden) • Semiadjustable sutures • Lid retraction and inferior rectus(IR) recession Adjustable suture strabisumus surgery

5. Special circumstancesAdjustable superior oblique surgery • Surgical technique of adjustable SO suture spacer • Using non-absorbable suture • (b) Seperating the cut ends of the SO tendon • (c) Refined intraoperatively after traction test and fundus check • (d) Final position • # long-term results of AHP and vertical deviation improved • in patients with Brown syndrome • An adjustable superior oblique tendon spacer with the use of non-absorbable suture. Suh DW, Guyton DL, Hunter DG. J AAPOS 2001; 5: 164–171. • Adjustable Harada-Ito procedure • 6–0 Vicryl was sewn through the anterior fibers of SO tendon. • The anterior half of the tendon was reattached to the eye 4 mm anterior and 6 mm temporal to the original insertion. A sliding noose was then secured anterior to the SO suture attachment. • # no subjective cyclotorsion or iatrogenic Brow n in 20 mths post-op • The adjustable Harada-Ito procedure. Metz HS, Lerner H. Arch Ophthalmol 1981; 99: 624–626. Adjustable suture strabisumus surgery

6. Special circumstancesAdjustable inferior oblique surgery • Hang-back recession of inferior oblique muscle in V-pattern strabismus with inferior oblique overaction. Kumar K, Bhola R, et al. J AAPOS 2008; 12: 401–404. • a double-armed 6–0 Vicryl • passed through the inferior oblique muscle 5mm from the insertion, secured with locking bites on both ends • passed through the muscle a second time just 3mm from the insertion without tying the proximal end. • This forms a loop between the proximal and distal muscle, and the muscle is cut between the sutures. • The amount of recession (8mm for mild cases and 12mm for severe cases) is determined using the length of suture between cut ends, and the proximal ends of the suture are tied. • Although this technique provides a theoretical opportunity for suture adjustment, no adjustment was performed in any patient. Adjustable suture strabisumus surgery

7. Special circumstancesAdjustable posterior fixation sutures • Posterior fixation suture (Faden operation) is used in patients with incomitant strabismus to limit movement of the less severely affected eye without affecting primary position alignment. • Holmes et al described a method of placing a longitudinal split in the lateral rectus muscle at the point of attachment of the two posterior fixation sutures, thus allowing for adjustable recession of the lateral rectus muscle. • # all three pts improved incomitant exo. • Lateral rectus posterior fixation suture. Holmes JM, at al. J AAPOS 2010; 14: 132–136. Adjustable suture strabisumus surgery

8. Special circumstancesSemiadjustable sutures • IR is uniquely prone to overcorrection after recession. • may be related to the gravitational pull of the muscle away from the eye during healing. • Kushner described a ‘semiadjustable’ technique in an effort to secure the IR muscle more firmly to the globe. • Semiadjustable sutures showing that the corners of IR are sutured firmly to the sclera and the center of the muscle is placed on an adjustable suture. • It limits the capability to increase the amount of recession at the time of adjustment. An evaluation of the semiadjustable suture strabismus surgical procedure. Kushner BJ. J AAPOS 2004; 8: 481–487 Adjustable suture strabisumus surgery

9. Special circumstancesLid retraction and inferior rectus recession • Retraction of the lower eyelid occurs frequently after large IR recession. • Pachecho et al described a technique that involved an adjustable suspension of the lower eyelid retractors from the inferior rectus insertion. • Surgeon’s view of IR muscle • Appearance of capsulopalpebral head (CPH) (*) • (c) Double-armed 6–0 polyglactin 910 sutures on IR and on the cut end of the CPH • (d) Adjustable sutures for IR and lower eyelid retractors • Changes in eyelid position accompanying vertical rectus surgery and prevention of of lower lid retraction with adjustable surgery. Pacheco EM, Guyton DL, Repka MX. J Pediatr Ophthalmal Surg 1992; 29: 265–272. 2.5 mths F/U lid retraction - in all six patients lid retraction + in 9 controls Adjustable suture strabisumus surgery

10. Postoperative drift • Both ET and XT groups had equal tendency to drift toward either under- or overcorrection over 6–8 months. Postoperative drifts after adjustable suture strabismus surgery. Eino D, Kraft SP. Can J Ophthalmol 1997; 32: 163–169. • Most XT patients developed a general drift toward undercorrection. Drift of ocular alignment following strabismus surgery. Part 2: using adjustable sutures. Isenberg SJ, Abdarbashi P. Br J Ophthalmol 2009; 93: 443–447. • Postoperative drift was toward undercorrection in patients with ET, XT and vertical deviation. Short tag noose technique for optional and late suture adjustment in strabismus surgery. Nihalani BR, Hunter DG, et al. Arch Ophthalmol 2009; 127: 1584–1590. Adjustable suture strabisumus surgery

11. Complications Ocular complications • increased postoperative inflammation • exposed sutures • suture granuloma or cyst (1.7%, Hunter et al) • slipped knot (0.3%, Budning et al) or slipped sliding noose (0.8%, Hunter et al) Intra-adjustment complications • nausea, vomiting, ocular pain • oculocardiac reflex, bradycardia, syncope, light headedness, diaphoresis, a sense of temperature change more likely to occur during late suture adjustments minimized by subconj. lidocaine, keeping the patient informed about what to expect at every step of the procedure Adjustable suture strabisumus surgery

12. Future directions • Postoperative healing process causes adhesions and inhibits delayed adjustment • Efforts have been made to facilitate delayed adjustment by … • silicone • viscoelastic material • absorbable adhesion barrier • polyglactin 910 mesh, polytetrafluoroethylene • bioresorbable film • antiproliferative agents such as mitomycin-C • Adcon-L • Polylactide-co-glycoside copolymer • Dexamethasone, Transilast (antiallergic drug), Paclitaxel (chemotherapeutic agent), all-transretinoic acid • Further studies are required to evaluate the effect and safety of various agents Adjustable suture strabisumus surgery

13. Conclusion • Adjustable sutures have not been universally accepted, partly because of: • Insufficient evidence that the considerable extra investment of time and effort is worth the benefit • not all programs teach trainees the nuances of the approach • Most published studies suggest that there is a benefit of suture adjustment. • probably about a 10% improvement in success rates • The use of adjustable suture strabismus surgery makes intellectual sense even in the absence of high-level evidence. Adjustable suture strabisumus surgery

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