Adjustable Suture Strabismus Surgery Research Articles

Early and delayed suture adjustments after adjustable suture strabismus surgery: a randomized controlled trial.

Adjustable sutures increase the success rate of strabismus surgery. However, the optimal timing of postoperative suture adjustment remains controversial. This trial was aimed at comparing the surgical outcomes and pain scores of early or 2 - 4 h and delayed or 24 h postoperative suture adjustment in adult patients undergoing strabismus surgery. An open-label, prospective, randomized, comparative interventional study was performed in consecutive adult patients scheduled for eye muscle surgery. Patients were randomized into two groups: the early group, with suture adjustment 2 - 4 h postoperatively, and the delayed group, with suture adjustment 24 h postoperatively. Subjective pain scores during the adjustment were also analyzed. The angles of misalignment at 1 and 3 months and the success rate at 3 months postoperatively were compared. Forty-five (90%) patients completed the follow-up, including 23 (92%) in the early adjustment group and 22 (88%) in the delayed adjustment group, with a mean (standard deviation) age of 25.6 (9.5) years and a male-to-female ratio of 46.7:53.3. Thirty patients (66.7%) had exotropia, and 15 (33.3%) patients had esotropia. Both groups had comparable baseline characteristics (all P > 0.05). The mean pain scores during adjustment did not differ significantly between groups (P > 0.05). The postoperative angles of alignment were comparable between the groups before suture adjustment and at the 1- and 3-month follow-ups (all P > 0.05). The success rate in the early adjustment group was slightly higher (87.0% versus 63.6%), but the difference was not statistically significant (P > 0.05). The success rate was comparable between the groups in patients with esotropia or exotropia (both P > 0.05). Although the early adjustment group had a slightly higher success rate, the difference was not significant. Both groups had comparable subjective pain scores during adjustment, final motor alignment, or success rate. Future clinical trials should be performed different time intervals for postoperative suture adjustment, and subjective and objective outcomes, such as diplopia and stereopsis, should be compared between patients with a first strabismus surgery and those who underwent reoperation. This could better resolve the persistent controversy related to the optimal time for suture adjustment.

Long-term outcomes of adjustable strabismus surgery at a Pakistani university hospital.

Strabismus, whether congenital or acquired, is a common visual and cosmetic problem, especially for the young. Adjustable suture strabismus surgery is not in vogue in our country. This technique gives the surgeon a second attempt to provide a better outcome for the patients. Our objective was to assess the long-term success of adjustable strabismus surgery in terms of postoperative alignment. We carried out a prospective study utilizing the fornix approach for adjustable strabismus surgery, in mainly horizontal, but also vertical strabismus in adults and cooperative children, to enhance the postoperative outcomes. The patient characteristics, preoperative deviation, type and pattern of strabismus, were evaluated and analyzed. The postoperative alignment was evaluated at 1year and beyond, to assess the success of this adjustable surgery. This study recruited 50 adults and children with a female predominance of 39 (78%); and with the mean age being 18.34 ± 9.88years. Exotropia was the primary diagnosis in the majority with 21(42%) cases; with purely horizontal strabismus in 23(46%) cases. The mean preoperative horizontal deviation was 48.76 ± 20.35prism diopters (PD) and the mean postoperative horizontal deviation was 2.73 ± 3.63 PD. The mean preoperative vertical deviation was 4.8 ± 8.54 PD whereas the mean postoperative vertical deviation was 0.86 ± 1.73 PD. The Wilcoxon Signed Ranks test analyzed the difference between the two which was statistically significant (p = 0.000). Surgical success, defined as postoperative horizontal alignment within ≤ 10 PD of orthotropia at the end of one year or more of follow-up after surgery, was achieved in 49 (98%) cases. The average follow-up was 21.47 ± 8.7months. Adjustable strabismus surgery has very good long-term outcomes in terms of postoperative alignment and patient satisfaction.

Anaesthetic considerations for strabismus surgery in children and adults.

Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4% lifetime risk of developing strabismus. Current treatment options include pharmacological injection of botulinum toxin or bupivacaine, conventional corrective surgery, adjustable suture surgery and minimally invasive surgery. Repeated surgery is common as each operation has a 60%-80% chance of successful correction. The benefits of early surgical correction in large-angle strabismus in children outweigh the risks of anaesthesia. General anaesthesia is suitable for patients of all age groups, for complicated or repeated surgery, and bilateral eye procedures. Regional ophthalmic block reduces the incidence of oculocardiac reflex and emergence agitation, and provides postoperative analgesia, but requires a cooperative patient as many experience discomfort. Topical anaesthesia has been used in pharmacological injection, minimally invasive surgery, uncomplicated conventional strabismus surgery and some adjustable suture strabismus surgery. Its use, however, is only limited to cooperative adult patients. Prophylactic antiemesis with both ondansetron and dexamethasone is recommended, especially for children. A multimodal analgesia approach, including paracetamol, intravenous non-steroidal anti-inflammatory drugs, topical local anaesthetic and minimal opioid usage, is recommended for postoperative analgesia, while a supplementary regional ophthalmic block is at the discretion of the team.

Pain Score in Adjustable Strabismus Surgery

Purpose: To assess the pain experienced by patients at the time of suture adjustment using topical proparacaine hydrochloride 0.5% anesthesia, in adjustable suture strabismus surgery.
 Study Design: Prospective, interventional study.
 Place and Duration of Study: Eye department of Fauji Foundation Hospital, Rawalpindi from May, 2017 to March, 2019.
 Material and Methods: A prospective study was carried out to assess the pain experience of patients undergoing suture adjustment under topical proparacaine hydrochloride 0.5% anesthesia, during routine adjustable squint surgery. All surgeries were performed under general anesthesia with suture adjustment done 1 hour or more after surgery when the effects of general anesthesia had worn off. Horizontal and vertical muscle recessions and resections were included along with inferior oblique surgeries, and transposition procedures. The patients were given the ‘Wong-Baker FACES® Pain rating Scale’; along with a ‘Numeric Pain Rating Scale’ from 0 to 10 (0 signifying ‘no pain’ and 10 signifying ‘worst possible pain’) on a proforma. The response of the patients was noted.
 Results: Thirty three patients who underwent adjustable strabismus surgery were included in this study. The mean age was 19.1 ± 11.1 years. The average number of muscles operated upon for each patient were 2.87 ± 1.08. The patients’ response to the ‘Wong-Baker FACES® Pain rating Scale’ ranged from 0 to 8, with a mean of 2.03 ± 1.81 SD. On the ‘Numeric Pain Rating Scale’ a similar response was obtained with a mean of 2.0 ± 1.82 SD. Augmentation of anesthesia was not needed in any patient.
 Conclusion: Adjustment of sutures under topical proparacaine hydrochloride 0.5% anesthesia after strabismus surgery is a practical, comfortable and safe procedure.

The Value of Fusional Convergence Amplitudes in Esodeviation Surgery Without Adjustable Sutures.

To explore the application of preoperative fusional convergence amplitudes in the selection of a target angle for non-adjustable suture strabismus surgery with deteriorated intermittent esotropia and diplopia. Thirty-one consecutive cases of presumed acquired non-accommodative, deteriorated intermittent esotropia managed surgically between 2005 and 2016 were reviewed retrospectively. For each individual, a target angle (deviation angle for which surgery was based) was selected preoperatively after analysis of fusional convergence amplitudes. Outcomes in patients selected for overcorrection at 6 meters (target angle > angle in primary position at 6 meters) were compared to those who had planned surgery based on a target angle that did not exceed their measured angle (target angle ≤ angle in primary position) at 6 meters. All 31 patients achieved binocular single vision in primary position at both near and 6 meters without prisms, orthoptic therapy, or additional surgery at 4 to 6 months postoperatively. Greater mean correction in the target angle > angle in primary position group compared to the target angle ≤ angle in primary position group was observed, but this difference was not statistically significant (P = .57). Among this diagnostically specific cohort with intermittent esotropia with symptomatic diplopia and measurable binocular single vision preoperatively, targeted surgery based on an analysis of preexisting fusional convergence amplitudes had an outcome that compared favorably to that of documented adjustable suture strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2018;55(6):375-381.].

Comparison of immediate and long-term outcomes in basic exotropia treated with and without adjustable suture strabismus surgery

Comparison of immediate and long-term outcomes in basic exotropia treated with and without adjustable suture strabismus surgery

Clinical outcomes of adjustable strabismus surgery for sensory exotropia

The purpose of this retrospective study is to look into the immediate and long-term postoperative anatomic and functional outcomes following adjustable suture strabismus surgery in sensory exotropia.

Adjustable suture strabismus surgery in infants and children: a 19-year experience

To evaluate the success rate of adjustable suture techniques in horizontal eye muscle surgery in children ≤15years of age over a 19-year period by a single surgeon. The medical records of all consecutive patients in this age group who underwent horizontal eye muscle surgery from 1989 through 2012 were reviewed retrospectively. Patients were divided into two groups: those in whom a nonadjustable suture technique was used and those in whom adjustable sutures were used. The following data were collected: type of strabismus, preoperative measurements, postoperative results, and reoperation rates. A total of 116 cases in the nonadjustable group and 521 cases in the adjustable group were included. In the adjustable group, adjustment was performed in 63% of the cases, because of either an under- (41%) or overcorrection (22%). The adjustment procedure was performed under topical proparacaine in 15% of cases and under intravenous propofol in 85%. For the adjustable group, 3-5minutes more per muscle intraoperatively and 15-20minutes for adjustment were required. No complications were encountered during the adjustment procedures. Early success rate, defined as alignment within 8Δ of straight at 3 to 6months' postoperative follow-up, was significantly greater in theadjustable group than in the nonadjustable group (77.7% vs 64.6% [P≤0.03]). Of the adjustable patients, 15% required reoperation compared with 21% of the nonadjustable patients. Use of adjustable sutures in horizontal eye muscle surgery in children ≤15years of age provided an improved success rate and fewer reoperations compared with nonadjustable sutures.

Sedated suture adjustment in children undergoing adjustable suture strabismus surgery

To study methods and adverse events of postoperative, sedated suture adjustment after strabismus surgery in the post-anesthesia care unit (PACU). We reviewed the postoperative experience of all children ≤18years of age undergoing adjustable suture strabismus surgery at Boston Children's Hospital over a 3-year period. Time in the hospital, adverse events, and surgical outcomes were reviewed to evaluate safety and healthcare resource utilization. Of 356 patients, 113 required suture adjustment in the PACU, including 24 adjusted while awake and 89 adjusted under sedation. For sedation, sequential boluses of propofol were administered until adjustment was complete. Complete data from the sedated adjustment was available in 76 patients. The median initial bolus was 30mg; the median total propofol rate was 273 mcg/kg/min. Twelve patients (16%) required only a single bolus of propofol. Of remaining 64 patients, median time from initial to final propofol dose was 7minutes. Median anesthesiologist time in the PACU was 13minutes. In the sedated adjustment group, there were no clinically significant adverse events, and the pain score never exceeded 6 (of a possible 10). Median duration of PACU stay was shortest in the group not requiring adjustment. Sedated suture adjustment allows for fine-tuning of postoperative binocular alignment in children and uncooperative adults. No adverse events were observed in our study group, but the procedure does increase the time patients spend in the hospital. This work will inform disclosure of risks and benefits of sedated adjustment while allowing for more accurate assessment of the cost and quality of adjustable sutures in children.

Adjustable suture strabismus surgery in pediatric patients using pull-string technique.

BACKGROUND/PURPOSE:The concept of adjustable suture has been developed in strabismus surgeries for nearly four decades. This technique is not yet universally embraced by strabismus surgeons, especially in pediatric patients. The aim of this study is to describe and evaluate the application of the adjustable suture with pull-string technique in pediatric patients.METHODS:A retrospective medical record review was conducted for patients aged 18 years and under who received adjustable suture strabismus surgery using short tag sliding noose with pull-string technique. For the analysis, the patients were arbitrarily divided into three age groups: 6 years and younger, between 6 and 12 years, and 12 years and older. Patients were examined at 1 week and 1, 3, and 6 months after surgery.RESULTS:A total of 123 patients were enrolled in this study. The mean age at the time of surgery was 9.4 years, ranging from 0.7 to 18.4 years. Eighteen (14.6%) patients required adjustment and 105 (85.4%) patients did not require adjustment. The average follow-up was 10.2 months (range, 1–48 months). At their final postoperative follow-up, 93 of 123 (75.6%) patients were within 10 prism diopters of orthophoria. The success rates were 77.6% (66/85) in exotropia patients and 71.1% (27/38) in esotropia patients. The success rates were 76.4% (84/110) for those who receive the procedure as primary surgery and 69.2% (9/13) for those who receive the procedure as reoperative surgery. Of the 18 patients who required adjustment, 16 (88.9%) patients were successful. Of the 105 patients who did not require adjustment, 77 (73.3%) patients were successful.CONCLUSION:This study showed that the pull-string technique provided similar success rate compared to those reported in literature in pediatric patients. The pull-string technique is developed to simplify the postoperative adjustments. Many surgeons encounter difficulties to handle the postoperative adjustments, especially when they need to retrieve the buried subconjunctival adjustable sutures. The obstacles are reduced with the aid of pull string. Using the pull-string technique, the surgeon can perform adjustable suture surgeries in any age group with confidence.

Evaluation of Postoperative Povidone-Iodine in Adjustable Suture Strabismus Surgery to Reduce Suture Colonization: A Randomized Clinical Trial.

Although the association between suture colonization and postoperative infections remains hypothetical, measures to reduce perioperative suture colonization may minimize postoperative infections. The suture colonization rate in adjustable suture strabismus surgery is not well defined, and the effect of povidone-iodine use on suture colonization is unknown. To assess whether povidone-iodine application at the end of adjustable suture strabismus surgery decreases the suture colonization rate. In this randomized clinical trial designed in 2015 and performed from June 1 through October 31, 2015, a total of 65 adjustable and 43 control suture specimens from 65 demographically similar adults undergoing adjustable suture strabismus surgery were studied. A random sampling assigned participants into group 1 (with povidone-iodine) or group 2 (without povidone-iodine) at the end of surgery. A control suture specimen was obtained if ipsilateral nonadjustable surgery was performed. Both groups received antibiotic ointment at the end of the procedure. No patients refused participation or withdrew. Data analysis was performed from October 1 to December 31, 2015. Observers were unaware of patient grouping. One drop of 5% povidone-iodine directly over the sliding noose of the adjustable suture at the end of surgery. The suture colonization rate after adjustment in group 1, group 2, and the control group. Of 65 adults undergoing surgery, there were 17 men (49%) and 18 women (51%) in group 1 and 10 men (33%) and 20 women (67%) in group 2, as well as 20 men (47%) and 23 women (53%) in the control group. The mean (SD) age of the patients was 48.5 (16.8) years in group 1, 46.6 (18.1) years in group 2, and 47.7 (17.0) years in the control group. There was no difference in the colonization rate between group 1 (57%) and group 2 (47%) (relative risk [RR], 1.1; 95% CI, 0.6-1.7; P = .80), group 1 and the control group (44%) (RR, 1.0; 95% CI, 0.5-1.8; P > .99), or group 2 and the control group (RR, 1.3; 95% CI, 0.8-2.1; P = .62). Eleven bacterial species were identified. Staphylococcus epidermidis was the predominant isolate (40 of 56 [71%]). A longer interval between the end of surgery and adjustment was associated with higher culture positivity (6.3 hours in positive vs 4.4 hours in negative cultures, P = .001); however, there was no difference in bacterial growth between the groups. No adverse effects of povidone-iodine were observed. This study was not able to demonstrate that povidone-iodine at the end of adjustable suture strabismus surgery reduces the suture colonization rate. clinicaltrials.gov Identifier: NCT02424357.

Evaluation of the Risk of Postoperative Infection in Adjustable Suture Strabismus Surgery.

Evaluation of the Risk of Postoperative Infection in Adjustable Suture Strabismus Surgery.

Sedated suture adjustments in children undergoing adjustable-suture strabismus surgery

While adjustable sutures may be used in children of any age, widespread adoption of this approach may have been limited in part by a lack of published studies on the methods and potential complications of sedated adjustment in the post-anesthesia care unit (PACU).

Slipping the knot: a comparison of knots used in adjustable suture strabismus surgery

To evaluate the frictional force created by different knots used in adjustable suture strabismus surgery. To allow the simulation of strabismus surgery suture tying methods a model using 6-0 polyglactin 910 suture was created. Three different knots were evaluated: (1) the sliding noose knot with a double wrap of suture, (2) the cinch knot with a single throw on both sides of the pole suture, (2) and a single-throw square knot. (Bow-tie knots were not included.) A digital force meter was used to measure the force (gram-force [gf]) required to overcome the static friction created by the knot. Each simulation was repeated with new suture material 5 times and the force required after subsequent repositioning was also recorded. The force to overcome static friction of the sliding noose knot was 240 gf [95% CI, 187-284 gf]; of the cinch knot, 150 gf [95% CI, 123-167 gf]; and of the square knot, 110 gf [95% CI, 95-121 gf]. Subsequent movement of each knot along the same suture required progressively less force, with the sliding noose maintaining the most static friction. The sliding noose knot generates the most frictional force and also maintains the most friction after subsequent repositioning. Important consideration should be given to multiple repositioning movements, because the force required for each subsequent repositioning decreases.

Ophthalmic Anesthesia Society 2014 Annual Scientific Meeting Summary

Ophthalmic Anesthesia Society 2014 Annual Scientific Meeting Summary

Slipping the knot: a comparison of knots used in adjustable suture strabismus surgery

Adjustable suture strabismus surgery has been performed for many years and multiple suture tying techniques have been developed. These tying techniques are meant to hold the muscle in place well yet also slide to allow adjustment. The friction related to this process has not been well characterized.

Strabismus Surgery Reoperation Rates With Adjustable and Conventional Sutures

To determine the association of strabismus surgery reoperation rates with adjustable or conventional sutures. Retrospective cross-sectional study. setting: Review of a large national private insurance database. Adults aged 18-89 having strabismus surgery between 2007 and 2011. Adjustable vs conventional suture strabismus surgery. Reoperation rate in the first postoperative year. Overall, 526 of 6178 surgical patients had a reoperation (8.5%). Reoperations were performed after 8.1% of adjustable suture surgeries and after 8.6% of conventional suture surgeries (P = .57). Of the 4357 horizontal muscle surgeries, reoperations were performed after 5.8% of adjustable suture surgeries, and after 7.8% of conventional suture surgeries (P = .02). Of the 1072 vertical muscle surgeries, reoperations were performed after 15.2% of adjustable suture surgeries and after 10.4% of conventional suture surgeries (P = .05). Younger age (18-39 years) was associated with a lower reoperation rate (P ≤ .02). The significant multivariable predictors of reoperation for horizontal surgery were adjustable sutures (odds ratio [OR] 0.69, 95% confidence interval 0.52-0.91), monocular deviation (OR 0.64), complex surgery (OR 1.63), and unilateral surgery on 2 horizontal muscles (OR 0.70, all P ≤ .01). Adjustable sutures were not significantly associated with reoperation rates after vertical muscle surgery (multivariable OR 1.45, P = .07). Adjustable sutures were associated with significantly fewer reoperations for horizontal muscle surgery. Adjustable sutures tended to be associated with more reoperations for vertical muscle surgery, but this observation was not statistically significant in the primary analysis after controlling for age.

The quest for effective pain control during suture adjustment after strabismus surgery: a study evaluating supplementation of 2% lidocaine with 0.4% ropivacaine.

PurposeTo determine whether the addition of 0.4% ropivacaine to the standard 2% lidocaine peribulbar anesthetic block improves pain scores during suture adjustment in patients undergoing strabismus surgery with adjustable sutures.MethodsProspective, double-blind study of 30 adult patients aged 21–84 years scheduled for elective strabismus surgery with adjustable sutures. Patients were divided into two groups of 15 patients each based on the local anesthetic. Group A received 2% lidocaine and Group B received 2% lidocaine/0.4% ropivacaine. Pain was assessed using the visual analog scale (VAS) preoperatively and at 2, 4, and 6 hours postoperatively. The Lancaster red-green test was used to measure ocular motility at the same time points.ResultsThe pain scores in the two groups were low and similar at all measurement intervals. The VAS for Group A versus Group B at 2 hours (1.7 versus 2.4, P=0.5) and 4 hours (3.5 versus 3.7, P=0.8) showed no benefit from the addition of ropivacaine. At 6 hours, the VAS (3.7 versus 2.7) was not statistically significant, but the 95% confidence interval indicated that ropivacaine may provide some benefit. A repeated measures ANOVA did not find a statistically significant difference in VAS scores over time (P=0.9). In addition, the duration of akinesia was comparable in both groups (P=0.7).ConclusionWe conclude that the 50:50 mixture of 2% lidocaine with 0.4% ropivacaine as compared to 2% lidocaine in peribulbar anesthetic blocks in adjustable-suture strabismus surgery does not produce significant improvements in pain control during the postoperative and adjustment phases. In addition, ropivacaine did not impair return of full ocular motility at 6 hours, which is advantageous in adjustable-suture strabismus surgery.

A survey of outcome of adjustable suture as first operation in patients with strabismus.

Background:Adjustable suture used for years to improve the outcome of strabismus surgery. We surveyed outcome of our patients with strabismus who underwent adjustable suture.Materials and Methods:This retrospective study was performed at Ophthalmology Centre of Feiz Hospital in Isfahan on 95 participants that candidate for adjustable suture strabismus surgery. Patients were divided into three age groups: Under 10 years, 10-19 years, and 20 years and over. Outcome of adjustable suture surgery consequence of residual postoperative deviation was divided into four groups: Excellent, good, acceptable, and unacceptable.Results:Out of 95 patients studied, 51 (53.7%) were males and 44 (46.3%) were females. The mean of deviation angles were 53.8 ± 17.9 PD (Prism dioptres) in alt XT, 44.5 ± 12 PD in alt ET and 52 ± 13.5 PD in const ET, 47.1 ± 13.1PD in cons XT, respectively. There was no significant difference between the groups (P = 0.051). Results of surgery were in 38 patients (40%) excellent, in 31 patients (32.6%) good, in 19 patients (20%) acceptable, and in 7 patients (7.4%) unacceptable. Seven (7.4%) patients required reoperation.Conclusions:In the present study, the frequency of re-operation was much lower than other similar studies (7.4% vs. 30-50%). This suggests that the adjustable technique that used in our study can be associated with lower reoperation than other adjustable techniques used in the other similar studies.

ADJUSTABLE SUTURE STRABISMUS SURGERY: A REVIEW OF 850 CASES

Purpose. The aim of the study is to investigate the relationship between the different kinds of squint and the adjustament re- quired in post-op. Methods. Our personal case histories concerns 850 patients that underwent adjustable suture strabismus surgery during the last ten years, examinated in our Department of Ophtalmology over the period 2000-2009. The same surgeon (G.L.) performed adjustable suture strabismus surgery as routine duties, whether on horizontal or vertical rectus muscles, but never on oblique muscles. Adjustments were always performed in the 24 postoperative hours. With regard to the relationship between previous surgeries, and requested regulation: 669 cases not underwent previous sur- gery; 181 cases peviously underwent surgery one or more times. results. First we seek for the statistical significant difference between the various results found, computing X2, ρ and the rel- ative risk. We can conclude by saying that who made a vertical muscle squint surgery presents a relative risk of 3 times greater to take hypocorrection rather than hypercorrection and that who made before squint surgery presents a relative risk of 2,72 times greater to take regulation. Conclusions. We predicted this result because it confirms that the use of adjustable suture is the more frequent as the muscle fibrosis is the more significant. And the fibrosis is an usual outcome of previous squint surgery.