Use Of Adjustable Sutures Research Articles

Variation between surgeons in rate of reoperation after horizontal strabismus surgery among Medicare beneficiaries: associations with patient and surgeon characteristics and adjustable sutures.

Objective: To quantify variation between surgeons in reoperation rates after horizontal strabismus surgery, and to explore associations of reoperation rate with surgical techniques, patient characteristics, and practice type and volume. Methods: Fee-for-service payments in a national database to providers for Medicare beneficiaries having strabismus surgery on horizontal muscles between 2012 and 2020 were analyzed retrospectively to identify same calendar year reoperations. Multivariable linear regression was used to determine predictors of each surgeon's reoperation rate. Results: The reoperation rate for 1-horizontal muscle surgery varied between 0.0% and 30.8% among 141 surgeons. Just 7.8% of surgeons contributed over half of the reoperation events for 1-horizontal muscle surgery, due to the presence of high-volume surgeons with high reoperation rates. Surgeon seniority, gender, surgery volume, and use of adjustable sutures were not independently associated with surgeon reoperation rate. We explored associations of reoperation with patient characteristics, such as age and poverty. Surgeons in the South tended to have a higher reoperation rate (p=0.03) in a multivariable model. However, the multivariable model could only explain 16.3% of the inter-surgeon variation in reoperation rate for 1-horizontal muscle surgery. Discussion: Strabismus surgery is similar to other areas of medicine, in which large variations in outcomes between surgeons are observed. Future work can be directed towards explaining this variation. Conclusions: Patient-level analyses that fail to consider variation between surgeons will be dominated by a small number of high-reoperation, high-volume surgeons. Order-of-magnitude variations exist in reoperation rates among strabismus surgeons, the cause of which is largely unexplained.

Variation between surgeons in reoperation rates following vertical strabismus surgery: Associations with patient and surgeon characteristics and adjustable sutures.

To quantify inter-surgeon variation in vertical strabismus surgery reoperation rates, and to explore associations of reoperation rate with practice type and volume, surgical techniques, and patient characteristics. Fee-for-service payments to providers in a national database for Medicare beneficiaries having vertical strabismus surgery between 2012 and 2020 were retrospectively analyzed to identify reoperations in the same calendar year. Predictors of the rate of reoperation for each surgeon were determined by multivariable linear regression. Among 73 surgeons, the reoperation rate for 1-vertical muscle surgery varied from 0.0% to 40.7%. Due to the presence of high-volume surgeons with high reoperation rates, just 11% of surgeons contributed over half of the reoperation events for 1-vertical muscle surgery. Use of adjustable sutures, surgeon gender, and surgical volume were not independently associated with surgeon reoperation rate. Associations of reoperation with patient characteristics, such as age and poverty, were explored. Patient poverty was independently associated with a lower surgeon reoperation rate (p = 0.03). Still, the multivariable model could explain only 14.2% of the variation in surgeon reoperation rate for 1-vertical muscle. Patient-level analyses which ignore inter-surgeon variation will be dominated by the practices of a small number of high-volume, high-reoperation surgeons. There are order-of-magnitude variations in reoperation rates among strabismus surgeons, the cause of which remains largely unexplained.

Adjustable Suture Technique Is Associated with Fewer Strabismus Reoperations in the Intelligent Research in Sight Registry

To compare the reoperation rates after strabismus surgery with and without the adjustable suture technique. Retrospective cohort study. Patients 18 years of age or older in the Intelligent Research in Sight (IRIS®) Registry who underwent strabismus surgery between January 1, 2013, and December 31,2018. Data were collected from the electronic health records of practices participating in the IRIS Registry. The primary exposure of interest was use of the adjustable suture technique, identified by Current Procedural Terminology coding. The primary outcome was repeat strabismus surgery within 1 year of initial strabismus surgery. Odds ratios (ORs) were derived from a multivariable logistic regression model evaluating the association between the use of adjustable sutures and reoperation rate, adjusting for patient demographics and surgical factors. A total of 34 872 patients who underwent strabismus surgery during the study interval were identified: 72% underwent horizontal muscle surgery, 17% underwent vertical muscle surgery, and 11% underwent combined horizontal and vertical muscle surgery. Adjustable sutures were used in 18% of patients. The overall reoperation rate within 1 year of strabismus surgery was 7.7%. The 1-year reoperation rate was 6.0% for patients treated with adjustable sutures and 8.1% for patients treated without adjustable sutures (P < 0.001). The multivariable regression model revealed a statistically significant 30% decrease in the odds of reoperation within 1 year of surgery when adjustable sutures were used (OR, 0.70; 95% confidence interval [CI], 0.62-0.78), a 40% increase in those with a history of prior strabismus surgery (OR, 1.40; 95% CI, 1.28-1.53), and a 9% increase per decade of age at surgery (OR, 1.09; 95% CI, 1.06-1.11). In adults cared for in practices participating in the IRIS Registry, the adjustable suture technique was associated with a significantly lower reoperation rate within 1 year of undergoing horizontal or combined horizontal and vertical strabismus surgery. Adjustable suture use in vertical strabismus surgery alone did not reduce the 1-year reoperation rate significantly. A history of prior strabismus surgery was associated with increased odds of reoperation.

Strabismus surgery outcomes for internuclear ophthalmoplegia with exotropia

ABSTRACT Exotropia (XT) in internuclear ophthalmoplegia (INO) is a difficult problem to treat. The purpose of this study is to describe surgical approaches in treating INO and glean insight into various pre-operative factors that may affect outcomes for XT in INO. We conducted a retrospective review from 1 January 1995 – 5 January 2021 and identified seven patients with INO who underwent strabismus surgery for XT. Patient age, sex, etiology of INO, pre-operative alignment and sensorimotor exam, presence of diplopia, surgery performed, subsequent surgeries, use of adjustable sutures, post-operative alignment, presence of post-operative diplopia, presence of post-operative diplopia with use of prism correction, and length of follow-up were all collected. Initial surgeries undertaken included unilateral medial rectus (MR) plication and lateral rectus (LR) recession, bilateral medial rectus (MR) plications or resections, or bilateral MR plications combined with either unilateral or bilateral LR recessions. Chart review yielded ten charts, however two were excluded due to manifest esotropia (ET), and one was excluded due to incomplete records. Seven total patients were used in final analysis. The cohort age range was from 29 to 79 years. Pre-operative horizontal distance alignment ranged from 35 to 95 XT with an average exodeviation of 67.8 ± 22.6 prism diopters (PD). Horizontal adduction deficit ranged from −1 to −4 and was present bilaterally in all patients. A variety of initial surgical approaches were undertaken. After two muscle surgeries, distance deviation had an average change of 57.3 PD. After three muscle surgeries, distance deviation had an average change of 75 PD. After four muscle surgeries, distance deviation had an average change of 60 PD. Three patients required additional surgery for XT. Time to follow-up ranged from 1 to 58 months. Horizontal distance alignment in primary gaze at latest follow-up ranged from 30 ET to 30 XT with an average of 0 (orthotropia) ± 16.0 PD. One patient had a consecutive esotropia of 30 PD, one had a persistent exotropia of 30 PD, and five patients were orthotropic at distance. All patients reported relief of diplopia in primary gaze at near and distance either with or without use of prism. Horizontal ductions improved to some degree in all patients. Horizontal rectus surgery can treat many cases of XT in INO. Surgeons should consider INO etiology and concomitant vertical deviations when considering surgery. The degree of pre-operative adduction limitation is another important factor, though did not always dictate final motor and sensory outcomes.

Risk Factors for Reoperation after Strabismus Surgery among Patients with Thyroid Eye Disease

To examine risk factors for strabismus surgery reoperation in patients with thyroid eye disease (TED). Retrospective cohort study. An insurance claims database was used to identify patients with TED who underwent at least one strabismus operation between 2003 and 2019. We recorded specific muscles operated on, as well as the timing and frequency of reoperations. Cox regressions were used to estimate associations between time to reoperation and patient and primary surgery characteristics. Of the 448 patients who met inclusion criteria, 111 (24.8%) underwent a reoperation. Patients were followed for an average of 5.4 ± 3.0 years after their initial strabismus surgery. The rates of reoperation among patients whose initial surgery involved horizontal muscles only, vertical muscles only, and horizontal and vertical muscles were 29 of 120 (24.2%), 33 of 169 (19.5%), and 49 of 159 (30.8%) respectively (P=.05). The number of muscles operated on initially was the only independent predictor for undergoing a strabismus surgery reoperation (odds ratio, 1.27; 95% confidence interval, 1.03-1.57; P=.03). The number of muscles operated on initially was also associated with shorter time to first reoperation (hazard ratio, 1.22; 95% confidence interval, 1.02-1.46; P=.03). Age at first surgery, time between diagnosis of TED and first strabismus surgery, gender, race, and use of adjustable sutures were not associated with time to reoperation. Approximately 1 in 4 patients with TED require reoperation after strabismus surgery. The number of muscles operated on was the only independent predictor for both undergoing a reoperation and time to first reoperation.

ADVANCES IN AUTISM GENETICS: FROM GENE DISCOVERY TO ASPECTS OF HETEROGENEITY

We describe a surgical technique to perform strabismus surgery in patients with a scleral buckle that allows for the use of adjustable sutures without removing or modifying the exoplant.

PSYCHEMERGE: A DEEP DIVE INTO THE WORLD OF EHR-BASED PSYCHIATRIC GENOMICS

We describe a surgical technique to perform strabismus surgery in patients with a scleral buckle that allows for the use of adjustable sutures without removing or modifying the exoplant.

POLYGENIC RISK OF COMORBID ANXIETY AND DEPRESSION ACROSS HEALTH SYSTEMS

We describe a surgical technique to perform strabismus surgery in patients with a scleral buckle that allows for the use of adjustable sutures without removing or modifying the exoplant.

BRINGING VALUE FROM CONSUMER GENETICS TO THE CLINIC

We describe a surgical technique to perform strabismus surgery in patients with a scleral buckle that allows for the use of adjustable sutures without removing or modifying the exoplant.

Population trends in adult strabismus surgery

To review the trends in adult strabismus procedures in Ontario from 2000-2013. Population-based, retrospective data analysis. All patients 18 years or older who underwent a strabismus related procedure in Ontario and all ophthalmologists who performed these procedures from 2000-2013. Ontario Health Insurance Plan billing claims for strabismus procedures were collected and subdivided by number of muscles repaired, the use of adjustable sutures, repeat procedures, and pharmacological injection of the extraocular muscles adjusted by the total adult population. The number of ophthalmologists performing adult strabismus surgery was also analyzed, subdivided by high-volume and low-volume surgeons. From 2000-2013, per 100 000 adult population, the number of total strabismus surgeries in Ontario increased 26.0%; single-muscle surgery increased 24.2%, 2-muscle surgery increased 43.1%, and 3 or more muscle surgery increased 3.8%. During the study period, strabismus procedures using adjustable sutures increased 30.3%, and repeat procedures increased 19.1%. The number of surgeons performing adult strabismus surgery decreased 30.0% from 2000-2013. In 2013, 92.6% of surgeries were performed by 35.7% of surgeons who performed adult strabismus surgery. From 2000-2013, more strabismus surgery was performed in adults by fewer surgeons, including procedures using adjustable sutures and repeat procedures. These increases may be due to increases in health care funding and a heightened awareness of the functional and psychosocial benefits of strabismus surgery.

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.

Why strabismus surgery works: the legend of the dose–response curve

The dose-response relationship has historically been regarded as an important approach to improve the success of strabismus surgery. The purpose of this study was to explore the role of preoperative deviation, in addition to the amount of surgery, as a predictor of the response to strabismus surgery. Dose-response data from a variety of sources are analyzed in a multiple linear regression model with both preoperative deviation and surgical dose as independent variables. Pvalues and partial correlations from these regressions are used to investigate the relative contribution of each factor. These analyses consistently show that preoperative deviation is statistically a better predictor of the response to surgery than the amount of surgery. In data sets where one factor is constant, preoperative deviation alone accounts for 78%, and the amount of surgery alone accounts for 46% of the variance of the surgical response. The importance of preoperative deviation as an independent variable implies a biologic response to strabismus surgery that tends to produce more change in alignment when the deviation is large and less when it is small. The strong association of amount of surgery with surgical outcome in bivariate analysis studies may be an artifact of making the amount of surgery a strict function of the preoperative deviation. Because of its lesser role as a predictor, accuracy of preoperative deviation measurement upon which the amount of surgery is based, refinement of the dose-response curve, or use of adjustable sutures may have less potential to improve surgical outcome than generally believed.

A modified technique for strabismus surgery in the presence of a scleral buckle

We describe a surgical technique to perform strabismus surgery in patients with a scleral buckle that allows for the use of adjustable sutures without removing or modifying the exoplant.

Treatment of ocular motor palsies.

The management of ocular motor palsies first requires careful determination of the etiology. Possibilities include ischemia, inflammation, infection, trauma, compression, or congenital. Prognosis for recovery varies greatly between etiologies; hence, determination of the underlying process is crucial in the short- and long-term management of these patients. Naturally, our ultimate goal is to improve visual function as much as possible. A guiding principle in the initial management of ocular motor palsies is to improve patient comfort and visual function by eliminating diplopia in primary position while clinically observing the patient for improvement or stability. Offering a definitive treatment which creates the largest possible zone of binocular single vision in primary and reading positions can be undertaken once stability has been demonstrated. In the initial phase after an acute ocular motor palsy has occurred, occlusion of an eye can be used to eliminate diplopia. Options include a patch or applying translucent or satin tape to one of the lenses which prevents diplopia but still lets light through. Alternatively, prismatic correction placed on or ground into spectacles may improve function and restore binocularity in patients with temporary or permanent ocular deviations. This is generally effective for patients with up to 20 to 25 prism diopters (PD) of horizontal misalignment and 10 to 15 PD of vertical. Once a stable misalignment has been demonstrated (several months), a variety of surgical options exist. Use of adjustable sutures, improved suture materials, and surgical techniques has expanded the role and scope of surgery for these patients. Planning the surgical approach is based on residual extraocular muscle function, careful measurements, and assessment of patient expectations.

Adjustable sutures in children

Although adjustable sutures are considered a standard technique in adult strabismus surgery, most surgeons are hesitant to attempt the technique in children, who are believed to be unlikely to cooperate for postoperative assessment and adjustment. Interest in using adjustable sutures in pediatric patients has increased with the development of surgical techniques specific to infants and children. This workshop briefly reviews the literature supporting the use of adjustable sutures in children and presents the approaches currently used by three experienced strabismus surgeons.

Adjustable Augmented Rectus Muscle Transposition Surgery with or Without Ciliary Vessel Sparing for Abduction Deficiencies

Background: Vertical rectus transposition (VRT) is useful in abduction deficiencies. Posterior fixation sutures enhance the effect of VRT, but usually preclude the use of adjustable sutures. Augmentation of VRT by resection of the transposed muscles allows for an adjustable technique that can reduce induced vertical deviations and overcorrections.Methods: We retrospectively reviewed the records of all patients undergoing adjustable partial or full tendon VRT augmented by resection of the transposed muscles. Ciliary vessels were preserved in most of the patients by either splitting the transposed muscle or by dragging the transposed muscle without disrupting the muscle insertion.Results: Seven patients with abducens palsy and one with esotropic Duane syndrome were included. Both vertical rectus muscles were symmetrically resected by 3–5 mm. Preoperative central gaze esotropia of 30.6 ± 12.9Δ (range, 17–50Δ) decreased to 10.6 ± 8.8Δ (range, 0–25Δ) at the final visit (p = 0.003). Three patients required postoperative adjustment by recession of one of the transposed muscles due to an induced vertical deviation (mean 9.3Δ reduced to 0Δ), coupled with overcorrection (mean exotropia 11.3Δ reduced to 0 in two patients and exophoria 2Δ in one patient). At the final follow-up visit 3.8 ± 2.6 months postoperatively, one patient had a vertical deviation <4Δ, and none had overcorrection or anterior segment ischemia. Three patients required further surgery for recurrent esotropia.Conclusions: Augmentation of VRT by resection of the transposed muscles can be performed with adjustable sutures and vessel-sparing technique. This allows for postoperative control of overcorrections and induced vertical deviations as well as less risk of anterior segment ischemia.

Adjustment versus no adjustment when using adjustable sutures in strabismus surgery

To compare long-term postoperative outcomes when performing an adjustment to achieve a desired immediate postoperative alignment versus simply tying off at the desired immediate postoperative alignment, when using adjustable sutures for strabismus surgery. We retrospectively identified 89 consecutive patients who underwent a reoperation for horizontal strabismus with the use of adjustable sutures and also had a 6-week and 1-year outcome examination. In each case, the intent of the surgeon was to tie off and only to adjust if the patient was not within the intended immediate postoperative range. Postoperative success was predefined on the basis of the angle of misalignment and diplopia at distance and near. Of the 89 patients, 53 (60%) were adjusted and 36 (40%) were tied off. Success rates were similar between patients who were simply tied off immediately after surgery and those who were adjusted. At 6 weeks, the success rate was 64% for the nonadjusted group versus 81% for the adjusted group (P=0.09; difference of 17%; 95% CI, -2% to 36%). At 1 year, the success rate was 67% for the nonadjusted group versus 77% for the adjusted group (P=0.3; difference of 11%; 95% CI, -8% to 30%). Performing an adjustment to obtain a desired immediate postoperative alignment did not yield inferior long-term outcomes compared with tying off to obtain that initial alignment. If patients who were outside the desired immediate postoperative range had not been adjusted, it is possible that their long-term outcomes would have been worse. Therefore, overall, an adjustable approach may be superior to a nonadjustable approach.

Simulated strabismus surgery—a practical and interactive demonstration of novel simulation techniques

To demonstrate how the safety of strabismus surgical training can be enhanced by the use of novel simulation techniques, using life-like silicone model eyes. Ophthalmologists involved with teaching strabismus surgery and surgical trainees. Patient safety should be our principle concern when teaching any form of surgery. However, very few training programs provide any form of strabismus surgery simulation. This means surgical trainees may not have developed core surgical skills, such as rectus muscle and scleral suturing techniques, before operating on patients. A simulation program, using life-like silicone eyes, to teach basic suturing techniques before moving on to performing recession / resection techniques, inferior oblique surgery and then the use of adjustable sutures. Trainees are required to have performed at least 5 complete rectus muscle procedures satisfactorily, before being allowed to operate on patients. All delegates will be aware of the potential benefits of simulation training for patients, trainees and trainers and will have observed live demonstrations of rectus muscle and oblique muscle surgery on the model eyes. They will also have learnt how to incorporate surgical simulation into their training programs or practices. Introductory lectures (40 minutes), live strabismus surgery demonstration, by leading surgeons from the USA and UK (20 minutes), Q&A session (15 minutes). This workshop will demonstrate how strabismus surgical simulation, using life-like model eyes, can enhance patient safety and the quality of surgical training. The combination of lectures, live surgical demonstrations, followed by a Q&A session, will we hope be conducive to an educational and interactive workshop.

Adjustable augmented rectus muscle transposition surgery with or without ciliary vessel-sparing for abduction deficiencies

Vertical rectus transposition (VRT) is useful in Duane syndrome and abducens palsy. However, many clinicians avoid transpositions due to the risk of induced vertical deviations and overcorrections. Posterior fixation sutures enhance the effect of VRT, but preclude the use of adjustable sutures. An adjustable augmented VRT with or without ciliary vessel-sparing is described.

Surgical management of vertical ocular misalignment in thyroid eye disease using an adjustable suture technique

To report a surgical approach to managing hypotropia associated with thyroid eye disease (TED) that uses adjustable sutures. The medical records of consecutive patients with TED and hypotropia who underwent adjustable suture inferior rectus muscle recession with or without superior rectus muscle recession of the hypertropic eye were reviewed retrospectively. The initial goal was undercorrection in primary gaze and no hyperdeviation in downgaze. Outcomes were rated according to the presence of diplopia in primary and reading positions as excellent (none), good (no diplopia with <10(Δ) correction), and poor (diplopia). Fifty-four patients were included. The initial median primary position deviation was 16(Δ). Of the 54 patients, 39 (72%) underwent unilateral inferior rectus muscle recession; 15 (28%), bilateral; and 24 (44%), superior rectus muscle recession. On mean follow-up of 38 weeks, 35 patients (65%) had excellent results (30 aligned in primary and reading position, 5 of whom could fuse small deviations [average, 3(Δ)]); 17 (31%), good results (13 < 6(Δ)); and 2 (3.7%), poor results, but aligned after reoperation (6(Δ) overcorrection, 16(Δ) undercorrection). Of the 24 misaligned patients (ie, those with small deviations, good results, and poor results), 13 were undercorrected an average of 4.9(Δ) and 11 (20%) were overcorrected an average of 6.2(Δ). Adjustment timing, number of muscles recessed, preoperative deviation, and previous orbital decompression did not affect outcomes. In this series, patients with hypotropia and TED were effectively managed by the use of adjustable sutures and by surgeons operating on multiple muscles, anticipating drift toward overcorrection of the recessed inferior rectus muscle, and using prism for residual deviation.