Use Of Adjustable Sutures Research Articles

Adjustable sutures

This review discusses outcomes and recent advances in the use of adjustable sutures in strabismus surgery for children and adults. Several large studies have compared the success rates of strabismus surgery with adjustable sutures versus nonadjustable sutures by the same surgeon or group of surgeons, and demonstrate a significant increase in the short-term alignment for both children and adults with the use of adjustable sutures. Modifications of adjustable sutures technique that make adjustable sutures a more attractive option, especially for children. Recent studies have shown better short-term success rates when using adjustable sutures versus conventional sutures in strabismus surgery. Improved outcomes combined with increased options in surgical technique may lead more surgeons to use adjustable sutures in both children and adults.

Goal-determined, risk-stratified assessment of esotropia surgery outcomes

Concern over cost of health care has resulted in a call for meaningful outcome metrics. We describe a novel, goal-determined, risk-stratified (GDRS) outcomes analysis tool applicable to strabismus surgery, and utilize it to report our results in esotropia surgery. A GDRS outcomes analysis tool was applied to all patients undergoing esotropia surgery between 2006 and early 2011 at Children's Hospital Boston. One of four primary goals was assigned to each case: binocular potential; restoration of eye contact; diplopia control; or torticollis management. Pre- and postoperative alignment, fusion, age, alphabet patterns, accommodative status, and use of adjustable sutures were documented, as were potential ocular and systemic risk factors. Criteria for success were linked to the primary goal. A total of 733 patients underwent surgery for esotropia performed by 14 attending surgeons. Ocular or systemic risk factors were present in 376 (51%). Of these, 170 (45%) had prior strabismus surgery. 349 procedures were performed to improve binocular potential, 220 to restore eye contact, 121 to resolve diplopia and 43 to remediate torticollis. Excellent (70.4%) or good (13.8%) results were obtained in 84.2% of patients. The primary surgical goal did not influence success rates. Patients with ocular or systemic risk factors had significantly lower success rates (P = 0.036), most certainly in those with prior strabismus surgery (P = 0.004). In contrast, better outcomes were obtained in patients without associated risk factors (P = 0.032). Within the binocular potential cohort, patients with partially accommodative esotropia showed better outcomes (P = 0.038). GDRS analysis provides meaningful stratification of patients undergoing strabismus surgery allowing for clinically relevant measurements of outcomes.

Improved Ocular Alignment with Adjustable Sutures in Adults Undergoing Strabismus Surgery

To assess whether outcomes of strabismus surgery are improved by using the adjustable suture technique and to determine which subgroups of strabismus patients benefit most from the adjustable suture technique. A retrospective chart review. A total of 535 adults who underwent strabismus surgery between 1989 and 2010. Success was defined as ≤10 prism diopters (PD) for horizontal deviations and ≤2 PD for vertical deviations. Differences in the proportion of successful strabismus surgery were analyzed using a chi-square test with an alpha of 0.05. Ocular alignment in primary position at a 7-day to 12-week follow-up examination. A total of 491 patients met the inclusion criteria (nonadjustable suture, n = 186; adjustable suture, n = 305). The success rates for the nonadjustable and adjustable groups were 61.3% and 74.8%, respectively (χ(2)=9.91, P=0.0016). Adjustable suture use was particularly beneficial for patients undergoing a reoperation for childhood strabismus (success rate: nonadjustable, 42.4%; adjustable, 65.7%; P=0.0268; n = 100). The differences in outcomes were not statistically significant for patients with childhood strabismus undergoing a primary surgery (nonadjustable, 65.0%; adjustable, 81.4%; P=0.1354; n = 90) or with thyroid orbitopathy (nonadjustable, 76.7%; adjustable, 74.1%; P=0.8204; n = 57). Strabismus surgery using adjustable sutures was associated with improved short-term ocular alignment compared with strabismus surgery without the use of adjustable sutures. Adjustable sutures were most beneficial for patients undergoing reoperations for childhood strabismus.

Adjustable suture strabismus surgery

Surgical management of strabismus remains a challenge because surgical success rates, short-term and long-term, are not ideal. Adjustable suture strabismus surgery has been available for decades as a tool to potentially enhance the surgical outcomes. Intellectually, it seems logical that having a second chance to improve the outcome of a strabismus procedure should increase the overall success rate and reduce the reoperation rate. Yet, adjustable suture surgery has not gained universal acceptance, partly because Level 1 evidence of its advantages is lacking, and partly because the learning curve for accurate decision making during suture adjustment may span a decade or more. In this review we describe the indications, techniques, and published results of adjustable suture surgery. We will discuss the option of 'no adjustment' in cases with satisfactory alignment with emphasis on recent advances allowing for delayed adjustment. The use of adjustable sutures in special circumstances will also be reviewed. Consistently improved outcomes in the adjustable arm of nearly all retrospective studies support the advantage of the adjustable option, and strabismus surgeons are advised to become facile in the application of this approach.

A Comparison of the Intraocular Pressure Lowering Effect of Adjustable Suture Versus Laser Suture Lysis for Trabeculectomy

To compare the intraocular pressure lowering effect of adjustable sutures and laser suture lysis for trabeculectomy in eyes with primary open angle glaucoma. Fifty patients with primary open angle glaucoma were studied. Eyes were assigned randomly to either trabeculectomy augmented with mitomycin C with adjustable sutures or with laser suture lysis. Patients were followed up for 12 months and success rate based on intraocular pressure was compared. Adjustable sutures were carried out as reported by Wells et al. Mean baseline intraocular pressure was 27.8±2.8 mm Hg in the adjustable suture group and 27.3±2.9 mm Hg in the laser suture lysis group (P=0.7). Mean postoperative intraocular pressure was 12.1±2.0 mm Hg at 3 months, 12.7±3.2 mm Hg at 6 months, and 12.9±3.4 mm Hg at 12 months in the adjustable suture group and 12.1±2.6 mm Hg at 3 months, 13.1±4.7 mm Hg at 6 months, and 13.4±3.5 mm Hg at 12 months in the laser suture lysis group. There was no significant difference in the mean intraocular pressure between the groups at any time point. At 12 months, 24 patients (96%) in the adjustable suture group and 23 patients (92%) in the laser suture lysis group achieved an intraocular pressure of ≥20 mm Hg without medication and a minimum of 30 percent reduction (P=0.7). Significant anterior chamber reduction was found in no patient (0%) in the adjustable suture group and 6 patients (24%) in the laser suture lysis group after loosening of the adjustable sutures or laser suture lysis. There was no significant difference in hypotensive efficacy between adjustable suture group and laser suture lysis group. The use of adjustable sutures may reduce the incidence of shallow anterior chamber and hypotony after postoperative intraocular pressure lowering procedures.

Binocular Vertical Rectus Muscle Recession For Comitant Vertical Strabismus

Binocular vertical rectus muscle recession has not been formally evaluated in the correction of comitant vertical strabismus. Eight patients with stable comitant vertical strabismus for at least 6 months were included. All underwent recession of the superior rectus muscle of the hypertropic eye combined with an equal or nearly equal recession of the inferior rectus muscle in the hypotropic eye. On the day before surgery, on one of the first three postoperative days, and at one year postoperatively, ocular alignment in vertical and horizontal gaze directions were measured with simultaneous and alternate cover test at a viewing distance of 5 meters, and with the two dimensional Hess screen test. The field of single binocular vision was determined with a Goldmann perimeter. The Lang stereopsis chart was presented at the last follow-up visit. All patients were orthotropic at the last postoperative follow-up visit. In primary gaze, the degree of vertical and horizontal phoria diminished significantly. Normal alignment was achieved in nearly all gaze directions and stereopsis was reestablished. The field of single binocular vision enlarged after the surgery. Binocular vertical rectus muscle recession is an effective surgical approach for patients with comitant vertical ocular misalignment.

Adjustable suture strabismus surgery in infants and children

To evaluate the success rate of adjustable suture techniques in horizontal eye muscle surgery in children aged 10 years and younger. A retrospective review of children who had horizontal eye muscle surgery at or before the age of 10 years. Patients were divided into 1 of 2 groups according to whether a nonadjustable or an adjustable technique was used. The preoperative measurements, type of strabismus, and postoperative results were analyzed. A total of 98 cases in the nonadjustable group and 298 cases in the adjustable group were identified. Early success rate, defined as alignment within 8(Delta) of straight at the end of 3 months, was notably greater in the adjustable group (79%) than in the nonadjustable group (64.5%). The difference was statistically significant (p < 0.01). In the adjustable group, adjustment was performed in 64% of the cases, either because of an undercorrection or overcorrection. The adjustment procedure was performed under topical proparacaine in 20% of cases and under intravenous propofol in 80%. No complications were reported during the adjustment procedure. The use of adjustable sutures can provide an improved success rate over nonadjustable sutures in eye muscle surgery in children aged 10 years or younger.

The Active Pulley Hypothesis

&lt;h4&gt;EXCERPT&lt;/h4&gt; &lt;p&gt;For the most part, the techniques used in strabismus surgery have not changed over the years. Most are variations of recessions and resections of the rectus and oblique muscles. Certainly advances have been made, most notably the use of adjustable sutures and anteriorization of the inferior oblique muscles. These operations are now part of the accepted surgical armamentarium. What has changed, however, is the more scientific approach we use in planning and performing surgery. For example, we have the ability to use ophthalmic imaging tools such as magnetic resonance imaging (MRI) and ultrasonography to help plan surgical procedures.&lt;/p&gt;

Releasable Adjustable Suture Technique for Children

Residual esotropia is a problem for children with esotropia that can follow bilateral medial rectus recession, and the use of adjustable sutures is nearly impossible. The aim of this work is to describe a new suture technique to overcome this problem. Medial rectus muscle was recessed and secured to the sclera at the predetermined recession position after suspending it 1.50-2.00 mm farther. A second, releasable suture was placed at the original insertion site, passed under the previously tied muscle suture knot, and tied in a strengthened loop knot, advancing the muscle to the new scleral insertion. The looped end was left long enough to be kept in the inferior fornix. The next day, if the child was undercorrected, intranasal midazolam was given and the releasable suture was drawn out, providing additional muscle recession. Patients aged 10 to 94 months (mean 34 months) with angle of deviation 20 to 60 prism diopters (PD; mean 33 PD) and with follow-up 1 to 12 weeks (mean 4.5 weeks) were studied. Success was defined as alignment within 10 PD. Of 50 children with esotropia, 32 (64%) were successfully aligned, and 18 (36%) were undercorrected with residual angle 14 to 25 PD (mean, 18 PD). After release of the suture, 15 children (83%) were successfully aligned, and 3 children were still undercorrected. The overall success rate was 94%. Releasable adjustable suture is a new technique that can help strabismologists attempt bilateral medial rectus recession in children, with a second chance for correction during early postoperative period.

Surgical results in large-angle exotropia

Purpose: This study examines the surgical results of correcting large angle exodeviationsin adults who may lack bifixation. The expected results in adults are not to achieve improved fusion but, rather, to construct the alignment. Methods: A retrospective chart review was conducted of all patients withcomitant exodeviation greater than 35 Δ examined and treated by 1 pediatric ophthalmologist between January 1994 and May 1999. Any patients with large A or V patterns, nystagmus, history of botulinum toxin injections for strabismus, paralytic or mechanical cause for strabismus, or use of adjustable sutures were excluded. Charts were reviewed for postoperative alignment. Postoperative results were separated into 3 categories: exodeviation greater than 10 Δ, successful outcome (esotropia<10 Δ, orthotropia, or exodeviation <10 Δ), or esotropia greater than 10 Δ. Results: Sixty-three patients met the inclusion criteria. Their median age at the time of surgery was 18, with a standard deviation of 20. The majority of them had intermittent exotropia that had deteriorated into constant exotropia. Fifty-two patients had bilateral lateral rectus recessions, and 11 patients had recess/resect procedures. Sixty-two percent (39 of 63) had successful outcomes overall. Only 2 patients had overcorrection (esotropia>10 Δ). In patients with deviations greater than 50 Δ, 82% (9 of 11) were undercorrected (exodeviation >10 Δ). Conclusions: Large-angle exodeviations can be successfully approached with bilateral lateral rectus recessions or recess/resect procedures in preoperative deviations up to and including 50 Δ with a success rate of 71%. In larger deviations, 2-muscle surgery was not as successful (18%, or 2 of 11). (J AAPOS 2002;6:77-80)

Timing of postoperative adjustment in adjustable suture strabismus surgery

Purpose: The use of adjustable sutures in strabismus surgery has increased the rate of surgical success. Little data are available on the optimum timing for postoperative adjustment after strabismus surgery. We wanted to compare 2 common practices of adjustable suture technique after strabismus surgery. Methods: Two comparable groups of 40 patients each, who had strabismus surgery with adjustable suture technique, were prospectively studied. Group A had early adjustment the same day of the surgery about 6 hours after the operation, and group B had late adjustment the next day about 24 hours after the operation. Subjective scoring tables were used to evaluate the pain felt by the patient before, during, and after the adjustment and any difficulties of the adjustment process. Requirements of postoperative pain medications and final alignment 6 weeks after surgery were also compared. Results: Despite adequate statistical power, no significant differences were found between the groups regarding pain before, during, and after adjustment, difficulties performing the adjustment, and final alignment after 6 weeks (P >.05). Both adjustment schedules were equally associated with mild to moderate pain before, during, and after the adjustment. In the first 24 hours after surgery, no overall difference in the use of pain medications was found. Nausea and vomiting in the first 24 postoperative hours were more common in the early adjustment group (P =.02). Conclusion: The surgeon can feel free to choose the timing for postoperative adjustment. However, when performing an early adjustment, the surgeon should be especially prepared to control nausea and vomiting. (J AAPOS 2001;5:178-83)

The use of subtenon ropivacaine in managing strabismus with adjustable sutures

Background: Squint angle alterations with the use of adjustable sutures after strabismus surgery can be painful. Ropivacaine is a long-acting local anesthetic that, at low doses, produces sensory block with limited nonprogressive motor block. Method: We performed a double-blind, randomized, pilot study using subtenon ropivacaine or placebo at the time of surgery in patients undergoing adjustable suture surgery. Surgery was performed by the same surgeon in each case. Later in the day, the same surgeon adjusted the sutures. At the time of adjustment, the patient recorded pain using a linear pain score, and the surgeon recorded ease of adjustment using a linear score. The results of surgery were noted at 4 weeks. Results: Ten patients were randomized to receive ropivacaine and 11 to receive placebo. All 10 of the ropivacaine group and 9 of the placebo group had suture adjustment. In the ropivacaine group, there was a significantly lower pain score (P < .05, Mann-Whitney U test) but no significant difference in ease of adjustment. There appeared to be no demonstrable difference in the results of surgery between the 2 groups. Conclusion: Ropivacaine appears to reduce the pain of postoperative suture adjustment without adversely affecting the final outcome, although it does not appear to ease the adjustment itself. This small pilot study shows promising results in postoperative analgesia in these patients, although further larger trials are recommended. (J AAPOS 2001;5:95-7)

Late overcorrections in inferior rectus muscle surgery for vertical squint correction

The aim of this study was to evaluate postoperative results in 21 patients with vertical strabismus and diplopia who underwent surgery on the inferior rectus. Postoperative results were obtained 1, 3, and 6 months after surgery. We concluded that inferior rectus recession may have unpredictable outcome despite the use of adjustable sutures. Whenever surgery on this muscle is considered, patients must be left undercorrected to avoid late overcorrections.

Ocular muscle surgery in thyroid eye disease

This paper is about the results of muscle surgery to correct double vision and any associated compensatory head posture in 58 patients with thyroid eye disease. A strict definition of success whereby the patient has binocular single vision in the straight ahead and reading areas restored by a single operation on the muscles without the subsequent use of prisms is used. The pre-operative states which may influence the outcome of surgery are examined and it is concluded that the preferred starting point for ocular muscle surgery is that the patient is euthyroid, with proptosis less than 26 mm and that binocular single vision has thus far been maintained by the use of prisms and/or a compensatory head posture. Records of the ocular movements must have been stable for at least six months. The techniques of surgical correction are described including the use of adjustable sutures.

Oculocardiac Reflex During Manipulation of Adjustable Sutures after Strabismus Surgery

We studied 44 patients who underwent strabismus surgery with the use of adjustable sutures to determine the occurrence of the oculocardiac reflex during the postoperative adjustment process. We defined the reflex as at least a 10% decrease in the baseline heart rate. Only two patients (4.5%) displayed an oculocardiac reflex during the adjustment. We did not identify any preadjustment factors that would increase the susceptibility to develop the reflex.

The Use of Adjustable Sutures in Upper Eyelid Surgery

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