Overview #2 - The Private Eye Clinic

Adjustable suture
strabismus surgery
- Overview Part 2 Fumitaka Nonaka
Adjustable suture strabisumus surgery
Overview Part 2
Adjustable sutures in children
Special circumstances
Postoperative drift
Future directions
Adjustable suture strabisumus surgery
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-adjustable pediatric control group.
Adjustable suture strabisumus surgery
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
Special circumstances
Adjustable superior oblique surgery
Surgical technique of adjustable SO suture spacer
Adjustable Harada-Ito procedure
(a) 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
(a)6–0 Vicryl was sewn through the anterior fibers of SO tendon.
(b)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
An adjustable superior oblique tendon spacer with the use of nonabsorbable suture. Suh DW, Guyton DL, Hunter DG. J AAPOS 2001; 5:
The adjustable Harada-Ito procedure. Metz HS, Lerner H. Arch Ophthalmol
1981; 99: 624–626.
Adjustable suture strabisumus surgery
Special circumstances
Adjustable 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
 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
Special circumstances
Adjustable 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
Special circumstances
Semiadjustable sutures
• IR is uniquely prone to overcorrection after
• 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.
An evaluation of the semiadjustable
suture strabismus surgical procedure.
Kushner BJ. J AAPOS 2004; 8: 481–487
• It limits the capability to increase the amount
of recession at the time of adjustment.
Adjustable suture strabisumus surgery
Special circumstances
Lid 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.
(a) Surgeon’s view of IR muscle
(b) Appearance of capsulopalpebral head
(CPH) (*)
(c) Double-armed 6–0 polyglactin 910
sutures on IR and on the cut end of the
(d) Adjustable sutures for IR and lower
eyelid retractors
2.5 mths F/U
lid retraction - in all six patients
lid retraction + in 9 controls
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.
Adjustable suture strabisumus surgery
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
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
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
o nausea, vomiting, ocular pain
o 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
Adjustable suture strabisumus surgery
Future directions
 Postoperative healing process causes adhesions and inhibits
delayed adjustment
 Efforts have been made to facilitate delayed adjustment by …
viscoelastic material
absorbable adhesion barrier
polyglactin 910 mesh, polytetrafluoroethylene
bioresorbable film
antiproliferative agents such as mitomycin-C
Polylactide-co-glycoside copolymer
Dexamethasone, Transilast (antiallergic drug), Paclitaxel (chemotherapeutic agent), all-transretinoic
 Further studies are required to evaluate the effect and safety
of various agents
Adjustable suture strabisumus surgery
 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
Adjustable suture strabisumus surgery
Thank you
Adjustable suture strabisumus surgery
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