Adjustable suture strabismus surgery - Overview Part 1 - Christolyn Raj Adjustable suture...

Adjustable sutureAdjustable suturestrabismus surgerystrabismus surgery

- Overview Part 1 -- Overview Part 1 -

Christolyn Raj

Adjustable suture strabisumus surgery

Adjustable sutures Indications Patient selectionAnaesthetic considerations Techniques Complications


Overview Part 1Overview Part 1

Adjustable sutures in strabsmus surgery

• Principle : to secure EOM to sclera with a sliding knot , then when pt is awake , the length of suture b/w attachment site and muscle may be shortened or lengthened

First described by Claude Worth , first practised by Jampolsky 1975 No prospective RCTs to date on selective advantage of adjustable sutures Few reports on use of adjustable sutures on children

Adjustable sutures in strabismus surgery . Hunter, D. Dingeman RS et al. J Paed Opthal 2009. Number of surgeons decribe adjustable sutures in adults to improve immediate post-op

alignment [refs 3, 17, 22, 26, 30-32] Summary by Hunter, Dinegeman et al., promote use of adjustable sutures on ALL adults ,

including those with comitant strabismus & no prior surgery Authors also describe use in children who met select criteria


Standard indications for adjustable suture strabismus surgery

• Restrictive strabismus eg: TED• Previous trauma or surgery• Slipped, lost, disinserted muscles• Incomitant deviations eg : Duane’s syndrome ,

MG • Any longstanding, complex strabismus


Patient selection


Adjustable sutures can be used with recessed or resected muscles and also been successfully described on superior oblique tendon .

Goldenberg-Cohen N, et al. 2005. Strabismus 13;5-10. • Most surgeons advocate adjustable suture technique in children aged 12 yrs & older • and only younger if co-operative & may require two stages of anesthesia • Active participation of parents is a key factor (Dawson et al. 2001)

Can perfom “Q-tip” test to identify suitable pts – consists of touching a cotton tip to the MR or LR aspect of the unanesthetized bulbar conjunctiva as a pre- test tolerability

If patient fails Q-tip test : consider non-adjustable suture surgery or arrange for back-up sedation

Anaesthetic considerations

1). Recovery of extraocular muscle function-GA: EOM function recovers when pt awakes-LA: short acting agents require 5hrs minimum for motility to recover 2). Patient comfort & alertness in recovery-pre-medication: for post-op nausea-induction with propofol preferable , shorter acting muscle relaxants

preferable -avoid opiate analgesia which may cause sedation & nausea-topical tetracaine is often sufficient -ketorolac early intraop is another option /7 is m.effective


Anaesthetic considerations

3). Post-op nausea & vomiting-ondansetron is very effective & has few SE’s -use with dexamethasone may augment effects of

ondansetron 4). Sedation protocol for suture adjustment -mainly for unco-operative pts-inform anaethetist-should be monitored in recovery room setting to ensure

airway & basic monitoring equipment is readily available-may need propofol induction dose


Surgical techniques

Limbal vs fornix approacho Limbal appoach provides broad exposure but requires conjunctival closure post suture

adjustment o Fornix approach may be more comfortable as sutures are covered

TechniqueBow tie

o Sutures ae tied together in a single-loop bow-tie like a shoelace o At adjustment the bow is untied , muscle adjusted & re-tied, bow cut & converted to a

square knot


Sliding-noose o sutures are passed through scleral tunnels emerging <1mm apart , a noose is created by tying a separate piece of suture around the scleral sutures

Surgical techniquesSemi-adjustable sutures

o Described by (Kushner et al.) to reduce muscle slippage whilst preserving potential for adjustment o Involves suturing corners of muscle to sclera & placing centre of muscle on adjustable

Authors’ preferred technique o Describes “noose” suture o For adjustable recession standard hangback doses usedo For adjustable resection an extra 1-3mm muscle is resected , then muscle allowed to hang back by

same amt o After the sutures are passed , they are pulled to original insertion then these sutures are secured to

each other with an overhand knot- these joined sutures are ‘ple sutures’o For the adjustable noose , an absorbable suture is used , placed underneath the pole sutures &

wrapped around a second time, finally tying a square knot to prevent slippage o At adjustment the bow is untied , muscle adjusted & re-tied, bow cut & converted to a square knot


Complications

*Intra-adjustment complications : Nausea& vomiting oculucardiac reflex possible bradycardia Syncope

*Postoperative healing process may be very inflammatory : conjunctival suture granulomas etc Adhesions


Conclusion

• Adjustable sutures provide a second chance to improve outcomes of initial strabismus surgery

• However…. They can add to complexity of case Require appropriate patient selection Evidence to validate their advantage over convential surgery is still not

universally acknowledged Difficult learning curve involved


Adjustable suture strabismus surgery - Overview Part 1 - Christolyn Raj Adjustable suture...

Documents

Transcript of Adjustable suture strabismus surgery - Overview Part 1 - Christolyn Raj Adjustable suture...