Alfred J. Cossari, MDPort Jefferson, NY

Financial Disclosure

I have no financial interests or relationships to disclose.

My Objectives

Describe the 2 stages of strabismus surgery Briefly compare 3 basic adjustment procedures Look at the timing of adjustments with respect to

events occurring in the healing process Provide details of the 7th day fixed suture procedure Encourage surgeons who have avoided hang-back

sutures to consider the 7th day procedure Recommend that all patients be prepared by their

surgeon for a possible adjustment•••

Strabismus Surgery- requires 1 or 2 stage -

1st stage (primary surgery): procedure that executes the type and amount of surgery determined to best correct a specific set of sensorimotor defects

2nd (adjustment) stage: a brief interruption of the healing process that provides a second guess opportunity when the primary surgery appears to be failing

After 7-10 days, interruption of the healing process isno longer temporary due to advancing scar formation;revision at this stage requires a reoperation

•••

Suture Adjusting - an overview -

Standard hang-back suture: has been the centerpiece for routine or selective suture adjusting within 24 hours of surgery

Short tag noose suture: is one example of a modified hang-back suture that eliminates the need to tie the suture when no adjustment is required

7th day fixed suture: is an approach that avoids using a special suture and defers adjustment of the suture position to the 7th day

Reality is: there is an adjusting procedure suited to the preferences of most strabismus surgeons

•••

Adjustment Procedures- percentage adjusted -

100% of patients with a standard hang-back suture need either an early adjustment or a tie-off

< 50% of patients with a short tag noose suture are early adjusted; the remainder absorb without tying

5% of all patients have an aberrant primary surgery result requiring a 7th day fixed suture “rescue” adjustment at day #7

•••

Early Adjustment- 24 hours / early inflammatory phase -

Easiest time to adjust a hang-back suture Minimal fibrosis of the platelet clot Least accurate time to perform a motility

assessment Pain, splinting and drowsiness are present Patient interaction is often part of this 2nd guess;

O.R, bedside or exam chair •••

7th Day Fixed Suture Adjustment- early proliferative phase -

More accurate time for a motility assessment (including diagnostic gaze positions)

Pain, splinting and drowsiness are resolved Blunt dissection is required to replace the fixed

suture Fibrin/collagen have begun to fibrose the tissues Patient interaction is not used for this 2nd guess

•••

Typical Example- supporting 7th day adjust -

4 year old X(T) = 27, RH(T) = 5 Recessions (LROU and RSR) ET = 30, LHT = 4 (day #1) With a hang-back suture, an early adjustment

would probably have been performed A hang-back was not used, so early adjustment

was not considered

F/T alternate occlusion was prescribed with probability of a 7th day adjustment

ET = 10, LHT =2 (day #6) 7th day adjustment deemed unnecessary Orthophoric (week #3 – year #4) An early adjustment would have adjusted him out of this excellent result

•••

7th Day Fixed Suture - surgeon profile -

Distrusts hang-back sutures and nooses Distrusts early postop assessment of motility Distrusts bedside interactive decision-making Enjoys a high surgical success rate w/o early adjusting Recognizes the need for an occasional “rescue”

adjustment Or, uses a hang-back but occasionally has need for a 7th

day rescue•••

7th Day Fixed Suture - patient experience -

100% of patients are prepared for the 5% probability of an adjustment

95% are happy when they discover an adjustment is not needed

5% are not surprised when an adjustment is recommended

•••

7th Day Fixed Suture - surgical issues -

All 6 EOMs have been adjusted Adjustments are scheduled as an add-on to my weekly

block-time The same anesthetic technique is used (general or

regional) as the primary surgery Tugging on muscle hooks is avoided to prevent

breaking the suture or tearing it from the muscle Fixation and rotation of the globe are accomplished

with bridle sutures and locking Stern-Castroviejo forceps

The new suture is secured before cutting the old •••

7th Day Fixed Suture - cost reduction issues -

Reduced personnel time for up to 95% of surgeries (surgeon, anesthesiologist, OR nurses, RR nurses, techs, etc.)

Fewer instrument trays and materials Suture adjustment submissions are reduced by up to 95% No increase in reoperations due to long-term failures

compared with other adjustment techniques•••

suggestions for successful

Second Guessing

Determine your preference: hang-back or 7th day fixed suture adjustment technique (or both)

Prepare all patients for the 7th day fixed suture adjustment process; an early adjustment preference does not preclude possible need for a 7th day rescue

Develop your second guessing skills and statistics – don’t forget to assess motility on POD #6

Decrease the need for 2nd guessing with better stage 1 planning

•••

Semantics of this 7th Day 2nd Guessing

(adjustment vs. reoperation) Back to OR on a different day Repeat anesthetic Same healing process with muscle position adjustment No excision of scar No new muscle operated Placement of a new suture in the same muscle or tendon Late second guess opportunity

Your choice!•••

Summary All patients should be afforded the opportunity of having the

surgeon second guess the placement of muscle attachments before healing occurs whenever there is an unexpected response to surgery

3 basic second guessing approaches: - standard hang-back suture- short tag noose suture- 7th day fixed suture

Success is largely the result of a good sensorimotor assessment and sound surgical decisions; not a specific adjustment technique

•••