Adjustable sutures in children using a modified technique

Laser-Assisted Adjustable Suture Technique in Strabismus Surgery

Purpose

The aim of this study was to assess the efficacy and safety of a new technique (argon laser-assisted lysis of the adjustable suture) in strabismus surgery.

Patients and Methods

Recession of lateral rectus muscle was done and was secured to the sclera at the predetermined recession position after suspending it 1.5–2.5 mm farther. A 10-0 nylon suture was placed at the original insertion site, passed under the previously tied muscle suture knot, and tied, advancing the muscle to the new scleral insertion. Postoperatively in the same day of surgery, if the targeted slight overcorrection was not achieved, a topical anesthetic was given, and argon laser was used to cut the nylon suture providing additional muscle recession.

Results

Forty-two patients with exotropia were included: 11 children and 31 adults. Eleven (26.2%) patients became orthophoric immediately following muscle recession. Thirty-one (73.8%) patients were undercorrected with a mean residual angle of 8.2±3.3 pd. After laser-assisted release of the suture, 12 (28.6%) patients were orthophoric, with 4 (9.5%) patients still undercorrected and 26 (61.9%) patients overcorrected. By the end of 6 months postoperatively, the overall success rate of the procedure was 88.1%, with only 5 (11.9%) patients with exotropia.

Conclusion

The laser-assisted adjustable suture technique had an overall success rate of 88.1% with only 11.9% of the patients showing exotropia. The technique can help achieve successful alignment.

Outcome of delayed adjustable strabismus surgery in children using a bow-tie optional adjustable technique

Purpose:

The aim of this article is to study the feasibility of a delayed adjustable technique of strabismus surgery in children using an optional adjustable suture technique.

Methods:

The retrospective study included patients <12 years of age. Recessions were done using an optional adjustable bow-tie technique and resections were done by the conventional technique. Patients were evaluated on the third postoperative day and adjustments done when needed. Statistical analysis was done using Microsoft Excel 2010®.

Results:

The study included 11 patients with exotropia and 16 patients with esotropia. The mean age of the patients was 5.2 years (range 1–11 years). The mean preoperative distance deviation was 46.7 ± 10.4 prism diopters (PD) for exotropic patients and 47.1 ± 16.9 PD for esotropic patients. The mean preoperative near deviation was 46.6 ± 11 PD for exotropic patients and 52.4 ± 17.1 PD for esotropia. Two patients with exotropia (18.2%) and four patients with esotropia (25%) were adjusted under intravenous ketamine in the operating room under anesthetist supervision. No difficulty was encountered in advancing/recessing the muscles. The success rate at 1 month was 100% for exotropia and 87.5% for esotropia. The success rate at the final follow-up was 81.8% for patients with exotropia and 68.7% for patients with esotropia.

Conclusions:

This delayed optional adjustable strabismus surgery technique provides good short-term results and lower adjustment rates.

Early postoperative changes of motor alignment after surgery for intermittent exotropia

PURPOSE

To evaluate the early postoperative changes of the angle of deviation after surgery for intermittent exotropia.

METHODS

We retrospectively reviewed the medical records of 114 patients who had been surgically treated for intermittent exotropia and followed-up on postoperatively for 1 month or more. Patients were observed at postoperative 6 h, 1 day, 1 week, and 1 month. The main outcome measure was the change of the angle of deviation during the early postoperative period (from 6 h to 1 day postoperatively).

RESULTS

The mean preoperative angle of exodeviation was 26.3 ± 7.6 PD at distance and 25.4 ± 10.3 PD at near. The angle of deviation was -3.3 (esodeviation) ± 7.0 PD at distance and -0.7 ± 7.1 PD at near at postoperative 6 h, and -3.7 ± 6.9 PD and -0.8 ± 6.8 PD at postoperative 1 day. Neither of these sets represented a significant change from 6 h to 1 day postoperatively (p = 0.300 at distance, p = 0.945 at near). However, in 25 patients (21.9%) the angle of deviation changed 5 PD or more from 6 h to 1 day. Among them, ten showed exodrift and 15 esodrift. At postoperative 1 month, the deviations became significantly more exotropic compared with postoperative 1 day (p < 0.001).

CONCLUSIONS

The mean angle of deviation showed no significant change from 6 h to 1 day postoperatively, but 21.9% of patients showed a change of 5 PD or more in this period. These results should be considered in determining the time and the target angle of adjustment in adjustable strabismus surgery for exotropia.

Adjustable suture strabismus surgery in pediatric patients using pull-string technique

BACKGROUND/PURPOSE:

The concept of adjustable suture has been developed in strabismus surgeries for nearly four decades. This technique is not yet universally embraced by strabismus surgeons, especially in pediatric patients. The aim of this study is to describe and evaluate the application of the adjustable suture with pull-string technique in pediatric patients.

METHODS:

A retrospective medical record review was conducted for patients aged 18 years and under who received adjustable suture strabismus surgery using short tag sliding noose with pull-string technique. For the analysis, the patients were arbitrarily divided into three age groups: 6 years and younger, between 6 and 12 years, and 12 years and older. Patients were examined at 1 week and 1, 3, and 6 months after surgery.

RESULTS:

A total of 123 patients were enrolled in this study. The mean age at the time of surgery was 9.4 years, ranging from 0.7 to 18.4 years. Eighteen (14.6%) patients required adjustment and 105 (85.4%) patients did not require adjustment. The average follow-up was 10.2 months (range, 1–48 months). At their final postoperative follow-up, 93 of 123 (75.6%) patients were within 10 prism diopters of orthophoria. The success rates were 77.6% (66/85) in exotropia patients and 71.1% (27/38) in esotropia patients. The success rates were 76.4% (84/110) for those who receive the procedure as primary surgery and 69.2% (9/13) for those who receive the procedure as reoperative surgery. Of the 18 patients who required adjustment, 16 (88.9%) patients were successful. Of the 105 patients who did not require adjustment, 77 (73.3%) patients were successful.

CONCLUSION:

This study showed that the pull-string technique provided similar success rate compared to those reported in literature in pediatric patients. The pull-string technique is developed to simplify the postoperative adjustments. Many surgeons encounter difficulties to handle the postoperative adjustments, especially when they need to retrieve the buried subconjunctival adjustable sutures. The obstacles are reduced with the aid of pull string. Using the pull-string technique, the surgeon can perform adjustable suture surgeries in any age group with confidence.

A comparative study of adjustable and non-adjustable sutures in primary horizontal muscle surgery in children

PurposeTo compare the results of using adjustable and non-adjustable sutures in primary horizontal strabismus surgeries in children.MethodsThis randomized control trial included 60 cases of primary horizontal deviation. The adjustable suture (AS) group included 30 patients, and the non-adjustable suture (NAS) group included 30 patients. The follow-up period was at least 6 months. A successful motor outcome was defined as orthophoria or a horizontal tropia of 8 PD or less at both near and far distances. The success rate and ocular drift were recorded and analysed.ResultsThe mean age in the AS group was 3.48±2.37 years at the time of surgery. The mean age in the NAS group was 3.55±2.64 years at the time of surgery. The success rate at the end of 6 months was 86.67% in the AS group and 73.33% in the NAS group (P=0.197). In exotropic patients, there was a mean undercorrection drift of 2.86 PD in the AS group and a mean undercorrection drift of 2.17 PD in the NAS group. In esotropic patients, there was a mean undercorrection drift of 0.26 PD in the AS group and a mean undercorrection drift of 1.83 PD in the NAS group.ConclusionThere was no significant difference between the groups. However, the success rate was clinically higher in the AS group than in the NAS group.

An external pilot study to test the feasibility of a randomised controlled trial comparing eye muscle surgery against active monitoring for childhood intermittent exotropia [X(T)]

INTRODUCTION

The evidence base for the treatment of strabismus (squint) is poor. Our main aim is to improve this evidence base for the treatment of a common type of childhood squint {intermittent exotropia, [X(T)]}. We conducted an external pilot study in order to inform the design and conduct of a future full randomised controlled trial (RCT).

METHODS

Children of between 6 months and 16 years with a recent diagnosis of X(T) were eligible for recruitment. Participants were recruited from secondary care at the ophthalmology departments at four UK NHS foundation trusts. Participants were randomised to either active monitoring or surgery. This report describes the findings of the Pilot Rehearsal Trial and Qualitative Study, and assesses the success against the objectives proposed.

RECRUITMENT AND RETENTION

The experience gained during the Pilot Rehearsal Trial demonstrates the ability to recruit and retain sites that are willing to randomise children to both trial arms, and for parents to agree to randomisation of their children to such a study. One child declined the group allocation. A total of 231 children were screened (expected 240), of whom 138 (60%) were eligible (expected 228: 95%) and 49 (35% of eligible) children were recruited (expected 144: 63% of eligible). Strategies that improved recruitment over the course of the trial are discussed, together with the reasons why fewer children were eligible for recruitment than initially anticipated. Attrition was low. Outcome data were obtained for 47 of 49 randomised children.

TRIAL PROCESSES AND DATA COLLECTION

The Trial Management processes proved effective. There were high levels of completion on all of the data collection forms. However, the feedback from the treatment orthoptists revealed that some modifications should be made to the length and frequency of the health service assessment and travel assessment questionnaires, thus reducing the burden on participants in the main trial. Modifications to the wording of the questions also need to be made.

MONITORING OF BIAS

Children who recruited to the trial were older and had more severe strabismus than those children eligible but declining participation. Strategies to account for this in a full trial are proposed.

REASONS FOR PARTICIPATION OR DECLINING STUDY

These were identified using qualitative interviews. The principal reasons for declining entry into the study were strong preferences for and against surgical treatment.

HARMS

There were no serious unexpected adverse events. Two children had overcorrection of their X(T) with reduction in binocular vision following surgery, which is in line with previous studies. No children in the active monitoring arm developed a constant strabismus although two showed some reduction in control.

CONCLUSIONS

The SamExo study has demonstrated that it is possible to recruit and retain participants to a randomised trial of surgery compared with active monitoring for X(T). For longer-term full RCTs, in order to maximise the generalisability of future studies, consideration needs to be given to planning more time and clinic appointments to assess eligibility and to allow consideration of participation; the greater use of research nurses for recruitment; and accommodating the strong preferences of some parents both for and against surgical intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN44114892.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 39. See the NIHR Journals Library website for further project information.

Rates of Reoperation and Abnormal Binocularity Following Strabismus Surgery in Children

PURPOSE

To determine predictors of reoperation and abnormal binocularity outcomes (including amblyopia and diplopia) following pediatric strabismus surgery.

DESIGN

Retrospective cross-sectional study.

METHODS

setting: Review of a national insurance database.

STUDY POPULATION

Children under age 18 years having strabismus procedures between 2007 and 2013.

INTERVENTIONS

Adjustable- or fixed-suture strabismus surgery, or botulinum toxin injection.

OUTCOME MEASURES

Reoperation or diagnosis of abnormal binocularity in the first postoperative year.

RESULTS

Of 11 115 children having strabismus procedures, 851 (7.7%) underwent reoperation. The reoperation rate was 7.4% for fixed-suture surgeries, 9.6% for adjustable-suture surgeries (P = .18), and 44.9% for botulinum injections (P < .001). Age under 2 years was associated with higher reoperation and abnormal binocularity rates (P < .001). For horizontal strabismus, the postoperative abnormal binocularity rate was 12.8% for fixed-suture surgery and 26.5% for botulinum injection (P = .005). Reoperation rates tended to be higher with adjustable sutures (odds ratio [OR] 1.69, 95% confidence interval [CI] 0.94-3.03, P = .08) or botulinum toxin injection (OR 10.36, 95% CI 5.75-18.66, P < .001) and lower with 3- or 4-muscle surgery (P = .001). Esotropia, hyperopia, and botulinum injection were independently associated with higher rates of postoperative abnormal binocularity (P ≤ .005). For vertical surgeries, predictors of reoperation were adjustable-suture use (OR 2.51, P = .10) and superior oblique surgery (OR 2.36, P < .001).

CONCLUSIONS

Adjustable sutures were not associated with a lower reoperation rate in children. Younger age, esotropia, hyperopia, and botulinum injection were associated with postoperative abnormal binocularity. Superior oblique surgery and botulinum injection were associated with higher rates of reoperation.

Adjustable sutures: an update

PURPOSE OF REVIEW

This review discusses outcomes and recent advances in the use of adjustable sutures in strabismus surgery for children and adults.

RECENT FINDINGS

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.

SUMMARY

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.

Changes in the interpupillary distance following general anesthesia in children with intermittent exotropia: a predictor of surgical outcomes

PURPOSE

To determine whether changes in ocular alignment following general anesthesia, as measured by interpupillary distance, can be used as a predictor for surgical outcomes in children with intermittent exotropia.

METHODS

The authors obtained digital photographs of 40 children with exotropia and 20 children with epiblepharon (control group) before and immediately after induction of general anesthesia in the primary supine position. Differences in the anatomic interpupillary distance (aIPD) for each patient were measured and compared with the preoperative angles of deviation. They were also correlated with surgical outcomes on the first day and 1 year after surgery.

RESULTS

All 60 patients demonstrated an increase in aIPD following general anesthesia. The mean change in aIPD in patients with exotropia was similar to that in patients with epiblepharon (3.78% ± 2.53% and 3.15% ± 1.05%, respectively). In patients with exotropia, there was a significant positive linear correlation between the preoperative distance deviation (P) and the change in eye position (A): A = 0.362 P - 4.488, r(2) = 0.476 (P < .001). Five (71%) of seven patients whose changes were outside the 80% confidence interval for expected values had poor surgical outcomes on the first postoperative day and four had unsatisfactory results 1 year after surgery.

CONCLUSIONS

Changes in aIPD following general anesthesia were strongly correlated with preoperative angle of deviation. Therefore, they may be a useful predictor of surgical outcomes in children with exotropia.

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.

The short adjustable suture

OBJECTIVE

To describe a new, adjustable suture technique for strabismus surgery that is safe and effective and allows for adjustment during the postoperative week only when required.

DESIGN

Retrospective review.

PARTICIPANTS

A total of 304 patients, of which 149 were male and 155 female, with an age range from 4 to 89 years and a median age of 42 years.

METHODS

All patients treated with the short adjustable suture technique between September 2007 and April 2009 were reviewed retrospectively. Details of cause, complexity and reoperation, operative success, requirement for adjustment, and success of adjustment were collected. Success was defined as horizontal deviation < or = 10 prism diopters (PD) and vertical deviation < or = 6 PD.

RESULTS

Overall, 84% of horizontal deviations and 74% of vertical deviations were treated successfully with 1 operation. Twenty-one adjustments were performed. Complications included 1 slipped slip knot and 6 conjunctival or Tenon cysts.

CONCLUSIONS

The short adjustable suture is a safe and effective variation of the standard slip-knot adjustable suture technique. It allows for adjustment up to 6 days postoperatively with minimal patient discomfort. When adjustment is not indicated, the suture can be left in place to absorb.

Adjustable suture strabismus surgery in infants and children

PURPOSE

To evaluate the success rate of adjustable suture techniques in horizontal eye muscle surgery in children aged 10 years and younger.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Adjustable suture use in strabismus surgery

PURPOSE OF REVIEW

This review includes updated information regarding adjustable suture strabismus surgery for children and adults.

RECENT FINDINGS

Main themes in the literature reviewed in this article include the appropriate timing for the adjustment technique, appropriate anesthesia, recent modifications in adjustable strabismus surgery techniques, and future developments.

SUMMARY

Improved timing of adjustment, improved anesthesia, and newer surgical techniques allow strabismus surgeons to offer treatment options better suited to the needs of each strabismus patient.