A Survey of the Management of Globe Perforation During Strabismus Surgery in the United Kingdom

Unilateral surgery for pediatric sensory exotropia: clinical characteristics and surgical results

BACKGROUND

To delineate the clinical characteristics and surgical outcomes of large angle sensory exotropia in pediatric patients.

METHODS

The medical records of 54 large angle exotropia ≥40 PD patients aged from 1 to 18 years who were operated on between 2018 and 2021 and were followed up for 1 year were reviewed and contacted. Clinical characteristics and surgical outcomes were analyzed retrospectively. Patients were divided into two groups, group S patients had supermaximum recession resection and group E had augmented recession by lateral rectus muscle elongation with an autograft from the resected medial rectus muscle in the same eye. The clinical characteristics and results of both groups were compared.

RESULTS

The mean age of the studied patients with sensory exodeviation at the time of surgery was 8.3 ± 4.2 years. Mean of the duration of exotropia was 6.9 ± 2.2 years, and the mean of postoperative follow-up was 14.3 ± 4.2 months. Surgical success was achieved in 73.07% of group S and 82.14% of group E. Recurrence was more common with anterior segment pathology. Larger post-operative distant angles were strongly related to poorer visual acuities P = 0.001 and not related to the age of onset or the duration. Narrowing of the palpebral fissure improved in both groups at the last follow up P = 0.336. The limitation of abduction in both groups improved in the last follow up P = 0.145.

CONCLUSION

The outcome of monocular surgery for sensory exotropia in children is satisfactory with no significant differences in results between lateral rectus muscle tendon autograft elongation technique and supermaximum recession resection. Recurrence is more common with anterior segment pathology. Larger post-operative distant angle of deviation is strongly related to poorer visual acuity.

CLINICAL TRIAL REGISTRATION

This study was retrospectively registered at clinicaltrials.gov (ID: NCT04286945) on 25-2-2020.

Scleral Perforation as a Complication of Strabismus Surgery: A Literature Review

The aim of this review was to report the existing literature on the incidence, risk factors, treatment, and outcomes of scleral perforation as a vision-threatening complication of strabismus surgery. The current literature reported an incidence range of scleral perforation/penetration between 3 in 1,000 and 7.8%. Rectus muscle recession was the most commonly mentioned risk factor among the studies. Other risk factors were myopia, previous extraocular muscle surgery, surgeon experience, S-24 needle use, muscle reattachment posterior to the original insertion site, operating on a horizontal rectus muscle, and young age. Different views existed in the literature regarding scleral perforation management. Some ophthalmologists advocated management by cryopexy or indirect ophthalmoscopic laser uniformly, whereas others reserved it for more complicated cases. Antibiotic therapy for endophthalmitis prophylaxis was recommended by one study and shown to be practiced by some ophthalmologists. [J Pediatr Ophthalmol Strabismus. 2022;59(4):214-223.].

Wright hang-back recession with fibrin glue compared with standard fixed suture recession for the treatment of horizontal strabismus

OBJECTIVE

To evaluate the clinical safety and efficacy of the novel Wright hang-back recession with fibrin glue for the treatment of horizontal strabismus.

STUDY DESIGN

Retrospective, case-controlled clinical study comparing surgical outcomes of the Wright hang-back rectus recession with fibrin glue (WHBG) versus standard fixed suture rectus recession (SFR).

METHODS

Medical records of all patients who underwent strabismus surgery by one strabismus surgeon between 2016 and 2018 for horizontal deviations only, including cases of WHBG (group 1) or SFR (group 2), were reviewed. Good surgical outcome was defined as a postoperative deviation ≤10 prism diopters (PD) at a minimum 2 months of follow-up.

RESULTS

32 eyes of 17 patients underwent WHBG and 32 eyes of 17 patients underwent SFR; in each group, 35% had esotropia and 65% had exotropia. Mean preoperative deviations between groups were similar: esotropia 25.5 PD and exotropia 26.6 PD in WHBG; esotropia 28.3 PD and exotropia 23.8 PD in SFR. The mean postoperative deviation was <7 PD for both groups. Good surgical outcomes were similar between groups, 16/17 (94%) in WHBG and 15/17 (88%) in SFR, with no complications.

CONCLUSIONS

WHBG was safe and effective with postoperative results similar to SFR. WHBG has an important advantage, eliminating the complication of retinal perforation that can occur with SFR while avoiding under- or overcorrection that can occur with traditional hang-back recession. This technique increases patient safety without sacrificing surgical outcomes and is especially useful in patients with thin sclera such as patients with high myopia or with difficult posterior exposure.

Impact of a Strabismus Surgery Suture Course for First- and Second-Year Ophthalmology Residents

PURPOSE

To investigate the effectiveness of an eye muscle surgery course on first- and second-year postgraduate ophthalmology residents.

METHODS

This prospective cohort pilot study invited first- and second-year ophthalmology residents to participate in a 2-hour strabismus surgery course at Wills Eye Hospital. The course consisted of a didactic session followed by a wet laboratory session. The wet laboratory session simulated strabismus surgery using a model constructed of chicken breast followed by partial-thickness scleral suture passes in pig eyes. A structured self-assessment evaluation form and a questionnaire in the validated Ophthalmology Surgical Competency Assessment Rubric approved by the International Council of Ophthalmology (ICO-OSCAR:strabismus) were used to assess the effectiveness of the course.

RESULTS

A total of 12 residents, 8 (67%) first-year and 4 (33%) second-year, were enrolled for this survey. Following the course, most residents felt less anxious (73%). All residents responded that the course was helpful or somewhat helpful in preparation for strabismus surgery. Regarding the distribution of ratings on questions of subjective experience, knowledge of steps, and understanding of potential complications, the residents gave significantly higher ratings after the course (P < .029). The change in the modified ICO-OSCAR:strabismus assessment's mean score was statistically significant before and after training (P = .038).

CONCLUSIONS

A strabismus course can play an important role in preparing residents for strabismus surgery. [J Pediatr Ophthalmol Strabismus. 2017;54(6):339-345.].

Tendon elongation with bovine pericardium (Tutopatch®) when conventional strabismus surgery is not possible

PURPOSE

Sometimes, a conventional recess-resect surgery may not be sufficient to obtain satisfactory ocular alignment. Patients who have previously undergone surgery and/or have a large difference in visual acuity between both eyes and do not wish to undergo surgery on the sound eye provide a surgical challenge. In these cases, tendon elongation with bovine pericardium may be an option.

METHODS

We retrospectively reviewed the charts of 38 patients who underwent strabismus surgery with tendon elongation. Before surgery, 31 had exotropia (angle -21.8 ± 5.7 degrees) and 7 esotropia (angle +19.1 ± 5.4 degrees). Reasons for tendon elongation included the following: 15 patients refused surgery on their sound eye; in 15 patients, conventional recess-resect was not possible; and in 7 patients, the elongation best fitted the motility pattern. In one patient, tendon elongation was preferred over conventional recession because of a thin sclera. Follow-up was 0.5 to 4 years.

RESULTS

At last follow-up visit, in patients with previous exotropia, the angle was -3.3 ± 5.9 degrees; in patients with previous esotropia, +0.2 ± 0.5 degrees. Most had some duction limitation in the direction of the elongated muscle. All patients but one were satisfied with the result. In the patients with previous exotropia, there was a small but nonsignificant regression to recurrence of the exodeviation (on average 0.5 degree per year).

CONCLUSIONS

Tendon elongation is a valuable addition to our strabismus surgery repertoire. However, because of duction limitations after surgery, it should be reserved for those cases in which conventional surgery is not an option.

[Eye muscle surgery]

Eye muscle surgery is as a rule surgery on healthy eyes. It therefore requires particularly high standards in terms of a lack of complications and predictability of surgical results. Misalignment of the eyes, binocular diplopia and ocular torticollis are all indications for eye muscle surgery as are enlargement of the binocular visual field, asthenopic complaints in heterophoria or the stabilization of binocular functions. Eye muscle surgery is binocular surgery and differs from monocular surgery. It has its own complications and requires specific skills.