ORLY HALACHMI- EYALJNC APRIL 2012

Adjustable sutures –

WHY

Paper 1

Utility of Adjustable Sutures in PrimaryStrabismus Surgery and ReoperationsKamiar Mireskandari, FRCOphth, PhD,1,2

Melissa Cotesta, BSc, OC(C),1Jennifer Schofield, BA, OC(C), COMT,1 Stephen

P. Kraft, MD, FRCSC1,2Ophthalmology 2012;119:629–633

Purpose:

To evaluate the success of adjustable suture (AS) and nonadjustable suture (NAS) in strabismus surgery.

Questions of the research:(1) Do AS cases have a higher success rate than

NAS? (2) Are the success rates different in primary and

reop?(3) Do patients with ET and XT have different

success rates?(4) Does the presence of amblyopia affect the

success rates?

Design:

Retrospective case series , at the Sick children hospital in Toronto, over a 13-year period.

404 pts, Age >12 yoF/U: At list 6 months A single surgeon (S.P.K.) in both the AS and NAS

groups.Main Outcome Measures: Surgical success, ie

alignment within 10PD for H sx and within 5 PD of orthophoria for V Sx (without diplopia or further surgery).

Surgical Technique

Limbal incision Crossed swords at the insertionbow-tie knotAdjustment at the afternoon for morning

operations & conjunctival closure.All pts were given the option for AS (non

randomized).

Results

1963 pts underwent strabismus procedures over the 13-year period.

Of these, 798 were <12yo458 were complex/ had oblique muscle

sx/incomplete data, 303 had < 6 months f/u.Therefore, 404 pts met the inclusion criteria

for the study

Table 1: Pt’s demographics

Results

76 (28.8%) in the AS group had adjustments postop.

Mean change in immediate postop angle after adjustment was 6.5 PD (range, 2–18 PD).

Success was achieved in 205 AS patients (77.7%), and in 96 NAS (69.1%). (Although P 0.059, there is a trend toward higher success with AS (table 2).

Table 3: A higher success for AS in XT in primary surgery.

Table 4: overall success rate

Table 5

Conclusions:

Primary surgery in adults with exotropia has a more successful outcome with AS surgery.

This supports the belief of many strabismus surgeons that AS surgery should be performed on most suitable patients and not just in complex strabismus and repeat surgery.

Conclusions

Overall higher success rate (multivariate analysis) in No mechanical/ neurogenic strabismus Male gender Previous surgery (univariate analysis only)

No affect on success rates for pts with amblyopia.

For AS surgery for ET and vertical deviation – needed bigger numbers.

Paper II

Strabismus surgery: adjustable sutures goodfor all?A Tripathi, R Haslett and IB MarshEye (2003) 17, 739–742

Aims

To analyze the efficacy of adjustable sutures (AS) in squint surgery as a routine procedure and also studied patients’ satisfaction

To determine the role of AS in routine strabismus surgeries*

*AS: previously were limited to conditions like dysthyroid restrictive myopathy, blow-out fractures, aberrant regeneration of nerves, and other long-standing and complicated squints).

Introduction

The two primary indications for AS in strabismus surgery are:

(1) In difficult to estimate results in a cooperative pt

(2) In pts with fusion potential when precise alignment is needed.

Methods

443 patients, 141 – AS, 302 w/o ASAged : 13- 78 years, Surgery from January 1996 to January 2000, F/U: 12 to 50 months. The main outcome measure was a need for a

reoperation.Collected data about pts’ satisfaction with

regard to final cosmetic appearance or relief of diplopia and the final surgical outcome.

Results: reoperation

Of the AS group 70% required postop adjustment Of these, 55.1% were undercorrected and 45.9%

overcorrected.8.5% of the patients in the AS and 27.1% in

the non AS needed a reoperationIn the fixed sutures group- A total of 84.4% of

reoperations were for undercorrections and 15.6% for overcorrections. The adjustable reoperations were all for undercorrection.

Results- patient satisfaction*

*Assessed by orthoptist – after at-least 4 months r/v

Surgical results

Surgical results were found to be significantly better in patients who had AS

Recommendation:

The authors recommend that strabismus surgery with adjustable sutures should be the procedure of choice for all the patients who are fit and willing to cooperate.