Original Article
Adjustable Strabismus Surgery: An
Early Glance
Sana Nadeem,
B.A Naeem, Farman Khan
Pak J Ophthalmol 2018, Vol. 34, No. 2
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See end of article for authors affiliations …..……………………….. Correspondence to: Sana Nadeem Eye
Department Fauji
Foundation Hospital, Rawalpindi Email: sana.nadeem018@gmail.com |
Purpose: To assess the short term
success rate of adjustable suture technique on rectus muscle strabismus
surgery in terms of postoperative alignment Study Design: Prospective, interventional
study Place and Duration of Study: Eye Department,
Fauji Foundation Hospital, Rawalpindi, from 25th June, 2016 to 25th
December, 2017 Material and Methods: We
carried out a study using the fornix approach for adjustable squint surgery,
in mainly horizontal strabismus in adults and cooperative children, to finely
tune the postoperative alignment. The preoperative deviation, strabismus
type, patterns, were measured and analyzed. The early postoperative alignment
was measured at 6 weeks postoperatively, to assess the success of the
adjustable suture technique. A sliding noose knot was used to adjust the
sutures, 1 hour postoperatively under topical proparacaine anesthesia, after
the effects of general anesthesia had worn off. Results: 31 patients were included in
this study. The majority were female being 23 (74.5%). The age ranged from 9
to 37 years, with the mean age 16.87 ± 5.5 years. All consenting adults and
teenagers, with strabismus were included in this study and operated via the
adjustable suture technique. The mean preoperative deviation was 49.38 ±
16.29 Δ prism diopters, and the mean postoperative deviation was 3.5 ±
5.42Δ prism diopters. The difference between the two was
statistically significant (p < 0.05), using the Wilcoxon Signed Ranks test
(p = 0.000). Early surgical success defined as alignment within ± 10Δ (prism diopters) of orthotropia
at the end of 6 weeks after surgery, was found in 27 (87.1%) of our
strabismus cases. Conclusion: Adjustable strabismus surgery
is associated with excellent short-term postoperative outcomes in terms of
alignment and patient satisfaction. Adjustable sutures should be considered
in all strabismus cases, whether adults or children. Key Words: short term, success,
adjustable, strabismus, fornix approach, alignment. |
Adjustable strabismus surgery1
is an art, dating back to 1907, with the ideation of Bielchowsky, O’Connor and
Harms who first introduced this technique to refine postoperative alignment. Jampolsky1
later re-introduced the adjustable suture technique to achieve stable motor
alignment and sensory improvement. Although most strabismus surgeons who use
adjustable sutures, including me, would prefer them for all their patients
regardless of the cause of strabismus, or age of the patient; there are certain
indications2 where they are necessary for good cosmetic results:
restrictive strabismus including thyroid myopathy, anesthetic myotoxicity,
scleral buckles, paralytic strabismus, and diplopia to name a few. This art however,
has failed to gain universal acceptance so far, and especially in Pakistan3.
Strabismus surgery can be tricky3 in terms of its outcomes, despite
accurate measurements and nomograms followed, and may yield different results
in different patients, in spite of the same amount of alignment. Thus, the need
arises, to adjust the eyes postoperatively, to maximize the chances of success.
Adjustable sutures give the operating surgeon a ‘second chance’ at achieving a stable
alignment4.
In June 2016, we started doing adjustable
strabismus surgery, and found it to achieve superior cosmesis, and improve
binocular vision and diplopia5. Since we are relatively new at this technique,
we decided to review and share our early postoperative alignment at six weeks6
postoperatively, as this is the time, which reflects the chance of the patient achieving
eventual long term stable alignment of eyes.
The aim of this study is to describe the adjustable suture technique
and to assess its effectiveness and success in the early postoperative period,
prospectively, in addition to highlight the importance and benefits of
postoperative adjustment on postoperative outcomes. The importance of sharing
our experiences with others is to benefit those who want to help their patients
in achieving the best postoperative cosmetic results.
MATERIAL AND METHODS
All consenting adults and co-operative
teenagers with strabismus were included in this ongoing study, reaching 31
patients. This study was carried out in the Department of Ophthalmology, Fauji
Foundation Hospital, Rawalpindi, which is a tertiary care, teaching hospital
affiliated with Foundation University Medical College; from 25th June
2016 to 25th December 2017. Approval from the ethical committee was
taken. The strabismus cases included both horizontal and vertical strabismus,
with only one horizontal muscle being used for adjustment. Patients with
previous history of strabismus surgery were also included. The first author
performed all surgeries. Restrictive strabismus, myasthenia gravis, and uncooperative
children less than 9 years of age were excluded.
Visual acuity was documented for every case
with a refractive correction given to patients prior to consideration for
surgery. The type of strabismus was noted for each patient. The preoperative
angle of deviation was assessed by the prism cover test for both near and distance
with the refractive correction in place. In certain cases of sensory strabismus
with poor fixation, the Krimsky test was used for analysis of the angle or a
pen torch used as a target for near and distance. The angle of deviation was
measured for both near and distance as well as in up gaze, downgaze, right and
left gaze. However, the distance angle with refractive correction in place was
considered as the angle of deviation in all cases, and the surgical alignment was
sought to correct this angle. At the time of suture adjustment, though, both
near and distance alignment was corrected. Exception to this was accommodative
refractive esotropia, for which the near deviation with distance spectacles in
place was considered for correction of the alignment. A plus sign (+) was
assigned to an exotropic angle and a negative sign (-) was assigned to an
esotropic angle. The measurements were taken by the operating surgeon and a
certified orthoptist, and repeated by the operating surgeon one day prior to
surgery, to obtain maximum cosmesis. Binocular vision and stereopsis were
assessed by the Titmus fly test and Worth four-dot test, routinely by the
orthoptist preoperatively. A thorough eye examination was performed including
fundus and intraocular pressures, and was documented.
All surgeries were performed under general
anesthesia. A drop of phenylephrine 10% (Ethifrin®) were instilled
into the conjunctival fornix at the beginning of surgery in each eye. The
fornix approach for strabismus surgery was used in every case. Each muscle was
hooked, and then secured with a double armed 6-0 vicryl (polyglactin 910)
absorbable suture, which was passed through the sclera at its insertion, or transposed
above or below the insertion in case of ‘A’ or ‘V’ patterns, in a ‘hang-back’7,8
fashion. The medial recti were transposed towards the apex, and the lateral
recti were transposed away from the apex, in case of ‘A’ or ‘V’ patterns. The
recessed muscles were mostly placed for adjustable purpose, with the required
recession held in place by Guyton’s9 modification of the sliding
noose knot, which was fashioned with a 6-0 Vicryl suture. The amount of ‘hang-back’
recession was calculated for each patient using standard tables4,10,11.
The traction suture for holding the sclera for postoperative adjustment was created
with ethibond 5-0 in every case. For the non-adjustable recessions, the muscle
was tied and allowed to ‘hang-back’ from its insertion, with the required
amount of recession calculated as required. Resections were also put up for
adjustment in one case only, but avoided mostly, as they tend to cause more
pain. For resections, the amount of resection is overcorrected by 2 mm, and
allowed to ‘hang-back’ for this distance, to be adjusted if required
postoperatively. Only one muscle was kept on an adjustable sliding noose knot
per case.
All patients were assessed for alignment
and final adjustment at least 1 hour or more after surgery, in the recovery
room, to allow time for the effects of general anesthesia to wear off12.
The eyes were anesthetized topically with Alcaine® (proparacaine hydrochloride
0.5%) eye drops. The patients were assessed with the cover-uncover test at
distance and near, with a torch light for distance if the vision was blurred (due
to viscoelastic, antibiotic/steroid drops placed postoperatively or pupillary
dilatation with phenylephrine or general anesthesia), or a distance readable
target, and for near an accommodative target was used. If the alignment was
satisfactory, with no movement on cover testing, the sutures were tied off in
their existing position, held in place by the sliding noose, which was
removable after tying the ends of the muscle sutures. Thereafter, the traction
knot was cut, and the conjunctiva was sutured with at least one 6-0 vicryl suture.
The final tying off point was orthotropia or maximum possible under-correction
as required. In cases of exotropia, the goal was orthotropia or mild esotropia.
In cases of esotropia, the goal was either orthotropia, if achieved, or slight
under-correction.
The alignment was noted postoperatively the
next day, at 2 weeks and 6 weeks after surgery. The patients were given postoperative
topical steroid and antibiotic drops twice a day and ointment at night for a
minimum of 2 weeks. The follow up is being continued to assess long term
postoperative alignment as well.
Early
surgical success was defined as alignment within ± 10Δ (prism
diopters) of orthotropia at the end of 6 weeks after surgery. This
postoperative residual deviation was the average of the distance and near
deviations noted on prism cover testing. Although both horizontal, vertical and
complex strabismus were included in our study, the horizontal alignments
preoperatively and postoperatively, were mainly assessed and analyzed for
surgical success purpose.
The results were noted, tabulated and analyzed using the SPSS
statistics version 20. Frequencies were calculated for age, gender, type and
pattern of strabismus, surgical procedure performed, as well as the follow-up. Statistical
analysis of success rate was done, and assessment of statistically significant
differences between the preoperative and postoperative strabismus deviations
was analyzed by the Wilcoxon Signed Ranks
test. The success rate was compared and analyzed for the type of strabismus
as well.
RESULTS
31 patients were included in this study,
with predominantly 23 (74.2%) females and 8 (25.8%) males. The mean age was
16.87 ± 5.5 years with a range from 9 years to
37 years. The early postoperative alignment was measured at 6 weeks follow up, and
the average follow up was 52.7 ± 13.76 days, with an actual range from 38 to 94
days.
The patients were
classified based on type of deviation and the majority of them were exotropic
with 16 (51.6 %) cases [Table 1]. Table 1 categorizes the patients based on
type of strabismus, with predominance of purely horizontal cases in 17 (54.8 %)
cases; the rest being a combination of horizontal, vertical and/or complex
strabismus. Associated patterns, A, V, X, Y were tabulated in Table 2, with
predominance of V-pattern.
Table 1: Type of Strabismus.
Deviation Type |
Frequency (Percent) |
Exotropia |
16 (51.6) |
Esotropia |
6 (19.4) |
Exotropia
& DVDɸ |
2 (6.5) |
Esotropia
& DVDɸ |
1 (3.2) |
Exotropia
& Hypertropia |
5 (16.1) |
Esotropia
& Hypertropia |
1 (3.2) |
Horizontal |
17 (54.8) |
Horizontal
and Vertical |
7 (22.6) |
Horizontal
& Complex€ |
4 (12.9) |
Horizontal,
Vertical & Complex€ |
3 (9.7) |
ɸ Dissociated vertical deviation
€
Sensory, paralytic strabismus or DVD
Table 2: Pattern of Strabismus if
Present.
Pattern |
Frequency (Percent) |
V-pattern |
20 (64.5) |
A-pattern |
4 (12.9) |
None |
7 (22.6) |
Table 3: Surgical Procedure Performed.
Surgical Procedure |
Frequency (Percent) |
BLRc¶ |
12 (38.7) |
BMRc§ |
5 (16.1) |
BMRsĄ |
1 (3.2) |
MRc¤ + LRs× |
1(3.2) |
MRsř + LRcĦ |
6 (19.4) |
BLRc¶ + MRsř |
4 (12.9) |
BMRc§ + LRs× |
1 (3.2) |
MRc¤ |
1 (3.2) |
¶ Bilateral recessions
§ Bimedial
recessions
Ą Bimedial resections
¤ Unilateral
medial rectus recession
× Unilateral lateral rectus resection
ř Unilateral medial rectus resection
Ħ Unilateral lateral rectus recession
The various
surgical procedures performed to correct horizontal component of strabismus are
listed in Table 3. Associated vertical deviations were addressed with
concurrent procedures on the vertical Recti or obliques, which are listed in
Table 4. A summary of the data in accordance with the type of deviation is
elaborated in Table 5.
The mean preoperative
deviation was 49.38 ± 16.29Δ (prism diopters), with a range
from 23 to 85Δ. The mean postoperative deviation was 3.5 ± 5.42Δ
(prism diopters), with a range from zero to 20Δ. The difference
between the preoperative and postoperative deviation was analyzed by the Wilcoxon Signed Ranks test and found to be statistically significant
(p = 0.000) [Table 6]. Early surgical success defined as satisfactory alignment within ± 10Δ
(prism diopters) of orthotropia at the end of 6 weeks after surgery, was
found in 27 (87.1%) of our strabismus cases, and were tabulated for each
deviation type [Table 7], and under corrections were found in 3 (9.6%) cases of exotropia and 1
(3.2%) case of esotropia only. Figures 1-3 depict our post-operative success.
Reoperation has not been required in any of these cases so far. No complication
was encountered in any patient during suture adjustment and all proceeded
smoothly with minimal patient discomfort.
Table 4: Surgery on Vertical Recti &
Obliques.
Surgery on Vertical Recti & Obliques |
Frequency (Percent) |
Unilateral IOα myectomy |
3 (9.7) |
Bilateral IOα myectomies |
6 (19.4) |
IOα anteriorization |
1 (3.2) |
SRβ transposition |
1 (3.2) |
Bilateral IOα myectomies + SRcƩ |
1 (3.2) |
None |
19 (61.3) |
α Inferior oblique β Superior rectus
Ʃ Superior rectus recession
Table 5: Data Analysis According to
Deviation Type.
Type of Deviation |
Age in Years (mean ± SD) |
Gender |
Preoperative Angle (PD) (Mean ± SD) Ω |
Postoperative Angle (PD) (Mean ± SD) |
Pattern |
||
Male |
Female |
V-Pattern |
A-Pattern |
||||
Exotropia |
19.06 ± 6.18 |
4 |
12 |
48.1 ± 16.7 |
4.46 ± 6.77 |
9 |
2 |
Esotropia |
14.17 ± 4.4 |
2 |
4 |
60.1 ± 13.3 |
2.58 ± 4.34 |
4 |
2 |
Exotropia & DVDɸ |
13.5 ± 4.9 |
1 |
1 |
34 ± 8.4 |
1.00 ± 1.41 |
2 |
0 |
Esotropia & DVDɸ |
15.0 |
1 |
0 |
70 |
0 |
1 |
0 |
Exotropia & Hypertropia |
15.0 ± 3.53 |
0 |
5 |
47.8 ± 10.7 |
2.30 ± 2.58 |
4 |
0 |
Esotropia & Hypertropia |
16.0 |
0 |
1 |
23 |
8 ± 3.50 |
0 |
0 |
PD
Prism diopters
SD
Standard deviation
Ω
distance deviation in all cases except accommodative esotropia in which near
deviation with distance correction was taken
Table 6: Preoperative and Postoperative
Deviations.
Descriptive Statistics |
|||||||
|
Mean |
Std.
Deviation |
Minimum |
Maximum |
Percentiles |
||
25th |
50th
(Median) |
75th |
|||||
Preoperative Deviation (PD) |
49.3871 |
16.29249 |
23.00 |
85.00 |
40.0000 |
45.0000 |
65.0000 |
Postoperative Deviation (PD) at 6 weeks |
3.5000 |
5.42525 |
.00 |
20.00 |
.0000 |
1.0000 |
6.0000 |
PD
Prism diopters
Test Statisticsa
|
Postoperative Deviation at 6 weeks - Preoperative Deviation
(prism diopters) |
Z |
-4.862b |
Asymp. Sig. (2-tailed) |
.000 |
a. Wilcoxon Signed Ranks Test |
|
b. Based on positive ranks. |
Table 7: Surgical Success.
|
Surgical
Success with Postoperative Deviation within 10 Prism Diopters |
||
Yes |
No |
||
Total
31 |
27 (87.1) |
4 (12.9) |
|
Deviation Type |
Exotropia |
13 (41.9) |
3(9.6) |
Esotropia |
5 (16.1) |
1 (3.2) |
|
Exotropia & DVDɸ |
2 (6.4) |
0 |
|
Esotropia & DVDɸ |
1 (3.2) |
0 |
|
Exotropia & Hypertropia |
5 (16.1) |
0 |
|
Esotropia & Hypertropia |
1 (3.2) |
0 |
ɸ Dissociated vertical
deviation
Fig. 1 (A): 20 year old girl with congenital alternate esotropia of 70Δ, a
left hypertropia of 8Δ, and a V-pattern of 15Δ. Bimedial recessions
of 7mm OD and 8 mm OS after adjustment and a left inferior oblique myectomy was
done.
Fig. 1 (B): Postoperatively, she is well
aligned.
Fig. 2 (A): A 15-year-old girl with an alternate exotropia of 70Δ and a
V-pattern of 32Δ was managed by bilateral lateral rectus recessions of 7mm
and a right medial rectus resection of 6 mm, and bilateral inferior oblique
myectomies. No adjustment was needed postoperatively and the sutures were tied
off.
Fig. 2 (B): Postoperatively she is
orthotropic.
Fig. 3 (A): A 12 year old boy with an alternate exotropia of 40Δ and a
V-pattern of 20Δ was managed with bilateral lateral rectus recessions 6mm
OD and 8 mm OS after adjustment, along with a half tendon width upward
transposition of both muscles was done.
Fig. 3 (B): Postoperatively, he is
orthotropic, with resolution of the V-pattern.
DISCUSSION
In our study, we found adjustable
strabismus surgery to be highly effective for postoperative satisfactory
alignment with a high success rate of 87.1%. The patients experienced no
adverse effects or complications during the adjustable procedure, and did not
report much discomfort during suture tying. We minimized patient discomfort by
putting only one muscle on an adjustable noose knot per procedure, and this too
has borne fruitful results. Suture adjustment was needed in the majority of
patients postoperatively, amounting to 26 (83.8%) cases, and no adjustment was
required for 5 (16.1%) cases, thus indicating the need to fine tune the
postoperative alignment to achieve orthotropia and better surgical outcomes,
because the nomograms and tables may not be appropriate for each individual
case.
Thus, our study findings indicating
positive and encouraging outcomes with the adjustable suture technique are
consistent with numerous studies worldwide, which report high success rates
with the likes of Wisnicki, Repka and Guyton13, who reported a huge
success rate of this adjustable procedure in a massive 290 patients, and rate
of reoperation in just 9.7%. Eino et al14, reported a success rate
of 91.7% in 109 patients, and Tripathi et al15, observed a higher
success rate with adjustable versus non-adjustable surgery in 443 total cases.
Engel et al16 reported a high short-term success rate of 88% in
their adjustable suture technique in 61 children, and so did Awadein and Guyton12,
with their study on children and infants using propofol anesthesia, who noted a
success rate of 79%. Nihalani and Hunter16 also noted a high success
rate for both vertical and horizontal muscle surgery using a short tag noose
technique. Budning et al17 developed a short adjustable suture with
high success in 304 patients. Locally, a study done by Shakir et al18
at LRBT Free Base Eye Hospital in Karachi, reported a success rate of 88% in 18
exotropic subjects with adjustable technique.
Several other authors Park et al19
and Bishop et al20, have contrasting evidence in their reported
studies, where they did not find any difference in surgical success, when
comparing adjustable versus non-adjustable techniques.
The strengths of our study are its success
in terms of surgical results. There are both vertical and horizontal strabismus
patients included along with complex cases like consecutive strabismus, DVD,
patterns, and one case of a sixth nerve palsy. Transpositions were also
performed during surgery on these patients. The surgeries were carried out in a
single step to restore ocular alignment, rather than splitting the large
alignments at a second stage.
A few limitations of our study are a relatively small sample size,
because we wanted to share our early postoperative results, and we do intend to
add more patients to this study with time. Strabismus patients are not that
frequent in our set up and using this technique on more patients is our
priority, for the interest of the patients. Four of our patients did not have a
successful postoperative alignment, and we could attribute it to measurement
errors21,22, or muscle abnormalities, hypoplasia or pulley
anomalies, which can be assessed preoperatively with neuroimaging23.
Also early alignment may vary from subsequent long-term alignment, which is
more important to the patient especially, and to the operating surgeon,
although we have observed them to be quite similar in many of the cases. In
addition, we used only one muscle per patient for the adjustable suture
technique both to avoid excessive discomfort, and to save time. Others2
recommend using adjustable sutures on all muscles, except on the inferior
oblique, in order to adjust the muscles symmetrically and achieve a balanced
alignment between the two eyes. We intend to broaden our experience on
adjustable strabismus, to include all cases including children, to offer our
patients a better chance of success. Some patients have not returned for a
follow up, which we had to exclude from the study, decreasing our eventual
total number of cases.
Future work required is a large-scale study
with more subjects, which we are recruiting, and assessment of long-term
outcomes at one year postoperatively and beyond. Using the adjustable suture on
multiple or all muscles may further enhance the success rate of this procedure.
Infants and children12 also need to be given a chance at better
postoperative success with the use of propofol anesthesia. Superior oblique
adjustment can also be done with this technique, if the need arises to operate
on this muscle.
The need arises to
encourage strabismus surgeons, to use this adjustable technique to maximize the
chances of their surgical success, and to reduce the number of reoperations
needed to satisfy the patients.
CONCLUSION
Adjustable strabismus
surgery has been found to yield excellent short-term postoperative outcomes in
terms of alignment and patient satisfaction. The adjustable suture technique
should be considered in all strabismus cases, whether horizontal, vertical or
cyclovertical; simple or complex strabismus, and irrespective of the subjects
being adults or children.
Author’s Affiliation
Dr.
Sana Nadeem
Assistant
professor
Ophthalmology
Department
Fauji
Foundation Hospital/FUMC, Rawalpindi
Prof. Dr.
B.A Naeem
Professor
and Head
Ophthalmology
Department
Fauji
Foundation Hospital/FUMC, Rawalpindi
Farman
Khan
Orthoptist
Ophthalmology
Department
Fauji
Foundation Hospital/FUMC, Rawalpindi
Role of Authors
Dr.
Sana Nadeem
Principle
author, Performed all surgeries, Orthoptic assessment & Evaluation of all
patients, Data Analysis.
Prof. Dr.
B.A Naeem
Reviewing
author, Opinion about patient management, Head of Department
Farman
Khan
Orthoptic
assessment & Fusion of all the patients
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