Orly halachmi- Eyal

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Adjustable sutures WHY

• Orly halachmi- Eyal
• JNC April 2012

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Paper 1

• Utility of Adjustable Sutures in Primary
• Strabismus Surgery and Reoperations
• Kamiar Mireskandari, FRCOphth, PhD,1,2 Melissa
  Cotesta, BSc, OC(C),1
• Jennifer Schofield, BA, OC(C), COMT,1 Stephen P.
  Kraft, MD, FRCSC1,2
• Ophthalmology 2012119629633

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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?

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Design

• Retrospective case series , at the Sick children
  hospital in Toronto, over a 13-year period.
• 404 pts,
• Age gt12 yo
• F/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).

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Surgical Technique

• Limbal incision
• Crossed swords at the insertion
• bow-tie knot
• Adjustment at the afternoon for morning
  operations conjunctival closure.
• All pts were given the option for AS (non
  randomized).

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Results

• 1963 pts underwent strabismus procedures over the
  13-year period.
• Of these, 798 were lt12yo
• 458 were complex/ had oblique muscle
  sx/incomplete data,
• 303 had lt 6 months f/u.
• Therefore, 404 pts met the inclusion criteria for
  the study

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Table 1 Pts demographics
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Results

• 76 (28.8) in the AS group had adjustments
  postop.
• Mean change in immediate postop angle after
  adjustment was 6.5 PD (range, 218 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).

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Table 2 immediate postop results
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Table 3 A higher success for AS in XT in
primary surgery.
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Table 4 overall success rate
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Table 5
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Table 6
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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.

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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.

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Paper II

• Strabismus surgery adjustable sutures good
• for all?
• A Tripathi, R Haslett and IB Marsh
• Eye (2003) 17, 739742

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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).

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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.

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Methods

• 443 patients, 141 AS, 302 w/o AS
• Aged 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.

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Results Reoperation required
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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 reoperation
• In 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.

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Results

• Surgical results were found to be significantly
  better in patients who had AS.
• Age, gender, number of previous surgeries,
  previous injections of botulinum toxin, and type
  and amount of deviation had no influence on the
  outcome.

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Results- patient satisfaction

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

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Results percentage change in angle of
deviation
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Surgical results

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

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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.

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