STRABISMUS TREATMENT

The choice of using a closed conjunctival delayed approach to adjustable suture surgery may present some significant advantages to more traditional adjustable suture techniques in the treatment of strabismus, according to David B Granet MD, FACS, FAAP.

Dr Granet said that the technique offers a valuable option for the strabismologist, especially in the case of repeat surgeries and complex strabismus cases.

“Potential advantages include the decreased risk of infection owing to immediate conjunctival closure, decreased interference from pain and oedema on postoperative measurements and less physician and patient time due to the decreased need for postoperative adjustment,” he explained.

He said that the closed conjunctival approach is a refinement of the traditional adjustable suture technique, which allows fine-tuning of surgical outcomes in the immediate postoperative period. The adjustment usually takes place 3-7 days after surgery, and is performed by removing or stretching conjunctival sutures and positioning the globe with the traction suture to enable exposure of the cinch or bow knot. The knots are adjusted until the muscle is in its desired position as confirmed by motility testing before the conjunctiva is re-sutured.

In a large multicentre retrospective review of the technique published in the British Journal of Ophthalmology, postoperative ocular adjustments were required in 26 per cent of patients and were performed from two hours to 14 days after surgery, with an average adjustment time of 2.5 days. The study evaluated outcomes in 440 patients ranging from 10 to 91 years performed at four centres in the US by five surgeons.

Patient satisfaction

In the total sample, all strabismus subgroups had high levels of patient satisfaction, defined as no report of diplopia in the chief complaint in target gaze and/or had cosmetic improvement during the follow-up period, noted Dr Granet. The lowest long-term satisfaction group had the highest rate of thyroid-associated ophthalmopathy-induced strabismus.

Complications associated with the procedure were transient and included dellen, poor conjunctival appearance, filamentary keratitis, infection, granuloma, exposed suture and corneal abrasion. There was one case of corneal microperforation treated with glue and contact lens in a patient with severe-trauma-induced dry eye and one case of scleral perforation in a patient with previous retinal detachment and high myopia treated with retinal laser and repeat detachment surgery. The total untoward event rate, including all events, was six per cent (29 of 440) with individual surgeon rates as low as 0.8 per cent said Dr Granet.

While the retrospective study only included patients older than 10 years of age, Dr Granet told EuroTimes that the technique has also been successfully utilised in younger patients.

Summing up, he said that while prospective, randomised trials are needed to validate the closed conjunctival delayed approach to adjustable suture surgery, the technique represents a valuable addition to the armamentarium of the strabismus surgeon.

David B Granet: dgranet@ucsd.edu