Adjustable Sutures in Strabismus Surgery
Federico G. Velez, MD
PREOPERATIVE CONSIDERATIONS
Indications:
Patient selection:
Any patient undergoing eye muscle surgery who can tolerate adjustment under topical anesthesia (pediatric patients if the surgery center or hospital allows short sedation in the recovery room). Preoperatively, the conjunctiva can be manipulated with cotton swabs to get an idea of the patient’s ability to cooperate with adjustment.
Adjustable sutures can be especially helpful in conditions in which the results of surgery may be unpredictable (eg, thyroid eye disease, reoperations) or in situations in which the patient does not have a large range of fusion or suppression, and results must be exact to avoid diplopia.
Indications/conditions:
Diplopia.
Reoperations.
Restrictive strabismus.
Harada-Ito procedure (see Chapter 47).
Adjustable “Faden” operation (see chapter 49).
Hang-back technique.
Thin sclera (ie, high myopia).
Surgery secondary to retinal detachment or glaucoma devices (see chapter 59).
Surgical procedures in which adjustable sutures may be used:
INTRAOPERATIVE CONSIDERATIONS
Keep the cornea moist and protected to reduce post-operative blur. Consider using apraclonidine for vasoconstriction rather than phenylephrine to reduce pupillary dilation that may interfere with postoperative adjustment.
Anesthesia (see chapter 1):
Topical.
Potential indications:
First time surgery.
Recession, plication, and resection.
Risk for general anesthesia.
Technique:
Start with topical anesthetic eye drops in both eyes.
Place lidocaine 3.5% ophthalmic gel on the surgical eye.
Prep and expose both eyes for patient comfort, keeping in mind that the patient will need to sit up during surgery.
Use sterile strips on eyelashes, rather than sticky plastic adhesives.
Evaluate the alignment intraoperatively. Sit the patient up and do a cover test while the patient is fixing at a target placed as far away as possible. Keep all drapes and equipment sterile in case additional surgery is needed.
Complete the adjustment in the operating room or perform a same day or delayed adjustment in the recovery room or clinic.
Peribulbar or retrobulbar block:
Typically only considered for unilateral surgery.
Limits immediate and early postoperative adjustment because there must be adequate time for the anesthetic to reverse prior to adjustment.
General anesthesia:
Preferred in patients who are uncooperative or anxious.
Preferred in patients needing extensive dissection such as glaucoma shunt, scleral buckle, severe scarring, oblique muscle surgery.
Use with caution in patients with medical comorbidities.
Do not use bupivacaine (Marcaine) in the block if same day adjustment is planned. Consider avoiding dilating drops because pupil reactivity can be one indication of anesthetic reversal.
Incision (see chapter 43):
Fornix.
Advantages:
Less scarring.
Less postoperative irritation.
Preservation of limbal vessels.
Single incision allows surgery on two adjacent rectus muscles.
Covered sutures.
Disadvantages:
