Cut and Paste: Sutureless Conjunctival Closure in Strabismus Surgery

To assess the safety and efficacy of a fibrin tissue adhesive (Tissucol Duo(®) ) used to close the conjunctiva in trabeculectomy. A nonrandomized prospective study including 57 patients with chronic simple glaucoma who underwent trabeculectomy surgery. All the trabeculectomies were conducted by the same surgeon using the same surgical technique with the exception that conjunctival closure was achieved by either running Nylon 10/0 suture (n = 29) or using the fibrin glue (n = 28). Preoperative and postoperative data were obtained on intraocular pressure (IOP), number of hypotensive medications used, self-reported discomfort and complications arising during and after surgery. No differences were detected between the two patient groups regarding the intraocular pressure reduction achieved during follow-up. In the first 2 weeks of follow-up, reported discomfort assessed using a visual analogue scale was significantly lower in the Tissucol Duo(®) group. Two patients in the Tissucol Duo(®) group suffered conjunctival dehiscence and suturing was required at 24 hours postsurgery. Remaining complications were similar in the two groups. The use of Tissucol Duo(®) seems to be a safe and efficient option for conjunctival closure in trabeculectomy that simplifies the surgical procedure and reduces patient discomfort in the immediate postoperative period.

Can Verbal Interview Decrease Preoperative Anxiety and Postoperative Discomfort in Oral and Maxillofacial Surgery Patients?: A Randomized Clinical Trial

Purpose. To evaluate the surgical outcomes of unilateral or bilateral medial rectus (MR) muscle resection for recurrent exotropia after bilateral lateral rectus (BLR) muscle recession based on a novel surgical formula. Methods. Forty-one consecutive patients with unilateral or bilateral MR muscle resection for recurrent exotropia after BLR muscle recession were included in this retrospective study. All surgeries were performed according to the formula: 1.0 mm MR muscle resection for every 5 prism dioptres (PD) of exotropia, with an addition of 0.5 mm to each MR muscle operated on. Results. The mean recurrent exotropia distant deviation was 28 PD ± 11.2 (range 14 to 55 PD). Overall at postoperative 1 month, 36 (88%) achieved successful outcomes, 4 (10%) had undercorrection, and 1 (2%) had overcorrection. At postoperative 6 months, 29 (71%) achieved successful outcomes, 12 (29%) had undercorrection, and none had overcorrection. Subgroup analysis showed no statistically significant difference in success rates between unilateral and bilateral MR groups. Conclusion. Unilateral or bilateral MR muscle resection using our surgical formula is a safe and effective method for calculating the amount of MR resection in moderate to large angle recurrent exotropia, with a low overcorrection rate.

ABSTRACTPurpose: Mobius sequence is a rare disorder that results from underdevelopment of the sixth and seventh cranial nerves, with subsequent facial weakness and impairment of ocular abduction. Approximately half of the affected patients have esotropia with limitation of extraocular movements. This study retrospectively reviews the long-term outcome of strabismus surgery for such patients.Methods: The long-term follow-up results in five children with Mobius sequence, who were observed after strabismus surgery for congenital esotropia, were analyzed.Results: All patients had a limitation of abduction in both eyes. Preoperative esotropia ranged from 20 to 30 prism diopters (PD) (mean 27 PD). Patient age at surgery ranged from 4.5 to 14 months. Bilateral medial rectus muscle recession was performed in all cases, ranging from 4.0 to 6.5 mm. Inferior transposition of the medial rectus muscles was performed in two patients for treatment of V-pattern, and two patients also had surgery for vertical strabismus. Follow-up ranged from 4 to 19.5 years (mean 11.7 years). The final horizontal alignment was <8 PD in all patients, and all demonstrated some binocularity.Conclusion: Bilateral medial rectus muscle recession is an effective treatment for esotropia associated with Mobius sequence, with good long-term stability.

The aim of present study was to compare the results of conjunctival closure by fibrin glue with vicryl in strabismus surgery. 19 patients undergoing bilateral symmetrical strabismus surgery were included in this study. Conjunctival incisions were closed with 6-0 vicryl in the right eye and fibrin glue in the left eye. On first post-operative day 15 out of 19 eyes (78.9%) had well apposed conjunctiva, 3 out of 19 eyes (15.79%) had 1 mm retraction and one out of 19 eyes (5.26%) had 2 mm retraction, which needed suturing, in cases in which fibrin glue was applied. Increased discomfort and excessive watering was noted during the early postoperative period in 8 out of 19 eyes (42.1%), in eyes in which the conjunctiva was closed with 6-0 vicryl, as compared to none in the fibrin glued eyes (p=0.005). However, the difference disappeared after 21 days. Fibrin glue can be used as an alternative to suturing for conjunctival closure following strabismus surgery.

The purpose of this study is to describe the first reported case of a subretinal abscess after strabismus surgery and the successful treatment with vitrectomy, intravitreal antibiotics, and cryotherapy. This is a retrospective case report and literature review. A 4-year-old boy underwent uncomplicated bilateral medial rectus muscle recession. Within 9 days after surgery, he developed unilateral endophthalmitis with a subretinal abscess at the approximate location of the medial rectus muscle insertion. The rectus muscle-scleral suture was removed, and transscleral cryotherapy was applied to the abscess site. Vitrectomy with injection of intravitreal antibiotics was performed. A bacterial culture of the removed suture was positive for Staphylococcus aureus and sensitive to his antibiotics. By 1 month, the abscess and vitritis had resolved completely. This is the first reported case of endophthalmitis with a subretinal abscess occurring after strabismus surgery. In general, endophthalmitis after strabismus surgery has a poor visual prognosis. Early diagnosis and intervention with intravitreal antibiotics and possible vitrectomy may be advantageous for patients with a subretinal abscess.

Abstracts

Outcomes for maximal bilateral lateral rectus recession in large-angle exotropia

Accommodative esotropia decompensated to cyclic esotropia in a 6-year-old boy

PurposeThe aim of this study was to evaluate postoperative discomfort in patients undergoing ambulatory strabismus under general anesthesia, and to identify risk factors associated with the discomfort.Patients and MethodsA cross-sectional study was conducted among 210 consecutive patients undergoing ambulatory strabismus under general anesthesia. Postoperative discomfort including nausea, vomiting, dizziness, and headache was recorded and quantified. Univariable and multivariable logistic regression were performed to detect the risk factors associated with postoperative discomfort.ResultsOf 210 participants, 199 (94.76%) patients experienced mild discomfort after ambulatory strabismus surgery under general anesthesia, and 31 (14.76%), 11 (5.24%), 60 (28.57%), 23 (10.95%) patients suffered from nausea, vomiting, dizziness, and headache, respectively. A multivariate analysis indicated that female sex, the surgery on inferior rectus, and the surgery on inferior oblique were the independent risk factors for postoperative vomiting while, mild anxiety was the independent risk factor for postoperative dizziness.ConclusionPatients undergoing ambulatory strabismus surgery tended to experience postoperative nausea and dizziness. Female sex, the surgery on inferior rectus, mild anxiety, and the surgery on inferior oblique were the independent predictors of postoperative discomfort.

Background/Objectives: Conjunctival closure may influence early postoperative comfort and wound healing after pediatric strabismus surgery. We compared fibrin glue with absorbable sutures using anterior segment optical coherence tomography (AS-OCT)-based conjunctival thickness, serial clinical scores, ocular-surface screening, and operative time. Methods: We retrospectively reviewed 82 children (5-15 years) who underwent bilateral medial rectus recession. The conjunctiva was closed with 8-0 polyglactin 910 (Vicryl) (suture group, n = 40) or fibrin glue (fibrin group, n = 42) according to routine practice; right eyes were analyzed. Conjunctival thickness was measured by AS-OCT preoperatively and at week 6. The comfort questionnaire (CQ) score and inflammation score (IS) were recorded on postoperative day 1 and weeks 1, 2, and 6. Total operative time and closure time were obtained from surgical video recordings. Ocular Surface Disease Index-6 (OSDI-6) and non-invasive keratographic break-up time (NIKBUT) were assessed preoperatively and at week 6 in cooperative children (n = 62). Results: Conjunctival thickness increased in both groups and was slightly higher at week 6 with sutures (p < 0.001), with a slightly greater percentage increase (p = 0.001). CQ and IS were worse with sutures through week 2 (all p < 0.05) and converged by week 6 (both p > 0.05). Fibrin glue shortened total operative time (32.75 vs. 35.46 min; p < 0.05) and closure time (3.90 vs. 5.35 min; p < 0.001). In the ocular-surface subset, OSDI-6 and NIKBUT did not differ between groups at week 6. No infections or granulomas occurred; two early conjunctival wound gaps occurred in the fibrin group and one resolved with topical management, while the other met the dehiscence definition (≥2 mm) and required re-suturing, and both healed without sequelae. Conclusions: In pediatric strabismus surgery, fibrin glue demonstrated better early comfort with a modest difference in conjunctival thickness at week 6 along with slightly shorter operative time while clinical scores converged by week 6, and ocular-surface screening outcomes were similar.

Photorefractive keratectomy followed by strabismus surgery for the treatment of partly accommodative esotropia

To investigate clinical findings of the pseudo inferior oblique overaction (IOOA) syndrome and the outcomes of strabismus surgery and to discuss the mechanisms proposed for this disease. This syndrome is defined by Y pattern strabismus with exotropia in upgaze. There is marked abduction and hypertropia of the adducting eye when elevation is carried out in side gaze, but there is no hypertropia of the adducting eye in horizontal side gaze. Sixteen patients were included and surgery was performed in 14 patients. Success of the surgical intervention was defined as correction of the Y pattern, orthotropia in primary position, upgaze, and downgaze. Thirteen of the sixteen patients were female. The mean age was 9.6 ± 6.1years. The mean follow-up time was 14.7 ± 16.9months. Pre-operatively, 12 patients were orthophoric, and four patients were exophoric (4 to 8 PD) in primary position. In downgaze, all patients were orthophoric. Mean exotropic deviation in upgaze was 25.06 ± 5.9 (18 to 40 PD). Fourteen patients underwent surgery with 2-mm bilateral lateral rectus recession and full tendon supraplacement in seven cases, and 2/3 tendon supraplacement in the other seven patients. The success rate of surgery was 92.8% after the first operation, which reached 100% after a second surgical procedure was performed on one of the patients. Strabismus surgery is effective in correcting the Y pattern in patients with pseudo IOOA. A 2/3 tendon supraplacement combined with 2-mm recession of the lateral rectus muscles is the preferred treatment.

PurposeTo investigate the clinical course in patients who underwent surgical correction of consecutive esotropia.MethodsThe medical records of 13 patients who underwent surgical correction of consecutive esotropia were reviewed retrospectively. The authors investigated the deviation and surgical method at the time of exotropia surgery. During the follow up period, the authors also studied incidence of amblyopia development, the effect of occlusion therapy, surgical methods for consecutive esotropia, and postoperative change of deviation.ResultsThe average exodeviation was 27.1 prism diopter (PD). Bilateral lateral rectus muscle recession was performed in all patients. In all patients, alternate occlusion was tried from 2 weeks after development of consecutive esotropia. However, there was no effect on 7 patients. None of the patients developed amblyopia. Surgery for consecutive esotropia was performed on the average 15.3 months after exotropia surgery. The average esodeviation was 21.1PD. Medial rectus muscle recession was performed in 10 patients and lateral rectus muscle advancement in 3 patients. The average deviation of the subject group immediately after surgery was 1.2PD esodeviation, 0.9PD esodeviation one month after surgery, 2.4PD exodeviation 6 months after surgery, and 4.7PD exodeviation at the last follow up, and it showed a tendency to progress to exodeviation as the follow up period increased. Ten patients (76.9%) showed deviation within 8PD at the last follow up.ConclusionsThe success rate of surgical correction for consecutive esotropia was a favorable outcome. But, careful decisions of the surgical method and amount is needed because the conversion of exodeviation during long-term follow-up is possible.

The efficacy of asymmetric bilateral medial rectus muscle recession surgery in unilateral, esotropic, type 1 Duane syndrome