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Published byEaster Booker Modified over 9 years ago
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Alfred J. Cossari, MD Port Jefferson, NY
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Financial Disclosure I have no financial interests or relationships to disclose.
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My Objectives Describe the 2 stages of strabismus surgery Briefly compare 3 basic adjustment procedures Look at the timing of adjustments with respect to events occurring in the healing process Provide details of the 7 th day fixed suture procedure Encourage surgeons who have avoided hang-back sutures to consider the 7 th day procedure Recommend that all patients be prepared by their surgeon for a possible adjustment
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Strabismus Surgery - requires 1 or 2 stage - 1 st stage (primary surgery): procedure that executes the type and amount of surgery determined to best correct a specific set of sensorimotor defects 2 nd (adjustment) stage: a brief interruption of the healing process that provides a second guess opportunity when the primary surgery appears to be failing After 7-10 days, interruption of the healing process is no longer temporary due to advancing scar formation; revision at this stage requires a reoperation
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Suture Adjusting - an overview - Standard hang-back suture: has been the centerpiece for routine or selective suture adjusting within 24 hours of surgery Short tag noose suture: is one example of a modified hang-back suture that eliminates the need to tie the suture when no adjustment is required 7 th day fixed suture: is an approach that avoids using a special suture and defers adjustment of the suture position to the 7 th day Reality is: there is an adjusting procedure suited to the preferences of most strabismus surgeons
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Adjustment Procedures - percentage adjusted - 100% of patients with a standard hang-back suture need either an early adjustment or a tie-off < 50% of patients with a short tag noose suture are early adjusted; the remainder absorb without tying 5% of all patients have an aberrant primary surgery result requiring a 7 th day fixed suture “rescue” adjustment at day #7
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Early Adjustment - 24 hours / early inflammatory phase - Easiest time to adjust a hang-back suture Minimal fibrosis of the platelet clot Least accurate time to perform a motility assessment Pain, splinting and drowsiness are present Patient interaction is often part of this 2 nd guess; O.R, bedside or exam chair
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7 th Day Fixed Suture Adjustment - early proliferative phase - More accurate time for a motility assessment (including diagnostic gaze positions) Pain, splinting and drowsiness are resolved Blunt dissection is required to replace the fixed suture Fibrin/collagen have begun to fibrose the tissues Patient interaction is not used for this 2 nd guess
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Typical Example - supporting 7 th day adjust - 4 year old X(T) = 27, RH(T) = 5 Recessions (LROU and RSR) ET = 30, LHT = 4(day #1) With a hang-back suture, an early adjustment would probably have been performed A hang-back was not used, so early adjustment was not considered
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F/T alternate occlusion was prescribed with probability of a 7 th day adjustment ET = 10, LHT =2(day #6) 7 th day adjustment deemed unnecessary Orthophoric(week #3 – year #4) An early adjustment would have adjusted him out of this excellent result
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7 th Day Fixed Suture - surgeon profile - Distrusts hang-back sutures and nooses Distrusts early postop assessment of motility Distrusts bedside interactive decision-making Enjoys a high surgical success rate w/o early adjusting Recognizes the need for an occasional “rescue” adjustment Or, uses a hang-back but occasionally has need for a 7 th day rescue
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7 th Day Fixed Suture - patient experience - 100% of patients are prepared for the 5% probability of an adjustment 95% are happy when they discover an adjustment is not needed 5% are not surprised when an adjustment is recommended
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7 th Day Fixed Suture - surgical issues - All 6 EOMs have been adjusted Adjustments are scheduled as an add-on to my weekly block-time The same anesthetic technique is used (general or regional) as the primary surgery Tugging on muscle hooks is avoided to prevent breaking the suture or tearing it from the muscle Fixation and rotation of the globe are accomplished with bridle sutures and locking Stern-Castroviejo forceps The new suture is secured before cutting the old
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7 th Day Fixed Suture - cost reduction issues - Reduced personnel time for up to 95% of surgeries (surgeon, anesthesiologist, OR nurses, RR nurses, techs, etc.) Fewer instrument trays and materials Suture adjustment submissions are reduced by up to 95% No increase in reoperations due to long-term failures compared with other adjustment techniques
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suggestions for successful Second Guessing Determine your preference: hang-back or 7 th day fixed suture adjustment technique (or both) Prepare all patients for the 7 th day fixed suture adjustment process; an early adjustment preference does not preclude possible need for a 7 th day rescue Develop your second guessing skills and statistics – don’t forget to assess motility on POD #6 Decrease the need for 2 nd guessing with better stage 1 planning
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Semantics of this 7 th Day 2 nd Guessing (adjustment vs. reoperation) Back to OR on a different day Repeat anesthetic Same healing process with muscle position adjustment No excision of scar No new muscle operated Placement of a new suture in the same muscle or tendon Late second guess opportunity Your choice!
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Summary All patients should be afforded the opportunity of having the surgeon second guess the placement of muscle attachments before healing occurs whenever there is an unexpected response to surgery 3 basic second guessing approaches: - standard hang-back suture - short tag noose suture - 7 th day fixed suture Success is largely the result of a good sensorimotor assessment and sound surgical decisions; not a specific adjustment technique
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