1. ORLY HALACHMI- EYAL JNC APRIL 2012 Adjustable sutures – WHY

2. 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 2012;119:629–633

3. 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?

4. Design: Retrospective case series, at the Sick children hospital in Toronto, over a 13-year period. 404 pts, Age >12 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).

5. 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).

6. Results 1963 pts underwent strabismus procedures over the 13-year period. Of these, 798 were <12yo 458 were complex/ had oblique muscle sx/incomplete data, 303 had < 6 months f/u. Therefore, 404 pts met the inclusion criteria for the study

7. Table 1: Pt’s demographics

8. Results 76 (28.8%) in the AS group had adjustments postop. Mean change in immediate postop angle after adjustment was 6.5 PD (range, 2–18 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).

9. Table 2: immediate postop results

10. Table 3: A higher success for AS in XT in primary surgery.

11. Table 4: overall success rate

12. Table 5

13. Table 6

14. 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.

15. 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.

16. Paper II Strabismus surgery: adjustable sutures good for all? A Tripathi, R Haslett and IB Marsh Eye (2003) 17, 739–742

17. 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).

18. 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.

19. 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.

20. Results: Reoperation required

21. 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.

22. 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.

23. Results- patient satisfaction* *Assessed by orthoptist – after at-least 4 months r/v

24. Results : percentage change in angle of deviation

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

26. 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.