Users Online: 268
Home Print this page Email this page
Home About us Editorial board Search Browse articles Submit article Ahead of Print Instructions Subscribe Contacts Login 


 
Previous article Browse articles Next article 
ORIGINAL ARTICLE
Adv Biomed Res 2014,  3:179

A survey of outcome of adjustable suture as first operation in patients with strabismus


1 Department of Ophtalmology, Isfahan University of Medical Science, Isfahan, Iran
2 Department of Psychiatry, Iran University of Medical Science, Tehran, Iran

Date of Submission11-May-2013
Date of Acceptance07-Aug-2013
Date of Web Publication26-Aug-2014

Correspondence Address:
Najmeh Karbasi
Department of Ophtalmology, Isfahan University of Medical Science, Isfahan
Iran
Login to access the Email id

Source of Support: Isfahan University of medical sciences, Conflict of Interest: None


DOI: 10.4103/2277-9175.139529

Rights and Permissions
  Abstract 

Background: Adjustable suture used for years to improve the outcome of strabismus surgery. We surveyed outcome of our patients with strabismus who underwent adjustable suture.
Materials and Methods: This retrospective study was performed at Ophthalmology Centre of Feiz Hospital in Isfahan on 95 participants that candidate for adjustable suture strabismus surgery. Patients were divided into three age groups: Under 10 years, 10-19 years, and 20 years and over. Outcome of adjustable suture surgery consequence of residual postoperative deviation was divided into four groups: Excellent, good, acceptable, and unacceptable.
Results: Out of 95 patients studied, 51 (53.7%) were males and 44 (46.3%) were females. The mean of deviation angles were 53.8 ± 17.9 PD (Prism dioptres) in alt XT, 44.5 ± 12 PD in alt ET and 52 ± 13.5 PD in const ET, 47.1 ± 13.1PD in cons XT, respectively. There was no significant difference between the groups (P = 0.051). Results of surgery were in 38 patients (40%) excellent, in 31 patients (32.6%) good, in 19 patients (20%) acceptable, and in 7 patients (7.4%) unacceptable. Seven (7.4%) patients required reoperation.
Conclusions: In the present study, the frequency of re-operation was much lower than other similar studies (7.4% vs. 30-50%). This suggests that the adjustable technique that used in our study can be associated with lower reoperation than other adjustable techniques used in the other similar studies.

Keywords: Adjustable sutures, complex strabismus, pediatric strabismus, strabismus surgery


How to cite this article:
Razmjoo H, Attarzadeh H, Karbasi N, Najarzadegan MR, Salam H, Jamshidi A. A survey of outcome of adjustable suture as first operation in patients with strabismus. Adv Biomed Res 2014;3:179

How to cite this URL:
Razmjoo H, Attarzadeh H, Karbasi N, Najarzadegan MR, Salam H, Jamshidi A. A survey of outcome of adjustable suture as first operation in patients with strabismus. Adv Biomed Res [serial online] 2014 [cited 2020 Sep 19];3:179. Available from: http://www.advbiores.net/text.asp?2014/3/1/179/139529


  Introduction Top


Strabismus is the term used to describe an anomaly of ocular alignment. Strabismus has a prevalence rate approximately 2% to 4% of the population. [1],[2],[3] Risk factors for strabismus include a positive family history and low birth weight. [4]

Strabismus can be treated as medical or surgical treatment depending on the type of strabismus. Strabismus surgery has a high success rate in both children and adults, and may be useful in improving diplopia, binocular fusion, and psychosocial functioning. [5],[6]

Methods of external eye muscle surgery are different and include the use of adjustable suture or nonadjustable suture [7] and to get late acceptable results. [8] The adjustable suture technique is used for years to improve the outcome of strabismus surgery. [9] The main purpose of using this method is to achieve a good result in one procedure but in the nonadjustable suture technique, it sometimes require multiple surgeries to achieve good results. [10] The adjustable suture technique is used when reoperation with nonadjustable suture is highly probable and the results are unpredictable, for example in restrictive strabismus like thyroid orbitopathy, previous surgery on the eye muscles and excessive deflection angle. [11],[12] The adjustable suture is used mostly in muscle recession. [13],[14]

Previous studies show that the reoperation rate is reduced to 10.5% with use of adjustable suture and this technique has improved the outcome of strabismus surgery. [9],[10],[11] While some case series have reported improved outcome using adjustable sutures, others have shown no benefit and found no evidence to support the use of adjustable sutures when performing strabismus surgery. [11],[15],[16]

We performed a study on adults and children who had undergone strabismus surgery with adjustable sutures at Feiz Hospital in Isfahan to determine outcome of our patients who underwent the adjustable technique.


  Materials and methods Top


This retrospective study was done at Ophthalmology Centre of Feiz Hospital in Isfahan from February 2012 to February 2013. The study population consisted of 95 participant candidates for adjustable suture strabismus surgery. Inclusion criteria were consent to participate in the study and first strabismus surgery with adjustable suture. Patients who did not return for follow-up after surgery were excluded from the study. All patients had informed consent.

After collecting demographic data such as age and gender, patients were divided into three age groups: Under 10 years, 10-19 years, and 20 years and over. Type of patient's strabismus before surgery or esotropia and exotropia, intermittent or constant deviation, the first postoperative deviation and number of reoperation were recorded.

On the day of surgery, all adult patients were placed under general anesthesia. Children were placed under topical anesthesia with Tetracaine (Tetracaine 0.5% ophthalmic drops, Darou Pakhsh Phama Co., Iran). After opening the conjunctiva fornix base, muscles were disinserted and if necessary resection was done then reattachment was performed. Muscles were attached to the sclera with simple stitches and three nodes, and then the conjunctiva was sutured. The next day, under local anesthesia the deviation was determined with Krimsky test, Hirshburg test, and alternative cover test. Based on the test results, adjustment was done and carried out the final node. After 3 days, patients were examined again and adjustment was done again if it was necessary and final adjustment was performed 1 week later if needed.

Next, the patients were asked to come to the ophthalmology clinic for post strabismus surgery examination at the certain times. Surgery results were evaluated using the cover-uncover test, Hirschberg test, and Krymsky test. The alignment of the eye, under correction, and overcorrection were determined.

Outcome of adjustable suture surgery consequence of residual postoperative deviation was divided into four groups: Excellent (perfect aligned eyes after strabismus surgery), good (residual postop deviation <8 Prism dioptres (PD)), acceptable (acceptable cosmetic or residual deviation 8-15 PD), and unacceptable (residual postop deviation >15 PD). [17]

The data collected was analyzed using chi-square and t-test with SPSS software version 20.


  Results Top


Out of 95 patients studied, 51 (53.7%) were males and 44 (46.3%) were females. 48 (50.5%) of these patients were under 10 years old, 21 patients (22.1%) aged 10-19 years, and 26 patients (27.4%) were aged 20 years and above [Table 1]. In [Table 2], the frequency of age group has been shown by sex. In the chi-square test, there was no significant difference in the age distribution of patients according to sex. Types of strabismus were: In 29 patients (30.5%) alternating exotropia (alt.XT), in 47 patients (49.5%) alternating esotropia (alt.ET), in 5 patients (5.3%) cons ET, and in 14 patients (14.3%) const XT. In [Table 3], the frequency of strabismus by age group is shown. Fisher's exact test showed a significant difference in type of strabismus between the age groups (P < 0.001).
Table 1: Patient baseline characteristics

Click here to view
Table 2: Distribution of outcome in terms of patient variables

Click here to view
Table 3: Distribution of types of strabismus in age groups

Click here to view


The mean preoperative angle of deviation in patients was 48.1 ± 14.7 prism dioptres (PD) with range of 90-30 PD. The mean of angle deviation was 48.6 ± 17.6 PD in men and 47.5 ± 10.5 PD in women and the difference between two groups was not significant (P = 0.71). The mean of deviation angle in patients under 10 years, 10-19 years, and 20 years and older was respectively, 44 ± 11.9 PD, 50.7 ± 18.2 PD, and 53.7 ± 14.4 PD and according to the one-way ANOVA, the difference was significant (P = 0.015).

The mean of deviation angle were 53.8 ± 17.9 PD in alt.XT, 44.5 ± 12 PD in alt ET and 52 ± 13.5 PD in const ET, 47.1 ± 13.1 PD in const XT, respectively. There was no significant difference between the groups (P = 0.051).

Results of surgery were in 38 patients (40%) excellent, in 31 patients (32.6%) good, in 19 patients (20%) acceptable and in 7 patients (7.4%) unacceptable. Seven (7.4%) patients required reoperation. In [Table 3], distribution of outcome in terms of patient variables is shown. Fisher's exact test and ANOVA showed that there was no significant difference (P > 0.05) in the result on the data by age, sex, type of strabismus, and angel of deviation. The mean angel of deviation in patients with excellent result was 45.9 ± 12.3 D.


  Discussion Top


The goal of strabismus surgery is to correct alignment of the eyes to promote fusion, recover vision using two eyes with overlapping fields of view, allowing good perception of depth, enlarge the field of vision without diplopia, and obtain normal eye contact. [18] The aim of this study was survey of outcome of adjustable suture surgery in patients with strabismus in Feiz Hospital at Isfahan. Patients, who participated in this study, at first, were studied in terms of age, gender, and type of strabismus and the impact of these factors were studied in outcome of surgery. According to our results, no significant difference in outcome in terms of those variables was found; thus, the confounding effect was neutralized in consequence of these factors and our results were relevant to outcome of adjustable suture for treatment of strabismus. Based on our study results of adjustable suture surgeries were 40% excellent, 32.6% good, 20% acceptable, 7.4% unacceptable, and 7.4% of the patients required reoperation. The mean angel of deviation in patients with excellent result was 45.9 ± 12.3 D.

Our findings are similar to the results of Tripathi et al. who reported that strabismus surgery with adjustable sutures had significant better results than surgery without adjustable sutures. In the study of Tripathi, the re-operation rates for adjustable suture were 8.5% and in non-adjustable were 27.2%. [14] Some other previous studies show that the rate of postoperative adjustment is usually between 39% and 50%. [19],[20],[21]

Our findings showed that 40% of patients had excellent surgery result. Study of Zhang and colleagues confirms our results. In this study on 305 patients with adjustable suture, 47% had excellent outcome after surgery. [17]

Recent studies have shown better success rates when using adjustable sutures versus non-adjustable sutures in patients with strabismus surgery. [22] Nevertheless, some studies report no advantage of adjustable sutures. Park et al. found that strabismus surgery with adjustable sutures did not show significantly better results than surgery without adjustable sutures. They surveyed adjustable suture in the treatment of 20 patients with sensory exotropia who had underwent unilateral lateral rectus recession and medial rectus resection. [23] Bishop and Doran in a retrospective study on 52 patients with strabismus found 81% success rate in adjustable suture and 88% in non-adjustable suture. Results of this study showed equal success rates of adjustable and non-adjustable suture. [16]

However, a review study by Cochrane in 2005 suggested that the few numbers of retrospective studies directly compared adjustable and non-adjustable suture techniques and most of them were nonrandomized. Because of clinical heterogeneity of previous studies, they were difficult to compare and advantages of adjustable suture surgery in general or of any approach were not reliable. [11]

On the other hand, patient satisfaction from results of strabismus surgery is very important. In a study on 14 patients with thyroid ophthalmopathy, 7 patients underwent non-adjustable suture surgery and 7 patients underwent adjustable suture surgery. Patients with adjustable suture had no reoperation and all the patients were satisfied with the results but only 42.8% of patients with non-adjustable suture were satisfied with the results. Two patients of this group required reoperation and two patients needed prismatic correction. [24]

In study of Eino et al., 104 patients with strabismus were divided into four groups. The first group consisted of esotropia (ET) patients who underwent surgery for the first time, the second group had ET patients undergoing reoperation, the third group had exotropia (XT) patients who underwent surgery for the first time, and the fourth group had XT patients undergoing reoperation. The corresponding surgical success rates were 82.4%, 92.6%, 93.1%, and 94.4% in the four groups, respectively, [25] which is close to our results.

However, adjustable sutures is not a common practice among the strabismus surgeons, partly because of insufficient evidence that the considerable extra investment of time and effort is worth the benefit, and partly because of the lack of proper training of details and benefits of this technique. As a result, many strabismus surgeons do not perform adjustable suture surgery and become confident that there is no benefit. [26]

In the present study, the frequency of re-operation was 7.4%. Similar studies reported various results, whereas Dawson et al. mentioned 5.1% for reoperation rate and Leuder et al. reported 15% reoperation rate in adjustable suture strabismus surgery. [27],[28]


  Conclusion Top


It is suggested that the method used in the present study for adjustable suture is proper for adjustable suture strabismus surgery.


  Acknowledgment Top


The authors wish to thank nurses and personnel of operating room and clinic of ophthalmology of Feiz Hospital for their help to perform this research.

 
  References Top

1.Abrahamsson M, Magnusson G, Sjostrand J. Inheritance of strabismus and the gain of using heredity to determine populations at risk of developing strabismus. Acta Ophthalmol Scand 1999;77:653-7.  Back to cited text no. 1
    
2.Greenberg AE, Mohney BG, Diehl NN, Burke JP. Incidence and types of childhood esotropia: A population-based study. Ophthalmology 2007;114:170-4.  Back to cited text no. 2
    
3.Williams C, Northstone K, Howard M, Harvey I, Harrad RA, Sparrow JM. Prevalence and risk factors for common vision problems in children: Data from the ALSPAC study. Br J Ophthalmol 2008;92:959-64.  Back to cited text no. 3
    
4.O'Connor AR, Stephenson TJ, Johnson A, Tobin MJ, Ratib S, Fielder AR. Strabismus in children of birth weight less than 1701 g. Arch Ophthalmol 2002;120:767-73.  Back to cited text no. 4
    
5.Merrill K, Satterfield D, O'Hara M. Strabismus surgery on the elderly and the effects on disability. J AAPOS 2010;14:196-8.  Back to cited text no. 5
    
6.Jackson S, Harrad RA, Morris M, Rumsey N. The psychosocial benefits of corrective surgery for adults with strabismus. Br J Ophthalmol 2006;90:883-8.  Back to cited text no. 6
    
7.Nield LS, Mangano LM. Strabismus: What to Tell Parents and When to Consider Surgery. Consultant 2009;49:122-8.  Back to cited text no. 7
    
8.Razmjoo H. Adjustable suture in strabismus surgery. Med J Islam Repub Iran 1997;11:7-10.  Back to cited text no. 8
    
9.Awadein A, Sharma M, Bazemore MG, Saeed HA, Guyton DL. Adjastable suture strabismus surgery in infants and children. J AAPOS 2008;12:585-90.  Back to cited text no. 9
    
10.Dawson E, Bentley C, Lee J. Adjustable squint surgery in children. Strabismus 2001;9:221-4.  Back to cited text no. 10
    
11.Sundaram V, Haridas A. Adjustable versus non-adjustable sutures for strabismus. Cochrane Database Syst Rev 2005;1:CD004240.  Back to cited text no. 11
    
12.Buffenn AN. Adjustable suture use in strabismus surgery. Curr Opin Ophthalmol 2005;16:294-7.  Back to cited text no. 12
    
13.Neumann D, Neumann R, Isenberg SJ. A comparison of sutures for adjustable strabismus surgery. J AAPOS 1999;3:91-3.  Back to cited text no. 13
    
14.Velez FG, Chan TK, Vivez T, Chou T, Clark RA, Keyes M, et al. Timing of post operative adjustment in adjustable suture strabismus surgery. J AAPOS 2001;5:178-83.  Back to cited text no. 14
    
15.Tripathi A, Haslett R, Marsh IB. Strabismus surgery: Adjustable sutures-good for all? Eye (Lond) 2003;17:739-42.  Back to cited text no. 15
    
16.Bishop F, Doran RM. Adjustable and non-adjustable strabismus surgery: A retrospective case-matched study. Strabismus 2004;12:3-11.  Back to cited text no. 16
    
17.Zhang MS, Hutchinson AK. Improved ocular alignment with adjustable sutures in adults undergoing strabismus surgery. Ophthalmology 2012;119:396-402.   Back to cited text no. 17
    
18.Nihalani BR, Hunter DG. Adjustable suture strabismus surgery. Eye (Lond) 2011;25:1262-76.  Back to cited text no. 18
    
19.Weston B, Enzenauer RW, Kraft SP, Gayowsky GR. Stability of the postoperative alignment in adjustable-suture strabismus surgery. J Pediatr Ophthalmol Strabismus 1991;28:206-11.  Back to cited text no. 19
    
20.Keech RV, Scott WE, Christensen LE. Adjustable suture strabismus surgery. J Pediatric Ophthalmol Strabismus 1987;24:97-102.  Back to cited text no. 20
    
21.Pratt-Johnson JA. Adjustable-suture strabismus surgery: A review of 255 consecutive cases. Can J Ophthalmol 1985;20:105-9.  Back to cited text no. 21
    
22.Engel JM. Adjustable sutures: An update. Curr Opin Ophthalmol 2012;23:373-6.   Back to cited text no. 22
    
23.Park YC, Chun BY, Kwon JY. Comparison of the stability of postoperative alignment in sensory exotropia: Adjustable versus non-adjustable surgery. Korean J Ophthalmol 2009;23:277-80.  Back to cited text no. 23
    
24.Karhanová M, Vlác¡il O, Sín M, Mares¡ová K. Adjustable versus non-adjustable sutures in strabismus surgery in patients with thyroid ophthalmopathy. Cesk Slov Oftalmol 2012;68:207-13.  Back to cited text no. 24
    
25.Eino D, Kraft SP. Postoperative drifts after adjustable-suture strabismus surgery. Can J Ophthalmol 1997;32:163-9.  Back to cited text no. 25
    
26.Karmel M. Second chances: Adjustable sutures for strabismus corrections. Eyenet 2010:31-3. http: //www.aao.org/publications/eyenet/201005/strabismus.cfm. [Last accessed on 2013 April 31].  Back to cited text no. 26
    
27.Keech RV, Scott WE, Christensen LE. Adjustable suture strabismus surgery. J Pediatr Ophthalmol Strabismus 1987;24:97-102.  Back to cited text no. 27
    
28.Leuder GT, Scott WE, Kutschke PJ, Keech RV. Long term results of adjustable strabismus. surgery for strabismus secondary to thyroid ophthalmopathy. Ophthalmology 1992;99:993-7.  Back to cited text no. 28
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]


This article has been cited by
1 Adjustable suture strabismus surgery in infants and children: a 19-year experience
Ahmed Kassem,Gilbert Xue,Niral B. Gandhi,Jing Tian,David L. Guyton
Journal of American Association for Pediatric Ophthalmology and Strabismus. 2018;
[Pubmed] | [DOI]



 

Top
Previous article  Next article
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and me...
Results
Discussion
Conclusion
Acknowledgment
References
Article Tables

 Article Access Statistics
    Viewed860    
    Printed28    
    Emailed0    
    PDF Downloaded147    
    Comments [Add]    
    Cited by others 1    

Recommend this journal