Modern suture techniques perform better in pediatric, adult cases

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With modern techniques and recent innovations, adjustable suture strabismus surgery can be performed in nearly all pediatric and adult cases, provided that ophthalmologists have had sufficient training.

Dr. Guyton

By Nancy Groves; Reviewed by David L. Guyton, MD

Baltimore-Modern adjustable suture techniques are much improved and applicable to children and adults, as practically all strabismus procedures can be adjusted. However, there are both advantages and disadvantages in choosing the adjustable technique over standard strabismus surgery, according to David L. Guyton, MD.

“The concept of fine-tuning the surgery makes sense in preoperative discussions (because) there is less anxiety for the surgeon, and in our hands we really do get better results,” said Dr. Guyton, Zanvyl Krieger Professor of Pediatric Ophthalmology at Zanvyl Krieger Children’s Eye Center at the Wilmer Institute, The Johns Hopkins University School of Medicine, Baltimore. “We don’t always know where to leave the muscle, but we definitely know where we don’t want it to be, such as causing a large overcorrection or undercorrection. That’s where adjustable sutures really come to the rescue.”

Disadvantages

Using adjustable sutures may cost more initially because of more intraoperative and postoperative time involved-plus an additional anesthesia cost in young children-but this may be offset by less morbidity and fewer reoperations, Dr. Guyton said.

To date, however, no cost-benefit studies have been performed nor randomized clinical trials performed to demonstrate that adjustable suture strabismus surgery is better than the fixed-suture technique. Use of the adjustable technique is largely a matter of the ophthalmologist’s personal preference, he added.

The roadblocks that prevent some strabismus surgeons from using the technique include a steep learning curve. Dr. Guyton noted that surgeons will need training and experience to achieve high success rates and that success is highly technique-dependent. Also, more time is required for the adjustable suture technique-about 3 to 5 minutes per muscle intraoperatively and 15 to 20 minutes for adjustment.

Anesthesiologists tend to be initially resistant to this technique, questioning the safety of giving brief IV propofol anesthesia in the recovery room, but with experience this resistance evaporates quickly, Dr. Guyton said.

The techniques for adjustable sutures in children evolved from those used in adults, he noted. Although such a technique was first described over a century ago, it was rarely used until resurrected and improved by Arthur Jampolsky, MD, in the 1970s.

Adjustable sutures originally were used for less predictable operations, but Dr. Guyton said he uses them for practically any muscle procedure, except when weakening the inferior oblique muscle. Procedures suited to the adjustable suture technique include recessions, resections, tucks, Harada-Ito procedures, transpositions, and lower lid suspensions.

New techniques

Dr. Guyton and colleagues published results of their adjustable suture technique in children in 2008 in the Journal of AAPOS, measuring success within 8 prism D of straight. The success rate increased from 62% with nonadjustable sutures to 78% with the adjustable technique in esotropia patients, and from 69% to 80% in exotropia. He has since used the adjustable suture technique in practically all pediatric cases since 1993.

In the October 2013 issue of the Journal of AAPOS, Dr. Guyton and colleagues published a report on a new, removable sliding polyglactin 910 suture noose-a clove hitch with three slip knots. This minimizes the suture material left to resorb, reducing discomfort, inflammation, and scarring.

“When you finish adjusting and tying the muscle sutures off, you simply pull sideways on the portions of the noose knot and it just comes off,” Dr. Guyton said. “We’ve used that for several years and we’re quite pleased with it.”

Another new technique, developed by David Hunter, MD, PhD, professor of ophthalmology, Boston Children’s Hospital, Harvard Medical School, is the “short-tag” noose. Trimmed pole sutures and the trimmed noose are buried under the conjunctiva. The suture can remain in place if no adjustment is required, but if needed, adjustments can be made up to seven days after surgery.

When performing surgery, Dr. Guyton said he prefers making a cul-de-sac conjunctival incision, which he says is faster, and because the knot and suture ends are totally buried. This approach leads to better postoperative comfort and less scarring, however, this technique requires a skilled assistant for best outcomes, he added.

He recommended general anesthesia for children and adults because it’s easier to judge the rest position of the eyes and forced ductions are more reliable. It also wears off more quickly than local anesthesia, which may require a wait of five or six hours before adjustments can be made.

Adjustments in young children are usually performed one to two hours postoperatively in the recovery room. Dr. Guyton said his protocol is to instill a drop of topical proparacaine, do a cover test or corneal light reflex test to judge the alignment, then have the anesthesiologist briefly administer intravenous  propofol (2-3 mg/kg ± 1 mg/kg as needed) before making the adjustment. The actual adjustment procedure itself typically lasts from 5 to 7 minutes.

David L. Guyton, MD

E: dguyton@jhmi.edu

P: 410-955-5492

Dr. Guyton has received grant support from the Hartwell Foundation and the National Eye Institute. He holds patents on fixation detection technology.

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