Wagner: An 18-year-old man underwent an uneventful 5-mm adjustable suture recession of the right medial rectus muscle using a limbal incision with minimal posterior dissection. There wasn't much scarring. It was a fresh case so it was just moving the muscle for the recession. A double-armed 5-0 polyglactin suture was used to hang the muscle back 5 mm from the insertion using a crossed swords central exit. Then a 6-0 polyglactin suture was used to tie a sliding knot around the 5-0 sutures as they exited from the sclera. The conjunctiva was recessed because it was a limbal incision, just to cover the knot, and the four sutures were taped to the lower eyelid. The patient was examined 3 hours after surgery and no adjustment was required. The 5-0 sutures were tied using a surgical knot and then the four suture ends were cut, leaving a knot that was tucked under the conjunctiva, and the patient was discharged to go home.The next day the patient called saying that his right eye looked to be turning out and his eye was really bothering him and felt a lot of irritation. He came back the next day and had right exotropia of approximately 15 prism diopters with what I would describe as a −2 adduction deficit. There was no complaint of diplopia because he was not really binocular. How would you proceed?
Dotan: When a patient calls and thinks something is wrong, I always tell them I will see them. It's better to see one more patient than just wait and possibly lose the muscle.
Weaver: Yes, especially after an adjustment.
Dotan: For me the most important thing is the adduction limitation that he has, which is fairly noticeable, especially on the first day after surgery. This was just a medial rectus recession and there was no resection of the ipsalateral lateral rectus muscle?
Dotan: Sometimes performing a large resection of the lateral rectus muscle can create early post-operative adduction limitation. However, in this case, because no resection was performed, I would take him back to the operating room and look at where the muscle is and resuture it.
Weaver: The first step is to make sure the patient is really exotropic. You have to be objective about how you evaluate the patient.Second, you're going to have a secondary deviation that's going to be larger. As Dr. Dotan pointed out, you have to look for adduction deficit. If the eye is unable to move, that implies there's been slippage of the muscle. Sometimes I will examine the patient at the slit lamp to make sure the eye is not splinting. I put topical anesthesia in the eye, make sure there is really a −2 deficit, and then determine if I can see anything beneath the conjunctiva.You can sometimes see the muscle. Depending on the patient, you can sometimes advance it. It could be that the whole muscle has slipped back. But I have salvaged cases like this in the office. I might take down the limbus incision and, if he's able to tolerate that without having a bradycardic cardiac reflex, take a look.
Kassem: If he has a true adduction deficit, you know there's a problem. But if you're not totally sure, you could also look for incomitance. I would look in all fields of horizontal gaze just to confirm that it's a true problem.
Wagner: This patient was brought back to the slit lamp and a knot was not visible. He was resistant to lifting up the conjunctiva with topical anesthetic. Two sutures were seen through the somewhat translucent conjunctiva, extending posteriorly from the insertional area. When questioned, the patient said that he had been rubbing his eye extensively and perhaps even during sleep the night before. He obviously felt something had happened because he called the next day. What would be your next step?
Kassem: I would take him to the operating room because it's not going to get better. In the operating room, I would open the conjunctiva and use a locking forceps to secure the suture as soon as it is visible. I would first look for an issue at where I did the scleral pass as opposed to where I secured the muscle.
Weaver: You're probably not going to lose a muscle in an 18 year old, but if you're in the operating room and you've prepared the eye and you blade the conjunctiva back, the first thing I would do is put a locking forceps on one of the sutures just to make sure everything stays in place. Then you need to determine where the problem happened because you were obviously happy about where things were at the time of the adjustment. You want to get back to where you were at the end of the case the day before. I'll do a double throw surgeon's knot and a double throw slip knot. I don't do a sliding noose because I've had that slip before. Then you have to decide where you're going to put it. If you are able to measure at the end of the case the day before, you could put it back to that same spot and then sew it down in each corner.
Wagner: You wouldn't use another adjustable suture?
Weaver: I probably would not in this case.
Dotan: You can now use information obtained while performing the adjustment. You performed a 5-mm medial rectus recession and did not need to move the muscle during the adjustment. Therefore, I would suture the muscle to the sclera 5 mm posterior to the insertion.
Weaver: That's my point. You had a good end point.
Wagner: Correct. That's the good thing about this. This patient was taken to the operating room and evaluated under general anesthesia with minimal manipulation. No knot was located. The conjunctiva was open. The two sutures were located attached to the medial rectus muscle that was approximately 9 mm from the insertion. The end of the superior suture was frayed, going nowhere, and the inferior suture was within the insertional tunnel slightly, but not secured with the knot.
Dotan: So the next step is to secure the muscle.
Weaver: I would just probably sew it down, do a direct scleral approach instead of Parks, just to make sure.
Kassem: Did the knot untie or did it come off the sclera?
Wagner: The knot was gone.
Weaver: He probably just rubbed it right off. It happens.
Wagner: Where would you reattach the muscle at this point?
Dotan: My preference is for scleral fixation, especially after a case like that. You know exactly where you're at, you tie it well, and it is secure.
Wagner: One of the things that I think was an advantage in this case is that he had minimal dissection. I used to dissect farther back on a lot of these muscles and I don't as much anymore, especially on a recession. I make sure the insertion is clean and that I can see what I need to do, but I don't necessarily clean all of the attachments posteriorly as I used to.
Weaver: When we were trained, you cut all that back. I don't do any of that anymore.
Wagner: I think in this particular case, that might have worked in your favor because it may be less likely to slip back farther. Do you do much dissection?
Dotan: I tend to do more cleaning backwards.
Kassem: I'm more concerned about visualizing anteriorly where we suture the muscle. That's why I make sure it's clean of Tenon's capsule. Posteriorly, I just clear enough so I know it's not going to be tethered.
Wagner: Do you use a limbal incision for an adjustable suture?
Dotan: I usually prefer the fornix incision, but for an adjustable procedure I do a limbal incision.
Kassem: I use the limbal incision, but I go a millimeter or two behind the limbus. I saw another ophthalmologist do this a few years ago and I have been doing it ever since.
Wagner: You make your incision slightly away from the limbus?
Kassem: Yes, just a little back so you close by sewing conjunctiva to conjunctiva.
Weaver: That's a good idea.
Kassem: I think it's easier to visualize the muscles and more comfortable for the patient since I like to bury conjunctival sutures.
Weaver: I also do a limbus incision and I hang it back the way I was taught.
Wagner: How do you secure the knot for an adjustable suture?
Dotan: Sliding noose.
Kassem: Sliding noose.
Weaver: Sliding noose.
Wagner: I do, too. I call it a sliding noose, but many times it's not so easy to slide it because I've tied it pretty tight for those same reasons. You can always move it if you have to, but I don't like it too loose because sometimes you come back the next day and it's halfway undone.
Weaver: I've also had times where you're pulling on it and it breaks. That's not fun.
Wagner: There is a poster at this meeting on the frequency of using adjustable sutures. They have a graph showing how many they did over the past 10 years and it has decreased significantly. I think I do less than I used to, but what is your experience?
Weaver: When I started practice more than 20 years ago I hardly did any adjustables, partly because my mentor did not like adjustables. Then I started doing more adjustable procedures, especially as I started doing more talks in South America, because a lot of South Americans use them. Now I feel like I'm doing less again. I still think there's a time to use adjustables, but it's mostly for older patients.
Kassem: My fellowship was mostly adjustable sutures and then over time I did less. Now it's mostly for reoperations and neurological cases where it's difficult to predict what the outcome is, such as thyroid cases.
Dotan: I usually perform scleral fixation, but occasionally I will use adjustable sutures with the sliding noose technique.
Wagner: One of the things I worry about is that if you only do adjustable sutures you sort of lose your judgment on some of the cases where you attach the muscle to the sclera for the standard cases that you would do. If you do an adjustable suture, when do you do the adjustment?
Weaver: I do it as an early case in the morning and adjust them in the afternoon.
Dotan: I do them the next morning.
Kassem: Same day. Logistically it's too difficult for me and I'm worried that they're going to pull at the suture.
Wagner: What is your normal follow-up for a routine case that you were satisfied with?
Dotan: I see them the morning after.
Wagner: Even if it's not adjustable?
Dotan: I see every patient at 1 to 2 days after surgery and then 1 month later. I also instruct patients or their caregivers to call me immediately if they have a concern that something wrong happened.
Weaver: In a rural area, my patients sometimes come from great distances and it's expensive for them to stay. I try to see them within the first week, just because of the studies on endophthalmitis, and then usually at 3 months after that. For exotropia that is overcorrected more than 10, I'll see them sooner to make sure they're not going more exotropic.
Kassem: Within the first week. Typically, I do surgery on Monday or Tuesday and then see them at the end of the week. Then at 1 and 3 months.
Wagner: Thank you for participating in this discussion.
This Eye to Eye session was conducted on March 28, 2019.