Bilateral medial rectus recession with or without posterior fixation in large-angle infantile esotropia: a randomized controlled trial.

PURPOSE: To compare the results of bilateral medial rectus recession (BMRc) versus bilateral medial rectus recession with Faden operation (BMRF) in the treatment of large-angle infantile esotropia. STUDY DESIGN: A double blinded, parallel, randomized controlled trial. METHODS: Patients with large-angle infantile esotropia (≥ 60 prism diopters, [PD]) aged between 3 and 15 years old were included and assigned to either the BMRc or BMRF group. Mean difference and mean reduction of angle deviation between the two groups were compared at 1 week, 1, 3, and 6 months by using generalized estimating equations analysis. Surgical success rates, defined as an esodeviation ≤ 10 PD at near fixation, were evaluated at 6 months postoperatively. Complications from the surgical procedures were observed. RESULTS: Of 40 enrolled patients, the mean (SD) age of the patients in the BMRc group was 3.4 (1.9), and in the BMRF group, 5.2 (3.8) years old. The overall mean differences of angle reduction between both groups were not significant (-6 PD, 95%CI -14 to 2, P = .12). The surgical success rate at 6 months in the BMRF group (72%) was not different compared to BMRc group (84%, P = .45). Overall consecutive exotropia was 5%, not different between groups (P > .99). There was no difference of complications between the two groups (P = .51). CONCLUSION: BMRF and BMRc approaches show no difference in treatment of large-angle infantile esotropia. Nevertheless, a long-term assessment for consecutive exotropia should be considered for both surgical procedures.

The Use of Fixation Suture to Treat Inferonasal Hypertrophic Bleb after Xen Gel Stent Implant: A Case Report.

We report a case of an inferonasal hypertrophic bleb complication which formed 5 months after Xen Gel Stent implantation for intraocular pressure (IOP) control in a primary open-angle glaucoma patient and its management using a fixation suture. The patient underwent an uneventful right-eye phacoemulsification and intraocular lens implantation combined with Xen Gel Stent ab interno implantation surgery. A month after the surgery, a second needling was performed due to a flat bleb and increased IOP. Post-needling slit-lamp examination showed a well-formed diffuse bleb in the superonasal quadrant. Two months after the needling, the patient presented with redness and irritation medially. Upon examination, a large inferonasal bleb was observed together with scarring of a previously formed superior bleb above the Xen Gel Stent implant. Fornix-based conjunctival incision technique was used to release the conjunctival scarring, and a fixation suture was used for the Xen implant in order to change the filtration direction. A Palmberg compression mattress suture was used to stop the inferior filtration. Despite an open conjunctiva surgical revision in the superior quadrant, no additional scaring was formed in the follow-up period of 20 months. There was good post-operative IOP control and formation of superiorly positioned bleb. To our knowledge, this is the first report to describe the use of a fixation suture for treating inferonasal hypertrophic bleb as a late complication of Xen Gel Stent implantation surgery.

No difference in clinical and radiological outcomes following fixation of transverse patella fractures with either suture tape or metallic cerclage: A retrospective comparative study.

INTRODUCTION: Several surgical techniques have been proposed for the treatment of patellar fractures. The aim of this study is to compare the clinical efficacy and complication rates of treatment using suture tape circumferential cerclage (STCC) and metallic wire circumferential cerclage (MWCC) for the surgical treatment of displaced transverse patellar fractures (TPFs). HYPOTHESIS: The hypothesis is that the use of the suture tape would be associated with a significantly lower rate of re-operation than metallic cerclage but no differences in other clinical outcomes. PATIENTS AND METHODS: A retrospective comparative analysis of the clinical outcomes of consecutive patients undergoing fixation of TPFs with either MWCC or STCC between January 2017 and December 2018 was undertaken. All patients underwent evaluation with standardised radiographs at one, three, and six months after surgery to determine rates of union, non-union, loss of fixation and malunion. All patients underwent a final clinical evaluation at 18 months postoperatively to evaluate clinical scores and complications. RESULTS: A total of 26 patients were included in the study. Thirteen patients underwent STCC and 13 underwent MWCC. There were no complications in the STCC group. In the MWCC group, one patient underwent hardware removal at 2 months postoperatively due to painful prominence. There was no significant difference in re-operation rates between the STCC and MWCC groups (p=1). There were no cases of non-union, malunion or loss of fixation throughout the series. At the final clinical follow-up of 18months, there were no significant differences in KSS, KOOS or Böstman scores between the groups. CONCLUSION: No significant differences were identified when comparing the clinical outcomes of fixation of AO/OTA 34C1/2 fractures with suture tape or metallic cerclage fixation concerning re-operation rates, union rates, loss of fixation and functional outcome measures. These results cannot be extrapolated to more complex injury patterns or surgical techniques in which prominence of implanted material is more likely. LEVEL OF EVIDENCE: III.

Single horizontal rectus muscle vertical augmented transposition with posterior fixation suture in management of monocular elevation deficiency.

We describe successful management of three cases of acquired monocular elevation deficiency (MED) with superior transposition of the lateral rectus augmented with a posterior fixation suture with or without simultaneous inferior rectus muscle weakening. In each case, the lateral rectus muscle was transposed superiorly to the superior rectus muscle along the spiral of Tillaux, with maintained distance between the original lateral rectus muscle poles and the limbus. Augmentation was achieved with a posterior fixation suture 8 mm posterior to the muscles' insertion. At the time of lateral rectus transposition, simultaneous inferior rectus recession by 5.5 mm was performed in case 1 whereas simultaneous botulinum toxin injection was performed in case 3. With regards to all three cases, the mean age was 32 years [10-46 years] and the mean follow-up period was 10 months. The mean hypotropia was reduced from 35 prism diopters (PD) (range: 20 to 60 PD) to 4.67 PD (range: 0 to 14 PD) with a mean correction of 32.57 ± 9.34 PD after 9 months. In our experience, full-tendon-width transposition of the lateral rectus to the superior rectus with posterior fixation suture corrects primary position hypotropia in MED and does not always require simultaneous inferior rectus recession. When transposing the lateral rectus muscle along the spiral of Tillaux, the measured distance of the original muscle insertion point to the limbus must be maintained in order to prevent recession of the muscle.

Long-term outcome of full tendon vertical rectus transposition with Foster suture in unilateral complete sixth cranial nerve palsy.

PURPOSE: To evaluate the success rate and long-term motor and sensory outcomes of the full tendon vertical rectus transposition (VRT) with Foster suture for unilateral complete sixth cranial nerve palsy. PATIENTS AND METHODS: We reviewed the medical records of patients with unilateral acquired sixth cranial nerve palsy who underwent unilateral full tendon VRT with Foster suture between 2005 and 2016 and had a follow-up of ≥2 years. Data on pre- and postoperative diplopia, face turn, ocular deviation, and limitation of abduction were collected. A successful outcome was defined as a horizontal deviation ≤10 prism diopter (PD) of ortho in a primary position at distance and absence of diplopia. RESULTS: A total of 20 patients were included in this study. Median (IQR) preoperative deviation was esotropia 65 (40-130) PD, which improved to 10 (-4 to 45) PD postoperatively. Median (IQR) improvement of esotropia was 54 (30-76) PD (P<0.001). Median (IQR) preoperative limitation of abduction was -15° (-22.5° to 10°; negative value means before reaching midline), which improved to 15° (7.5°-45°) pass midline postoperatively. Median (IQR) improvement of abduction deficit was 26° (15°-35°) (P<0.001). Successful surgical outcomes were obtained in eleven patients (55%). All patients in the non-successful group (n=9, 45%) had residual esotropia. Two of them underwent additional bilateral medial rectus recession. No postoperative vertical deviation or torsional diplopia was observed. CONCLUSION: In our series, the full tendon VRT with Foster suture in unilateral complete sixth cranial nerve palsy resulted in significant improvement of the ocular alignment and range of abduction over the 2-year follow-up period.

Adhesion after Y-split procedure can affect its mechanism for treating overshoots in Duane's syndrome.

PURPOSE: To investigate the extent of adhesion and changes in the Y configuration after the Y-split procedure, compared with the posterior fixation suture. METHODS: Twelve New Zealand white rabbits were included in the study. The 10-mm Y-split procedure was performed in the superior rectus muscle (SR) of one eye, and the 10-mm posterior fixation suture was made in the SR of the other eye. Six weeks after surgery, the Y arm lengths and lengths of adherence to the sclera were measured. If the adhesion involved the whole Y arm, the distance between the original SR insertion and most proximal part of the adhered SR was measured. In the eyes with posterior fixation suture, the distance between the SR insertion and most proximal part of the adhered SR was evaluated. RESULTS: The average nasal and temporal Y arm lengths were 6.37 ± 0.65 and 6.54 ± 0.63 mm, respectively, a significant decrease from those measured immediately after surgery (P = 0.002 and 0.002, respectively). Adhesions involved the entire Y arms in 11 of 12 SRs (91.7%), with an average adhesion length of 7.01 ± 1.04 mm. In SRs with posterior fixation sutures, the average adhesion was 9.18 ± 0.62 mm from the insertion, which was only 2.17 mm posterior to proximal portion of adhesion in Y-split SR (P < 0.001). CONCLUSIONS: Healing process reduces the Y arm length. Adhesion may involve the entire Y arm and could weaken or alter the therapeutic mechanism after the Y-split procedure.

Treatment of Epiphora in Patients with Conjunctivochalasis Using Conjunctival Fixation to the Sclera

PURPOSE: To report the effects and complications of conjunctival fixation to the sclera in conjunctivochalasis patients with inferior punctal occlusion. METHODS: The authors of the present study evaluated the degree of conjunctivochalasis and performed Fluorescein Dye Disappearance Test (FDT) in 15 eyes of 8 patients diagnosed with conjunctivochalasis with inferior punctal occlusion. Under topical anesthesia, the inferior bulbar conjunctiva was attached to the sclera with 3 8-0 vicryl stitches 8 mm posterior from the limbus. After surgery, the relief of symptoms, postoperative complications and improvement of conjunctivochalasis were observed. RESULTS: One week after the surgery, all 15 eyes achieved a subjective improvement of symptoms and the degree of conjunctivochalasis and FDT showed statistical difference after surgery (p = 0.000, 0.000, respectively). A complication occurred in 1 eye which was a retinal hemorrhage due to scleral puncture. CONCLUSIONS: Conjunctival fixation to the sclera could improve epiphora in conjunctivochalasis patients with inferior punctal occlusion. However, this procedure should be performed with caution.

The Surgical Effect of Posterior Fixation Suture in Incomitant Strabismus

PURPOSE: To know the surgical effect and the indication of posterior fixation suture in incomitant strabismus. METHODS: From January 2003 to October 2004, posterior fixation sutures were used in five patients with strabismus after orbital wall fracture and in three patients with high AC/A accommodative esotropia. Using Worth 4-dot tests, we compared the amount of incomitant deviation before and after surgery. RESULTS: The mean decrease in deviation after surgery was 7.8+/-2.6PD(P=0.04) in patients with strabismus after orbital wall fracture, and 11.3+/-4.2PD in those with high AC/A ratio accomodative esotropia. CONCLUSIONS: The posterior fixation suture was effective in reducing the amount of incomitant deviation occurring in cases of strabismus after orbital wall fracture and cases of high AC/A accommodative esotropia.

Use of Tissue Adhesives in Experimental Porterior Fixation Suture

Inadvertent perforation of the globe, granuloma and hypersensitivity reaction have been recognized complications of the strabismus surgery. We performed experimental strabismus surgery with No.240 retinal band and histoacryl(group I), histocracyl only(group II), 6-0 vicryl(group III) in rabbit model to determine whether these techniques can replace the classic suture and decrease its complications. We measured maximum adhesion power by force gauge and observed histopathologic findings after sacrificing four rabbits at 1 day, 1 week, 4 week, and 8 weeks, respectively following experimental strabismus surgery. There were chronologically increasing tendency of adhesion power in all groups but no statistically significant differences among three groups. Pathologically inflammatory and foreign body reactions were decreased with time and there were no differences of inflammatory reactions among three groups. At four weeks after the experiment, there was encapsualation lined with loose fibrous tissue around the band in group I.In conclusion, We found that experimental strabismus surgery with tissue adhesives and No.240 retinal band showed good adhesion power and minimal tissue reaction. So, it is possible to do posterior fixation suture with tissue adhesive and No.240 retinal band in classic strabismus surgery.

Clinical Experience of Canaliculaoplasty Using Mini-Monoka

Surgical effects were evaluated in 37 cases of mono-canalicular laceration following canaliculoplasty using Mini-Monoka from April, 1993 through SEptember, 1997 in the Department of Ophthalomology, Yeungnam University, College of Medicine. Lower canalicular laceration was included in 33 cases and upper canalicular laceration was found in 4 cases. Distance from the punctum to the lacerated canaliculus was noted to be 1 to 9mm(mean 4.6mm) and age ranged from 3 to 57 years(mean29.3 years). Thirty-four patients were men and three were women. Punctal portion of Mini-Monoka was fixated at the punctum with 6-0 black silk suture. End to end anastomosis was performed with 9-0 Ethylone(spatula needle) or 6-0 Vicryl(round needle). Steroid and antibiotics eye drops were used for 6 months after surgery. Mini-Monoka was removed 4 months postoperatively. After the follow-up period of 6-49 months(mean 11.3 months), 36 cases became recanalized well but 1 case showed obstruction because the laceration site was distant, 9mm from the punctum. Postoperative complications included loss of tube(3 cases), granuloma of the punctum(3 cases) and corneal abrasion(2 cases). Canaliculoplasty using Mini-Monoka is a procedure of choice for repair of mono-canalicular laceration with prevention of loss of the tube by punctal fixation suture without damage of the intact another canaliculi and the inferior meatus.

Surgical Results of Duanes Retraction Syndrome

The authors reviewed medical records of 25 patients undergoing treatment for Duanes retraction syndrome. The patients were treated with appropriate horizontal muscle recession with or without posterior fixation suture, transposition procedures, and lateral rectus Y split and recession in order to relieve face turn, significant tropia in primary position, and upshoot or downshoot. The deviation in primary position was reduced by an average or 20.5 prism diopters; 19.5 prism diopters in horizontal muscle recession with or without posterior fixation suture, and 17.4 prism diopters in lateral rectus Y split and recession. The face turn was eliminated in 84%, while 100% in horizontal muscle recession with posterior fixation suture. The upshoot or downshoot was essentially corrected by lateral rectus Y split and recession(100%). Motility of the eye was not increased following each surgical procedures. According to the results, we could obtain appropriate deviation in primary position with each surgery postoperatively. Horizontal muscle recession with posterior fixation suture was effective in eliminating the face turn. Lateral rectus muscle Y-split and recession effectively corrected upshoot and downshoots.

Surgical Correction of Involutional Entropion

The pathophysiologic changes that lead to involutional entropion are Weakness of the lower lid retractors, Upward migration of preseptal orbicularis over pretarsal orbicularis and forward rotation of lower border of tarsal plate, Horizontal lid laxity from involutional changes of medial and lateral canthal ligament and Enophthalmos from atrophy of the orbital fat with age. In the correction of involutional entropion, the first three factors must be considered for adequate correction. Hsu and Lieu reported Pretarsal orbucularis oculi muscle fixation method for the correction of involutional entropion. Authors performed this method in the 20 patients with involutional entropion of thirty-one eyelids and the results were sucessful.

Surgical Effect of Type I Nystagmus Blockage Syndrome

Six patients of nystagmus blockage syndrome (type 1) underwent both medial rectus recession and posterior fixation suture. Associated amblyopia wsa treated with occlusion or atropinization before and after surgery. During follow-up period for 12 weeks (4-36 weeks), four patients revealed orthophoria and one was esotropi a less than 5 delta and the other was 4-5 delta exotropia. The tropic status was stable, and in two patients who had manifest latent nystagmus, the amplitude of nystagmus was markedly decreased. Head turn was present in all patients before surgery. After surgery head turn was disappeared in five patients but still remained in one although their tropic status changed to orthophoria and the visual acuities of both eyes were equal.

Surgical Effect of Type I Nystagmus Blockage Syndrome

Six patients of nystagmus blockage syndrome (type 1) underwent both medial rectus recession and posterior fixation suture. Associated amblyopia wsa treated with occlusion or atropinization before and after surgery. During follow-up period for 12 weeks (4-36 weeks), four patients revealed orthophoria and one was esotropi a less than 5 delta and the other was 4-5 delta exotropia. The tropic status was stable, and in two patients who had manifest latent nystagmus, the amplitude of nystagmus was markedly decreased. Head turn was present in all patients before surgery. After surgery head turn was disappeared in five patients but still remained in one although their tropic status changed to orthophoria and the visual acuities of both eyes were equal.

Histopathological Study of Extraocular Musele followinr Posterior Fixation Suture in Rabbits: Pathogenesis of Musele Fibrosis

The authors observed the histological and ultrastructural findings in a study of the fibrosis of the extraocular muscles following a posterior fixation suture in rabbits. the early findings demonstrated hyalinosis, clumping of the nuclei of muscle cells and collagenization of the muscle tissue. However, there was no evidence of collagen tissue in the degenerated muscle fiber, reserving cell membrane and basement membrane ultrastructurally. The late findings showed splitting and irregular stain of the muscle fibers, many nuclei of presumed muscle cell and filamentous structure at the collagen tissue in the extracellular space. Electron microscopic study showed atrophy and angulation with distortion of the myofibrillar matrix, along with other cytoplasmic degenerative phe nomena in the muscle fibers. Clumps of the well-arranged microfibrils(Mf) and irregularly arranged Mf with fine granular materials(FGM) were adjacent to the immature collagen fibrils. Many of the Mf and FGM were closely associated, and the number of the Mf and FGM decreased with the degree of maturity of the collagen fibrils. The anatomical structure of the myofibrill was identified as that of the Mf. From these findings, it would appear that formation of collagen fiber occurs in the extracellular space and that Mf and FGM are primarily responsible for the formation of the collagen fibils.