Gold: We hear about all of these minimally invasive procedures in ophthalmology and in anything else, and this is being touted as not necessarily minimally invasive but less invasive. Cheng: That is the same thing as taking 30 seconds off the cataract operation. Regarding minimally invasive, now you have two incisions instead of one in the cul-de-sac, and you put in a suture or not. I do not close my cul-de-sac incisions, and it all works out fine.
I wonder whether this is everything that it is touted to be? I certainly do not disagree with you. Johnson: With the minimally invasive approach, like I have seen on video, it seems like the tinier incision would, for me, make it harder. Wilson: I am not sure it preserves blood supply, but it certainly may. You still may interrupt some of the blood supply, but I would think that it has less risk of anterior segment ischemia.
We do not see anterior segment ischemia often anyway, but I would think it would. I do not recommend that people do this through a smaller incision when they start. I think you should do the operation through whatever incision you like to do. But after becoming comfortable with plication, making incisions smaller and learning to dissect underneath the conjunctiva and learning to stretch the conjunctiva less is advantageous in the adult population, especially the older adults, in whom the conjunctiva tears and rips.
But it is more difficult. Disclosure: The round table participants report no relevant financial disclosures. With minimally invasive surgery, we can do strabismus surgery with topical anesthesia and correct small, even micro, deviations without adjustable sutures. The use of the grooved hook rather than the standard hook facilitates strabismus surgery with topical anesthesia and allows safe surgery through small incisions. The Wright grooved hook self-retracts the conjunctiva, allowing excellent insertion exposure even with small incision surgery. It is also very helpful for suturing tight muscles.
Standard strabismus surgery does not correct these micro-deviations. A vertical microtropia may not seem like much, but it is quite debilitating to the patient with double vision. These patients are not happy campers after paying out of pocket for refractive surgery or enhanced cataract surgery when they are told they need prism glasses. Approximately 10 years ago, I developed a minimally invasive procedure for patients with a micro-hypertropia—the Wright central tenotomy—which can be done using topical anesthesia in a fully awake patient and takes less than 1 minute.
This no-suture technique is safe and adjustable. I have had no overcorrections and only an occasional undercorrection. The enhancement is only a 2-minute procedure if needed. Minimally invasive strabismus surgery has expanded our horizons necessary for the increasing expectations of our patients.
The ability of these minimally invasive procedures to reliably correct small and even micro deviations greatly has changed the way we approach strabismus. We are no longer dependent on prism glasses, and for the most part, do not need the often aggravating and painful adjustable suture technique.
Except for the unusual difficult reoperation, the days of large incisions and big dissections are gone. I look forward to younger, innovative strabismologists moving minimally invasive surgery even further. One day I would love to see endoscopic strabismus surgery.
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Kenneth W. He can be reached at wrightmd aol. Mojon, MD, requires an operating microscope, which minimizes the surgical field. Many strabismus surgeons find the use of a microscope to be counterproductive. In fact, Dr. Mojon believes the ideal patient for this procedure should be 14 years of age or older, when the normal physiologic reduction in the connective tissue surrounding the muscles commences. All of these advantages are accomplished by using a conjunctival fornix incision.
For me, this is MISS with better visualization. Furthermore, in many recessions I prefer minimal dissection of the perimuscular connective tissue and check ligaments and require only a few millimeters of clean insertion in which to pass the sutures to secure the tendon prior to disinsertion. I suspect the procedure described by Dr. Mojon takes longer.
A Review of Minimally Invasive Strabismus Surgery (MISS): Is This the Way Forward? | SpringerLink
Quality surgical efficiency should always be a goal in the operating room. Could I think of a case where the placement of a few keyhole openings of the conjunctiva would be desirable? Perhaps, if I have excellent visualization through a transparent conjunctiva as occurs in some elderly patients with minimal connective tissue. We all need to better describe how the different procedures used to isolate an extraocular muscle are all examples of MISS. Rudolph S. Disclosure: Wagner reports no relevant financial disclosures. Tell us what you think about Healio.
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Principles of Strabismus Surgery for Common Horizontal and Vertical Strabismus Types
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Wilson: No, it has been done for a long, long, long time. Warman: We may have to look into it again. Olitsky: But it sounds like it may become the more standard procedure. Wilson: You may be right.
Wilson: That would be interesting. And does it preserve the blood supply like it theoretically suggests? References: Chauhuri Z, et al. JAMA Ophthalmol. Mojon DS. Eye Lond. Wright KW, et al.
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The shortened extraocular muscle is then reattached. A resection strengthens muscle function by shortening the muscle and then reattaching it to the eyeball at its original position. A suture is placed through the muscle at the new intended length.
The segment of muscle between the suture and the eyeball is removed or folded over plication , and the shortened muscle is reattached to the eye [See figure 2]. Standard strabismus surgery no adjustable suture utilizes a permanent knot tied during the surgical procedure. Adjustable suture technique utilizes a bow-knot or slip-knot temporary knot in an accessible position.
After surgery, the eye alignment can be altered by adjusting the temporary knot. The adjustment is typically done with the patient awake and the operated eye numbed, so adjustable suture surgery generally may only be offered to patients who are able to fully cooperate with the adjustment process. A patch is usually applied to the eye if the time until adjustment is sufficiently long. It is normal for the white part of the eyes to be red after surgery. It may take several weeks or occasionally months for the redness to disappear.
The eyes are usually scratchy and are sore upon movement. The soreness usually improves after a few days dependent upon the exact surgery performed. Some surgeons will prescribe a similar drop after surgery for a few days as well. More technical information may be found on the EyeWiki Site.