Avoiding the Pitfalls of Strabismus Surgery


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Volume 1 - Avoiding the Pitfalls of Strabismus Surgery

Lecture 5 of 24 NEXT»

Some Tips for "What About Anesthesia?"

Local: Okay for adults and some older children
Topical - for rectus muscle - straightforward - can be challenging
Sub Tenon injection over the muscle- OK for rectus muscles (S.R. most difficult) inject approx. 2cc xylocaine plain or with 1:100,000 epinepherine
Peribulbar - for any muscles - use local of choice
Retrobulbar - for any muscles - use local of choice - can adjust after about 4 hours
General: anesthesiologist's choice - ask about family history of malignant hyperthermia (Rx Dantrolene no Halothane) - ketamine can get pretty "ugly" with head motion, secretions, etc. used in some cases where pediatric anesthesia is marginal - avoids need for intubation or L.M.A.

Anatomy

1 replacement *Demer has shown that the rectus muscles have a bifed configuration with the orbital head inserting into a pulley mechanism in line with the junction of the middle and posterior 1/3 of the globe

The pulleys act as an anterior - (functional) insertion of the rectus muscles. They help explain and validate Fick's axes and Listing's plane.

Cross Section
2 replacement
View of Rectus Muscle after Limbal Approach
3 replacement

The pulleys do not change standard surgical techniques with this exception - that the Faden (posterior fixation suture) may not have to be put back as far as has been suggested - maybe okay at equator

Strabismus Surgery Is Done Under Anterior Tenon's - In the Plane of Posterior Tenon's (Intermuscular Membrane/Muscle Capsule)

Anterior segment blood supply from EOM. All recti have 2 anterior ciliary vessels except LR which has one - no ant. seg. blood supply from obliques.

SO - More Tissue

Near Trochlea (off limits) Tendon is the "Messenger"

IO lower border IR embedded in Posterior Tenon Capsule (Intermuscular Membrane)

LR More Room

MR - No Other Attachments

MR Insertion 5.5 mm

SR Insertion 7.7 mm

SO Underneath SR (common capsule)

LR Insertion 6.9 mm

One anterior cilliary

IR Insertion 6.5 mm

IR - IO - Lockwood Ligament

Watch IO for inadvertent incision

Some Errors to Avoid during Surgery:

Fat Exposure, IO Inclusion, Deep Suture Placement, Aggressive Treatment of Inadvertent Retinal Perforation, Conjunctival "Abuse", "Stripping" Muscle Capsule

Leave 1.5 mm cuff for SR limbal incision this avoids increasing the commonly occurring superior pannus

Medial Rectus Recession can be done in the Capsule with Minimum Disruption of Posterior Tenon's Capsule.

Non-Surgical Technique Factors:

Communication - talk to the patient/family

Plan- have one (diagnosis and surgical scheme)

Follow-up - timely

Intervention - when indicated

Accountability - be able to explain what you did

Patience - don't declare a bad result too soon

It has been said - It may be better to do the "wrong operation" well than the "right operation" with poor technique. It is nearly always possible to salvage the former - often impossible to salvage the latter. Best plan - do it right the first time.

Important advances in strabismus surgery in the last 40 years are:

* Synthetic absorbable suture

* Sharp spatula needles

* Better understanding of anatomy - especially Tenon's capsules - oblique muscles, pulleys

* Refinement of diagnostic techniques leading to better understanding of motor and sensory factors.

* Refinements in anesthesia, especially for infants

Editor-in-Chief: Eugene M. Helveston, M.D.

Associate Editor: Faruk H. Orge, M.D.

Editorial Board: Bradley C. Black, M.D.

Edward O'Malley, M.D.

David A. Plager, M.D.

Derek T. Sprunger, M.D.

Daniel E. Neely, M.D.

Naval Sondhi, M.D.

Senior Editorial Consultant: Gunter K. vonNoorden, M.D.

Graphics: Michelle L. Harmon

Technical Support: George J. Sheplock, M.D.

Lecture 5 of 24

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