1. Alfred J. Cossari, MD Port Jefferson, NY

2. Financial Disclosure  I have no financial interests or relationships to disclose.

3. My Objectives  Describe the 2 stages of strabismus surgery  Briefly compare 3 basic adjustment procedures  Look at the timing of adjustments with respect to events occurring in the healing process  Provide details of the 7 th day fixed suture procedure  Encourage surgeons who have avoided hang-back sutures to consider the 7 th day procedure  Recommend that all patients be prepared by their surgeon for a possible adjustment

4. Strabismus Surgery - requires 1 or 2 stage -  1 st stage (primary surgery): procedure that executes the type and amount of surgery determined to best correct a specific set of sensorimotor defects  2 nd (adjustment) stage: a brief interruption of the healing process that provides a second guess opportunity when the primary surgery appears to be failing After 7-10 days, interruption of the healing process is no longer temporary due to advancing scar formation; revision at this stage requires a reoperation

5. Suture Adjusting - an overview -  Standard hang-back suture: has been the centerpiece for routine or selective suture adjusting within 24 hours of surgery  Short tag noose suture: is one example of a modified hang-back suture that eliminates the need to tie the suture when no adjustment is required  7 th day fixed suture: is an approach that avoids using a special suture and defers adjustment of the suture position to the 7 th day  Reality is: there is an adjusting procedure suited to the preferences of most strabismus surgeons

6. Adjustment Procedures - percentage adjusted -  100% of patients with a standard hang-back suture need either an early adjustment or a tie-off  < 50% of patients with a short tag noose suture are early adjusted; the remainder absorb without tying  5% of all patients have an aberrant primary surgery result requiring a 7 th day fixed suture “rescue” adjustment at day #7

7. Early Adjustment - 24 hours / early inflammatory phase -  Easiest time to adjust a hang-back suture  Minimal fibrosis of the platelet clot  Least accurate time to perform a motility assessment  Pain, splinting and drowsiness are present  Patient interaction is often part of this 2 nd guess; O.R, bedside or exam chair

8. 7 th Day Fixed Suture Adjustment - early proliferative phase -  More accurate time for a motility assessment (including diagnostic gaze positions)  Pain, splinting and drowsiness are resolved  Blunt dissection is required to replace the fixed suture  Fibrin/collagen have begun to fibrose the tissues  Patient interaction is not used for this 2 nd guess

9. Typical Example - supporting 7 th day adjust -  4 year old  X(T) = 27, RH(T) = 5  Recessions (LROU and RSR)  ET = 30, LHT = 4(day #1)  With a hang-back suture, an early adjustment would probably have been performed  A hang-back was not used, so early adjustment was not considered

10.  F/T alternate occlusion was prescribed with probability of a 7 th day adjustment  ET = 10, LHT =2(day #6)  7 th day adjustment deemed unnecessary  Orthophoric(week #3 – year #4) An early adjustment would have adjusted him out of this excellent result

11. 7 th Day Fixed Suture - surgeon profile -  Distrusts hang-back sutures and nooses  Distrusts early postop assessment of motility  Distrusts bedside interactive decision-making  Enjoys a high surgical success rate w/o early adjusting  Recognizes the need for an occasional “rescue” adjustment  Or, uses a hang-back but occasionally has need for a 7 th day rescue

12. 7 th Day Fixed Suture - patient experience -  100% of patients are prepared for the 5% probability of an adjustment  95% are happy when they discover an adjustment is not needed  5% are not surprised when an adjustment is recommended

13. 7 th Day Fixed Suture - surgical issues -  All 6 EOMs have been adjusted  Adjustments are scheduled as an add-on to my weekly block-time  The same anesthetic technique is used (general or regional) as the primary surgery  Tugging on muscle hooks is avoided to prevent breaking the suture or tearing it from the muscle  Fixation and rotation of the globe are accomplished with bridle sutures and locking Stern-Castroviejo forceps  The new suture is secured before cutting the old

14. 7 th Day Fixed Suture - cost reduction issues -  Reduced personnel time for up to 95% of surgeries (surgeon, anesthesiologist, OR nurses, RR nurses, techs, etc.)  Fewer instrument trays and materials  Suture adjustment submissions are reduced by up to 95%  No increase in reoperations due to long-term failures compared with other adjustment techniques

15. suggestions for successful Second Guessing  Determine your preference: hang-back or 7 th day fixed suture adjustment technique (or both)  Prepare all patients for the 7 th day fixed suture adjustment process; an early adjustment preference does not preclude possible need for a 7 th day rescue  Develop your second guessing skills and statistics – don’t forget to assess motility on POD #6  Decrease the need for 2 nd guessing with better stage 1 planning

16. Semantics of this 7 th Day 2 nd Guessing (adjustment vs. reoperation)  Back to OR on a different day  Repeat anesthetic  Same healing process with muscle position adjustment  No excision of scar  No new muscle operated  Placement of a new suture in the same muscle or tendon  Late second guess opportunity Your choice!

17. Summary  All patients should be afforded the opportunity of having the surgeon second guess the placement of muscle attachments before healing occurs whenever there is an unexpected response to surgery  3 basic second guessing approaches: - standard hang-back suture - short tag noose suture - 7 th day fixed suture  Success is largely the result of a good sensorimotor assessment and sound surgical decisions; not a specific adjustment technique