Lecture: Controversies in Strabismus Surgeries

DR GANESH: Welcome to our webinar on controversies in strabismus surgeries. Strabismus has always been exciting, with controversies, and always with one or two different strategies and management. While it is important to couple the existing scientific literature and discuss with clinical experiences. So we have thus interesting topics for discussion. And I think we are all fortunate to have two great strabismologists, who have mentored many people, including me, in the last 20 years. We have listened to their lectures, read their books, read their articles, and have groomed ourselves. Dr. Molinari is a director of fellowship in pediatric ophthalmology in Ecuador, in addition to being an associate professor. She has been a mentor on Cybersight for over 20 years, since its inception, working with Dr. Helveston. She’s also an Orbis volunteer faculty. Dr. Pradeep Sharma is director of oculoplastic ophthalmology in India. For all of us, in India and Asia, we know him as the father of squint, as we have all grown listening to his lectures and reading his books. He has more than 200 scientific publications and chapters of books. He is also Orbis faculty and has been a surgeon aboard the Flying Eye Hospital. I now invite Dr. Molinari to upload her talk. And Lawrence, the first polling question, please. Okay. There’s a mix. I think Dr. Andrea, you can begin.

DR MOLINARI: Thank you, Dr. Suma, for your kind introduction. It’s a great pleasure for me to share, again, this webinar with you. And also having the honor to share it also with Dr. Pradeep. As you all know, a Faden procedure is a special surgical technique, very useful for the management of incomitant strabismus. Especially in cases like this one, where the patient is orthophoric in primary position, but has a significant deviation in another position. Or in cases like this other one, with significant far-near incomitance, where you want the correction of the deviation only or preferably in a certain gaze position. So the purpose of this talk will be to describe in the next couple of minutes the different surgical techniques that will allow us to obtain this effect of diminishing a deviation in a specific position, without affecting too much the eye position in other gazes. In a traditional Faden procedure, after opening the conjunctiva, preferably with a limbal incision, which makes the procedure easier to do over a fornix incision, the muscle is thoroughly dissected from its ligaments, and the intramuscular membrane. As you can see here, I also placed a suture on the borders of the conjunctival flap, in order to make it easier with a retraction of the flap to expose the muscle, and to visualize the site of the operation. After that, the Desmarres retractor is placed, and the pulley is observed. The anterior part of the pulley is dissected, but only the anterior part of the muscle, which will give you better exposure. Then a non-absorbable suture is placed carefully in the sclera, and involves the outer one third or one fourth of the muscle. After tying the muscle very, very tightly, the procedure is done also on the other side. You must make sure that the suture is very well tied. Here you can recognize the vortex vein, which is always very close to the site where you have to place the scleral suture. This is what makes the procedure also a little bit more difficult. After that, a recession can be done or not, depending on the effect that you want to obtain. This procedure, together with a small recession, will help correct small angles in primary position, and collapse the distance-near disparity, as can be seen in this patient. This girl was orthophoric for near and for distance after this procedure. There is a variant of this procedure called Faden stretch. In which the suture is placed in the same distant point on the sclera, but it is placed closer to the insertion in the muscle. How much closer? Well, generally as much as you want to recess the muscle. For example, if you want to recess the muscle 3 millimeters, the scleral suture is passed 12 millimeters, but the muscle suture is placed 9 millimeters. This makes the anterior part of the muscle, the anterior part of the muscle from the Faden, that stretched over the sclera. Which is not in the procedure shown before. This is a very powerful procedure that will correct larger angles of esotropia in primary position, as can be seen here in these two cases, with a large angle congenital esotropia, that needed only 3.5 millimeters recession of both medial rectus, combined with the Faden, to correct such large angles. There are other surgical techniques that can be used to correct incomitant strabismus, and that will have a similar effect. What we call a Faden effect. Among them, we have the bridge suture, the resect-recess, the pulley posterior fixation, Faden with adjustable sutures, and the Y split. The bridge suture, also known as cinglage in the French literature or Fadenoperation in the German literature, involves a suture being passed from one side to the other side of the muscle, without touching the muscle. And here you can compare this technique with the original technique described by Cuppers, and the Deller modification, which is the technique I showed you at the beginning of this presentation. This technique has several advantages. Among them, less adherences, since the muscle is not touched, and less muscle atrophy in front of the Faden. This makes it easier and faster to perform, and also much easier for reoperations. Resection-recession was described for the treatment of incomitant strabismus by Alan Scott and presented for the first time at the ISA AAPOS meeting in Vancouver in 1994. This technique was popularized by Buckley and co-authors, who published a much larger series in these papers. This technique is based on the fact that since the Faden produces usually atrophy in the part that is anterior to the Faden, then the effect would be the same, if a resection is made on this part, and then the same recession of the muscle was resected, with the advantage that the recession can be done with an adjustable suture. So one of the advantages of this technique is that there is no need to place scleral sutures too posteriorly, which makes the procedure much easier to perform, and the possibility to use adjustable sutures. But on the other hand, there is also concern that the muscle might not attach properly to the sclera. Since it is recessed so far back. And this is especially dangerous with the medial rectus muscles where the arc of contact is shorter. This is why it is better with the lateral rectus muscles, where the sutures must be placed farther back from the insertions. Also, this interferes with the oblique insertions. Also, it is important to know that there are no nomograms with this technique on how much to resect and recess in order to obtain a desirable effect. The pulley posterior fixation was described by Robert Clark at the 2004 AAPOS meeting held in Washington. This technique fixes the pulley to the anterior surface of the muscle. Here you can see with the forceps, we grab the tissue, firmer tissue, which is the pulley, and then a non-absorbable suture is placed through this tissue, and attached to the anterior surface of the muscle. This causes a mechanical restriction towards the operated muscle, which limits the muscle duction. And this is what the authors claim makes the effect in order to correct the incomitant strabismus. You can combine this with a recession, as you can see here. 6-0 Mersilene is also used in this technique. And after the procedure, you can see how the ductions are limited. Towards the operated muscle. In this other technique described by Jonathan Holmes, a scleral suture is placed underneath the muscle, not in the borders of the muscle, as we showed previously, and then the muscle is recessed with an adjustable suture. The suture over the muscle is tied loose, in order to allow the muscle to slide backwards or forwards, during the adjustment procedure. Finally, the Y splitting of the muscle was described first by Dr. John Polsky in 1980, for the lateral rectus, for avoiding sliding of the muscle and improving up and downshoots in certain gazes. Many years later the same technique was described in the medial rectus muscle, as an alternative for the operation described by Cuppers. In this technique, both halves of the muscles are split and separated 10 millimeters apart. This reduces the muscle torque, thus diminishing the rotational effect. It has several advantages. It is also easier to perform. You have to place very posterior scleral sutures. And it produces less adherences and cicatricial tissue, which makes reoperations easier. So to conclude, we have seen that we have many different surgical techniques in our surgical armamentarium for treating incomitant strabismus. You should choose the one you feel more comfortable with. And remember that some techniques are more suitable for certain muscles than for others. Thank you so much for your attention, and I will be happy to entertain any questions that might arise.

DR GANESH: At the present moment, in the chat box, I just caught a question. There are not questions in the chat box. I think we will wait. I think you can start your second lecture and then we can discuss more questions. Lawrence, the poll question, please, for the second talk. So 67% plication, and resection, 33%.

DR MOLINARI: It is more or less what I was expecting. Resection and plication are surgical techniques for strengthening intraocular muscles, but historically, resection has been the most popular procedure, as was shown in the poll. Muscle plication has been described in the past, but only more recently has this procedure received more attention in the medical literature. One barrier to greater acceptance of the plication procedure is the uncertainty regarding its effectiveness compared to an equivalent amount of muscle resection. Some very well known strabismus surgeons have found a reduced surgical success rate, when using plication, as you can see in this paper. And this explains also why the poll has demonstrated such results. So this has brought some concern to whether the dose response effect of horizontal rectus muscle plication is equivalent of that of resection. Therefore, the purpose of this presentation will be to point out the advantages and disadvantages of the plication procedure, compared to the resection, and demonstrate that plication can be as effective as resection, by showing the procedure I usually perform. I am convinced that the way the surgical technique is carried out in a plication will determine its effectiveness. In a resection, you generally resect a certain amount of muscle, and you suture the muscle back to the insertion. It doesn’t matter how you do this. You will get similar results. But when performing a plication, we must recognize that it is not the same if you fold the muscle anteriorly than if you fold it posteriorly from the insertion. The effectiveness will be different, since the folded muscle in this second case will shorten the muscle in a lesser amount. There is at least 1 millimeter difference if you place this part of the muscle anterior, or posterior to insertion. Let me explain this a little simpler. If you place this part anterior to the insertion, it will give you more effect than if you place it posterior to the insertion. This might explain why some papers refer to having less effectiveness, and others finding both procedures equally effective. Let me show you my technique. Double armed suture, usually 6-0 vicryl, is placed at the desired part of the muscle, in a very similar way as for an adjustable suture, only not at the insertion, but back of the insertion. It is very important to tie the suture in the middle, in order to prevent the suture to slide backwards or forwards, when the muscle is folded. As you can see here. Then the needles are passed through the sclera, anterior to the muscle insertion, probably from outside the muscle insertion. You have to make sure that the muscle enters the sclera. Not only the tendon of the muscle. And then you do this from the other side. And then the needle enters the muscle in front of the previously placed suture. And it comes out behind the suture. This should be done close to the muscle border. The same thing is done on the other side. Preferably closer to the border than it is shown in this video. And then the hooks are removed, and both sutures are pulled up, and towards the muscle insertion, allowing the muscle to fold on itself, without using any type of spatula. The suture is finally tied tightly, and the procedure is done. Rectus muscle plication is simple, and it involves fewer steps than a comparable resection. This is a fast procedure. Faster than a resection. So which are the advantages of this procedure? It’s definitely faster and simpler. It does not require cutting the muscle. Therefore the ciliary circulation is less disturbed. There is less surgical trauma, inflammation, and hemorrhage than a resection, it is reversible in the early postoperative period, and it eliminates any risk of lost muscle. It has also some disadvantages. There are concerns in plications that the effect will not be maintained after the absorbable sutures are absorbed. In my opinion, this does not happen. There is also a cosmetic concern about a postoperative bump. As you can see in this picture, taken from this paper. This does not occur when the muscle is folded over the muscle. So anteriorly. The use of adjustable sutures is also questioned. It was published in some papers like this one. But the case series are very scarce to draw a conclusion. On the other hand, it is difficult to think how a folded muscle that is partly unfolded during the adjustable procedure will adhere to the sclera. Vertical transposition of the muscle is definitely possible. Although only more difficult to perform — let me show you a video — in small plication, and if the transposition is very large. Here you can see how the suture is not placed in the middle, because in the middle of the muscle, there is a vessel. And you want to spare the circulation. So in this case, it was placed — the knot tied in the periphery. And then the suture is passed through the muscle. From one side to the other side. And then the difference with the other technique is that the suture is not placed here outside from the muscle insertion, but in the middle, because we want to place the transposition, or to do the transposition, superiorly. So in this case, the suture is placed in the middle of the insertion. And here it is placed half tendon superiorly to the border of the insertion. And you will notice that the sutures go obliquely toward the transposed insertion. Here we pass again the sutures behind the suture, and after the suture, and here you see that sutures go obliquely. Finally, you take the hooks away. And then again, you pull the sutures up, and towards the insertion. Finally, you tie the knot. Sometimes you need that the assistant holds the first knot with a needle holder, as you can see here, in order to prevent the knot to get untied. And here you can see how the muscle is superiorly transposed with a plication. So let me conclude by saying that in my opinion, plication is as effective as resection, but it depends on the technique employed. And it has several important advantages over resections. It is simpler. Faster. Less traumatic. And it disrupts less the anterior segment circulation. Thank you very much for your attention. Dr. Suma, unmute yourself.

DR GANESH: Thank you, Dr. Andrea. There are a lot of questions shooting in. The first question is how to identify the pulleys of the muscle.

DR MOLINARI: That’s a good question. Well, once you get more experience, you will recognize that the pulley has a different aspect to the check ligaments, which are the ones you cut first. And then when you place the Desmarres retractors, you can see a more whiter tendinous aspect structure, that lies approximately 10 millimeters behind the insertion of the muscle. And when you touch it with the forceps, you will feel that it is more firm.

DR MOLINARI: Dr. Lila is asking: She does pulley fixation, but she says it does not have a long effect. When you do a Faden, it has a good effect, but she says that pulley fixation does not.

DR MOLINARI: I agree with her. I have done the pulley fixation a couple of times. And I have seen the same thing. That’s why I have not done them anymore. I agree with her. The regular Faden procedure has a much more long lasting effect. And also a more powerful effect.

DR GANESH: So if you find any specific condition — maybe if the sclera is very then, you could do a pulley fixation?

DR MOLINARI: But in these cases, you can also do resect —

DR GANESH: Pradeep Sharma?

DR SHARMA: I am also not very much keen for pulley fixation. I feel it is not a firm structure. So you are fixating the muscle to something which is itself not firm. So that’s why I think the results are not as desirable as we will get with the conventional Faden, or even with the other procedures. Like especially with the lateral rectus, even with lesser amounts of resection and recession, it works. I found that instead of 12 to 13 to 14 millimeters conventional Faden, I just did 9 millimeter resection and recession. It worked as well. So the resection-recession or Scott-Buckley procedure is also a good procedure. And another procedure which Dr. Andrea talked about and I found interesting was the Y splitting for superior rectus. I think this is something which for DVD I have seen, that at times, you can do this procedure, and it works better than a Faden for superior rectus. A Y split superior rectus. You may add with a recession. So that’s another good procedure which she talked about.

DR MOLINARI: That’s very interesting. I have never tried it.

DR GANESH: How much? Large DVD? More than 15 to 20 DVD? Okay.

DR SHARMA: Yeah. So if it is a superior rectus that we want to handle, those DVDs in which we find inferior oblique overaction — obviously the choice is to do anterior positioning. Those in which the inferior obliques are not overacting, then we have a choice between inferior rectus plication, nowadays, that is the preferred technique that I have, but if I have to do a superior rectus recession, or a DVD, for a DVD, then I might do a Y split, along with a recession.

DR GANESH: Anything you want to add?

DR MOLINARI: No, I was very interested in listening to his explanation, because I have never tried this technique in a DVD. But it sounds very logical to me. I will try that.

DR GANESH: So the other question — same thing. Would you prefer DRS with upshoot Y split or Faden for lateral rectus?

DR MOLINARI: No, I prefer also the Y split.

DR SHARMA: When we are doing the Y split — it’s not actually working like a Faden. It is working more like splitting the lateral rectus and yoking the effects in the opposite direction, so that the eye doesn’t roll up or down, the upshoot or downshoot. We’re spreading it much more. About 15, 20 millimeters of split. So it’s working more like a splayed muscle, rather than a Faden. I wouldn’t do a Faden on the lateral rectus ever for a DRS.

DR MOLINARI: Yes, same.

DR GANESH: Do you prefer Y split with upshoots in severe contraction?

DR MOLINARI: Yes, yes. There is a very interesting question here. And this might be interesting for many people. How far from the muscle insertion do you do a routine Faden procedure? Because it’s different for the different rectus muscles. The medial rectus — at least you have to do it, place it 12 millimeters back from the insertion. But in the lateral rectus, you have to place it at least 15 or 16 or even 17 millimeters back from the insertion. This is why it makes it — the Faden procedure makes it not so convenient for operating on the lateral rectus, and in this muscle, the resect-recess procedure is much better to perform. And the superior rectus and the inferior rectus, the Faden must be placed at least 14 millimeters back from the insertion.

DR GANESH: And if the patient has nystagmus, which surgery is good?

DR MOLINARI: The Faden is —

DR GANESH: You can do so many surgeries.

DR MOLINARI: I know. The Faden has been described for nystagmus. Personally, I have no experience with the Faden. I do lots of Faden, but I have not used them in nystagmic patients. I use the Kestenbaum procedure, and if there is no abnormal head posture, I do recessions.

DR GANESH: In nystagmus blockade syndrome, maybe, Faden could be an option. Maybe. Maybe it means nystagmus blockade…

DR MOLINARI: In patients with congenital esotropia? Well, what makes me use the Faden — what makes me choose the Faden procedure in a congenital esotropia is not the presence of a nystagmus blockage syndrome, although it has been described for using in these cases. But how I see that the angle has a more dynamic component than contracture component. If I see that the child has a variable angle strabismus, a child with congenital esotropia, and during the anesthesia, I see that the eyes lie straight, then a Faden is — with a recession — is very useful. In these cases.

DR SHARMA: In the Alberto-Ciancia syndrome, in those cases, Faden on the medial rectus along with the resection takes care of the face turn.

DR MOLINARI: Those cases I showed — those two cases were Ciancia syndromes.

DR GANESH: There’s another question. Should we do recession before placing the Faden or after the Faden?

DR MOLINARI: That’s a very good question.

DR GANESH: The Faden stretch.

DR MOLINARI: Yeah. If it’s a stretch Faden, I place the sutures, but I don’t tighten them. I first recess the muscle and then I tighten the sutures. Because what you want is that the anterior part is stretched. If you tighten the sutures before recessing the muscle, then the anterior part of the muscle will not be stretched.

DR GANESH: Sir, do you want to tell your technique? Because sir has a different technique.

DR SHARMA: I think what Dr. Andrea described is correct. We want to do just a Faden. Then you may do the measurement — for example, if you want to do 5 millimeters of recession, and a 14 millimeter Faden, I would pass the sutures in the muscle at 9 millimeters. And in the sclera at 14 millimeters, and then when I recess 5, it takes into account and there won’t be any stretch of the extrarecession effect. But if you want an extrarecession effect, you can take into account that part.

DR MOLINARI: Exactly. I also sometimes tighten the Faden and then do the recession. For example, the case I showed with the girl who had only 15 prism diopters in primary position. In these cases, I don’t want a stretch in the anterior part, because these will give you much more effect.

DR GANESH: Yes, especially when you have to do a large recession. Then I think it’s better to do the technique where you measure it on the muscle and in the sclera, you measure how much the Faden and in the muscle you measure the recession effect.

DR MOLINARI: Let me say something regarding the amount of recession. If you plan to do a stretch Faden, be careful in not doing very large recessions. Because I have had very — I have not very large — but I have had overcorrections. When doing recessions over 4 millimeters, if I do a stretch Faden.

DR GANESH: I think other questions — I think Dr. Andrea, you’ll have to answer. Because there’s a shortage of time. There are a lot of questions you’ll have to answer in the question and answer session.

DR MOLINARI: I will do so.

DR GANESH: If any specific question — if there are two or three questions together, we can take that later. I’ll just check the questions. Because the questions are keeping on coming. Anything about plication basically — they asked to explain how close to the border you go. How close.

DR MOLINARI: How close to the border? I don’t understand that question.

DR GANESH: I think they mean that where do you take your bite in the sclera? What you said is a good point — yes.

DR MOLINARI: Yes, just in front of the insertion. Where the muscle is inserted. But always making sure that you’re passing the suture through the sclera. Not through the tendon. Okay? You want an apposition of the muscle with the sclera. Because muscle with sclera will attach much better than muscle with muscle.

DR GANESH: There’s a question too from Dr. Emmanuelle. Have you reoperated any of these patients?

DR MOLINARI: You mean the plications? Yes, and what you find is that the muscle looks like a normal muscle. There is no — the muscle does not look thicker. That’s amazing, but it’s like this. It fuses. All the folding muscle gets fused. And it remains just a normal muscle. Like a normal muscle.

DR GANESH: So please share your slides, please. You have many questions. We should have a class only on Faden. With the amount of questions.

DR MOLINARI: Don’t worry. I would like to listen to Dr. Pradeep’s talk. So I will not answer the questions now. But I promise to remain here until every question is answered.

DR GANESH: So the next topic we’re gonna cover is incomitant strabismus, adjustable versus non-adjustable. The next poll, please. How many of us do adjustable? So in selective cases, 59%. Not at all, 36%. And other, 4%. So we can discuss which cases we’re doing adjustable versus non-adjustable.

DR SHARMA: So I think it’s an interesting topic, and I really thank Dr. Suma. It’s a pleasure to be with Dr. Molinari and you on the Cybersight. Since we are in the COVID times, we are all used to wearing masks. And I was just wondering that in adjustable sutures also, we have similar differences of sliding noose or a 1.5 knot technique that we are seeing in the masks also, as you see here. We need to be adjustable. If you don’t have a Ford, you have an Ox Ford. And you will be more successful if you are adjustable. Adjustable strabismus surgery, if you see the history, it was first suggested by Harms in 1941, but if you take into account the German literature, it was mentioned by Bielschowsky in 1907 when he discussed a similar procedure. It was rejuvenated by Jampolsky and there has been rejuvenated interest time and again. We need to have this in our armamentarium, because the indications will be first and foremost those which are having incomitant strabismus. If you have a sensory anomaly in which the endpoint is not very clear, again, we have a problem. Reoperations, when the patients are more demanding, when there is a vertical strabismus or combined horizontal or vertical strabismus, and whenever the endpoint is more discrete and the patient is more demanding, you will need to have an adjustable surgery. Much more than the income pregnant strabismus where there is diplopia, and the patient is wanting diplopia treatment. In VI, IV, III nerve, restrictive strabismus, dysthyroid, ortho DRS, post-RD buckle are very demanding. The contraindications of course are those children who are not going to cooperate. Even apprehensive adults who behave like children may be uncooperative, high myopes, thin sclera, and inferior rectus — we have to make sure we don’t use an absorbable suture. Otherwise, there is a progressive recession. Published studies on adjustable surgeries are inconclusive. There are studies published by Nihalani and Hunter in Eye, but you’ll find mostly they’re retrospective, nonrandomized, and the numbers don’t give us a definitive answer. Even the Cochrane review, time and again, even in the latest one, recently done, has been inconclusive, and it doesn’t tell us, because there are no randomized controlled trials between these two. But whatever studies we have seen definitely show that the success rate improves between the non-adjustable and adjustable, and a difference of at least 10% jump is there when we use adjustable sutures. So the reoperation rates fall from 27% to 9.7%, as shown by Wisnicki, and we can adjust up to 20 prism diopters at a time. So whenever you have a demanding patient where you want an exact result, whether for a cosmetic reason or diplopia-free, you would have to do this technique. What are the different strokes that we are going to play? First of all, it may be preferable to do a limbal incision, although it can be done with a fornix incision, with a retractable suture to help you expose that. Secondly, we’re going to pass the needle radially, as shown here. It may be a full hangback or a hemihangback, in which — like in this case, we’re showing you a hemihangback, in which we pass in the sclera and then again in the insertion site. The third thing is that I am going to place a releasing suture, a silk suture, between the sclera and the first knot. So that it helps me in releasing the knot at the time of adjustment. You need to see that your suture moves in the tunnel. So check that at the time of surgery. So that it makes your life simpler. And this one and a half knots I’m placing instead of the regular one — the suture is tied as a loop knot, and finally, we have a bucket handled suture, which will help me hold the globe and not depend on a fixation fold, since sometimes the tissues can be cut through with the forceps. So these are the different techniques we will apply. There are different techniques of adjustable strabismus surgery. It may be a hemihangback or full hangback, as shown in a and b or a sliding noose technique as preferred by some people. When do you adjust? Intraoperatively, in a single stage stage, using topical and IV conscious anesthesia, or as a double stage, a more common method. It may be done after 5 to 6 hours, but some people do it as even one-hour adjustment. It may be done. After 24 hours is also done by some people, and there has been a study done that shows that there is not much difference between 5 to 6 hours or 24 hours. Even delayed techniques have been described. A technique that I usually follow is what I learned from Dr. Rosenbaum, and the simple instruments that are required are shown here. You may use proparacaine drops, the patient who had an exo has gone into post-op, over or under, you can adjust it accordingly. You need to release the 1.5 knot and for decreasing the recession, you hold the globe, and pull the suture so that the recession can be reduced, or if you want to increase the recession, you hold the globe, and ask the patient to contract that muscle, so that it recedes further. So both are possible, and for this reason, you may do an optimal surgery and not do an overrecession, as it was initially mentioned. The sliding noose technique is another technique, but my preferred technique is the one and a half knot. And that is what I have shown here, and we can do it. In children, Hakim has shown that you can do a 2 millimeter more recession that can be added, and this can be released by releasable suture, and you can have two options. Similarly, Helveston has shown the tendon suture technique which you can use. The Faden has been used as an adjustable suture, as we were just talking about, by Dr. Molinari’s talk, and this is especially so when we have a near-distance disparity, when we want a more exact result. Similarly, the superior oblique tuckings, we always do an intraoperative adjustment. This is also considered as an adjustable procedure in a way, and Harada Ito can also be done as an adjustable procedure to get the end result of torsion in a more accurate position. Coming to the VI nerve palsy, which I will be talking about in more detail in my next talk, the adjustable cross action partial VRT is a very definitive advantage, compared to the non-adjustable, in which you may have either an over or undercorrection, which may not be desirable by the patient, and as shown in this study, in these ten cases in each group, we found in adjustable, there is only one case, which are all less than 8 millimeters prism diopters, whereas in the non-adjustable group, we ended having five cases, and we could not adjust. So it is always better to have an adjustable technique on your sleeve. So to conclude, adjustable sutures provide a more definitive alignment. It requires a special technique, extra efforts are required, and you are not required to do adjustment in about 50% of cases. It is definitely a double trouble, but in demanding cases of diplopia, it offers a second chance or a safety net to fall back upon. So I would say whenever you have a very demanding patient, you should try to do this technique, so that we can definitely get an alignment in each type of surgery that we do. Thank you.

DR GANESH: Thank you, sir, for an excellent presentation. I think the questions are coming in. But one question which is written… Sir, as you pointed out, IR is a relative contraindication. Can we do adjustable in thyroid? We do adjustable inferior rectus in thyroid.

DR SHARMA: Yes, when you have to do adjustable on inferior rectus, it is preferred to use a non-absorbable suture, especially in thyroid cases, because you may have a posterior slippage or overrecession effect. Over a period of time. This has been reported by several people. So it is preferred to use non-absorbable suture when you do thyroid inferior rectus. It usually tends to recess more.

DR GANESH: So there’s no question, but sir, do you find that the noose technique, the one and a half technique better than the noose technique? Any special —

DR SHARMA: Yeah. In the noose, I have a fear that it may slip beyond my control. So because of the —

DR GANESH: In granuloma, the noose technique was a concern.

DR SHARMA: Okay. So that’s why I usually do not do a noose technique. And I find the one and a half knot can be easily pulled forward or backward, and given a final end result. So I usually prefer to do a one and a half knot. But there are people who do a noose technique. And it’s fine with me.

DR GANESH: There’s a question asking. How much do you split the muscle for Faden. I think this was for DVD.

DR SHARMA: For DVD, I would have to split at least 10 millimeters. And the separation between them is not as much as we do for a DRS. That is 20 millimeters for DRS. Here the splitting between the two ends of the superior rectus is about 8 or 10. Because this is what we need to do a Faden effect.

DR GANESH: Okay. So I think the questions will keep coming. I think we’ll start with the next presentation. So can you share your screen? It’s on abducens palsy, VRT versus modified Nishida technique. We’ll take questions after this, so please send in questions.

DR SHARMA: Now we’re talking about the vertical rectus transpositions versus Nishida for abducens palsy. I have no financial disclosures. The goals, as we know, are to bring the eye to the primary position, provide diplopia-free vision in the primary gaze, improve the abduction amplitudes, and finally to expand the field of binocular single vision. Let’s say if you have a 6th nerve palsy, we have seen the transposition procedures have evolved over a period of time. In 1907, Hamelschein had described a partial VRT. There have been several modifications since then, and each one has added value to it. When we do a partial technique, we know the effect might not be as much as desired, so we want to augment the force by adding various procedures. An augmentation done by posterior fixation suture which is passed 8 millimeters, to vectorize the force in the direction of the paretic muscle. This has also been done for partial VRT as well as a full thickness VRT, and there is an article from Velez-Rosenbaum group in which posterior fixation sutures are shown. But the problem with these techniques is that there is no ability to adjust. If you have a desired result, it is fine, but as we have seen, it may not be all the time, and you may sometimes have an under or an overcorrection. Even an overcorrection may not be so desirable, as the patient may be unhappy. So Guyton described a technique in which he was using a cross action, full width vertical rectus transposition, so it could be put on an adjustable suture, and this is a very interesting technique. But since we are using a full width, there is the risk of anterior segment ischemia, especially if you have to add a medial rectus resection as the antagonist muscle. Then you have to handle three muscles. So we thought: Why not do it with the partial VRT? What we have described is a partial VRT on cross section sutures, as shown in this schematic diagram, and the picture here. I’ll just show you a video. First the conventional VRT. Partial VRT. Using a resection to augment the effect. So we have split the superior rectus. Usually we try to save the muscles as much as possible. And this half of the muscle is the same. 2.5 millimeter resection effect we have developed in this by passing the sutures 2.5 millimeters away from the recession, so we will be effectively resecting this part of the muscle. In any case, whenever we are using superior rectus for lateral rectus, there will be augmentation, because the arc of contact will be stretched, when we are putting for a lateral rectus. And now we are passing the superior rectus at the upper edge of the lateral rectus. This is how we can do a conventional partial VRT. Similarly, the inferior rectus is passed. And as I’ve shown you, it can be put on an adjustable suture intraoperatively, or even as a two stage. You can keep it as one and a half knot. This will correct any torsion or vertical effect. For a cross section, the technique is similar. You just bring the superior part on the inferior end and the inferior part on the superior end of the lateral rectus. As you see in the schematic diagram here. And you can put them on an adjustable suture, or if you’re confident, you may put it as a non-adjustable suture, and do only an intraoperative adjustment to see that there is no torsion or a significant vertical deviation that you have created. But if you have to be more sure, you can keep them on adjustment, and adjust it after 6 hours. We had done a study comparing the adjustable and non-adjustable group. As you can see here, the pre-op large angle esotropia which was there has been corrected fully, the abduction has improved, and the distance deviation was improved in both the adjustable and non-adjustable techniques. And similarly, the binocular vision was also improved. But it was a larger improvement or more improvement in the adjustable group, compared to the non-adjustable group. And similarly, the abduction improved in both the groups. But slightly better in the adjustable group. So coming to the dinner plate that you have now, the options that you have, you can have a partial tendon VRT, a full tendon VRT, or you may have a single muscle SRT or an IRT. As described by this group. You can also add on the effect by augmenting by resection, 2.5 or 3 millimeters, you can add effect by Foster sutures, or also augment by a cross action suture. You can also increase your effect by doing an antagonist medial rectus recession. Sometimes if you have a full VRT you may not be able to do a recession. You just use Botox in the medial rectus. And you can also have an additional effect by doing a lateral rectus plication, so you have a full plate for your dinner right now. But this is not enough. We have the dessert still left. And that’s the Nishida procedure. It’s a very useful addition to our armamentarium that we have. Here we are not disinserting the superior or inferior rectus. We’re not splitting the superior or inferior rectus, but vectorizing the force, passing a non-absorbable suture, 8 millimeters, in the muscle, and then putting it closer to the muscle that we want the effect of. These are the pre-op and post-op pictures. Let’s have a video to see how it works. So in this, these two vertical recti, same as we did for the VRT, we’re going to identify — 3 up to 8 millimeters, mark it at 8 millimeters, non-absorbable 5-0 suture is what I like to pass, in the lateral one third of the superior and the inferior rectus. We also need to ensure that the nasal part of the intramuscular septum is spared, so that the muscle can be easily switched towards the side we want to switch. And 13 millimeters from the limbus in the sclera, a passage is made. And with both the needles — and then again I pass it in the muscle. The muscle, sclera, and muscle technique again, which will reinforce the vectorization fully in the direction of the absent or the weak muscle. This is a very simple technique, which has been initiated by Dr. Nishida’s group. And we have modified it slightly. That we vectorize it a little more towards the missing muscle. And the effect is very good. You can correct up to 35 to 40 prism diopters easily. And as we have seen in the study, we’ll close this here. This is the pre-op and post-op pictures. In the non-adjustable group, when we did the Nishida procedure, we found that we had overcorrection in several cases, and in one case, it was very severe. About 30 prisms. So we need to have an adjustable medial rectus, whenever we do a Nishida procedure, in order to have a more definitive result, as we saw in this group, in which the adjustable medial rectus recession takes care of the overcorrections. The preoperative fields have been centered and enlarged in the dimensions, the abduction has improved, and the anterior segment ischemia has not occurred, which we should be always careful in all the VRTs and examine the eye under the slit lamp on the first post-op day, so there is no anterior segment ischemia signs. The series that we have seen in the reviews — there are several studies which have been done. We have found that because the techniques are so different, and each one does it a little differently, there is no conclusive answer, but we definitely know that the single muscle techniques are less effective than the double muscle techniques. The partial vertical rectus transposition will be less effective than the full width transpositions, but there is risk of anterior segment ischemia. So our choice would be to use an adjustable cross section partial VRT to get a more definitive and predictable correction and in addition to the medial rectus recession. And in the Nishida’s group, whenever we are doing — we may have an adjustable MR, whenever it’s possible, like we are operating on an adult or a cooperative child, this would be our preferred technique. So to conclude, I would say: You need to have different techniques in your armamentarium. As this study has shown recently, and I also have seen ones that I have to do, when I was doing the partial VRT, the inferior rectus partial stump just gave way, and I was under a dilemma, what to do. So I used the inferior rectus Nishida technique, and the superior rectus was of course done with the VRT technique. So you can have a combination of different techniques, to get the desired result. I would like to thank you at this point. And for your questions. Thank you.

DR GANESH: Questions. What is ideal age for VRT?

DR SHARMA: We have done in children maybe even a child with three years old. I have done a VRT, as well as the lateral rectus split, and medial positioning also I have done in two and a half or three years old children. With a large third nerve palsy, with a large exodeviation. But in 6th nerve palsies, again, fortunately we do have less 6th nerve palsies, but when we have DRS cases, we may do children also with the VRT in younger children.

DR GANESH: In modified Nishida, how do we achieve shifting of the muscle without splitting?

DR SHARMA: What we need to ensure is split the intramuscular septum on the nasal side, so that the superior rectus can be easily transferred towards the side that you want. And secondly, you need to pass the reinforcing suture. First in the muscle, then in the sclera, and then a bite in the muscle again. This will bring the muscle in the desired position. But we need to free the intramuscular septum on the nasal side.

DR GANESH: So I’ll start sharing my screen. And meanwhile, the questions we’ll take at the end. More questions on plication. I’m gonna ask you and Dr. Andrea more questions on plication after my talk. Because I think that we have —

DR SHARMA: Dr. Suma is the prime mover for this Cybersight talk. We should thank her and we are excited for your talk now.

DR GANESH: Thank you, sir. I’m so honored to share the platform with Dr. Andrea Molinari, who has been my mentor for so many surgeries, and Dr. Pradeep, who I grew learning squint. So I want to speak on a surgical controversy which is a simple topic. But I think we always have this whenever we are dealing with intermittent exotropia. We know that intermittent exotropia is a common form of childhood exotropia, accounting for 50% to 90% of all exotropia. It is characterized by intermittent divergence, usually present initially on distance fixation when the child is tired but later at near fixation as well. It can deteriorate into a constant exotropia, and this can cause amblyopia. So we have the classification system, the Burian and the Kushners classification. We do follow these classifications for our management. The indications for surgery are a constant deviation, a deteriorating fusional control, large angle deviation, or if there is a reduction of loss of stereo acuity for distance and near. I will go to some basic cases. This is case one, which is a basic exotropia, with 35 prism diopters for distance, and also 35 prism diopters for near. Alternate suppression, postoperatively, after doing a bilateral lateral rectus recession, we got a reduction of 4X, but distance and near, stereopsis increased to 200 seconds of arc. Another child with 30 prisms exo, and 25 prisms near exo. After the operation, 400 seconds of arc. 8 prism diopters esotropia, but same for distance — was suppressed, and for near, BSV, stereopsis, 400 seconds of arc. Case three, near was 45 prisms, on patch test, one hour, it increased to 50 diopters, so pseudodivergence excess. Again, stereopsis absent. Performed a right lateral rectus recession with medial rectus resection. Small residual exotropia, but good sensory outcome. Similarly, basic exotropia case on an older male, 20-year-old. With a 45 and a 50, and there was a residual of 12 prisms exotropia. On the first month. Followed by fusional exercises, he improved to around 4 prisms with good stereo fusion at distance and near. So the goals: We know choice of surgery for basic exotropia is both lateral rectus recession or unilateral lateral rectus recession and medial rectus resection. What you want to know is which is more effective, in terms of long-term success rate, overcorrection rate, recurrence rate, or drift. What is the success rate for each procedures? What are the factors affecting the outcome? Like age of onset, duration of deviation, amount of pre-op and post-op deviation, presence of amblyopia, anisometropia, and incomitance? There was a paper published — a meta-analysis done in 2018, regarding these procedures. A comprehensive literature search was performed using PubMed, Embase, and the Cochrane library. To identify randomized controlled trials and comparative studies regarding the effectiveness. And they evaluated long-term success rate, overcorrection rate, and recurrence. They only chose basic exotropia cases, and there was a clear cut definition of success, in whom the primary outcome measures could be extracted. Out of 2,544 cases, published literature, coming to the strict criteria, only the studies which included were ultimately only 9 studies. Because most of the other papers did not give a clear cut definition of success. And what they found: The success rate of the two kinds of surgeries was comparable. The overcorrection rate was the same. But if you see the reference, they found that bilateral lateral rectus recession had a higher success rate after follow-up of more than two years. But R and R had a better outcome less than two years, but they definitely showed an exo drift in the long term period. So this was — for small angle, they found R and R had a better outcome than unilateral lateral rectus recession. So in other papers, also published in 2012, which they again took basic exotropia, but they chose different angles. A bilateral lateral rectus recession — they took deviation 40.5, and they preferably chose the eye with a dominating fixing eye for R and R. But still found a higher success rate in the bilateral recession-resection group. They found that the survival and analysis was better in the bilateral lateral rectus group. Because there was a difference in the deviation, this group had both — BLR and RR group — same amount of deviation, the number of patients, and they found that the RR group showed higher rates of success when the deviation was more than 45 prism diopters. So the pre-op deviation, if it is more than 45, they found that with the bilateral lateral rectus, there was a recurrence of 35.6%. Which was less with the R and R. And so this is how they concluded that maybe for more than 45 prism diopters, you need to do an R and R surgery. They found the prognostic factors were age at surgery, and recurrence rate decreased with increased age at surgery, and also found that the recurrence rate also increased with increased deviation at postoperative period. Similarly they found recurrence with unilateral, but with bilateral recess, there was 72% success rate, and the older the age, the larger the decrease in recurrence rate. The take-home message — and maybe points for discussion would be how many of us do bilateral lateral rectus recession, what is our criteria, if it is more than 45 prisms, we mostly go for unilateral lateral rectus recession and MR resection, and the better survival probability in the BLR group — the long-term lower recurrence rate and higher success rate is seen in the BLR group. So any questions?

DR SHARMA: Maybe you can carry on with your talk, Suma, and then we can have the questions.

DR GANESH: So the other discussion was, I think, the other controversy which we have is the A and V patterns. Whether we go for the vertical transposition of the horizontal or the oblique muscle surgery. We all know that AV patterns form around 15% to 25% of all strabismus practice. More seen in esotropia than exotropia. So A pattern, this is basically — we’re all aware that it is significant when it is around 10 prism diopters, and V pattern is significant when it’s around 15 prism diopters. Etiological factors have reported as oblique muscle, horizontal rectus muscle, vertical rectus muscle, et cetera. Most of us go in for the oblique muscle dysfunction present or not. We also find neurological involvement and malformative systemic disorders in A pattern showed a greater prevalence of neurological impairment, hydrocephalus whereas V pattern was more in craniosynostosis. We if oblique muscle is present, we do it. If not, we do a muscle weakening of the inferior oblique. It corrects around 15 prisms to 25 prisms of the V pattern. And greater anterior recession, anterior oblique — anterior transposition of the inferior oblique — is also found to get good effect in 82% of cases of esotropia and 80% of exotropia cases. But the response was mostly dependent on how much is the extent of the preoperative V pattern. And also they found that even if you do a bilateral recession of the inferior oblique, they got a good outcome. In this paper, they said that there was a vertical imbalance postoperatively, but we normally find that if there’s an asymmetric vertical in the primary position on the side gaze, asymmetric inferior oblique recession. So similarly in A pattern, when there is a superior oblique overaction, we normally go in for a superior oblique tenectomy. The posterior tenectomy of the superior oblique. And it is found to be effective in A pattern around 15 prism diopters, and it reduces it to a mean reduction of 12.75. But it does not have any effect on the primary position vertical deviation as well as ocular torsion. So this paper says that the dose is — there’s a uniform dose and it collapses the A pattern. But if there’s no oblique dysfunction, what we do is a vertical transposition of the horizontal rectus muscles. We shift the medial rectus to the apex and the lateral rectus to the base. Dr. Pradeep Sharma et al. concluded in this paper, published in the Indian Journal of Ophthalmology, a 5 millimeter shift was as effective as an 8 millimeter shift in monocular vertical displacement of horizontal rectus muscles. This is around 15 to 20 prisms. So if there is an exotropia, we shift the lateral rectus upwards and the medial rectus downwards. So the controversy is: Whether we do a horizontal muscle transposition or oblique muscle weakening for correction of the patterns. Why this controversy? Because the paper published in 1998 by Dr. Clark and the group of Dr. Rosenbaum and Demer, they found that the description of connective tissue sleeves that function as pulleys for the rectus is responsible for the abnormalities. The pulleys determine the paths and thus the pulling directions of the extraocular muscles. So the pulleys should be considered in the differential diagnosis of incomitant strabismus and oblique dysfunction. Whether to do transposition or weakening of the oblique muscle. The pulley concept says in the V pattern there is a downward displacement of the lateral rectus muscles. Pulleys. And upward displacement of the medial rectus, when it’s a V pattern. And for A pattern, there’s upward displacement of lateral rectus and downward displacement of medial rectus, A pattern, and nasal displacement of the superior rectus. So we found a similar case which we had done, where we didn’t touch the oblique muscles. And also the shifting of the lateral rectus. The 35 prism exotropia with the DVD just by doing a lateral rectus recession and a superior rectus recession, we found that the A pattern was crushed. So to design the paper where they have shown the high resolution surface coil MRI scans, done in contiguous, quasi-coronal planes, showed us that it should always be looked for in cases of A pattern. This is what they found. There is a displacement of the lateral rectus. And the inferior shift of the medial rectus, like in an A pattern or in a V pattern. So now the questions I have is that: So this is a patient with craniosynostosis. Operated already on right eye with lateral rectus recess, medial rectus resect. Had still a residual of 35 prisms exotropia with 16 prisms left hypertropia. And there is a 64 prism V pattern. We know that the causes are excyclotorsion of the globe, anomalous vectors of muscle action, shorter orbital floor. In these cases, we need to look for the MRI and look for displacement of the muscles. So maybe in this case, we should be shifting the lateral rectus and the medial rectus for a V pattern, along with the inferior oblique also when we do — since there is also an oblique overaction here. So Dr. Chaudhuri and Dr. Demer published this, and they found — they have concluded that pattern strabismus and congenital polyheterotropias correlate with abnormal pulley locations of the horizontal rectus muscles, and they were not due to oblique muscle dysfunction. Should we be doing MRI in all patients of A and V pattern, or only specific cases? I would like the poll question to be put, Lawrence. How many of us do MRI in all cases of A and V patterns, and do we ask for a specific MRI? So the verdict is in selective cases and not at all in 31% of cases. We’re done with all the presentations. Now we will take over the questions.

DR MOLINARI: I have a question for you, Dr. Suma. And for Dr. Pradeep too, regarding the effect or the position you look for when operating on intermittent exotropias. Have you found that the exo shift is different in children than in adults? For example, I always look for a small overcorrection of 5 or 10 diopters in children. But not as much in adults, because I have seen the adults don’t have such exo shift. What is your experience with this issue?

DR GANESH: In children, we aim for overcorrection, because I have seen in long-term practice we find that after 3 years, if we have not — if it has remained ortho, or if it has remained even in slight postoperative deviation, you have still exo remaining, I find they drift, and you have to add on a medial rectus resect maybe after 3 or 4 years. So it is better to keep them overcorrected. To first follow Dr. Raab, where he said you do 10 to 15 prisms eso overcorrection, but parents are very unhappy, so I left them 6 to 8 prisms eso. It’s not predictable. You aim for it, but it is not in all cases you get that. Like the cases I showed — you aim for an eso, an overcorrection. And I prefer to go for an ortho or an undercorrection. But there’s a drift. So basically… You see if the patient is — I think if the patient has no fusion, then I would aim for slightly overcorrection. Because then you cannot work on it, even for getting… You can’t even do the exercises. But if there is — if there is some amount of fusion, which I check whether the patient has fusion potential, I make it slightly undercorrected so we can work on the fusion.

DR MOLINARI: Dr. Pradeep?

DR SHARMA: I have a little different take. Children who are under 5 or 6 years of age, I would avoid doing an overcorrection. And secondly, I find in children there is — the DVD is much more than what we get in adults. So if you end up having a consecutive eso in a child, the risk of amblyopia is much more severe to deal with, rather than having a residual exotropia in which they can still fuse, in intermittent divergent squints. I try never to overcorrect in under 5-year-old children. I would aim for ortho, or even reduce a little bit, so I would get undercorrection, up to 5 years of age. Older children, yes, about 6 or 7 years, and adults, I would overcorrect so I get 8 to 10 prisms of eso, on the first day. I have seen this exo drift is maximally happening in the first month, and after that, the shift is only 2 to 5 prisms. Secondly, Dr. Molinari’s question about the drift — I do see it in adults also. Even in older children who are about — in terms of divergent squints, many times we’re operating around 25 to 30 years also. They do have an exo drift. And that is the reason why many people have a feeling that we should not be operating in children, and we should be operating only at a manageable age, because it will always come back. It doesn’t actually come back. It’s an exo drift. If you correct it, in an older child or adult, with an eso result, you will not have a loss of correction. You end up having the same thing for longer. You should overcorrect in adults and older children, but less than 5 or 6 years, I would say never overcorrect.

DR GANESH: For children less than 4 years, we do wait. I don’t go in for surgery so early. I do try another factor, like overminus lenses, 3 or 4 years of age, until we get the full proper deviation.

DR SHARMA: You mean — you have to — I think I would rather do a residual exo.

DR GANESH: Yes, if it’s a younger age, yes.

DR MOLINARI: I agree with you, Dr. Suma. I try not to operate under five years of age, actually. There are many questions here regarding your talk. Do you want me to read them? Yes, Dr. Suma. Go ahead.

DR GANESH: Could Sir Pradeep do advice on NAP?

DR SHARMA: It’s a similar principle, but we are using horizontal rectus transpositions for vertical muscle palsy. This is a different procedure. Although in principle it may be similar. So we do use the procedure for double elevated palsies or monocular elevation deficits. We can use the horizontal. The good thing is that when we are doing a full width horizontal rectus transposition, the risk of anterior segment ischemia is not much. Because the horizontal recti — there is a long posterior ciliary artery also to contribute. So the risk of doing a two-muscle surgery is usually not as much as when we have a vertical rectus transposition. Even with just two muscles and not the third muscle added on. There is a risk of anterior segment ischemia.

DR GANESH: Okay. Dr. Andrea? Suppression in a child — when do you plan surgery? I think one of the indications for surgery is suppression. If there is suppression, I would go for surgery. Unless the child — even if the child is very — like, say, four years of age. The child is going into suppression, I would do patching for some time. I would wait for some time. And then go ahead and do the surgery. I think more than 4 years of age, suppression is an indication that you need to go for early surgery. As soon as you see it.

DR SHARMA: Then we are losing binocular vision. If we have the child already suppressing, he is going to have loss of binocular vision, even though they may have 6/6 vision in each eye, but alternate suppression, which may not be a desirable result.

DR MOLINARI: There is a question regarding the inferior rectus for inferior rectus paresis. The question is: What is the role of Faden on the normal muscle like inferior rectus, in cases with inferior rectus paresis on the other side? Can it create a matching defect and improve depression in the affected eye? Well, exactly. This is one of the indications of a Faden for the inferior rectus. It will not improve depression — well, if it’s a paresis, yes. It might improve the depression in the affected eye, definitely. But what it will mostly do is restrict depression in the muscle where you perform the Faden.

DR SHARMA: We have a fixation effect. Getting more innervation to the conjoined movements if you have a Faden on the contralateral inferior or superior rectus.

DR MOLINARI: There is a question for Dr. Pradeep. For large exotropias, which is better? The question is for Dr. Pradeep — what do you think in large exotropias? Which is better, bilateral recessions or recess/resect?

DR SHARMA: What I have seen is that the R and R definitely gives a better effect. And also a more lasting effect than the bilateral recessions. And whenever I have to do a bilateral recession, like in a child maybe when we are doing a GA and it’s alternating eye, I do bilateral surgeries. I usually end up having more amount than when I would be having an R and R. R and R I have seen gives me about 25% extra effect compared to the same millimeters for a bilateral recession.

DR MOLINARI: I agree with you on that. But on the other hand, what makes me opt for a bilateral recession instead of R and R in many cases is the cosmetic effect. I have seen that the palpebral fissure can have — can be affected, and this will — especially in adult patients, especially in women that are very concerned about their cosmetic aspect, that the bilateral recessions are cosmetically better than the R and R.

DR SHARMA: Yeah. I would agree that whenever you have an alternating exotrope, you should do a bilateral recession. But if you have a unilateral squint, always having unilateral exotropia, then my mentor told me that the principle in strabismus is to do a symmetricizing surgery, not always necessarily a symmetrical surgery. So if there is a preexistent asymmetry, do an asymmetric procedure to restore symmetry. If there is symmetry already, you can do bilateral recessions.

DR SHARMA: Is Nishida’s procedure good enough in place of NAPS?

DR SHARMA: Yes, Nishida’s procedure can be used in place of NAPS also. There are some studies and we have used it. Especially in cases where there was a tight superior rectus. And I have done a recession of the superior rectus. And the inferior rectus was because of trauma already injured, it may be better to do Nishida’s procedure on the horizontal recti so we don’t risk anterior segment ischemia.

DR MOLINARI: Questions regarding plication. Is the formula or the indication similar to R and R? Yes. Because in my hands, plications give me exactly the same result as a resection.

DR SHARMA: I would agree.

DR GANESH: How long does it take for the bulk of the plicated muscle to flatten?

DR SHARMA: 3 to 4 weeks.

DR MOLINARI: I agree.

DR GANESH: That’s what Dr. Faroukh has written.

DR MOLINARI: There is another question regarding if the Faden is bilateral or unilateral procedure. That depends on the indication. For example, yeah, if you are going to use a Faden for a vertical incomitance, you do it only in — like we talked before, for the inferior rectus paresis in one eye, you do it only on the inferior rectus of the other eye. But if you want to correct esotropia with far distance incomitance, you do it in both medial rectus.

DR GANESH: How much maximum bilateral rectus recession we would perform? It’s a question to Sir. I don’t like to do more than 9 or 9.5. Do you do more than 10?

DR SHARMA: I wouldn’t do — if I have to do more than that, I would rather do an R and R. R and R will give me a better field. Maximum I go is 9 millimeters in comitant squints and if you take care of these numbers, you won’t have the palpebral finish issues also. There is a rotational effect on the globe rather than a retraction effect. So you should do equivalent amounts of recession and resection of the medial rectus and lateral rectus so you don’t have a palpebral change.

DR GANESH: Yes, sometimes there is a minimal limitation if you do more than 9 or 9.5. We could go on to a third muscle if we have to do more, or recess/resect,

DR SHARMA: For large exotropes, you could do more. There are articles coming out of China in which they correct large exotropes with 12 millimeters of recess/resect. Those have — incomitant squints, you can go beyond.

DR GANESH: In the third nerve palsy, we do large recessions of the lateral rectus. And the medial rectus.

DR SHARMA: 45 millimeters of recession.

DR GANESH: Andrea, this is for you. Which one do you prefer for high AC/A —

DR MOLINARI: Faden.

DR GANESH: Slanted recession?

DR MOLINARI: No, I prefer the Faden procedure. But I understand the slanted procedure is much easier. The thing is, I was trained in Argentina and in Germany. In Germany, the Faden procedure is very popular. So since I learned the procedure and I did it so many times, it is not a difficult procedure for me. But this is why I said in my conclusion slide that you have to use the procedure you feel more comfortable with. If you feel more comfortable with slanted recession, you should choose that one. But in my hands, a Faden procedure works very well. I am very used to do this.

DR GANESH: For a high AC/A ratio —

DR SHARMA: For incomitant, you may use bifocals.

DR GANESH: Do you go in for a Faden? Or for the convergence excess type with the Faden?

DR MOLINARI: I didn’t understand your question.

DR GANESH: If a patient with the bifocal is performing — you can make it ortho with the bifocal?

DR MOLINARI: No, no, if the patient gets corrected with a bifocal, I use a bifocal. I don’t operate. I don’t do a Faden, of course.

DR SHARMA: Non-accommodative excess esotropias.

DR GANESH: I think the last question we’ll take on is: Do you use non-absorbable in inferior oblique or any restricted muscle?

DR SHARMA: Inferior oblique? Why? Inferior rectus I had mentioned.

DR GANESH: I think this is a question from —

DR SHARMA: Non-absorbable sutures. Whenever we’re doing loop hangback for superior oblique, I use non-absorbable sutures.

DR MOLINARI: I think the question comes for example — some authors say that the inferior rectus tend to slip back. And this is why some authors I think — Irene Ludwig, I’m not sure, she recommends to use non-absorbable sutures for the inferior rectus. Personally, I use non-absorbable sutures.

DR GANESH: I have a question. For an A pattern with torsion, which is the procedure you prefer? You do a suture, superior oblique tenectomy?

DR MOLINARI: Superior oblique —

DR GANESH: For A pattern with torsion, what is your procedure of choice?

DR MOLINARI: Not a Brown syndrome.

DR GANESH: No, not a Brown syndrome. A pattern with superior oblique overaction like inferior oblique paresis.

DR MOLINARI: Superior oblique tenectomy, approaching it from the temporal side.

DR GANESH: Okay.

DR MOLINARI: Dr. Pradeep?

DR SHARMA: Superior oblique overaction and the torsion is not much, it’s a mild superior oblique overaction in A patterns, I would do a posterior tenectomy of superior oblique. But if it is a more severe 3+ or 4+ superior oblique overaction, then I usually nowadays do a hangback superior oblique recession. That is looped, which gives me a more graded result for the superior oblique weakening.

DR MOLINARI: How do you make sure, Dr. Pradeep, when you do recession with the hangback, that the superior oblique tendon really goes far back? Because of the frenulum? Are you very careful in cutting all the attachments?

DR SHARMA: You need to separate the frenulum between the superior rectus and the superior oblique. And see that the muscle has been — the tendon has been freed. And you can move it back and forth and see that yes, it is there. And then at the end of it, you will do a forced duction, exaggerated forced duction test, to ensure that the superior oblique is stretched and retracts back. That’s right. Unless you do the separation of the frenulum, you may not have the desired result.

DR GANESH: I think it’s past time. Thank you, Dr. Pradeep Sharma, Dr. Andrea, this has been a wonderful session. There are still questions coming in, but I think we’ve already answered the question with DVD with A pattern with superior oblique.

DR MOLINARI: Are we able to keep answering these questions? And there will be — will they be available for the audience if they want to look them afterwards?

>> I can jump in there. I can send you all a list of the remaining questions, and we can post the answers on Cybersight. If that’s all right with you.

DR MOLINARI: Perfect. We’ll do that.

>> I will send those over in a little bit. And thank you all for presenting.

DR SHARMA: Thank you.

DR MOLINARI: Yes, thank you, Dr. Suma again. It was a pleasure seeing both of you in the distance through the computer in these difficult times. And we hope we can do this sometime again. Bye.

DR GANESH: Bye. Thank you, Sir.

DR SHARMA: And all the people who have attended it. Thank you all.

DR GANESH: Thank you for nice participation. Thank you so much.