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Incidence of Inadvertent Globe Perforation During Strabismus Surgery Br J Ophthalmol: First Published As 10.1136/Bjo.74.8.490 on 1 August 1990

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Incidence of Inadvertent Globe Perforation During Strabismus Surgery Br J Ophthalmol: First Published As 10.1136/Bjo.74.8.490 on 1 August 1990 490 BritishJournalofOphthalmology, 1990,74,490-493 Incidence of inadvertent globe perforation during strabismus surgery Br J Ophthalmol: first published as 10.1136/bjo.74.8.490 on 1 August 1990. Downloaded from R J Morris, P H Rosen, P Fells Abstract before the widespread use of modern suture Visual loss following strabismus is rare and materials and needles in strabismus surgery, and usually follows inadvertent perforation of the it was our impression that with the use ofmodern globe at the time of surgery. Previous studies surgical techniques the incidence of scleral per- have reported that the incidence of this com- forations was much lower than previously plication occurs in 8% to 12-1% of patients reported. To try to establish the incidence of undergoing conventional strabismus surgery, globe perforation in our patients we conducted a and higher incidences have been reported for prospective study in consecutive patients under- posterior fixation sutures. We conducted a going strabismus surgery. prospective study to determine the incidence ofthis complication in our patients. We identi- fied one case ofglobe perforation in 67 patients Material and methods (100 eyes). Twenty-two patients (44 eyes) had Sixty-seven consecutive patients undergoing undergone previous strabismus surgery, and strabismus surgery in the six-month period there was no evidence of previous scleral October 1988 to March 1989 were included in perforation in this group. We discuss the the study. There were 33 males and 34 females, recent advances in strabismus surgery which and the age range was from six months to 52 may account for this difference in the inci- years (mean 112 years). dence ofscleral perforation. Prior to surgery the pupils of the operated eyes were dilated with cyclopentolate hydrochloride 1% and phenylephrine hydrochloride 2 5%. Inadvertent perforation of the globe is a recog- Fundal examination was performed by indirect nised complication of strabismus surgery. It ophthalmoscopy and scleral indentation, and usually occurs during intrascleral passage of any chorioretinal abnormalities noted. After sur- needles and may involve the sclera, choroid, or gery and before suturing the conjunctiva the retina. ' It has been reported when disinserting a retina was re-examined over the site of each muscle from the globe and may also occur when scleral suture by the indirect ophthalmoscope in passing sutures through a muscle prior to its order to identify any chorioretinal haemorrhages, http://bjo.bmj.com/ disinsertion. ' In the majority of cases scleral per- retinal tears, or vitreous haemorrhage indicative foration is undetected at the time of surgery and of inadvertent scleral perforation. The suture discovered later by the presence of a chorio- knot was held with a fine Colibri forceps so that retinal scar, which may represent deep choroidal gentle scleral indentation could be applied involvement rather than actual retinal per- directly over the site of the scleral passage of the foration. needle. In those cases with posterior fixation Sequelae leading to visual loss are rare and sutures this was not always possible, and the include retinal detachment, endophthalmitis, globe was gently indented with a squint hook on October 2, 2021 by guest. Protected copyright. posterior chamber haemorrhage, cataract, lens over the site of the suture. dislocation, hyphaema, and glaucoma.2'" Reports of the estimated incidence of retinal detachment in strabismus surgery vary from less SURGICAL TECHNIQUE than 1 in 1000012 to 1 in 37000.8 The reported Surgery was performed with the operating micro- incidence of endophthalmitis has varied from 1 scope. All extraocular muscle surgery was per- in 35008 to 1 in 8000,'3 but Locatcher-Khorazo formed with limbal conjunctival incisions. The and Seegal did not find one case in 12 263 cases of muscle insertion was directly visualised before strabismus surgery reviewed. 14 isolating it on a squint hook, and the muscle was As the majority of cases of scleral perforation then cleaned of its fascial attachments and the are minor and produce no complications, the intermuscular septum. true incidence of scleral perforation is not well Muscle recessions. A single armed 6-0 Vicryl established. It has been reported as occurring in (polyglactin 910) suture on a three-eighths circle 8%,'5 9-2%,3 and 12.1%16 of patients during spatulate needle was passed through the muscle standard strabismus surgery, and Moorfields Eye Hospital, higher inci- tendon from the centre to each border and lock City Road, London dences are described for posterior fixation bites taken to incorporate the outer one-third of EC1V 2PD sutures.'718 Inadvertent scleral perforation was the muscle tendon. The muscle was disinserted R J Morris not identified at the time of surgery in any of P H Rosen from the globe with Wescott scissors and haemo- P Fells these studies. Mittleman and Bakos'2 predicted stasis secured by bipolar cautery. The muscle Correspondence to: that, if the incidence of this complication is was then reattached to the globe at the appro- P H Rosen, Moorfields Eye 9-2%, as reported by Gottlieb and Castro,3 then priate distance behind its original insertion. Hospital, City Road, London EClV 2PD. in the United States there would be an incidence Scleral bites were passed from the outer border Accepted for publication of 7600 globe perforations a year. ofthe muscle tendon towards the centre, and the 8 March 1990 These retrospective studies were reported suture was tied to its free end; the second suture Incidence ofinadvertentglobe perforation during strabismus surgery 491 was then reattached in the same way. The Table I Diagnosis at presentation inferior oblique muscle was recessed to a Diagnosis No ofpatients Br J Ophthalmol: first published as 10.1136/bjo.74.8.490 on 1 August 1990. Downloaded from position 3 mm posterior and 3 mm lateral to the lateral border of the inferior rectus by a Esotropia 37 Exotropia 11 single suture through the anterior border of the IV nerve palsy 6 muscle. Duane's syndrome 4 VI nerve palsy 6 Muscle resections. The muscle was identified Blow-out fracture 1 and cleaned in the same way as for a recession. Thyroid eye disease 1 Congenital nystagmus I Two Chavasse muscle hooks were then placed under the muscle and two single armed 6-0 Vicryl sutures, on a three-eighths circle spatulate needle, placed through each borderofthe muscle, chorioretinal scarring to suggest previous ocular with lock bites being taken to secure the suture. perforation. The muscle was resutured to the globe at the original insertion. Ifthere was any bowing of the insertion another suture was placed through the Discussion central portion ofthe muscle. Strabismus surgery is one of the commonest Faden procedure. The technique used for procedures performed by the general ophthal- Faden sutures has been described in a previous mologist. Although the risk of visual loss is paper from Moorfields Eye Hospital. 18 remote, it is usually related to perforation of the Muscle transposition procedures. The vertical globe at the time of surgery,20 and every pre- recti were identified and two 6-0 Vicryl sutures caution should be taken to keep this risk to a passed through the tendon, as in a muscle minimum. recession, and the muscle was fully transposed In the 67 patients (100 eyes) studied prospec- laterally.'9 In one case the horizontal recti were tively, we identified only one case of scleral transposed inferiorly by a similar technique. perforation in the 134 procedures in which the muscle was reattached to the globe. In this case the perforation was suspected at the time of Results suture placement and confirmed by the presence The diagnosis at presentation in the 67 patients of a small deep retinal haemorrhage on fundal undergoing strabismus surgery can be seen in examination. No evidence of scleral perforation Table I. was found in the 22 patients who had had One hundred and thirty-seven muscles in the previous muscle surgery. In total only one scleral 67 patients (100 eyes) underwent surgery. One perforation was identified in 194 muscle pro- hundred and thirty-four required resuturing to cedures (144 eyes). This incidence of scleral the globe; the remaining three muscles under- perforation is lower than previously described. went superior oblique tenotomy (Table II). In Although Gottleib and Castro reported an incidence of 9-2% in their series, they did not only one patient did inadvertent perforation of http://bjo.bmj.com/ the globe occur at the time of surgery. This state whether the 68 patients recalled was the occurred in a five-year-old boy with right total number of patients operated on over a five- Duane's syndrome (type I). One year previously year period or only those who attended for re- he had undergone a right medial rectus recession examination.3 Kaluzny et al in their retrospective of 5 mm and right lateral rectus resection of study recalled 91 patients operated on over an 5 mm at another institution. In order to correct eight-year period and report an incidence of 10-2% in 108 eyes operated upon. 16 In both these reduced abduction associated with a persistent on October 2, 2021 by guest. Protected copyright. abnormal head posture a temporal transposition studies it is not clear ifthe figures represent a true of the vertical recti in the right eye was per- incidence of consecutive patients operated on or formed. Scleral perforation was suspected only the incidence in those patients they during the procedure when the medial border of examined. Rojas et al,5 however, reported on the superior rectus muscle was resutured to the consecutive patients but did not examine the globe, though there was no prolapse of uveal fundus before surgery, and, as in the other tissue or vitreous. This was subsequently con- studies, they included any retinal or choroidal firmed at the end of the procedure by indirect abnormality as indicative of perforation.
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