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490 BritishJournalofOphthalmology, 1990,74,490-493 Incidence of inadvertent perforation during 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 , 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 in our patients. We identi- fied one case ofglobe perforation in 67 patients Material and methods (100 ). 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 of the operated eyes were dilated with 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 and scleral indentation, and usually occurs during intrascleral passage of any chorioretinal abnormalities noted. After sur- needles and may involve the , , or gery and before suturing the the . ' 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 , , globe was gently indented with a hook on October 2, 2021 by guest. Protected copyright. posterior chamber haemorrhage, , over the site of the suture. dislocation, hyphaema, and .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 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 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 37 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 1 Congenital 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 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. There- ophthalmoscopy, when a small deep retinal fore it is possible that the reported figures haemorrhage was identified at the site of suture placement. This was not associated with a retinal Table 2 Surgical procedures hole or vitreous haemorrhage, and no transcleral Patients 67 was therefore applied to the site. No Eyes 100 complications developed over a six-month Muscles Recessions follow-up. Medial rectus 50 Prior to inclusion in the study 22 patients (44 Inferior oblique 14 Lateral rectus 14 eyes) had previously undergone strabismus sur- Inferior rectus 3 gery: 17 on one occasion, 4 on two occasions, and Resections Lateral rectus 24 1 on three occasions. The total number ofmuscle Medial rectus 8 procedures in which the muscle had been Faden Lateral rectus 9 resutured to the globe was 60. In addition, one Medial rectus 2 patient had an injection ofbotulinum toxin to the Transposition procedures 6 ModifiedHarada Ito 2 medial rectus five days before temporal trans- Faden with recession position of the vertical recti for a sixth nerve Medial rectus 2 Supenor oblique tenotomy 3 palsy. In none of these patients was there any 492 Morris, Rosen, Fells

overestimate the incidence of globe perfora- vided the edges of the needle are parallel to the tion. Nevertheless we consider these figures sclera during its intrascleral course the risk of are unacceptly high and that with appropriate inadvertent perforation is low. We use a three- Br J Ophthalmol: first published as 10.1136/bjo.74.8.490 on 1 August 1990. Downloaded from precautions and careful surgical technique a eighths circle spatulate needle, but in some lower incidence ofcomplications can beachieved. situations where access is difficult a half circle It is well documented that the sclera is thinnest spatulate needle can be advantageous. It has the (0 3 mm) behind the insertion of the rectus disadvantage of allowing a shorter scleral bite, muscles and thicker (0-6 mm) at the muscle but of the same depth as a three-eighths circle insertions.2' Scleral perforation is commoner needle.26 A reverse cutting needle has a cutting during muscle recessions than resections.22 Mills edge on the convex surface and therefore has a et al22 and Cap6 et al23 have recommended the use theoretically greater risk of causing scleral per- ofhang-back sutures to reduce the risk of scleral foration. However, some surgeons prefer it, as, perforation during standard muscle recessions. unlike the wider spatulate needles, it does not This procedure has the theoretical disadvantage have to remain exactly parallel to the scleral that the recessed muscle may creep forwards or surface during its intrascleral course.27 Posterior slip, causing vertical deviations. However, per- fixation sutures are inserted postequatorially on foration has been reported after muscle resec- larger needles where the sclera is thin and access tions39'5 and during suture placement at the difficult; this is the likely explanation for the original muscle insertion for adjustable sutures.7 higher incidence of scleral perforations with this In Gottleib and Castro's series3 four of the 10 procedure. patients developed perforation as a result of The management of such perforations is con- muscle resections, and in none of these patients troversial. Some authors recommend that they did they describe which suture material or needle should be treated with transcleral cryotherapy was used. Globe perforation has also been regardless of the depth of perforation, to reduce reported as the sutures are passed through the the incidence of retinal detachment.359 Mittle- muscle before the globe is disinserted.5'I and man and Bakos, however, in animal experiments may occur during disinsertion of the muscle found a higher incidence of retinal detachment from the sclera.' Although the sclera is thinner associated with heavy retinal cryotherapy, and behind the insertion of the rectus muscles, it is they suggest that unless intravitreal haemor- clear that this is not the only factor associated rhage occurs or the patient has a predisposing with scleral perforation. risk factor for retinal detachment no treatment is We suggest that all strabismus surgery should indicated.'2 Retinal detachment may be secon- be performed with some form of magnification, dary to vitreous traction and presentation either with the operating microscope or with delayed, so that patients with globe perforation spectacle mounted loupes. The operating micro- complicating strabismus surgery should be fol- scope provides excellent lighting and magnifica- lowed up long term. If scleral perforation is tion, but does reduce the field size and depth of detected at the time of surgery, conjunctival

focus and restrict the surgeon's mobility. With cultures should be obtained and antibiotics with- http://bjo.bmj.com/ loupes a headlight affords excellent lighting as an out steroids administered because of the small alternative to the standard overhead operating risk ofendophthalmitis. Such patients should be room lights. followed up closely for signs of infection in the When dissecting tissues in order to isolate early postoperative period. muscles it is important to directly visualise tissues before using sharp dissection, particu- 1 Wagner RS, Nelson LR. Complications following strabismus larly in the presence ofscar tissue in reoperations surgery. Int Ophthalmol Clin 1985; 25: 171-8. on October 2, 2021 by guest. Protected copyright. and in restrictive conditions such as thyroid eye 2 McLean JM, Galin MA, Baras I. Retinal perforation during strabismus surgery. AmJ Ophthalmol 1%0; 50: 1167-9. disease. Before disinserting a muscle or passing a 3 Gottleib FG, Castro JL. Perforation of the globe during suture through the sclera it is essential to ensure strabismus surgery. Arch Ophthalmol 1970; 84: 151-7. 4 Apple DJ, Jones GR, Reidy JJ, Loftfield K. Ocular perfora- good haemostasis and adequate exposure, by tion and secondary to strabismus surgery. Jf means of a Fison or Desmarres retractor if PediatrOphthalmolStrabismus 1985: 22: 184-7. When a 5 Salamon SM, Friberg TR, Luxenberg MN. Endophthalmitis necessary. muscle is reattached, the after strabismus surgery. Aml Ophthalmol 1982; 93: 39-41. needle should be placed through the superficial 6 McNeer KW. Three complications ofstrabismus surgery. Ann Ophthalmol 1975; 7: 441-6. 1/3 to ½12 of the scleral thickness and passed 7 Greenberg DR, Ellenhorn NL, Chapman LI, Miller MT, Folk tangential to the sclera, with the tip visible at all ER. Posterior chamber haemorrhage during strabismus surgery. AmJ Ophthalmol 1988; 106: 634-5. times. Magnification enables direct visualisation 8 Knobloch R, Lorenz A. Uberernste Komplikationen nach of the intrascleral course of the needle as well as Schieloperationen. Klin Monatsbl Augenheilkd. 1962; 141: 348-353. the intrascleral course of the vortex veins. 9 Basmadjian G, Labelle P. Dumas J. Retinal detachment after The most commonly used suture material in strabismus surgery. AmJ Ophthalmol 1975; 79: 305-9. 10 Hittner HM. Lens dislocation after strabismus surgery. Ann strabismus surgery is now 6-0 Vicryl (polyglactin Ophthalmol 1979; 11: 1115-9. 910).2 It has the advantages of causing minimal 11 Hanver WH, Kimball OP. Scleral perforation during strabis- mus surgery. AmJ Ophthalmol 1960; 50: 807-8. tissue reaction, having a high tensile strength, 12 Mittleman D, Bakos IM. The role of retinal cryopexy in the good knot holding ability, and a predictable management of experimental perforation of the eye during strabismus surgery. J Pediatr Ophthalmol Strabismus 1984; absorption rate, but has the disadvantage of 21: 186-9. adhering to tissues.25 Its high tensile strength 13 Weinstein R, Mondino BJ, Weinberg RJ, Biglan AW. Endophthalmitis in the pediatric population. Ann allows 6-0 sutures to be used with small needles. Ophthalmol 1979; 6: 935-43. Our preference is to use a fine spatulate needle 14 Locatcher-Khorazo D, Seegal BC. Microbiology of the eye. St Louis: Mosby, 1972: 74. which cuts tissue at the sides and tip. Other 15 Rojas B, Vargas A, Riveros M. Retinal periphery after spatulate needles with a point below lead to a strabismus surgery. Arch Chil Oftalmol 1979; 36: 119-21. 16 Kaluzny J, Ralcewicz H, Perlikiewicz-Kikielowa A. Eye deeper bite than those with a point above and are fundus periphery after operation for squint. Klin Oczna more likely to cause scleral perforation.26 Pro- 1977;47:557-8. Incidence ofinadvertentglobe perforation during strabismus surgery 493

17 Alio JL, Faci A. Fundus changes following Faden operation. 22 Mills PV, Hyper TJ, Duff GR. Loop recessions of the recti Arch Ophthalmol 1984; 102: 211-3. muscles. Eye 1987; 1: 593-6. 18 Lyons CJ, Fells P, Lee JP, MacIntyre A. Chorioretinal 23 Capo H, Repka MX, Guyton DL. Hang-back lateral rectus scarring after the Faden operation: a retrospective review of recessions for exotropia. Pediatr Ophthalmol Strabismus Br J Ophthalmol: first published as 10.1136/bjo.74.8.490 on 1 August 1990. Downloaded from 100 procedures. Eye 1989; 3: 401-3. 1989; 26: 31-4. 19 Fitzsimmons R, Lee JP, Elston J. Treatment of sixth nerve 24 Schwartz RL, Koller HP. Survey of sutures used in strabismus palsy in adults with combined and surgery. Pediatr Ophthalmol Strabismus 1981; 18 39-41. chemodenervation and surgery. 1988; 95: 25 Bladyes JE. The use of polyglactin-910 in muscle surgery. 1535-42. Ophthalmic Surg 1975; 6: 39-41. 20 Simon JW, Dannemann AF, Hampton GR, Richards R. 26 Goldstein JH, Prepas SB, Conrad SD. The effect of needle 'Which eye will you be straightening, doctor?' Pediatr characteristics in strabismus surgery. Arch Ophthalmol 1982; Ophthalmol Strabismus 1989; 26: 55. 100:617-8. 21 Naumann GOH, Apple DJ. Pathology of the eye. New York: 27 Helveston EM. An atlas of strabismus surgery. 3rd ed. St Springer, 1986: 23-4. Louis: Mosby, 1985: 70-1. http://bjo.bmj.com/ on October 2, 2021 by guest. Protected copyright.