Topical anesthesia strabismus surgery for adjustable sutures has advantages

Houston-Topical anesthesia strabismus surgery for adjustable sutures has many potential advantages, but surgical techniques need to be modified and patients chosen carefully, suggested David K. Coats, MD, professor of ophthalmology and pediatrics, Baylor College of Medicine, Houston.

Listing the advantages of topical anesthesia surgery, Dr. Coats explained that it is a one-step process completely performed in the operating room, where a sterile set-up can be maintained during the entire procedure and where lighting and surgical assistance are optimal. Cardiac monitoring and anesthesiology services also are available if needed.

Until recently, strabismus surgery under topical anesthesia required heavy support from an anesthesiologist, but advances have streamlined the process.

Dr. Coats said that he has used adjustable sutures less frequently over the years, but when he does use them he is more likely to use topical anesthesia.

His guideline is that the less systemic anesthesia used, the better, and that the prerequisites for successful surgery are a skilled, gentle surgeon, an experienced anesthesiologist, and a willing, non-squeamish patient.

Surgical preparation

Dr. Coats' preparations for this procedure include topical lidocaine gel, which is placed in both eyes in the holding area even if only one is to be operated on; intravenous propofol early in the case, only if needed and used sparingly; lidocaine drops as needed intraoperatively; a ceiling-mounted accommodative target for adjustments; and targets on the wall because alignment is sometimes done with the patient sitting.

Another suggestion Dr. Coats shared was to use only room light, eschewing a spotlight that could bleach the photoreceptors and hinder adjustment.

Dr. Coats said that he prefers a limbal incision to a fornix incision since the latter tends to be very uncomfortable under topical anesthesia, and commented that the surgeon has to be satisfied with limited, less-than-perfect exposure.

He also suggested that the surgical team minimize talking and noise, and stressed that the most important intraoperative technique is to be gentle and avoid pulling on the muscle, since excess manipulation is painful.

During a topical anesthesia procedure, his technique is to create a limbal incision and then put a bridle suture in the sclera, using it to retract the eye and lessen traction on the muscle. Rather than isolating and hooking the muscle, he dissects and exposes it without the hook. When the edge of the muscle is identified, the conjunctiva is released and the episcleral space is opened. When the insertion is exposed, a Wright hook is used to gain access without placing any tension on the muscle.

"Patients just don't complain if you use this technique, and it greatly facilitates your ability to perform adjustable suture surgery with little or no additional systemic sedatives or anesthetic agents," he said.

Dr. Coats also said that because of careful preoperative patient selection, he rarely has to convert to a retrobulbar or peribulbar technique during topical anesthesia strabismus surgery.

FYI

David K. Coats, MDPhone: 832/822-3234
E-mail: dcoats@bcm.tmc.edu

Dr. Coats does not have any relevant financial disclosures.