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    Short Tag noose adjustable suture for adjustment after strabismus surgery


    Watch as David G. Hunter, MD, performs the short tag noose adjustable suture technique. (Video courtesy of David G. Hunter, MD)

    The procedure

    The short tag noose approach can be performed through a small fornix incision. Once the muscle has been reattached to the eye with 6-0 Vicryl or an equivalent, the procedure involves five steps: securing the muscle pole suture ends to each other, placing a sliding noose around the pole sutures at the desired position near their exit from sclera, securing the noose suture ends to each other, trimming the pole and noose sutures to a 5 mm length, and tucking the sutures under the conjunctiva, he explained. Dr. Hunter is Ophthalmologist-in-Chief at Boston Children’s Hospital and Professor and Vice Chair of Ophthalmology at Harvard Medical School.

    He demonstrated the approach with a patient undergoing an inferior rectus muscle recession. He makes a 5-millimeter incision and isolates the inferior rectus muscle on a muscle hook. He passes a Guyton small-incision muscle hook that facilitates maintaining the incision under 5-6 millimeters, pulling the conjunctiva up and over the ball of the muscle hook. “We now have good visualization and can proceed with the surgery without the need to enlarge the incision,” he said.

    He explained that the muscle is disinserted after it has been secured, as in most strabismus surgeries, with a central knot followed by locking bites at the muscle poles. These pole sutures are then passed through the center of the original insertion to reattach the muscle to the eye, after which the muscle is pulled up and the sutures tied to each other with an overhand knot. Next the sliding slipknot is wrapped around the sutures and then tied tightly and securely using a square knot to hold the muscle in place postoperatively. An overhand knot holds these two ends together about 5 mm from the knot to make it easier to find the sutures in the event adjustment is needed.

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