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ORIGINAL ARTICLE
Year : 2021  |  Volume : 28  |  Issue : 2  |  Page : 93-97  

Limbal versus fornix incision for strabismus surgery: Preferences from a consultant to a trainee level in Saudi Arabia


1 Department of Pediatric Surgery, Division of Pediatric Ophthalmology, King Abdullah Specialist Children's Hospital, National Guards, Riyadh; King Abdullah International Medical Research Center, National Guards, Riyadh; King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS) Saudi Arabia, Abha, Saudi Arabia
2 King Abdullah International Medical Research Center, National Guards, Riyadh; Department of Surgery, Division of Ophthalmology, Asir Central Hospitwal, Abha, Saudi Arabia

Date of Submission24-Mar-2021
Date of Acceptance11-Aug-2021
Date of Web Publication25-Sep-2021

Correspondence Address:
Dr. Shatha Alfreihi
Department of Pediatric Surgery, Division of Pediatric Ophthalmology, King Abdullah Specialized Children's Hospital, Ministry of National Guards Health Affairs, Central Region, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/meajo.meajo_103_21

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   Abstract 


PURPOSE: This study aims to identify the use of limbal versus fornix incisions among strabismus surgeons in Saudi Arabia and the preferred approach to teaching trainees with the shortest learning curve.
METHODS: Two designed questionnaires were sent to local strabismus surgeons and ophthalmology trainees.
RESULTS: A total of 127 participants responded to our survey: fifty-nine consultants (53% Saudi nationals and 43% expat ophthalmologists) and 68 trainees. The limbal approach was the preferred approach for all settings, including the primary pediatric procedure (30, 55.9%), pediatric reoperation (40, 64.7%), adult primary procedure (32, 55.9%), and reoperation (40, 70%). The reason was attributed to better exposure. As for fornix incision, the most commonly cited reason was less pain and discomfort. For the adjustable suture technique, 29 (49.2%) did not use adjustable sutures, and 22 (37.3%) prefer the limbal approach. When we compared Saudi versus non-Saudi surgeons, 26 (83.87%) Saudi surgeons were trained to perform the limbal method, whereas 16 (57.14%) non-Saudi surgeons were trained to perform the fornix approach. Of the trainees, 35 (51%) were trained on the limbal approach. When asked about the learning curve for different methods, 41 (60.3%) noted a faster learning curve with the limbal approach.
CONCLUSION: Despite the many advantages of the fornix incision, it remains uncommon in our region. Each technique of strabismus surgery has its advantages and disadvantages. Programs should teach all methods to trainees. One should add all styles to his armamentarium and choose the appropriate one for each patient.

Keywords: Fornix incision, limbal incision, strabismus surgery, teaching residents


How to cite this article:
Alfreihi S, Ammar H. Limbal versus fornix incision for strabismus surgery: Preferences from a consultant to a trainee level in Saudi Arabia. Middle East Afr J Ophthalmol 2021;28:93-7

How to cite this URL:
Alfreihi S, Ammar H. Limbal versus fornix incision for strabismus surgery: Preferences from a consultant to a trainee level in Saudi Arabia. Middle East Afr J Ophthalmol [serial online] 2021 [cited 2022 Jun 25];28:93-7. Available from: http://www.meajo.org/text.asp?2021/28/2/93/326661




   Introduction Top


In the era of minimally invasive methodology and robotic revolution,[1] the trend is to minimize the incision size in strabismus surgery with minimal or no sutures if possible.[2] In strabismus surgery, the postoperative redness and patient's discomfort will be affected by the type and location of the conjunctival incision and the number of muscles operated.

The limbal incision[3] is popular as it provides good visibility of the muscle. It is the choice in reoperations where scarring and disruption of anatomical planes are present; it is relatively easy to teach residents. It provides excellent visibility and direct hooking of the muscles under clear visualization. However, in comparison with the fornix incision, there might be an increased risk for irritation from conjunctival sutures placed for closure, a higher risk of visible conjunctival scarring, corneal dellen formation, and loss of stem cells at the limbus. It is best for very elderly patients, as the conjunctiva has lost much of its average elasticity. If the patient is to undergo future trabeculectomy, there will be interference with the peritomy placed superiorly due to scar tissue formation at the site of a previous limbal wound.[3]

On the other hand, the fornix incision[4] is one of the most popular incisions worldwide for strabismus surgery,[5] yet unpopular in our country. A few of its advantages are that it is unlikely to cause extensive visible scarring because the incision is placed in the fornix, a single incision could allow access to more than one muscle, and the wound can be left to heal spontaneously with no conjunctival sutures, or few sutures placed in the cul-de-sac where there will be minimal discomfort at the site of conjunctival closure. The major disadvantage of the fornix incision, however, is that it requires a certain amount of training, less visible surgical field, more challenging to teach residents, and that it is harder to perform on inelastic elderly conjunctiva because it does not permit the reflection of the conjunctiva over the insertion of the muscle, making it challenging in the very elderly patients.[6]

Most surgeons in Saudi Arabia have been trained to perform limbal incisions. Despite the many advantages of fornix incisions, it is still uncommon in our country. In this study, we would like to get an insight into surgeons' preferences, the possible reasons they prefer a technique over the other, and trainees' learning curves in different methods. To the best of our knowledge, this is the first survey of its kind in Saudi Arabia.


   Methods Top


This study was approved by the Institutional Review Board of King Abdullah International Medical Research Center in Riyadh, Saudi Arabia. All information was collected from two designed English questionnaires sent to local strabismus surgeons and ophthalmology trainees [Supplementary Files 1 and 2]. We sent questionnaires through a general link on WhatsApp groups of the developed questionnaire on Google survey. We invited all members of the Saudi Group of Pediatric Ophthalmology and Strabismus (SGPOS) and other expatriate strabismus surgeons working in the region to participate on April 5, 2020. All ophthalmology residents and fellows in the Saudi Board of Ophthalmology were invited to participate. A second reminder was sent 2 weeks later to encourage more participation.

The consultants' questionnaire contained questions regarding demographics (nationality, cases performed per month and approach learned while under training), the preferred method for different settings and reasons why, the use of adjustable sutures, and the most preferred approach in general. The trainees' questionnaire contained questions regarding demographics (level of training, number of cases performed so far, and technique learned), the learning curve of trainees, and the approach chosen in different patients by the consultants and why. A copy of both surveys is attached. Statistical analysis was done by MS Excel (Microsoft Corp, Redmond, WA).


   Results Top


A total of 127 participants responded to our survey. Of the 90 consultants that we sent the questionnaire to, 59 (65.55%) responded, whereas of the 208 trainees we sent the questionnaire to, 68 (32.69%) responded. [Table 1] and [Table 2] show the demographics of the participant consultants and residents, respectively.
Table 1: Consultants demographics

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Table 2: Trainees demographics

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The consultants were asked about their preferred approach in different settings [Figure 1]. The limbal approach was the preferred approach for all settings, including pediatric, <16 years of age at the time of surgery, 30 (55.9%) for the primary procedure, 40 (64.7%) for reoperation, 32 (55.9%) for adult primary procedure, and 40 (70%) for reoperation. When asked about the reason, it was attributed to better exposure in all settings. As for the participants who chose the fornix approach, they attributed it to less pain and discomfort [Table 3].
Table 3: Reasons for the preferred approach in different settings

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Figure 1: Consultants' preferred incisions for different settings

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For adjustable suture technique, 29 (49.2%) did not use adjustable sutures, 22 (37.3%) prefer limbal approach, 5 (8.5%) prefer fornix, and 3 (5.1%) prefer paralimbal. When asked why 14 (63.6%) attributed choosing limbal to better access to adjustable sutures and 8 (36.4%) to better exposure during surgery.

When we compared Saudi versus non-Saudi surgeons, 26 (83.87%) Saudi surgeons were trained to perform the limbal approach, 23 (74.19%) preferred limbal in general, and 16 (51.6%) use adjustable sutures, whereas 16 (57.14%) non-Saudi surgeons were trained to perform the fornix approach, 17 (60.71%) preferred fornix in general, and 14 (50%) use adjustable sutures [Figure 2].
Figure 2: Consultants' preferred approach according to nationality

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When asked about their preference in general, 33 (55.9%) prefer limbal, 25 (42.4%) prefer fornix, and only 1 (1.7%) prefer paralimbal. However, 49 (83.1%) considered shifting to a different method if proven to have a better outcome and more comfortable for patients.

Demographics of trainees are shown in [Table 2]. Of the 68 respondents, 35 (51%) of trainees were trained on the limbal approach. When asked about the learning curve for different methods, 41 (60.3%) noted a faster learning curve with the limbal approach. Whereas 20 (29.4%) observed a speedier learning curve in fornix incision, 7 (10.3%) preferred paralimbal. When the trainees were asked about the consultants' approach and why they thought the consultant might have selected the path for pediatric and adult primary surgery, 38 (55.88%) chose fornix incision for both settings. The most common cause cited was the rapid healing of soft tissue 29–31 (76.32%–81.58%). For pediatric and adult reoperation, the limbal approach was the most common in 44 (64.7%) and 48 (70.59%), respectively. The most common reason chosen was better exposure in 38 (86.36%) and 42 (87.50%), respectively.


   Discussion Top


Our results show that the most popular approach for all age groups among strabismus surgeons in Saudi Arabia is the limbal approach. The number one reason for the preference of the limbal approach cited by the participants was better exposure. Moreover, trainees noted a faster learning curve with the limbal method. In contrast to our study, Mikhail et al., who surveyed the members of the American Association of Pediatric Ophthalmology and Strabismus, found that in primary operations on both pediatrics and adults, participants favored the fornix approach in 58.1% and 53.5%, respectively, whereas, in reoperations, they preferred the limbal approach in 58.1% and 63.4% for pediatrics and adults, respectively.[5]

Most pediatric ophthalmologists practicing in Saudi Arabia graduated from the same fellowship program established in 1988 at King Khaled Eye Specialist Hospital (KKESH). Although there is no published consensus, the most popular approach practiced at KKESH is the limbal approach. Eighty-three percent of Saudi surgeons participating in the survey stated they were trained to perform the limbal method. When we compared the Saudi to non-Saudi surgeons in our study, 83.87% of Saudi surgeons were trained to perform the limbal approach, while 57.14% non-Saudi were trained to perform the fornix approach.

The limbal approach has several advantages; Von Noorden popularized this incision in the sixties. In his initial paper, he mentioned that it gives a “perfect” cosmetic result, heals rapidly, and is ideal for reoperations as the relationship between Tenon's capsule and conjunctiva remains undisturbed with minimal or no complications.[3] However, it involves suturing the conjunctival wound at the limbus, which might induce dellen formation. To avoid this complication, several authors have studied using fibrin glue to close the conjunctival incision.[7],[8],[9] The off-label use of fibrin glue was found to have less postoperative inflammation and required less operative time. However, it increased the number of wound gaps requiring subsequent suturing and costs much more than sutures.[9]

The fornix approach advantages include a smaller incision covered by the eyelid, the ability to access more than one muscle with one incision, preservation of the conjunctiva for possible glaucoma surgery, and causes less pain and discomfort be left with no sutures. Disadvantages include that it is relatively harder to learn and requires elastic conjunctiva, making it challenging for the elderly. However, with gentle manipulation and better instrumentation, it is possible to perform at almost any age.[10],[11] In our survey and the survey by Mikhail et al., most surgeons who preferred the limbal approach for reoperation attributed it to better exposure.[5] Interestingly, in the initial paper by Parks describing the technique, he mentioned that the method is repeatable, and reoperations can be done through the initial surgery scar.[4]

Mojon recently introduced minimal incision strabismus surgery (MISS).[2] It involves making two small incisions parallel to the upper and lower margins of the muscle 1 mm shorter than the desired amount of recession or resection. Compared to the limbal approach, MISS causes minor lid swelling, minimal cicatrization making reoperation more feasible, and no difference in end acuity or alignment. We have not included it in our survey as it is not popular in our region. Hypothetically, the benefits of MISS could also be achieved with a fornix incision. It was not compared to Park's fornix incision yet, although one obvious advantage of MISS over the fornix approach is that it does not require an assistant.

Increasing evidence suggests that anterior segment ischemia (ASI) occurs more commonly with the limbal-based approach.[12] This is attributed to jeopardizing the perilimbal episcleral vessels with the limbal-based incision. On the other hand, it is preserved with the fornix-based incisions and the newer MISS.[2] This has led some authors to conclude that the fornix incision is the preferred approach to prevent ASI.[13]

In adjustable sutures, most surgeons prefer the fornix approach as it gives more convenient access to the sutures for adjustment and permits delayed adjustment.[6],[14] Adjustment is possible through a limbal approach.[15] Most surgeons surveyed here within preferred the limbal method.

Teaching strabismus surgery remains a challenge and an obligation. With the different techniques available, giving the trainee the most significant visibility will naturally be easier to teach. Moreover, it will have the shortest learning curve, as shown in our results; however, since no one approach fits all patients and evidence, smaller incisions give speedier recovery. Programs should teach trainees all the different techniques, perhaps start with the limbal approach and move on to the fornix approach since it requires familiarity with hooking the muscle and everting the conjunctiva with minimal manipulation.

Like any other questionnaire-based study, limitations of our study include the low response rate, especially from the trainees' group; 32% had the potential of response bias. The questionnaire was composed totally of closed ended questions without adding open fields for personal comment, leading to, for example, less insight on why one might prefer an approach over the other. There might be some bias in the shortest learning curve reported by trainees since most have been trained to perform the limbal method.


   Conclusion Top


Surgeons should adopt every possible technique that makes the surgery smoother and minimizes inflammation, discomfort, and visible scarring. Each method of strabismus surgery has its advantages and disadvantages. There is no one technique proven to be superior to the other in terms of outcomes. One should add all styles to his armamentarium and choose the appropriate one for each patient.

Acknowledgments

The authors would like to acknowledge the members of the SGPOS and the residents and fellows in the Saudi Board of Ophthalmology for participating in this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Supplementary Files Top


Supplementary 1: Residents and fellows

  1. Do you agree to take this survey?


    1. Yes
    2. No


  2. What's your training level?


    1. R1
    2. R2
    3. R3
    4. R4
    5. F1
    6. F2


  3. How many strabismus cases did you perform so far?


    1. Less than 10
    2. 10-30
    3. 31-50
    4. 51-70
    5. More than 70


  4. What method of conjunctival incisions where you mainly trained to do for strabismus surgery?


    1. Limbal
    2. Fornix


  5. Which method has the faster learning curve in your opinion?


    1. Limbal
    2. Fornix


  6. For the majority of patients ≤ 16 years of age undergoing their first strabismus surgery


    1. Please select the type of incision used:


      1. Limbal
      2. Fornix


    2. Why


    1. More rapid healing of soft tissue
    2. Better exposure during surgery
    3. Better for teaching junior surgeons


  7. For the majority of patients ≤ 16 years of age undergoing a re-operation on the same muscle


    1. Please select the type of incision used:


      1. Limbal
      2. Fornix


    2. Why


    1. More rapid healing of soft tissue
    2. Better exposure during surgery
    3. Better for teaching junior surgeons


  8. For the majority of patients > 16 years of age undergoing their first strabismus surgery, please select the type of incision used:


    1. Please select the type of incision used:


      1. Limbal
      2. Fornix


    2. Why


    1. More rapid healing of soft tissue
    2. Better exposure during surgery
    3. Better for teaching junior surgeons


  9. For the majority of patients > 16 years of age undergoing a re-operation on the same muscle


    1. Please select the type of incision used:


      1. Limbal
      2. Fornix


    2. Why


    1. More rapid healing of soft tissue
    2. Better exposure during surgery
    3. Better for teaching junior surgeons


    Supplementary 2: Consultants

  10. Do you agree to take this survey?


    1. Yes
    2. No


  11. How many strabismus cases do you operate per month?


    1. Less than 5
    2. 5-15
    3. 15-25
    4. 25-40
    5. More than 40


  12. 12. What method of conjunctival opening where you mainly trained to do for performing strabismus surgery?


    1. Limbal
    2. Fornix


  13. For the majority of patients less than or equal to 16 years of age undergoing their first strabismus surgery, please select from the following:


    1. Type of incision


      1. Limbal
      2. Fornix


    2. Why


    1. Less postoperative pain/discomfort
    2. Less postoperative conjunctival inflammation
    3. More rapid healing of soft tissue
    4. Better exposure during surgery
    5. Better for teaching junior surgeons


  14. For the majority of patients less than or equal to 16 years of age undergoing a reoperation on the same muscle, please select from the following:


    1. Type of incision


      1. Limbal
      2. Fornix


    2. Why


    1. Less postoperative pain/discomfort
    2. Less postoperative conjunctival inflammation
    3. More rapid healing of soft tissue
    4. Better exposure during surgery
    5. Better for teaching junior surgeons


  15. For the majority of patients greater than 16 years of age undergoing their first strabismus surgery, please select from the following:


    1. Type of incision


      1. Limbal
      2. Fornix


    2. Why


    1. Less postoperative pain/discomfort
    2. Less postoperative conjunctival inflammation
    3. More rapid healing of soft tissue
    4. Better exposure during surgery
    5. Better for teaching junior surgeons


  16. For the majority of patients greater than 16 years of age undergoing a re-operation on the same muscle, please select from the following:


    1. Type of incision


      1. Limbal
      2. Fornix


      3. Why


      1. Less postoperative pain/discomfort
      2. Less postoperative conjunctival inflammation
      3. More rapid healing of soft tissue
      4. Better exposure during surgery
      5. Better for teaching junior surgeons


    2. For the adjustable suture technique, please select the type of conjunctival incision you prefer and why


      1. Type of Incision


        1. Limbal
        2. Fornix
        3. N/A (I do not use the adjustable suture technique)


      2. Why


      1. Less postoperative pain/discomfort
      2. Less postoperative conjunctival inflammation
      3. More rapid healing of soft tissue
      4. Better exposure during surgery
      5. Better for teaching junior surgeons


    3. Which method do you personally prefer overall?


    1. Limbal
    2. Fornix


  17. Are you planning to shift to the other method if proven to have a better patient's satisfaction?


  1. Yes
  2. No




 
   References Top

1.
Davies B. Robotic surgery – A personal view of the past, present and future. Int J Adv Robot Syst 2015;12:54.  Back to cited text no. 1
    
2.
Mojon DS. Comparison of a new, minimally invasive strabismus surgery technique with the usual limbal approach for rectus muscle recession and plication. Br J Ophthalmol 2007;91:76-82.  Back to cited text no. 2
    
3.
Von Noorden GK. The limbal approach to surgery of the rectus muscles. Arch Ophthalmol 1968;80:94-7.  Back to cited text no. 3
    
4.
Parks MM. Fornix incision for horizontal rectus muscle surgery. Am J Ophthalmol 1968;65:907-15.  Back to cited text no. 4
    
5.
Mikhail M, Verran R, Farrokhyar F, Sabri K. Choice of conjunctival incisions for horizontal rectus muscle surgery – A survey of American Association for Pediatric Ophthalmology and Strabismus Members. J AAPOS 2013;17:184-7.  Back to cited text no. 5
    
6.
Sami DA. Conjunctival incisions for strabismus surgery: A comparison of techniques. Tech Ophthalmol 2007;5:125-9.  Back to cited text no. 6
    
7.
Basmak H, Gursoy H, Cakmak Aİ, Niyaz L, Yildirim N, Sahin A. Tissue adhesives as an alternative for conjunctival closure in strabismus surgeries. Strabismus 2011;19:59-62.  Back to cited text no. 7
    
8.
Lee JH, Kang NY. Comparison of fibrin glue and sutures for conjunctival wound closure in strabismus surgery. Korean J Ophthalmol 2011;25:178-84.  Back to cited text no. 8
    
9.
Yang MB, Melia M, Lambert SR, Chiang MF, Simpson JL, Buffenn AN. Fibrin glue for closure of conjunctival incision in strabismus surgery: A report by the American Academy of Ophthalmology. Ophthalmology 2013;120:1935-41.  Back to cited text no. 9
    
10.
Coats DK. Cul-de-sac incision for strabismus surgery in older patients. Binocul Vis Strabismus Q 2009;24:233-5.  Back to cited text no. 10
    
11.
Guyton DL. A small-incision muscle hook for the Parks cul-de- sac approach for strabismus surgery. Binocul Vis Strabismus Q 2005;20:147-50.  Back to cited text no. 11
    
12.
Fishman PH, Repka MX, Green WR, D'Anna SA, Guyton DL. A primate model of anterior segment ischemia after strabismus surgery. The role of the conjunctival circulation. Ophthalmology 1990;97:456-61.  Back to cited text no. 12
    
13.
Pineles SL, Chang MY, Oltra EL, Pihlblad MS, Davila-Gonzalez JP, Sauer TC, et al. Anterior segment ischemia: Etiology, assessment, and management. Eye (Lond) 2018;32:173-8.  Back to cited text no. 13
    
14.
Nihalani BR, Hunter DG. Adjustable suture strabismus surgery. Eye 2011;25:1262-76.  Back to cited text no. 14
    
15.
Chan TK, Rosenbaum AL, Hall L. The results of adjustable suture technique in paediatric strabismus surgery. Eye 1999;13:567-70.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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