|LETTER TO THE EDITOR
|Year : 2011 | Volume
| Issue : 5 | Page : 408-409
Cut and paste: A novel method of reattaching rectus muscles with cyanoacrylate during recessions in strabismus
Siddharth Agrawal, Vinita Singh
Department of Ophthalmology, CSM Medical University (Upgraded KG's Medical College), Lucknow, India
|Date of Web Publication||9-Aug-2011|
B/3, Kapoorthala Bagh, Kursi Road, Lucknow - 226 024
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Agrawal S, Singh V. Cut and paste: A novel method of reattaching rectus muscles with cyanoacrylate during recessions in strabismus. Indian J Ophthalmol 2011;59:408-9
|How to cite this URL:|
Agrawal S, Singh V. Cut and paste: A novel method of reattaching rectus muscles with cyanoacrylate during recessions in strabismus. Indian J Ophthalmol [serial online] 2011 [cited 2020 Jun 2];59:408-9. Available from: http://www.ijo.in/text.asp?2011/59/5/408/83632
We read with interest the article by Darakshan et al., titled "Cut and paste: A novel method of reattaching rectus muscles with cyanoacrylate during recessions in strabismus".  We wish to make the following comments:
The process being more time-consuming does not seem to offer any advantage. There is a definite possibility of muscle slippage and the benefits being attributed to the procedure are probably due to bias. Tissue glue is successfully used when a non-mechanically strained tissue like conjunctiva needs attachment but attempting to attach a muscle would be ambitious and using it for resections as suggested by the authors could be disastrous.
- Were the patients and the examiners blinded to the procedure performed in individual eyes? If not they are likely to induce bias in the observations.
- During recession surgeries it is attempted to keep the muscle capsule intact to prevent injury to the muscle belly and subsequent bleeding.  The muscle capsule is impervious to cyanoacrylate glue, which can be verified by simply applying the glue to a dissected muscle capsule from a resected muscle stump and observing the other surface for adhesiveness. The muscle tendon gets exposed when it is detached from its insertion and would provide a limited surface area for glue application and have a limited holding strength. We have not attempted to attach a muscle with glue after making this observation. The muscle in our opinion would have a definite possibility of slippage within its capsule. 
The authors have probably escaped this complication by using their "backup" option of vicryl which kept the recessed muscle in place for a sufficient duration to provide some adhesions. In spite of this they were probably lucky to avoid muscle slippage.
- It is not clear whether they sutured the conjunctiva or glued it in the eyes in which they used the glue for muscle attachment. What would be the point in suturing the conjunctiva as inflammation and patient discomfort are primarily because of the conjunctival sutures in strabismus surgery? 
- How could they be justified in using a vicryl suture coming out of the conjunctival incision and attaching it to the forehead? This extreme patient discomfort was not accounted for in the analysis. Moreover, they do not talk about how the conjunctiva was approximated after this suture was removed. Was there any need for suturing or reapplication of glue? What about the patient discomfort due to this?
- It is stated that cauterization was not a part of the protocol. One would be rather adventurous to use cyanoacrylate in a bleeding muscle. Why was cautery not used prior to muscle attachment?
- In our opinion a five-minute delay per muscle in our overworked operation theaters is significant. We have been using the same vicryl suture for both the eyes of the same patient according to a standard procedure.  It reduces the cost of sutures to half.
- It is well-documented that cyanoacrylate forms a solid, impermeable mass in situ and this persists as a foreign body causing inflammatory reactions.  The authors talk about ocular movements at six months' follow-up whereas the main concern at six months should be reaction to this foreign body. If movements are satisfactory at four weeks we do not expect a change at six months because the muscle has firmly attached by four weeks to its new insertion.
- Previous researchers have attempted to use glue in faden procedure and that too with limited success. 
The overall advantage of cyanoacrylate glue over conventional sutures for muscle attachment in terms of scientific plausibility and the need for change remains questionable.
| References|| |
Darakshan A, Amitava AK. Use of cyanoacrylate for recessions in strabismus. Indian J Ophthalmol 2010;58:395-8.
von Noorden GK. Priniciple of Surgical Treatment. In Binocular Vision and Ocular Motility: Theory and Management of Strabismus. 6 th
ed. St. Louis: Mosby, Inc.; 2002. p. 586-618.
Roper-Hall MJ. The Extraocular Muscles: Strabismus and Heterophoria. In Stallard's Eye Surgery. 7 th
ed. UK: Buttersworth; 1989. p. 171-2.
Panda A, Kumar S, Kumar A, Bansal R, Bhartiya S. Fibrin glue in ophthalmology. Indian J Ophthalmol 2009;57:371-9.
Tonelli E Jr, de Almeida HC, Bambirra EA. Tissue adhesives for a sutureless faden operation: An experimental study in a rabbit model. Invest Ophthalmol Vis Sci 2004;45:4340-5.