Surgery of muscle adhesions and effects of multiple operations.

The management of strabismus complicated by adhesions is always difficult; surgery to eliminate adhesions usually creates fresh difficulties unless one of three new techniques (described in this paper) is used.Their use still provides no absolute guarantee of success, but clinical experience has proved their value to me.Even if multiple-stage surgery by the most skilful surgeons succeeds in correcting the strabismus (apart from undercorrecting, overcorrecting, or the occasional creation of a new imbalance), adhesions which impair function by mechanical restriction of movement are likely to be produced.Brown (personal communication) has stated that once adhesions occur they can never be fully eliminated and that their recurrence can not be fully prevented, but the risk may be mitigated by the techniques to be described.Restricted ocular movement may be congenital or acquired, and may be mechanical or neurogenic in origin.Mechanically acquired restrictions may be caused by:(i) Adhesions;(2) Contracture of the conjunctiva;(3) Contracture of the antagonist of a paralysed muscle;(4) Shortening or weakening of muscles by excessive resection or recession;(5) Contracture or fibrosis of the muscle and/or the sheath.Other possible causes are:(i) Orbital fracture;(2) Penetrating orbital injury;(3) Surgery for retinal detachment;(4) Thyroid ophthalmopathy.Adhesions in their turn arise from:(i) Rough, sloppy, slovenly surgical technique;(2) Excessive or disregarded bleeding;(3) Excessive cautery;(4) Multiple procedures;(5) Excessive tissue reaction;(6) Suture reaction;(7) Operative or postoperative infection.Neurologically acquired restrictions arise from nerve paralysis, with or without secondary fibrosis in the involved muscle or secondary contracture of its antagonist. Acquired restrictions of ocular movementIn my opinion adhesions, which are largely iatrogenic, cause most of these problems.