الفهرس 
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Abstract
The present study aimed at achievement of a successful postoperative ocular alignment in strabismus surgery with the least postoperative ocular inflammation. It is a randomized control trial comparing ocular alignment and ocular inflammation after strabismus surgery with the traditional limbal approach versus the new MISS.
MISS was performed in (15) eyes of (11) patients {group A}, while limbal approach was performed in (18) eyes of (11) patients {group B}. All 22 patients underwent clinical assessment preoperatively and at 1st day, 1st week and 1st month postoperatively.
During this study, we tried to be committed to quality concepts, principles and methodology regarding healthcare provision. Evidence-based practice, clinical practice guidelines and preferred practice patterns were considered.
According to literature, most surgeons - when dealing with patients with strabismus - concern not only about postoperative ocular alignment but also postoperative cosmesis and patient comfort.
The study involved both male (50%) and female (50%) patients. (72.1%) of the male patients were operated using the limbal approach and (27.9%) were operated using the minimally invasive approach, while (72.1%) of the female patients were operated using the minimally invasive approach and (27.9%) were operated using the limbal approach.
However the sexual dimorphism in immune responses in humans is well known as females have more vigorous cellular and humoral immune responses, postoperative ocular inflammation tend to be more significant in limbal approach group than minimally invasive group that showed the superiority of MISS in reducing the postoperative inflammation.
All of the patients had normal healthy conjunctiva with no allergic or infective diseases, nor previous strabismus surgery or conjucnctival scarring.
The mean age of the study population of the two groups were nearly the same, where MISS group surgery was 13.1 ± 10.17 years ranging from 2 years to 35, while limbal approach group was 9.9 ± 6.45 years ranging from 1 year to 23 years. There was no noticeable relation in grading the inflammation according to the age.
All of the patients were complaining of concomitant horizontal strabismus for surgical intervention.
The mean amount of ocular deviation in the two group was nearly equal, where in patients who underwent Limbal approach strabismus surgery was 41.63± 13.18 ∆D ranging from 18-50 ∆D, while the mean amount of ocular deviation in patients underwent MISS was 42.91 ± 12.37 ∆D ranging from 20-50 ∆D.
The two groups underwent surgical correction using the surgical microscope in the operating theater under general anesthesia.
The present study revealed no significant difference between MISS and the traditional limbal approach for final ocular alignment (p value 1.00); both techniques achieved successful alignment in 90.9% of cases whereas they failed in 10.1% of cases.
The study was in agreement with Mojon D S (2007) who also found that there is no significant difference between the two approaches regarding postoperative ocular alignment.1
This demonstrates that the smaller conjunctival incisions of the minimally invasive technique don’t prevent good visualization and manipulation in operating horizontal extraocular muscles.
There was no difference in both techniques regarding intraoperative complications like excessive hemorrhage, scleral perforation or slipped muscles.
The present study revealed significant statistical difference in the postoperative ocular inflammation (lid edema, conjunctival chemosis & injection) between the 2 groups for MISS at the 1st day postoperative (P value 0.042), the 1st week postoperative (p value 0.035) and the first month postoperative (p value 0.018).
Ocular inflammation post strabismus surgery relates to the operation time, conjunctival incision and exposure, tissue trauma, closure of conjunctiva, materials and instruments used and excessive manipulation and surgeon experience, in this study we found that MISS took the same operation time, same instruments and materials used of in the traditional limbal approach, but factors that made MISS superior than the traditional limbal approach in minimizing the postoperative ocular inflammation and better and thus faster healing of conjunctiva are smaller conjunctival incisions away from the limbus, lesser tissue trauma and conjunctival manipulation, preservation of most of perimuscular tissue and better closure of conjunctiva.
Also the conjunctival incisions are remained covered by the eyelids in the forward gaze, and they heal completely within 2 to 4 weeks postoperatively leaving very minimal conjunctival linear scars that are hardly seen even with slit lamb examination.
In this study, we noticed unexplained postoperative mild subconjunctival hemorrhage in few cases of MISS that resolve spontaneously within few days postoperatively, we didn’t know the exact cause, but we think that it may be because some blood escape through the conjunctival tunnel during surgery and we couldn’t be able to remove it completely with the micro sponges.
The study was in agreement with other study in this aspect:
Mojon D (2007) reported that minimally invasive approach seems to be superior in the immediate postoperative period as, compared with the traditional limbal approach, he also reported that postoperatively, the conjunctival openings remain covered by the lids apart from during up gaze and excessive lateral gaze, which minimizes visibility of the surgical procedure during the immediate postoperative period.1
Pellanda N, Mojon D. (2010) concluded less conjunctival swelling and injection in the early postoperative course compared to the usual limbal approach and the minimally invasive approach seems to be superior in the postoperative period concerning the conjunctival status and healing process.69
Kushner B (2007) found that a minimally invasive strabismus surgery procedure causes less inflammation postoperatively, but is harder, provides limited exposure and probably has a steep learning curve. 61