anesthesia utilized was either standard peribulbar block or general anesthesia ( propofol and nitrous oxide ) .
one eye was randomized ( using an unbiased coin ) to standard paralimbal strabismus surgery ( spss ) while the other automatically qualified for miss .
after separating the lids with universal eye speculum , a 5 - 0 silk traction suture ( johnson and johnson ltd . aurangabad
; nw 5079 ) was passed through the superficial sclera near the limbus at 12 and 6 oclock to expose the quadrant of interest .
four points were marked on the conjunctiva : two at the upper and lower ends of the rectus muscle insertion and two at the posterior limits of the planned para - muscular conjunctival incisions [ fig .
the two points on each side of the muscle insertion were then incised with a bard - parker blade ( # 11 ) after raising a fold of conjunctiva by lifting the conjunctiva between forceps , so as to obtain two incisions parallel to the upper and lower edge of the horizontal rectus muscles , with their anterior limits at the upper and lower ends of the muscle insertion [ fig .
the radial length of these incisions was 1 mm less than the planned recession / resection if the latter was 5 mm , and two mm less if > 5 mm . using blunt wescott scissors ,
careful dissection was carried out to identify the muscle edge , under which a muscle hook was then passed [ fig .
further dissection then helped delineate the muscle and the adjacent sclera up to the site of recession .
a similar conjunctival incision was made at the superior border of the muscle , aided by the muscle hook already placed below the muscle .
subsequently , the strap of conjunctiva , overlying the muscle tendon , between the two conjunctival incisions , was meticulously dissected free of the muscle up to the insertion to facilitate subsequent surgery in that area [ fig .
this provided us access to the upper and lower edge of the muscle right up to the insertion , as also the sclera / muscle till the point where recession / resection was to be carried out .
the planned site of recession on the sclera , or the site of resection on the muscle , were marked [ fig .
( a - i ) figures showing surgical steps for miss ( recession ) ( see text ) for recessions : vicryl 6 - 0 ( johnson and johnson ltd .
aurangabad nw 2670 ) locking bites were taken from the muscle margins from near the insertion [ fig .
if the parallel conjunctival cut edges appeared to be in good apposition , no sutures were applied ; else , a single central vicryl 8 - 0 suture approximated the incisions .
good apposition was considered wherein the edges were no more than 2 mm apart at a point of maximum separation , after gently smoothening the conjunctival surface [ fig .
1i ] . in case of any complications , like excessive hemorrhage , or difficulty in suturing the muscles , were encountered , it was planned to prolong the conjunctival incisions towards the limbus and join them , effectively converting them to resemble the limbal approach ; in such an event , the miss approach would be considered to have failed . for resection : after a similar conjunctival approach as for recessions , two vicryl 6 - 0 sutures were applied at the edges of the extra - ocular muscle ( eom ) at the point of desired resection and passed through the insertion of the eom . the muscle between the suture bites was excised ; tying the sutures brought the point of resection to the insertion , effecting a resection .
we recorded the duration of surgery ( in minutes ) from the start of the conjunctival incision to the completion of surgery .
post - operatively graded scoring of inflammation ( o to 3 : nil , mild , moderate , severe ) was done by an observer masked to the randomization ; on day 1 , at 2 - 3 weeks , and 6 weeks : specifically redness , congestion ( these two were compared to standard photographs ) , chemosis , foreign body sensation ( fbs ) , drop intolerance were scored ; and each score combined to yield a total inflammatory score ( tis ; with a possible range from 0 to 15 ) .
visible scarring ( from one meter ) and final alignment were noted at 6 weeks .
we included 14 parallel designed surgeries on 10 patient ; 10 were bilateral recessions , while 4 of subjects participated a second time ( 3 months later ) undergoing planned second bilateral recestions on account of large angles not amenable to single strabismus - surgical correction .
the mean duration of surgery in the spss was 29.6 ( sd  5.37 ) minutes as compared to 40.4 ( sd  7.98 ) minutes in the miss approach , with a mean difference of 10.8 minutes ( 95% ci for difference : 2.67 to 18.92 minutes . ) , which was significant ( wilcoxon test ; p = 0.013 ) .
on the first post - operative day , there were significant differences ( p < 0.05 ) in the median inflammatory scores for fbs and tis ( wilcoxon test , table 2 ) . at 2 - 3
weeks , in addition , significant differences for redness and congestion . by 6 weeks , significant differences were restricted to redness and tis . at final follow - up at 6 weeks , significant scarring was observed in all the eyes , which underwent spss while it was present in 9 miss eyes ; the difference was not statistically significant ( chi - square , fisher 's exact test ; p = 0.09 ) .
there was no change in visual acuity postoperatively in any of the patients during any time in follow - up .
amount of strabismus , target surgery , final alignment along with status of fusion , and stereopsis at 6 weeks postoperatively are also shown in table 1 .
demographic details of the patients along with post operative functional outcomes median inflammatory scores and p value during post - operative follow - up
we compared post - operative comfort and cosmesis , by miss and spss , in patients undergoing symmetrical strabismus surgeries in a parallel design , randomizing one of two eyes , since that may be a superior model to compare inflammatory outcomes . on the first post - operative day , there was no significant difference between the two eyes in terms redness , congestion , chemosis , and drop intolerance ; only fbs ( p value < 0.01 ) was significantly less in the miss eyes .
this could be on account of the small incisions and posterior placement of conjunctival sutures ( if any ) in the latter group . at 2 - 3 weeks follow - up
, scores for redness , congestion , and foreign body sensation were significantly less in the miss eyes [ fig . 2 ] .
while at 6 weeks , we did not find any significant difference , except for redness and total inflammatory score [ table 2 ] .
comparative photograph at 2 - 3 weeks postoperatively , of the same patient operated through miss and spss in his introductory paper , mojon utilized the miss approach and compared them with a historical group , which underwent a limbal approach in cases undergoing horizontal rectii surgeries . although his main outcome measures ( fusion , alignment , and vision ) were different from ours , mojon did report significantly less lid swelling ( 0% vs. 21% ) in the miss group on the first post - operative day . on final analysis at 6 months , no significant difference was found . in another study on exotropes , pellanda and mojon
they found significantly less conjunctival swelling and injection on the first post - operative day (  test p < 0.001 ) .
they needed to convert 3/104 muscles in their miss group . in a similar analysis in esotropia ,
conjunctival swelling and injection were significantly less pronounced (  
 p value < 0.001 ) in the miss group .
we believe that a comparison of grades of inflammation by the mann - whitney test would have been superior , although the results are unlikely to have been different .
although we found 9 of 14 cases ( 64.3% ) of miss showing a significant scar at 6 weeks compared to all 14 cases ( 100% ) of spss , the results did not reach statistical significance ( fisher 's exact ; p value : 0.09 ) .
mojon has also commented in his comparative study that minimal cicatrization was seen along the incision line , which did not hinder free movement of the conjunctiva over the sclera . on occasion ( sic ) , no scar was seen biomicroscopically . only larger studies with more statistical power
may provide clear answers to this question . in our study , miss took significantly longer than spss ; but , it is likely that this would decrease as experience with miss accumulated .
although comparison of alignment by its very nature can not be compared in a study like ours , we are reporting post - operative alignment outcomes [ table 1 ] , since that would be of interest to our readers .
as is evident , 11 of 14 surgeries achieved correction to within 10 pd of target angle ; a success rate of 78.5% .
as highlighted by kushner , the miss approach interferes less with the peri - limbal episcleral vessels , which should decrease the chances of anterior segment ischemia .
although miss may appear to be superior to the paralimbal approach , it may not be much different to the parks fornix approach where too conjunctival incisions are far removed from the limbus .
we are acutely aware of the small number of cases in our study and suggest that more studies with a larger sample size would yield better evidence to either support or refute our findings . since all our patients were young adults , the results should be interpreted preferable for this age group .
the strength of our study is in its parallel design , a format superior in our opinion to compare inflammation scores .
our small study shows that a miss approach is more comfortable and offers better cosmesis ( in terms of redness ) in the short - term ( 2 - 3 weeks ) as compared to the spss ; this difference equates by 4 - 6 weeks .
 introduction : minimal access surgery is common in all fields of medicine . 
 we compared a new minimally invasive strabismus surgery ( miss ) approach with a standard paralimbal strabismus surgery ( spss ) approach in terms of post - operative course.materials and methods : this parallel design study was done on 28 eyes of 14 patients , in which one eye was randomized to miss and the other to spss . 
 miss was performed by giving two conjunctival incisions parallel to the horizontal rectus muscles ; performing recession or resection below the conjunctival strip so obtained . 
 we compared post - operative redness , congestion , chemosis , foreign body sensation ( fbs ) , and drop intolerance ( di ) on a graded scale of 0 to 3 on post - operative day 1 , at 2 - 3 weeks , and 6 weeks . 
 in addition , all scores were added to obtain a total inflammatory score ( tis).statistical analysis : inflammatory scores were analyzed using wilcoxon 's signed rank test.results:on the first post - operative day , only fbs ( p = 0.01 ) and tis ( p = 0.04 ) showed significant difference favoring miss . at 2 - 3 weeks , redness ( p = 0.04 ) , congestion ( p = 0.04 ) , 
 fbs ( p = 0.02 ) , and tis ( p = 0.04 ) were significantly less in miss eye . at 6 weeks , only redness ( p = 0.04 ) and tis ( p = 0.05 ) were significantly less.conclusion:miss is more comfortable in the immediate post - operative period and provides better cosmesis in the intermediate period . 
Materials and Methods
Results
Discussion
Conclusion