Adjustable sutures in strabismus surgery

Strabismus surgery is by no means an exact science. The outcome of surgery depends partly on measurements, partly on the experience and intuition of the surgeon, and very much on the healing capacity and fusion status of the patient. The goal of surgery is to align the eyes with fewest procedures; however, the surgeon may encounter surprises when the patient recovers from surgery. The same amount of surgery for the same angle of deviation will yield different results in different patients, often for no obvious reason. This is especially true for long-standing complicated strabismus, reoperations, innervational abnormalities, restrictive myopathies, or following injuries to the eye. A search for improved accuracy in strabismus surgery led to an approach which allowed adjustment during the early postoperative period. Adjustable suture strabismus surgery was first described by Claude Worth in 1908 [8]; however, the first modern account of adjustable suture surgery was presented by Jampolsky in 1975 [13, 14]. He described a two-stage adjustable suture technique with surgery under general anesthesia and adjustment of the ocular position under local anesthesia on the morning after surgery or on the same day after 4?8 h, when the patient was fully alert. The basic principle of the adjustable suture technique is to secure the extraocular muscle to the sclera using a temporary or sliding knot. After the patient has recovered from anesthesia, the alignment of the eyes is checked. The length of suture between the attachment site and muscle may be shortened or lengthened to fine-tune the alignment in an awake patient. The adjustments are usually performed within 24 h of the primary surgery. The goal of this extra step is to decrease the need for reoperation. A number of surgeons have used adjustable sutures in adults to improve immediate postoperative alignment. They have described their experiences with adjustable sutures [3, 17, 22, 26, 30, 31, 32,], but there have been no prospective randomized controlled trials that directly compare non-adjustable with adjustable sutures for strabismus surgery in adults [29]. There are very few reports on the use of adjustable suture surgery in children [5, 6, 10, 27]. This is most likely because of the difficulty obtaining the cooperation of a child for postsurgical manipulations. In this chapter, we describe current approaches to adjustable suture surgery, with an emphasis on our preferred techniques. single vision and when the patient has a risk of postoperative diplopia. In these cases the ability to adjust after surgery provides reassurance to the patient. It is our practice to use adjustable sutures on all muscles of all adults, even those with comitant strabismus and no prior surgery. We also use adjustable sutures in selected children who meet the standard indications mentioned in Table 16.1.