Adjustable sutures in strabismus surgery: why surgeons either love them or hate them after three decades

Abstract

Strabismus surgeons continually seek to achieve the best results from their surgery, which means stable motor alignment and sensory improvement with a minimum number of procedures (1) . But the tables and algorithms that we employ for the number of muscles to be included in the surgery, and for the doses of surgery, are often not appropriate for difficult or unpredictable cases (2) . The ability to modify the site of the muscle insertion on the globe to refine surgical results and to control postoperative deviations led Arthur Jampolsky to reintroduce an adjustable suture technique, almost four decades ago, based on the ideas of Bielschowsky, O'Connor, and Harms (3)(4)(5)(6) . Common indications for adjustable sutures include paralysis, restrictive strabismus, and reoperations. A few surgeons use them in practically all cases, in children as well as in adults (7) . Although the adjustable suture technique has been used for over 30 years, and there is a large volume of literature on the subject, randomized controlled trials have not been done (8) . Strabismus surgeons tend to be sharply polarized regarding their attitude toward adjustable sutures; they either love them and employ them often, as we do, or hate them and never employ them, claiming that equivalent results can be easily obtained without their use.Proponents of adjustable sutures cite better results, less stress, and better patient and surgeon confidence and satisfaction. Detractors of adjustable sutures cite equivalent results, more stress, extra time involved, higher cost, and patient discomfort. The different stress levels undoubtedly reflect different familiarity and experience with those advanced techniques that ease the stress of the surgeons skilled in these techniques. It is no surprise that lack of knowledge or experience with a technique leads to skepticism and even hostility, as witnessed in the early days of phacoemulsification for cataract surgery. From our teaching experience, confidence and success with adjustable sutures is only achieved after months of apprenticeship. One should not expect strabismus surgeons who are used to fixed-suture techniques to take the time and effort to become proficient with adjustable sutures -therefore the polarization in attitudes.It will be difficult to do a randomized clinical trial of adjustable sutures in strabismus surgery because only surgeons well-experienced and comfortable with adjustable suture surgery would be deemed appropriate to participate by the adjustable suture community, and those surgeons are generally too wedded to their fine-tu ned adjustable techniques to abandon them for any patient randomized to fixed-suture surgery.From the patients' point of view, a long-term follow-up study of results and patient satisfaction was conducted in 2013 in Bonn, Germany, of 113 patients after difficult strabismus surgery using adjustable sutures (9) . From the questionnaires they completed, 89.4% had no problems or did not remember the adjustment or tying off procedure. After an average period of 11 ...

Adjustable Versus Nonadjustable Sutures in Strabismus Surgery—Who Benefits the Most?

“…They also point out that the adjustment procedure is uncomfortable and stressful for the patient and requires special nursing care [5]. Interestingly, Vassconcelos and Guyton in their editorial for Arquivos Brasilerios de Oftalmologia indicated that the adoption of AS in strabismus surgery is partly related to surgical experience [6]. Successful use of AS requires a long apprenticeship and often promotes a high load of stress at the beginning of the learning curve, so some surgeons favor the simpler NAS technique.…”

Adjustable Sutures in the Treatment of Strabismus

“…Additionally, surgeons may be reluctant to incorporate adjustable suture techniques because of the additional surgical and postoperative investment of time and resources. 4,5 Despite this uncertainty, there have been advances in the technique of adjustable suture placement that have expanded its use and applicability. 6 Modifications in the suture technique allow for the possibility of delayed suture adjustment within 1 week of surgery.…”