Standard strabismus surgery involves altering the position or length of the extraocular muscles to improve ocular alignment. The muscle is reattached to the globe at a set position.
The adjustable suture technique was introduced to refine the result immediately after surgery in both adults and children. It is the favored technique at Boston Children’s Hospital and Massachusetts Eye and Ear for complex strabismus cases.
Indications
• Complex strabismus in adults and children, including but not limited to:
– Paretic strabismus
– Restrictive strabismus (e.g., thyroidassociated orbitopathy, congenital fibrosis of the extraocular muscles)
• Strabismus surgery to eliminate double vision
• Re-operations
Technique
Strabismus surgery with adjustable sutures is similar to nonadjustable surgery and is most commonly performed under general anesthesia. After adjustable sutures are placed, patients may be evaluated immediately and up to one week postoperatively to determine whether the position of the muscle requires adjustment.
Adult patients: The adjustment may be performed under topical anesthesia in an office-based setting.
Pediatric patients: The team at Boston Children’s Hospital and Massachusetts Eye and Ear has developed a protocol to perform a propofol-based sedated suture adjustment. This uniquely allows the team to offer this technique to the youngest patients.
Outcomes
Although the adjustable suture technique was popularized in the 1970s, the approach has been refined to allow for delayed suture adjustment within postoperative week one and for sedated suture adjustment when needed. Currently, level I evidence comparing surgical outcomes between adjustable versus nonadjustable techniques does not exist. Nevertheless, multiple large, retrospective comparative studies suggest a better success rate in strabismus surgery when adjustable sutures are used. This is especially true for complex strabismus cases.
Gena Heidary, MD, PhD
Assistant Professor of Ophthalmology, Harvard Medical School
Director, Pediatric Neuro-Ophthalmology Service, Pediatric and Adult Strabismus Service, Boston Children’s Hospital and Massachusetts Eye and Ear