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

Abstract

Background: Adjustable sutures have been used in strabismus surgery for more than 40 years, but controversy remains regarding their application. This review sought to analyze studies comparing the efficacy of adjustable sutures (AS) and nonadjustable sutures (NAS) in the treatment of different ocular deviations. Materials and Methods: The PubMed literature database was searched using the keywords ‘adjustable sutures’ and ‘strabismus surgery’, yielding a total of 209 results. Only comparative studies were extracted, and the results were divided into three categories: Adult comitant strabismus, childhood comitant strabismus, and paretic/restrictive strabismus. Results: The search revealed eleven comparative studies on AS versus NAS in adult strabismus, including only one randomized controlled trial. Five of these studies analyzed just the postoperative success rate, three studies analyzed just the reoperation rate, two studies analyzed both the postoperative success and reoperation rates, and one study evaluated achievement of the postoperative target angle. Three of seven studies analyzing postoperative success reported the statically significant superiority of AS over NAS, while four of five studies analyzing reoperation rate indicated a significantly smaller percentage of reoperations with the use of AS. The study covering postoperative target angle as an outcome favored the AS technique. Separately, the search revealed three comparative studies on AS versus NAS in childhood strabismus, one of which reported a statistically significant advantage with AS. Only four comparative studies on AS versus NAS in paretic or restrictive strabismus were found; all showed a tendency for better results with the use of AS but not in a statistically significant fashion. Overall, out of 18 studies analyzed in this review, 17 suggested better clinical results followed the application of AS versus NAS; however, only a minority had statistically significant results. Conclusion: The analysis of available research failed to support AS as the preferable surgery technique over NAS in cases of simple and predictive strabismus. Further research is needed to more precisely determine the group of patients able to benefit the most from AS.

Stepped strabismus surgery

“…The success rates of stepped strabismus surgery in esotropia and exotropia compared favorably with those of adjustable suture surgery which ranged between 77.7-91.7%, with the added benefit of potentially reduced operative time and postoperative care unit stay, particularly when a second stage is not required and additionally by eliminating the time needed for the patient to be evaluated and undergo suture adjustment in the postoperative care unit when adjustable sutures are used. [11][12][13][14] Similarly, the re-operation rate in our horizontal group was similar to re-operation rates following adjustable and non-adjustable strabismus surgeries in adults reported by Leffler et al upon review of a large national private insurance database. 15 Another advantage of stepped surgery over adjustable is the potential for reducing the number of extraocular muscles operated on without compromising the results.…”

Phased strabismus surgery under topical anesthesia

“…1 Adjustable sutures have been shown to improve the surgical outcomes, 5 even if only a minority of the studies has provided a statistical support. [11][12][13] The possibility of having a second chance to refine the position of the extraocular muscles is certainly reassuring, but it is not cost effective, as it requires additional time, being overall more expensive. 14 The last report of the American Academy of Ophthalmology highlighted the need for standardization regarding metrics of surgical success, postoperative alignment goals, logistics, timing and number of the adjustments.…”

Early and delayed suture adjustments after adjustable suture strabismus surgery: a randomized controlled trial

“…At the end of the 3-month follow-up, the early adjustment group had a slightly higher success rate without statistical significance, with a comparable mean postoperative angle difference between the groups. This postoperative adjustment has the advantage of modulating the position of the extraocular muscle in the early postoperative period, allowing for better surgical outcomes while lowering costs and reoperation rates [ 28 - 30 ]. However, in the current study delaying suture adjustment did not significantly affect the success rate.…”