What is an adjustable suture in strabismus surgery?

Adjustable suture strabismus surgery is a type of eye muscle surgery that allows the surgeon to be able to change the eye muscle position in the immediate postoperative period after standard strabismus surgery. By being able to adjust the muscle position, a surgeon may be able to maximize the probability of successful eye alignment.    

How is an adjustable strabismus procedure different from standard strabismus surgery?

The adjustable suture strabismus operation is performed in two steps. First, a standard strabismus surgery involving weakening or tightening one or more eye muscles is performed. During the procedure, an adjustable or  "releasable" suture is placed on one or more of the muscle sutures [See figure 1]. Second, usually within 24 hours after surgery, eye alignment is checked. If needed, the muscles can be moved or “adjusted” by sliding the adjustable suture knot. Once the desired alignment is achieved, the stitches are trimmed and tied into a permanent position

Who can have adjustable suture surgery?

Anyone who can cooperate with the technique can have an adjustable procedure. For the most part, cooperative adults, and occasionally teenagers are good candidates. Candidacy can be checked in the office pre-operatively by simulating the adjustable experience and seeing how the patient reacts. Young children and poorly cooperative patients could only have adjustments if further anesthesia is used after the initial surgery.

Is the patient asleep or under anesthesia during the suture adjustment?

In most cases the patient is awake for the adjustment. Most adults have the muscles adjusted on the same day or the day after surgery. The adjustment may take place in the recovery room shortly after surgery or in the doctor’s office later the same day or the next day. Topical anesthetic drops are used to numb the eye.  Full sedation is not desired as the patient needs to be able to “focus” with their eyes together as best as possible to help the surgeon determine the optimal alignment.

Is suture adjustment painful?

Most patients describe suture adjustment as annoying or uncomfortable but not necessarily painful. The anesthetic drops help to numb the surface of the eye, but there is still sometimes a pressure sensation when the muscle moves. The patient needs to be able to lay still and keep their eyes in one direction of gaze during the adjustment.

Is adjustable suture surgery new?

An adjustable suture technique was first described in 1941; popular use became more widespread after 1975.

What are some of the benefits of adjustable suture surgery?

The benefit of adjustable suture surgery is the ability to fine-tune the immediate surgical outcome. This technique hopefully leads to reduced re-operation rates and improved surgical success.    It is especially useful in more complicated strabismus surgery such as re-operations, trauma or eye movement disorders such as Graves disease (thyroid eye disease).

What are the disadvantages of adjustable suture surgery?

In an adjustable suture surgery, there is a possibility that a muscle can shift its position in the healing process. The muscle is not actually sutured directly to the sclera (wall of the eye) as in standard strabismus surgery. Therefore, eye muscles can both slip back farther than desired or “creep” forward after the adjustment period. Changes in eye alignment, however, can occur during the healing period with adjustable and non-adjustable techniques.

What are some possible complications of adjustable suture surgery?

Breakage of the suture or cutting of the knot can occur during an adjustment. If this happens, some patients will need to go back to the operating room to properly secure the muscle.

Sometimes the muscle won’t move forward or backward as desired. This complication is  due to healing of the muscle to the sclera, especially for late adjustments, scarred muscles, or muscles that have lost some of their elasticity.

The heart rate can slow down in some people when an eye muscle has tension put on it, and some people feel faint and nauseous. These reactions are usually very short lived and not serious or severe.

Sometimes the measurements are variable right after surgery and it is difficult to know what the “real” measurement is. Blurred vision and pain can limit the patient’s ability to cooperate with both the measurements and the adjustment procedure.

The adjustable suture knot also causes relatively more redness and discomfort after surgery and takes longer to dissolve than in standard strabismus surgery.

Do all strabismus surgeons use adjustable sutures?

Not all strabismus surgeons use adjustable sutures. This is largely due to the personal preference of your ophthalmologist.  Currently there is no data that proves adjustable suture strabismus surgery is better than standard surgical technique.

.6/11

Eye Terms & Conditions