Round table: Board members debate use of adjustable sutures

In this second excerpt from a round table conducted at the 2011 AAPOS meeting, members of the OSN Pediatrics/Strabismus Section address the merits of adjustable sutures after strabismus surgery.

Robert S. Gold

Erin D. Stahl

Robert S. Gold, MD: There is still a lot of talk about adjustable sutures in strabismus surgery. I no longer use them, but that does not mean it is not a good procedure. What do you think about using them?

Erin D. Stahl, MD: I was never trained to do adjustable sutures, so I do not do them at all.

Roberto Warman, MD: It is debatable. But pediatrics is a limited place for adjustable sutures, and I only do pediatrics now, so it has been a while since I used them.

Roberto Warman

Anthony P. Johnson

Anthony P. Johnson, MD: I used to do a fair number of adjustable sutures on adults; I have never done them on kids. I had one experience that really changed my approach. One thing that is never really measured is whether anyone is ever worse off with an adjustable suture. Aggregately, eyes are slightly more likely to be straight, but I am convinced that one patient in her late 20s, who had undergone two previous surgeries by another surgeon and whose eyes had been straight with her strabismus for a long time, had her third child and then a recurrence of her strabismus. She was a hard contact lens wearer and was a very active, busy teacher. At the time of the adjustment, I thought she might be a little under-corrected. I did the adjustment and she was forever over-corrected after that. Maybe she would have been over-corrected anyway. I don’t know, but that really changed my approach. There are many surgeons who use adjustable sutures. They have their own approach to it, even with kids and additional anesthesia and so forth. I do not have any reason not to have respect for them and the use of adjustable sutures in their hands, but I have not used adjustable sutures probably in 10 years.

Scott E. Olitsky, MD: I also used to use adjustable sutures and do not use them anymore. There is certainly a group of people who have used them and then stopped using them, and then there is another group who use them and find new ways to use them more often. It seems to really split the community.

Scott E. Olitsky

Kenneth P. Cheng

Kenneth P. Cheng, MD: I certainly do not use them in children at all, and I would like not to use them, but in certain cases, clearly they are very helpful: in a thyroid case or in a patient who long ago had multiple strabismus surgeries. Those patients, I think, can be unpredictable. Adjustable sutures can then be a valuable back-up, or they can be a back-up to your clinical judgment regarding where you position the muscle.

The flip side, though, is that patients are researchers. They look on the Internet, and they watch television. A number of years ago, after an adjustable suture surgery was shown on television, there was a flurry of patients who asked me to do adjustable sutures. Because of that, I am kind of jaded. I offer the procedure to adult patients who are going to have surgery if I think they are going to be a reasonable candidate for holding still and cooperating and if they are not too nervous for it. I certainly do not push it, but I offer it. If they decide that they would like to have an adjustable, then I will do the procedure and usually leave the muscle where it would have been put otherwise. But the patient makes the decision.

I have had to go back and re-operate after doing an adjustable procedure, even after doing as nice and clean a job as I can. There is just more scar tissue in those patients who have had adjustable sutures than in those who have not because you are fussing around with things more than you would otherwise. It is a minor thing and certainly not something you cannot overcome, but there is that potential downside to the procedure, too.

Dr. Gold: I stopped doing adjustable sutures many years ago after a patient had a vasovagal episode in my office. The caveat that I would add is this: Please make sure you have the proper set-up and staff. If you have an ASC, then do it in the ASC. The patient did fine, but I had the proper set-up to get her out of that situation.

Dr. Cheng: I do the primary procedure in the operating room and make sure the patient is not getting any narcotic, so that the patient wakes up quickly after the procedure. Then I do my next case and then return to the recovery room and do the adjustment right there in the recovery room where I have access to instruments and there is anesthesia staff available if necessary. Patients tolerate that very well. It is far easier than bringing them to the office, which I think would be horrible. I would never do it.

• Kenneth P. Cheng, MD, can be reached at 1000 Stonewood Drive, Suite 310, Wexford, PA 15090; 724-934-3333; email: kpc123@verizon.net.
• Robert S. Gold, MD, can be reached at 790 Concourse Parkway South, Suite 200, Maitland, FL 32751; 407-767-6411; fax: 407- 767-8160; email: rsgeye@aol.com.
• Anthony P. Johnson, MD, can be reached at Anthony P. Johnson, MD, FACS, can be reached at Jervey Eye Group, 601 Halton Road, Greenville, SC 29607; 864-458-7956; fax: 864-458-8390; email: apj@jervey.com.
• Scott E. Olitsky, MD, can be reached at Children’s Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64108; 816-234-3000; fax; 816-346-1375; email: seolitsky@cmh.edu.
• Erin D. Stahl, MD, can be reached at Children’s Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64108; email: edstahl@cmh.edu.
• Roberto Warman, MD, can be reached at Miami Children’s Hospital, 3200 SW 60th Court, Suite 103, Miami, FL 33155-4072; 305-662-8390; fax: 305-661-7862; email: rwarman@eyes4kids.com.
• Disclosures: No products or companies are mentioned that would require financial disclosure.

Adjustable sutures in strabismus surgery are championed by those who use them comfortably but are often criticized by those who do not. Advocates cite the readily accepted concept of fine-tuning the surgery, the ability to undo initial surprises, fewer re-operations, less stress when operating and overall improved results. Detractors cite discomfort during the adjustment, the extra time required, extra cost to the patient, resistance from anesthesiologists when adjusting children and unproven results.

To be sure, improved results require training, refined techniques and experience. There is a steep learning curve. I use adjustable sutures in practically every child and adult whom I operate upon, but my fellows, operating with me every week, do not become facile with adjustable sutures until 6 months into their fellowships. Those strabismus surgeons who have qualms about using adjustable sutures should not be using them. They will surely do a better job with their conventional techniques.

– David L. Guyton, MD
Zanvyl Krieger Professor of Pediatric Ophthalmology
Director, The Krieger Children’s Eye Center at The Wilmer Institute
The Johns Hopkins Hospital
Baltimore
Disclosure: No products or companies are mentioned that would require financial disclosure.