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What are the benefits and drawbacks of using adjustable sutures in surgical correction of pediatric strabismus?
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Option should be offered in complex cases
I can understand why many surgeons are not comfortable using adjustable sutures in children. It can be difficult to assess alignment in the immediate postoperative period, there are additional logistics to arranging for a second (if brief) anesthesia to perform adjustment, and we are not always sure about our postoperative alignment target. For these reasons, I do not use adjustable sutures in more straightforward pediatric cases. But when a child is returning for a second or third operation, or when there is a previous postoperative surprise or an incomitant deviation with restriction or paresis, it is essential for me to have a second chance to fine-tune the alignment after the procedure. Parents, too, are reassured when I put the adjustable option on the table. Although adjustable sutures do not give perfection, most studies document improvement in reoperation rates by about 10%. While I do not always know when the postoperative alignment is right, I do know when it is wrong, and I am glad to be able to send nearly every patient home close to the targeted angle. Furthermore, using short tag noose adjustables, the sutures are buried under conjunctiva; in my hands, 75% of these patients require no postoperative suture manipulation, and there is the option of performing a 5-minute adjustment with mask anesthesia in the operating room up to a week after surgery. It only takes a few extra minutes to add the short tag noose adjustable suture during a procedure, so why not offer that option to the family of a child with complex strabismus?
- References:
- Engel JM, et al. JAAPOS. 2014;doi: 10.1016/j.jaapos.2013.12.015.
- Kamal AM, et al. Eye (Lond). 2016;doi:10.1038/eye.2016.144.
David G. Hunter, MD, PhD, is ophthalmologist-in-chief and Richard Robb Chair in Ophthalmology, Department of Ophthalmology, Boston Children’s Hospital, and professor and vice chair of ophthalmology, Harvard Medical School, Boston. Disclosure: Hunter reports he is co-founder and equity holder in REBIScan Inc., which is developing instrumentation for pediatric vision screening.
Adjustable sutures are effective but take longer
Benefits: We have demonstrated higher success rates using adjustable sutures in children 10 years of age or younger (higher success rates of 11 to16 percentage points), thereby obtaining earlier alignment and fewer reoperations. There is less guesswork regarding muscle placement, especially with restrictive strabismus, slipped muscles or scarring from previous surgeries. The procedure may be used for recessions, resections, plications, transpositions, Harada-Ito procedures and adjustable suture spacer procedures on the superior oblique tendon. The sliding noose can be completely removed after adjustment with proper techniques, leaving less suture material behind to resorb and thereby speeding healing and decreasing scarring. The concept makes sense to parents. If my own grandchildren needed strabismus surgery, I would prefer adjustable sutures be used, but only by a surgeon well experienced in their use.
Drawbacks: For most children 10 years of age or younger, adjustment or simply tying off of the sutures requires 5 to 7 minutes of propofol intravenous anesthesia in the recovery room. Some surgeons use the short tag noose technique, avoiding the re-anesthesia and adjustment process entirely in greater than half of their adjustable suture cases. Extra time and cost are involved. There is a steep and prolonged learning curve to become proficient and confident. Therefore, I recommend this technique for routine use, if at all, not for infrequent use.
- Reference:
- Awadein A, et al. J AAPOS 2008;doi:10.1016/j.jaapos.2008.06.005.
David L. Guyton, MD, is Krieger Professor of Ophthalmology at The Johns Hopkins University, Krieger Children’s Eye Center at the Wilmer Institute, Baltimore. Disclosure: Guyton reports no relevant financial disclosures.