Adjustable and Tied-Off Sutures Similar for Strabismus

Alice Goodman

November 17, 2013

NEW ORLEANS — The jury is still out about whether adjustable or tied-off sutures are best to ensure that eye muscles remain aligned after strabismus surgery. In the absence of definitive evidence from randomized, controlled trials, experts say the decision rests on the preference and comfort level of the individual surgeon.

Ocular alignment in strabismus surgery is challenging.

"I wish that I was an orthopedic surgeon who just straightens the bone and then the muscles are straight," said David Hunter, MD, from Harvard Medical School in Boston, Massachusetts. "I also wish people were like erector sets and their eyes would stay where they are after surgery. But this isn't the case. For me, adjustable sutures work better and allow me to refine alignment postoperatively."

David Plager, MD, from the Indiana University Medical Center in Indianapolis, mused that adjustable sutures "are for surgeons who don't know where they want to put the muscle in the first place."

The 2 experts discussed the pros and cons of the approaches here at the American Academy of Ophthalmology (AAO) 2013 Annual Meeting.

Dr. Plager told specialists, "Use adjustable sutures if you want to. But don't feel you are depriving your patients if you don't use them."

Dr. Hunter said that both money and time can be saved by using optimal adjustment techniques, leaving some of the suture untied to allow for postoperative modifications.

Insufficient Evidence at Cochrane Review

Dr. Hunter pointed out that a 2013 Cochrane Review concluded that there was insufficient evidence from large, randomized trials to recommend adjustable sutures. However, evidence from 4 retrospective trials with more than 1000 patients suggests a 15% to 33% improvement in outcomes with adjustable sutures.

"Adjustable sutures give you a favorable return on the investment," Dr. Hunter said.

The estimated cost of strabismus surgery is about $9600. If adjustable sutures are used, a conservative estimate of added cost is about $960. Dr. Hunter explained that in actuality, insurance covers several of the components involved, so it really adds only about another $195.

Dr. Hunter acknowledged that there is a learning curve with the adjustable sutures that can take many months, and "you have to know when not to adjust. Adjustable sutures allow me to structure the surgical plan around the desired postoperative alignment of the eye muscles. Patients express satisfaction with the surgery," he said.

Dr. Plager countered that there is "no reliable evidence that adjustable sutures increase the surgical success rate and decrease the reoperation rate."

Three decades ago, strabismus surgery was a lengthy procedure, requiring 3 days in hospital. Now, it is done on an outpatient basis and takes 2 hours and 18 minutes, he said. Using an adjustable suture is not a simple matter. The timing and techniques are quite variable, consisting of "a hodgepodge of options," he noted.

Dr. Plager said he is against the use of adjustable sutures because of patient discomfort and trauma, added expense, and increased surgical time as well as the risk for more complications.

"Patients don't like it," he said. "It makes them uncomfortable. There are oculocardiac issues, and patients and surgeons have to stay around longer after the surgery," Dr. Plager explained.

In a study by Tripathi and colleagues, 443 patients were offered adjustable sutures, but only 141 elected to have them (Eye [Lond] 2003;17:739-742), Dr. Plager noted. "The authors concluded that adjustable sutures were recommended for all patients who are fit and willing to cooperate."

"Adjusting the sutures is more time-consuming for the surgeon and the patient, who has to come back at the end of the day. It may even be possible to adjust out of a good result into an even worse result," Dr. Plager cautioned.

Dr. Hunter has consulted for REBIScan. Dr. Plager reports no relevant financial relationships.

American Academy of Ophthalmology (AAO) 2013 Annual Meeting: Presented November 16, 2013.

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