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 Table of Contents  
Year : 2018  |  Volume : 111  |  Issue : 4  |  Page : 153-157

Adjustable strabismus surgery versus conventional surgery in esotropia

Department of ophthalmology, Helwan University, Helwan, Egypt

Date of Web Publication13-Feb-2019

Correspondence Address:
Karim Gaballah
Helwan University, Helwan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejos.ejos_64_18

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Purpose The aim of this study is to compare the adjustable strabismus surgery with the conventional strabismus surgery.
Patients and methods This is a randomized prospective study that was carried out by studying and comparing two groups of esotropia. The first group included 15 patients, in whom adjustable surgery was performed, and the second group included 15 patients, who were operated by conventional strabismus surgery, depending on the measured angle of deviation. The postoperative results were compared in the two groups on the postoperative day, and then after 1, 2, and 6 months.
Results cases of the first group, had the suture attaching the muscle and tied intraoperatively by a suture, that can be advanced modified according to the resulting ocular alignment, these cases entered into the operating theatre, the second day of operation, and had the muscle suture advanced or released and tied finally so as to bring the eyes in the desired orthotropic position, but within 6 months, two patients had a residual angle of less than 10 prisms. Among the patients in the second group, in three cases, there was undercorrection as detected at the end of the follow-up period.
Conclusion The results seemed comparable, the adjustable and the conventional surgery, and since the conventional surgery is requiring less manipulations and less exposure to anaesthesia, we recommend the conventional surgery in the cases when the results are predictable, and leave the choice of the adjustable suture technique in cases where the postoperative results cannot be predicted as in surgery of longstanding strabismus with known anatomical changes and to unexpected anatomical changes found during surgery.

Keywords: adjustable sutures, conventional strabismus surgery, esotropia

How to cite this article:
Gaballah K. Adjustable strabismus surgery versus conventional surgery in esotropia. J Egypt Ophthalmol Soc 2018;111:153-7

How to cite this URL:
Gaballah K. Adjustable strabismus surgery versus conventional surgery in esotropia. J Egypt Ophthalmol Soc [serial online] 2018 [cited 2019 May 21];111:153-7. Available from: http://www.jeos.eg.net/text.asp?2018/111/4/153/252175

  Introduction Top

The easiest technique of adjustable suture , is to be applied to introduced in strabismus surgery many years ago to decrease the number of surgeries that the patient has to undergo to achieve parallel eyes in the central position by the end of surgery, and after adjusting the eyes position the second day postoperative in the operating room.

The first modern account of adjustable suture surgery was presented by Jampolsky [1],[2]. He described a two-stage approach, with the muscle secured to the eye with a bow-tie knot, followed 4–24 h later with adjustment of the sutures under topical anesthesia and conversion of the bow-tie into a permanent knot [2].

The adjustable suture technique for strabismus is a method in which the surgical dosage may be altered postoperatively, typically the same day or up to a week later, with the intent to improve both short-term and long-term stability, by decreasing unintentional postoperative undercorrections and overcorrections [3].

The basic principle of any adjustable suture technique is to secure the extraocular muscle using a temporary or sliding knot. After the patient has recovered from anesthesia, the eye alignment is checked and the length of suture between the attachment site and muscle is shortened or lengthened to fine-tune the alignment. The advantage of this technique is to reduce the need for reoperation by refining alignment in the early postoperative period before the muscle has firmly reattached to the sclera [4].

There are many methods to perform the adjustable suture. First, an ordinary strabismus surgery is performed, by weakening or strengthening of one or more of the extraocular muscles, and applying a sliding knot over one or more of the muscles, to be adjusted and tied finally within 24 h of the surgery.

The easiest method of adjustment applied in this study, is to be applied with a recessed muscle, that is with the medial rectus for esotropia correction, recessing the medial rectus by hang-back, keeping it over recessed, and tying the suture over the tendon stump, by bow tie technique, to be adjusted within the next 24 hours, by pulling the muscle forward until getting the desired result, then making the final knot.

In the conventional strabismus surgery, an exact preoperative plan is followed, targeting the smaller angle of esotropia, avoiding a consecutive exotropic deviation, and accepting a small residual deviation in esotropia and targeting the larger angle in exotropia, which is the angle of deviation when the eyes are looking at a distance in exotropia, targeting the largest angle to achieve a postoperative full correction or mild postoperative consecutive esotropia.

  Aim of the study Top

The aim of this study was to compare the adjustable strabismus surgery with the conventional one to choose the most suitable surgery for patients in terms of the final outcome, the facility of the procedure, and the least manipulations.

  Patients and methods Top

This study is a randomized prospective study that included 30 patients with esotropia, nonaccommodative, attending Alex Eye Center in Alexandria, starting from January 15, 2015, to the end of February 2016. All patients included in this study or the parents of those less than 18 years , have signed an informed written consent to be included in the study. All of them required surgery for correction of their strabismus. Their age ranged from 4 to 58 years.

Inclusion criteria

Cases of esotropia.


Not previously operated from strabismus.

Accepting to re-enter the operating theater within 24 hours to readjust the surgical result.

Exclusion criteria

Cases with additional vertical deviation.

Accommodative strabismus, that is, strabismus corrected with glasses.

History of previous strabismus surgery.

Not accepting to re-enter the operating theater within 24 hours to readjust the surgical result.

All patients in this study, or the parents of patients younger than 18 years of age, signed an informed written consent for inclusion in this study.

The patients of this study were divided into two groups: group I included 15 patients, with esotropia, who were operated on using the adjustable suture technique in one extraocular muscle.

The easiest method, applied in this study, was the use of the adjustable suture in the recessed muscle, where the medial rectus muscle is recessed by the hang back technique, kept over-recessed, and the suture is tied over the tendon, by a bow tie technique and kept for the session of adjustment, to be advanced the second postoperative day as needed to make the eyes parallel, then the final knot is tied over the tendon stump.

  Results Top

Group I included 15 patients, nine males and six females. The age of the patients in group I varied from 4 to 58 years, and all of them had nonaccommodative esotropia. The angle of deviation varied from 22 to 55 prisms. These cases were operated by medial rectus recession with over-recessed adjustable suture, to be adjusted by advancement on the second postoperative day in 10 cases, whereas of five patients who needed two muscles surgery, three underwent bimedial rectus recession, with one medial rectus muscle finally recessed and attached to the sclera, and the other medial rectus muscle over-recessed and had a releasable suture to be advanced and adjusted the second postoperative day. Two patients with long-standing esotropia in one eye and requiring two muscles surgery underwent the recess–resect procedure, resecting the lateral rectus with final attachment, and recessing the medial rectus with adjustable suture ([Figure 1],[Figure 2],[Figure 3] and [Table 1]).
Figure 1 (a) Right esotropia preoperative. (b) After right medial rectus recession adjustable.

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Figure 2 (a) Left esotropia preoperative. (b) After left recess–resect adjustable.

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Figure 3 (a) Left esotropia preoperative. (b) After MR recession adjustable. (c) Muscle hypertrophic. MR, medial rectus.

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Table 1 Group I data

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Group II included 15 patients, seven males and eight females; eight of these patients needed one muscle surgery, where one medial rectus was recessed, and seven cases needed two muscles surgery. Four of these patients underwent bimedial recession, and three were operated by the recess–resect procedure in the same eye ([Figure 4] and [Table 2]).
Figure 4 (a) Alternating esotropia preoperative. (b) After conventional bimedial recession.

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Table 2 Group II data

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On follow-up of cases, for a period of 6 months, in group I, two cases showed a residual angle of less than 10 prisms, and in group II, three cases had a residual angle of less than 10 prisms.

Therefore, the final postoperative outcome was comparable in the two groups.

  Discussion Top

Multiple techniques have been described since the origin of the adjustable suture. The original ‘bow-tie’ technique remains in use today. Following disinsertion, the muscle is secured to the sclera at the insertion, and a knot is made, allowing the muscle to hang back the desired amount. Many techniques have been used for adjustable strabismus surgery [5],[6],[7].

The adjustable suture technique in strabismus surgery has advantages and limitations; the advantage is that when the surgeon finds anatomical variations during surgery that might affect the results obtained by his/her own nomogram, such as a hypertrophied muscle or an atrophic muscle, the adjustable suture could be a good option to achieve the best results, avoiding the need for reoperation because of unexpected postoperative results.

Most authors agree that adjustable sutures are indicated when the surgical outcome is unpredictable [4]. Other authors believe that these indications are too restrictive: Tripathi et al. [8] and others recommend adjustable suture strabismus surgery as ‘the procedure of choice for all patients who are willing to cooperate.’

Its limitations is that it requires a second session in the operating theater, also general anesthesia in young people, within 24 hours and doubling the surgeon’s effort and time.

Kassem and colleagues, studied the medical records of all consecutive patients in this age group who underwent horizontal eye muscle surgery from 1989 through 2012 and were reviewed retrospectively. Patients were divided into two groups: those in whom a nonadjustable suture technique was used and those in whom adjustable sutures were used. The following data were collected: type of strabismus, preoperative measurements, postoperative results, and reoperation rates [9],[10].

They found that among the patients where adjustable suture technique was performed, 15% of them required reoperation, compared with 21% of the patients where nonadjustable surgery was performed [10].

In this study,the results of adjustable and conventional strabismus surgery were comparable, and this might be because of the inclusion criteria where previously operated cases were excluded, but it is recommended to make such a comparison of surgical outcomes between the two procedures in previously operated cases, where we may find anomalies such as fibrotic muscles, stretched scars, and other anatomical changes that could make the postoperative results unpredictable in conventional surgery and make the adjustable procedure the method of choice.

Therefore, in straightforward strabismus cases that have not been operated on previously, as the results of the two procedures are comparable, we recommend the conventional strabismus surgery, where the postoperative results are predictable, and a second session of manipulation and also general anesthesia can be avoided in young patients.

  Conclusion Top

Adjustable strabismus surgery and conventional strabismus surgery were found to yield comparable results in patients who had not undergone a previous operation.

Therefore, using the conventional surgery, with applying the surgeon own nomogram, the need for a second session for postoperative adjustment and a second exposure to general anesthesia in young patients can be avoided and also avoiding the manipulation under local anesthesia in adults that are not always tolerated by the patients.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Jampolsky A. Strabismus reoperation techniques. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol 1975; 79:704–717.  Back to cited text no. 1
Jampolsky A. Current techniques of adjustable strabismus surgery. Am J Ophthalmol 1979; 88:406–418.  Back to cited text no. 2
Carlson MR, Jampolsky A. An adjustable transposition procedure for abduction deficiencies. Am J Ophthalmol 1979; 87:382–387.  Back to cited text no. 3
Nihalani BR, Hunter DG. Adjustable suture strabismus surgery. Eye (Lond) 2011; 25:1262–1276.  Back to cited text no. 4
Engel JM, Guyton DL, Hunter DG. Adjustable sutures in children. J AAPOS 2014; 18:278–284.  Back to cited text no. 5
Deschler EK, Irsch K, Guyton KL, Guyton DL. A new, removable, sliding noose for adjustable-suture strabismus surgery. J AAPOS 2013; 17:524–527.  Back to cited text no. 6
Marsh J, Del Monte M. Adjustable suture for strabismus surgery. EyeWiki AAO.org, November 2018. http://eyewiki.aao.org/Adjustable_Sutures_for_Strabismus_Surgery  Back to cited text no. 7
Tripathi A, Haslett R, Marsh IB. Strabismus surgery: adjustable sutures-good for all. Eye 2003; 17:739–742.  Back to cited text no. 8
Kassem A, Xue G, Gandhi NB, Tian J, Guyton D. Adjustable suture strabismus surgery in infants and children: a 19-year experience. J AAPOS 2018; 22:174–178.  Back to cited text no. 9
Leffler CT, Vaziri K, Cavuoto KM, McKeown CA, Schwartz SG, Kishor KS, Pariyadath A. Strabismus surgery reoperation rates with adjustable and conventional sutures. Am J Ophthalmol 2015; 160:385–290.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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