Adjustable Sutures


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- Adjustable Sutures

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Adjustable sutures tend to conjure a love-hate response in the strabismus surgeon who either loves them and uses them routinely or hates them, never using them or using them reluctantly and dreading the experience.

The Principle: An adjustable suture is done utilizing these basic steps:

1) Securing a muscle with a suture

sutures a-1

2) Detaching the muscle:

sutures a-2

3) Securing the muscle to the globe via the suture:

sutures a-3

4) Temporarily securing the suture so that it can be undone and the muscle allowed to slip back or be brought forward according to the alignment of the eye(s) and finally tied.

sutures a-4

The specific technique used for anchoring the suture to the muscle, securing the suture to the globe, and temporarily stabilizing the suture for later freeing and either adjustment followed by securing the tie, or simply securing the tie if no adjustment is needed can follow a variety of patterns.

Indications For Adjustable Suture

1. Some surgeons, the zealots, will use it for any muscle and in any patient who will cooperate for adjustment. This usually means older children (at least teenagers but sometimes younger) or adults and on rectus muscles. But they have been done on all muscles, even the inferior oblique (why?) and in children so young that they require a second anesthesia a few hours after initial surgery for the adjustment.

2. Selective indications for adjustable sutures are the following:

a. An adult cooperative patient suitable for rectus muscle surgery

b. A patient with fusion potential - usually one with diplopia preoperatively

c. A non-fusing patient, often one with restriction and/or a history of unpredictable results from prior surgery

Technique

Patients having adjustable suture surgery are often done with minimal local anesthesia, some even undergo adjustment on the table. These are typically patients who have diplopia after cataract, thyroid myopathy, or other adult acquired strabismus. In most cases, final adjustments are done later the day of surgery or the next day.

Patients with a history of prior surgery and scarring who require more dissection are done with general anesthesia. Retrobulbar anesthesia can be used with satisfactory adjustment done in 4 hours.

With local anesthesia, adjustment can be done on the table. In some cases the patient can sit up to check alignment.

The L.R. is easiest to adjust

S.R. hardest to adjust

The I.R. next easiest to adjust

M.R. harder to adjust

Be wary of trying to adjust the obliques!

A Standard Adjustable Suture Technique Use 6-0 synthetic absorbable suture or equivalent

Bite in middle of muscle with knot

sutures b-1

Split muscle with locking bites on sides

Place small suture loop near limbus as a "handle" suture to rotate eye during adjustment.

A limbal incision is best - especially for adults - it allows conjunctival recession

sutures b-3

___________________

A fornix incision can be used but requires a handle suture to move incision.

For adjustment to shorten muscle - decrease recession

sutures b-4

patient maintains fixation straight ahead

For adjustment to increase recession

sutures b-5

patient looks in direction of muscle to be loosened -- pulls muscle back for more recession

The tandem adjustable suture offers the benefits of a fixed (hang back) suture and an adjustable suture. See Strabismus Minute, Vol. 1, No. 12.

potential adjustable suture

sutures b-6

hang back suture can be cut if additional recession needed

The Timing of Adjustment

A. In the O.R. during surgery with patient supine or sitting up

B. In recovery or in the patient's room 1 to 4+ hours later

C. The next morning in the clinic

D. Some have claimed they can adjust up to several days later - WOW!

What Alignment is Ideal after Adjustment

A. Single binocular vision is a good end point in a fusing patient.

B. Orthotropia is a good end point in any patient.

C. If you do adjustable sutures for X(T), you should know your end point.

Results of Adjustable Suture:

Hard to say - those who like adjustable sutures just do them and report good results - few convincing controlled studies.

Tips Regarding Adjustable Sutures:

A. Adjustable resections tend to be more stressful for the patient.

B. Some say under recess - it is easier to let a muscle slip back than pull it forward - but it can be done if necessary. Others prefer over recession with pull up.

C. Suture breakage can occur - use at least 6-0 suture.

D. Cutting the wrong end of the suture can result in a slipped muscle. Be careful!

E. Patient noncooperation - fainting, etc. - this can be very unpleasant. Use topical anesthesia.

F. Late slippage can occur especially with the inferior rectus.

I saw a patient who had an attempt at adjustable resection of the superior rectus for iatrogenic Brown's from a S.O. tuck - two no-no's. At reoperation the S.R. was recessed 5-7 mm behind its insertion in a mass of scar tissue! The surgeon had "blind" reliance on the adjustable suture.

In strabismus teaching sessions, ophthalmologists universally are eager to hear about adjustable sutures possibly in the belief that even the occasional strabismus surgeon can get it right every time by simply making the correct adjustment. NOT SO!! In addition, the most common strabismus surgeries - congenital ET, intermittent XT, superior oblique palsy, and inferior oblique weakening are not suited well to adjustable sutures.

Editor-in-Chief: Eugene M. Helveston, M.D.

Associate Editor: Faruk H. Orge, M.D.

Editorial Board: Bradley C. Black, M.D.

   Edward R. O'Malley, M.D.

   David A. Plager, M.D.

   Derek T. Sprunger, M.D.

   Daniel E. Neely, M.D.

   Naval Sondhi, M.D.

Senior Editorial Consultant: Gunter K. von Noorden, M.D.

Graphics: Michelle L. Harmon

Technical Support: George J. Sheplock, M.D.

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