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adjustable suture

An adjustable suture is a strabismus surgery technique that reattaches a recessed or resected muscle to the sclera so the effect of surgery can be increased or decreased after the operation. The surgeon pulls on or loosens the sutures postoperatively and then reties them under topical anesthesia.1

The muscle is disinserted as for a recession, and the two suture ends pass side by side through the stump of the insertion. A second suture tied around the muscle suture forms a noose knot, and the conjunctiva is left open.2 Adjustment usually takes place a few hours after surgery, once the patient is fully awake. If more recession is needed, the noose knot is slid forward to give the recessed muscle slack. If less recession is needed, the muscle suture is pulled forward and the knot tightened against the stump.2

Adjustable sutures are particularly indicated when a precise outcome is essential and conventional surgery is likely to give unpredictable results. Examples include restrictive strabismus such as thyroid myopathy, previous surgery, slipped muscles and paralytic strabismus.1,2 No convincing data show the technique to be superior to conventional surgery, but the chance to reduce a large overcorrection or undercorrection on the first postoperative day reassures both surgeon and patient.1

More detail

Alignment soon after surgery does not reliably predict the final result. In one study the alignment 6 weeks after surgery differed from that at 24 hours in 28 (40%) of 70 patients.1 Adjustment in a child often requires sedation or general anesthesia, and some surgeons avoid the technique in children for that reason.1 Older children may tolerate adjustment under topical anesthesia, or the child can be kept fasting in the recovery room and re-anesthetized for the adjustment.2

Anxious patients, patients who cooperate poorly with tonometry or forced ductions, and patients who develop bradycardia on muscle traction during surgery are poor candidates for adjustment.1 Advancing a muscle at adjustment is easier than recessing it further, because the muscle adheres quickly to its new insertion. For a resection on adjustable sutures, the surgeon therefore adds 3 mm to the planned resection and recesses the muscle 3 mm at the same time.1

Sources (26)
  1. von Noorden and Campos, Binocular Vision and Ocular Motility, ch. 26
  2. Kanski's Clinical Ophthalmology (2024), ch. 18
  3. Agarwal, S. (2020). Strabismus Surgery. In: Agarwal, S. (ed.) Strabismus Simplified. Springer, Singapore. https://doi.org/10.1007/978-981-15-2135-0_9
  4. American Academy of Ophthalmology (2020). Adjustable Sutures for Strabismus Surgery. [online] Available at: https://eyewiki.aao.org/Adjustable_Sutures_for_Strabismus_Surgery [Accessed 7 May 2024].
  5. Coats, D.K. (2001). Ripcord Adjustable Suture Technique for Use in Strabismus Surgery. Archives of Ophthalmology, 119(9), pp.1364-1367.
  6. Engel, J.M., Rousta, S.T. and Felius, J. (2014). Adjustable suture strabismus surgery in children. Journal of American Association for Pediatric Ophthalmology and Strabismus, 18(3), pp.235-239.
  7. Kushner, B.J. (2017). Strabismus. In: Olitsky, S.E. (ed.) Pediatric Ophthalmology. Springer, Cham. https://doi.org/10.1007/978-3-319-28315-5_10
  8. Rutstein, R. and Daum, K. (1997). Anomalies of Binocular Vision: Diagnosis & Management. St. Louis: Mosby.
  9. Adjustable Sutures in Strabismus Surgery
  10. EyeWiki: Strabismus_Surgery_Complications
  11. Adjustable Versus Nonadjustable Sutures in Strabismus Surgery—Who Benefits the Most? - PMC
  12. What are the benefits and drawbacks of using adjustable sutures in surgical correction of pediatric strabismus?
  13. Adjustable Suture Technique. EyeRounds.org - Ophthalmology - The University of Iowa secondary
  14. PubMed Central: PMC3194320
  15. Laser-Assisted Adjustable Suture Technique in Strabismus Surgery | OPTH
  16. Adjustable Sutures in the Treatment of Strabismus: A Report by the American Academy of Ophthalmology - ScienceDirect
  17. Adjustable suture strabismus surgery in pediatric patients using pull-string technique - PMC
  18. Ripcord Adjustable Suture Technique for Use in Strabismus Surgery
  19. Evaluation of the Risk of Postoperative Infection in Adjustable Suture Strabismus Surgery
  20. Treatment Option: Adjustable Sutures | Harvard Medical School Department of Ophthalmology secondary
  21. Adjustable versus non‐adjustable sutures for strabismus - PMC
  22. Hyphema as a Complication of Adjustable Suture Surgery | JAMA Ophthalmology
  23. Nature: 6700465
  24. Adjustable Versus Nonadjustable Sutures in Strabismus Surgery—Who Benefits the Most?
  25. Ophthalmology (AAO journal): fulltext
  26. Adjustable sutures: who needs them? | Eye

Reviewed October 2026

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