A comparative study of adjustable and non-adjustable sutures in primary horizontal muscle surgery in children

SIR, We congratulate Kamal _et al_1 on effecting a randomised controlled trial in paediatric strabismus, an area in which such evidence is lacking, but wish to raise some concerns about the

techniques described. The authors randomly allocate the cohort into two groups that cannot readily be compared. For example, the proportion of exotropes in the non-adjustable group is 40%,

but only 23.3% in the adjustable group. Table 1 incorrectly states this percentage as 13.4%. There are no data on visual acuity, refraction or binocular status, which are important

determinants of strabismus surgical outcomes. Describing motor outcomes in isolation may lead to erroneous conclusions. Patients with concurrent vertical and horizontal strabismus are

included, but the vertical component ignored in analysis, which is not ideal as these patients have different responses to surgery. The authors describe adjusting sutures 1–4 h

post-operatively. This technique relies on orthoptic assessment of children recovering from general anaesthetic (GA) and who are kept fasted for further GA. Proponents of this technique have

described feigning dropping a child, who may be understandably uncooperative, to cause reflex eye opening to enable a Krimsky test.2 Examination in this setting is limited, as the authors

themselves state, and may be insufficient in guiding adjustment. These children often remain under long-term follow-up. A negative experience at surgery may adversely affect their

cooperation in future appointments. Adjustment requires a second GA. Recent evidence has demonstrated the long-term neurocognitive safety of a single GA before the age of 36 months, but the

effect of repeated GA on the developing brain remains unknown.3 We feel these factors are important and should considered prior to embarking on the technique described to maximise good

surgical outcomes. REFERENCES * Kamal AM, Abozeid D, Seif Y, Hassan M . A comparative study of adjustable and non -adjustable sutures in primary horizontal muscle surgery in children. _Eye_

2016; 30: 1447–1451. Article  CAS  Google Scholar  * Engel JM, Guyton DL, Hunter DG . Adjustable sutures in children. _JAAPOS_ 2014; 18 (3): 278–284. Google Scholar  * Sun LS, Li G, Miller

TL, Salorio C, Byrne MW, Bellinger DC _et al_. Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood. _JAMA_ 2016; 315

(21): 2312–2320. Article  CAS  Google Scholar  Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Ophthalmology, Royal Free Hampstead NHS Trust, London, UK N Tan

 & S Jain * Whittington Health NHS Trust, London, UK C Wu * University College London Medical School, London, UK S Jain Authors * N Tan View author publications You can also search for

this author inPubMed Google Scholar * C Wu View author publications You can also search for this author inPubMed Google Scholar * S Jain View author publications You can also search for this

author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to N Tan. ETHICS DECLARATIONS COMPETING INTERESTS The authors declare no conflict of interest. RIGHTS AND PERMISSIONS

Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Tan, N., Wu, C. & Jain, S. A comparative study of adjustable and non-adjustable sutures in primary horizontal muscle surgery

in children. _Eye_ 31, 1746–1747 (2017). https://doi.org/10.1038/eye.2017.140 Download citation * Published: 04 August 2017 * Issue Date: December 2017 * DOI:

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