Sir,

We congratulate Kamal et al1 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.