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.
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.
Engel JM, Guyton DL, Hunter DG . Adjustable sutures in children. JAAPOS 2014; 18 (3): 278–284.
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.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The authors declare no conflict of interest.
Rights 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
Published:
Issue Date:
DOI: https://doi.org/10.1038/eye.2017.140