Sir,

We commend Nihalani and Hunter1 on an excellent review of the adjustable suture strabismus surgery literature, especially with regard to paediatric squints. As the authors mention, the benefits of adjustable sutures have been demonstrated in both adults and children, although there is a general reluctance in attempting this technique in children owing to the perception that it would not be tolerated by the patient.

Between 2007 and 2010, our experience of adjustable suture use in a paediatric population aged between 8–15 years (mean 12.3 years old) reflects the benefits of this technique. Our current practice involves a hangback technique with a 6/0 vicryl adjustable, slip-knot tie, followed by sub-Tenon’s levobupivacaine (5 mg/ml). Within 2–3 h of recovery from general anaesthesia, topical tetracaine hydrochloride 1% is instilled and a prism cover test is performed. The suture is adjusted as required and the conjunctiva closed with 8-0 vicryl in the treatment room. Ninety-five percent (20/21) of our paediatric patients were able to tolerate this technique, with only one requiring a second general anaesthetic. The vast majority (90%) had a resultant angle <10 prism dioptres (Figure 1).

Figure 1
figure 1

Preoperative and postoperative angle of deviation for (a) distance and (b) near.

Full size image

While we agree that a certain amount of experience is required with adjustable sutures for this population, we feel the most important factor is suitable patient selection and thorough preoperative counselling of both the patient and the parents. We find that with suitable scrutiny it is possible to identify those who will tolerate the adjustment, such that the surgeon should not feel intimidated by the prospect of adjustment in this group of patients.