Sutureless Techniques Transform Conjunctival Management in Strabismus Surgery

What Advances Are Shaping Conjunctival Management in Strabismus Surgery?

Strabismus surgery, a common procedure aimed at correcting ocular misalignment, continues to evolve with significant innovations in conjunctival management techniques. Recent research has demonstrated that the approach to conjunctival incision and closure can substantially impact patient comfort, healing time, and surgical efficiency without compromising the primary goal of achieving proper ocular alignment. This systematic review synthesizes evidence from thirteen studies published between 2010 and 2025, offering insights into the comparative efficacy of traditional sutured approaches versus emerging sutureless techniques in strabismus surgery.

The comprehensive analysis incorporated seven randomized controlled trials and six comparative observational studies, collectively involving approximately 683 patients and 765 eyes across diverse geographical settings. Most investigations focused on horizontal rectus muscle surgeries, with participants ranging from pediatric to adult populations. The primary comparison centered on two distinct aspects of conjunctival management: the incision technique (traditional limbal/paralimbal versus minimally invasive approaches) and the closure method (conventional suturing versus fibrin glue or sutureless techniques). Outcome measures consistently included post-operative inflammation, patient comfort, operative time, and final alignment results, with follow-up periods typically extending from one to six months.

Could Minimally Invasive Approaches Improve Inflammatory Profiles and Patient Comfort?

A recurring finding across multiple studies was the superior inflammatory profile associated with sutureless closure methods, particularly when using fibrin glue. Kadam et al. demonstrated significantly reduced conjunctival hyperemia at two weeks post-operatively in the fibrin glue group compared to sutured closure (P < 0.001). This finding was further substantiated by objective anterior segment optical coherence tomography (AS-OCT) measurements, which revealed significantly lower conjunctival thickness at six weeks in the glue group, suggesting accelerated healing and reduced tissue reaction. Similarly, minimally invasive strabismus surgery (MISS) techniques demonstrated advantages over traditional limbal approaches, with Moawed et al. reporting significantly lower inflammation scores during the first post-operative month (P < 0.05). These findings align with the theoretical benefits of reduced tissue manipulation and elimination of suture-related irritation associated with minimally invasive approaches.

Patient comfort emerged as another domain where sutureless techniques demonstrated clear advantages. Lee and Kang reported significantly lower pain and tearing scores in the fibrin glue group on post-operative day one and week one (P = 0.000 for both metrics). The foreign body sensation (FBS), a common complaint following strabismus surgery, was also consistently reduced with both fibrin glue closure and minimally invasive incision techniques. Sharma et al. found that MISS resulted in significantly lower FBS (P = 0.01) and total inflammatory scores (P = 0.04) compared to standard paralimbal approaches on the first post-operative day. Interestingly, an exception was noted in the study by Anand et al., where the limbus sparing limbal incision (LSLI) resulted in significantly higher pain scores (P = 0.010) and FBS (P < 0.001) compared to the conventional limbal approach, suggesting that not all modifications yield improved comfort outcomes.

Do New Techniques Enhance Efficiency Without Sacrificing Alignment?

The impact of these techniques on operative efficiency revealed a nuanced picture. Fibrin glue closure consistently reduced surgical time, with Lee and Kang documenting a significant reduction in total surgery duration (48 ± 5 minutes versus 63 ± 7 minutes, P = 0.000). However, minimally invasive incision techniques often demonstrated an initial learning curve that temporarily increased operative times. The MISS technique took approximately 10.8 minutes longer than the standard paralimbal approach in one study (P = 0.013), while the single para-muscular approach required an additional 21.5 minutes compared to standard paralimbal techniques (P < 0.001). Encouragingly, Froelich et al. noted that this efficiency gap diminished over time as surgeons gained experience with modified techniques. Certain innovative approaches, such as the modified Swan incision described by Liu et al., actually reduced surgical time by nearly 50% compared to traditional Parks incisions (39.97 ± 15.13 minutes versus 71.70 ± 16.32 minutes, P < 0.0001).

Perhaps most critically for clinical outcomes, the final ocular alignment results remained comparable across closure techniques. Moawed et al. reported identical success rates of 90.9% for both MISS and traditional limbal approaches. Similarly, Liu et al. found no significant difference in six-month surgical success rates between modified Swan incision and traditional Parks incision groups (72.72% versus 69.70%, P = 0.422). This consistency in functional outcomes suggests that surgeons can select conjunctival management techniques based primarily on considerations of patient comfort, surgical efficiency, and tissue preservation without compromising the primary goal of strabismus correction. Safety profiles generally favored minimally invasive approaches, with no severe complications such as scleral perforation, slipped muscles, or endophthalmitis reported across the studies, although minor wound gaping was occasionally observed with fibrin glue closure.

What Challenges Limit the Adoption of Sutureless Approaches?

Despite the apparent advantages of sutureless approaches, several barriers to widespread adoption persist. Economic considerations remain significant, as fibrin glue represents a substantially higher upfront cost compared to conventional sutures. This cost differential may be partially offset by reduced operating time, but formal cost-effectiveness analyses are notably absent from current literature. Additionally, the learning curve associated with minimally invasive techniques presents a practical challenge for implementation. Surgeons must invest time and resources in acquiring new skills, potentially accepting initially longer operative times before achieving proficiency. The evidence suggests that conversion rates from MISS to larger incisions decrease substantially as surgical experience increases, highlighting the importance of adequate training and mentorship when transitioning to these techniques.

The methodological quality of the included studies was generally satisfactory, with most demonstrating low to moderate risk of bias. However, limitations included relatively small sample sizes in many studies, heterogeneous outcome measures, and follow-up periods typically limited to six weeks or less. These constraints highlight the need for larger, standardized multicenter trials with extended follow-up to definitively establish the long-term benefits of sutureless approaches. Future research should incorporate economic evaluations, standardized patient-reported outcome measures, and objective assessment tools to comprehensively evaluate the full impact of these evolving techniques.

How Will These Findings Influence Future Clinical Practice?

The clinical implications of this systematic review suggest that surgeons should consider adopting sutureless closure methods and minimally invasive incision techniques where feasible, particularly for cases where post-operative comfort and cosmesis are prioritized. However, the choice of technique should remain individualized based on surgical complexity, reoperation status, and institutional resources. As one survey highlighted, the limbal approach remains popular among consultants (55.9-70% preference) due to its superior exposure, which is particularly valuable for complex procedures or reoperations. This underscores that despite the advantages of newer techniques, there is no universally superior approach, and surgical decision-making must balance multiple factors including patient needs, surgeon expertise, and practical constraints.

This evolving landscape of conjunctival management in strabismus surgery raises important questions for clinical practice and future research. How might the demonstrated benefits in post-operative comfort and reduced inflammation translate to patient satisfaction and quality of life outcomes? Could these sutureless approaches eventually become the standard of care, or will they remain complementary techniques for selected cases? What role might emerging tissue adhesives and wound closure technologies play in further advancing these minimally invasive approaches? As techniques continue to evolve, ongoing rigorous evaluation will be essential to optimize patient outcomes while maintaining the fundamental goal of successful strabismus correction.

Summary

This systematic review synthesizes evidence from thirteen studies published between 2010 and 2025, examining advances in conjunctival management techniques during strabismus surgery. The analysis, encompassing seven randomized controlled trials and six observational studies involving 683 patients and 765 eyes, compares traditional sutured approaches with emerging sutureless techniques. Key findings demonstrate that sutureless closure methods, particularly using fibrin glue, significantly reduce post-operative inflammation, conjunctival hyperemia, and patient discomfort including pain, tearing, and foreign body sensation. Minimally invasive strabismus surgery techniques showed lower inflammation scores and improved comfort compared to conventional limbal approaches. While fibrin glue closure consistently reduced surgical time, some minimally invasive incision techniques initially increased operative duration due to learning curves, though this gap diminished with surgeon experience. Critically, final ocular alignment results remained comparable across different closure techniques, with success rates around 70-90% regardless of method, indicating that surgeons can select approaches based on patient comfort and efficiency considerations without compromising alignment outcomes. Barriers to widespread adoption include higher costs of fibrin glue compared to conventional sutures and the learning curve associated with new techniques. The review highlights the need for larger multicenter trials with extended follow-up periods and economic evaluations to establish long-term benefits and cost-effectiveness of sutureless approaches in strabismus surgery.