The paralimbal approach with deferred conjunctival closure for adjustable strabismus surgery.

Interest in the adjustable suture technique was renewed in the mid-1970s. The authors report a new modification of the fornix and limbal conjunctival approaches that combines the advantages of both. A paralimbal conjunctival incision is placed halfway between the limbus and the muscle insertion and directed parallel to the muscle insertion. This approach permits easy access to the rectus muscle. After the adjustable suture is temporarily secured with a bow-tie knot, the conjunctiva is partially closed using a loop suture over the muscle suture. An optional modification is the use of a "sweep suture" to break early adhesions at the time of adjustment. The adjustment procedure is performed at least 6 hours after the surgery. The conjunctiva is retracted as necessary for access to the muscle suture. If a sweep suture is used, this is first withdrawn before attempting any adjustment. After adjustment, the conjunctival loop suture is closed, covering the muscle suture. The sweep suture serves as a safeguard for what may otherwise be a difficult adjustment. This approach increases patient comfort after the surgery.