Comment on: Cut and paste: A novel method of re-attaching rectus muscles with cyanoacrylate during recessions in strabismus

Abstract

Dear Editor, We are grateful for the interest shown by the authors in our article,[1 2] and the issues raised by them. The patients were blinded to the procedure, being unaware which eye had been randomized to conventional surgery and which to cyanoacrylate. We are aware of the importance of the assessor being blinded too, but due to logistic constraints could not carry it out in the majority of the cases. This issue has been raised before, and we too feel that the ‘backup’ Vicryl suture, which would have bound the capsule to the muscle-tendon complex, possibly helped us avoid a slipped muscle. We sutured the conjunctiva with 8-0 Vicryl. The authors’ point is valid: we did consider using fibrin glue in our cases, but the cost precluded us from doing so. The ideal would have been to stick both the muscle and the conjunctiva. We needed to have a ‘safety net’ in case of muscle slippage, and so we had designed our study to include a ‘backup’ 6-0 Vicryl suture: this had to be accessible to be of use and was allowed to be attached temporarily to the forehead, for about 4-6 h postoperatively. We did not come across any patient who had additional discomfort on account of this. Under topical anesthesia and with slight traction on the suture, such that it removed any slack, the suture was cut flush with the conjunctiva after gently pushing the latter back with the spring scissors. Since prior explanation had been provided to the patients, none appeared to be discomfited by this. We had not included cauterization in our protocol and avoided deviating from it. We staunched the bleeding by pressure before applying the cyanoacrylate. Even we have concluded that cautery of the detached muscle would be both helpful and save time. Whether a five minute delay is significant or not is a subjective matter. Normally, we too use the same Vicryl suture to reattach muscles in the same patient in a standard manner. We were trying to assess how well the muscle holds with glue and what kind of tissue reaction occurs to it. The six-month information on ocular movements was to convey to the reader that the muscles were holding well to their points of attachments. There was nothing to suggest any reaction to the glue. We understand that any novel approach need not necessarily prove better than the existing procedure. But when such a possibility is likely, one should explore that possibility. We do not claim that gluing a muscle back should, at least at this point in time, replace the standard procedure of suturing it, but that it can be done, and successfully so has been demonstrated by our study. What is its future, only time will tell.