Comparison of Two Different Extraocular Muscle Suturing Techniques for Strabismus Surgery

To compare the surgical outcomes after bilateral medial rectus recession (BMR) or bilateral lateral rectus recession (BLR) performed with the 3-point fixation (3PF) vs 2-point fixation (2PF) suturing techniques.

Prospective clinical cohort study.

Patients diagnosed with concomitant esotropia or concomitant exotropia and undergoing BMR or BLR with the 3PF or 2PF techniques between January 2022 and January 2025 from the Nanjing Strabismus Cohort Study were included.

Postoperative deviation angles were recorded at regular follow-up visits. A Cox proportional hazards model was used to estimate the association between suturing techniques and surgical outcomes.

The primary outcome was overcorrection, defined as distant eso/exodeviation >10 prism diopters (PD) after BLR or BMR. The secondary outcome was undercorrection/recurrence, defined as distant exo/esodeviation >10 PD after BLR or BMR.

A total of 248 patients were included, with a mean age at surgery of 8.67 ± 6.35 years, of whom 52.42% were male. Of these, 113 underwent surgery with 2PF, and 135 with 3PF. Overcorrection occurred in 27 (10.89%) patients and undercorrection/recurrence occurred in 20 (8.06%) patients. The cumulative incidence of overcorrection was higher in the 2PF group (33.72%; 95% CI, 30.39%-37.22%) compared with the 3PF group (13.09%; 95% CI, 11.71%-14.43%) across the follow-up period (difference: 20.64%, 95% CI, 16.96%-24.28%). Patients in the 3PF group had a 62% decreased risk of overcorrection compared with those in the 2PF group (hazard ratio [HR] = 0.38; 95% CI, 0.16%-0.91%). No significant difference was observed in the cumulative incidence of undercorrection/recurrence between the 2PF group (46.50%; 95% CI, 43.18%-49.96%) and the 3PF group (47.50%; 95% CI, 44.04%-50.99%) over the follow-up period (difference: -1.01%, 95% CI, -5.85% to 3.91%). The suturing technique was not associated with undercorrection/recurrence (HR = 1.07; 95% CI, 0.42%-2.76%).

These findings support that the 3PF suturing technique is a superior alternative to the 2PF technique for reducing overcorrection in bilateral horizontal rectus muscle recession surgery.