Adjustable sutures play a very important role in strabismus surgery. When we perform surgery, the best we can hope for without adjustable sutures is an 80% surgical success rate. With the use of adjustable sutures, we offer another opportunity for surgical success. By applying local anesthesia while the patient is asleep or awake, we are able to perform the procedure. We do not permanently kill the sutures during the procedure, but we check the eye after the patient wakes up from anesthesia and recovers. If the eye is properly positioned, the outcome is very successful, and if it is not, we can adjust the sutures before the patient goes home the same day or the next day to loosen or tighten the muscles to restore the eye structure, which gives us a second chance to successfully restore the eye position This improves the success rate of the surgery, especially in difficult strabismus, by 10?20%, sometimes more, it’s like a second chance at life, it’s not a 100% guarantee of success, but it’s really very useful. Botulinum toxin in restrictive strabismus Botulinum toxin (Botox) is a scary sounding toxin, it is a toxin produced by a bacterium called Clostridium botulinum, which causes botulism and can be fatal. Botox is fatal because it paralyzes all your muscles so that you can’t breathe. But the treatment is done by injecting just a tiny amount of botulinum toxin, especially into the extraocular muscles to paralyze one of the extraocular muscles and then potentially treat the strabismus. We studied many types of strabismus, and we did find some improvement in patients, and even some patients were cured. But what we observed over time was that the drug was very unpredictable, that there was overcorrection in most patients, or some patients were not fully corrected, and many patients who were treated with botulinum toxin, after some years, had to be treated with surgery again. So it is not used as much as we originally expected it to be. The original expectation was that it would replace 89-90% of strabismus surgeries, however, in reality, the results were not satisfactory, with only 5-10% of patients being cured with Botox treatment. The type of strabismus that I believe is least suitable for treatment with Botox is restrictive strabismus. In this type of strabismus, although Botox is applied to relax the extraocular muscles, the muscles remain in place and do not allow Botox to work fully. Restrictive strabismus is probably the type of strabismus that benefits least from Botox treatment. Treatment of Restrictive Strabismus Restrictive strabismus is one of the most difficult types of strabismus surgery and can be challenging to treat. One of the most common types is congenital restrictive strabismus, also known as congenital fibrosis of the extraocular muscles or cranial innervation disorder syndrome, in which the muscles do not develop properly, become fibrotic, and the eye movements are poorly functioning. Thyroid eye disease or Grave’s disease limits eye movements. Some surgeries, such as retinal detachment surgery and some glaucoma surgeries, can cause muscle scarring and restrict eye movement. In general, a history of surgery on the extraocular muscles can cause scar tissue to grow and impede eye movement. Trauma and lacerations around the eye may also be related. Restrictive strabismus is actually very common and we need to identify if the eye is actually restricted by identifying it. If the strabismus is not caused by muscle atrophy, but if there is a real reason for restricting the eye movement, only then can we diagnose it. We need to loosen that muscle and then tighten the rest of the muscles to treat the strabismus. Again in this case, adjustable sutures are very important and adults with restrictive strabismus really benefit a lot from the adjustable suture as a surgical technique. What we normally do with surgery is to use tables to identify how much muscle we need to move, which is unpredictable in restrictive strabismus, and the ability to do this surgery, as well as assessing the post-operative response and fine-tuning the tensioning of the muscle before it heals, can greatly improve the success of the surgery. Future Advances in Amblyopia Treatment Amblyopia is a very old disease. For the past 250 years, the main method of treatment has been to cover the normal eye with gauze (masking therapy), where the patient’s normal eye is covered and the eye with amblyopia is used to look at things in order to train the patient, which is very effective, but it is very challenging for patients, especially children, to perform this treatment. During the treatment, the parents need to cover the child’s normal eye for several hours a day, but the child himself does not want to be covered and it is very difficult to insist on the covering. In the past, it was thought that the normal eye needed to be covered during all of the patient’s waking moments, believing that this was the standard of care. Recently, a team from the United States called the Pediatric Eye Disease Investigation Group (PEDIG) was formed to study amblyopia as well as other childhood eye diseases. They focused their main research on amblyopia, with hundreds of investigators in hundreds of different eye centers, conducted 18 different randomized clinical trials, and concluded that most patients only need to be covered for two to four hours a day, which is much easier for patients to treat. Today, we have learned another treatment method: atropine therapy, which is just as effective as masking therapy. Many families prefer this treatment, which is very effective over time, by giving daily eye drops to the normal eye as an alternative to masking therapy. For amblyopia caused by refractive error, where one eye is nearsighted and the other is farsighted, or where one eye is more nearsighted than the other, we can treat it with glasses and correct the vision without masking therapy. There is also a lot of research exploring the use of oral medications that may alter the plasticity of the brain to improve visual function in the amblyopic eye without masking therapy, and there are some clinical trials to support this. The PEDIG research group is continuing to study amblyopia and treatments for amblyopia, and it is hoped that we will have new treatments in the near future. Amblyopia is the most common cause of monocular vision loss in children, with up to 4 percent of children developing amblyopia for one reason or another. In the past, we usually did not worry about the amblyopic eye because patients had one eye that functioned normally, and using that good eye, they were able to do most things normally. What we are learning now is that as people live longer, the chances of patients having impaired normal eye function due to age-related macular degeneration and other blinding diseases increase, so it is very important to treat the amblyopic eye. In the future, research in this area will be even more important.