The most prominent advance in adjustable suture strabismus surgery in the past years is the use of general anesthesia with rapid recovery profile, this allowed surgery on almost all patients, regardless of their level of cooperation, or their age, and without any discomfort during adjustment. The use topical anesthesia with or without systemic sedation or analgesia is another important advance. This allowed intraoperative adjustment and prevented many of the complications of adjustment in the classic two stages adjustment. Many useful techniques were also described, aiming at making adjustment procedure easier such as releasable sutures, or avoiding further manipulation of the adjustable sutures if the eyes alignment was satisfactory and no adjustment is needed such as the Engel and Rousta technique.