MEDIAL RECTUS PULLEY SUTURE :

PRELIMINARY EXPERIENCE

LIONEL KOWAL

ELINA LANDA

RVEEH MELBOURNE

‘FADEN SUTURE’

Many synonyms Long history: Germany 50 yrs ago Frequently used in European and Latin

strabismus Lower acceptance in Anglo- American

strabismus

MECHANISM OF FADEN

Previous: change tangent of action of muscle

Demer: major mechanism - create restriction of movement through the pulley

New intra-operative end point: restriction

SEMINAL PAPER R A. Clark, J L. Demer Posterior fixation sutures: a revised mechanical explanation for the fadenoperation …. Am J Ophth 1999

COMMON USE : TO COMPENSATE FOR

INCOMITANCE

MR: Desired Effect: to have no effect on primary position, and to only effect ADduction.

Typically used to augment effect of MR recess esp for convergence Xs.

SR: to augment effect of SR recess in DVD IR: ..after contralateral blowout

Normal Adduction

PULLEY A

B

MR insertion

Medial orbital wall

A, B : ant & post extent of pulley sleeve

If we want toimpair Adductionwithout affecting primary position…

Scleral suture after Demer

MR insertion

A

B

MR

Medial orbital wall

MR

18º

A

B

PULLEY

A, B : ant & post extent of pulley sleeve

Primary gaze 18 degrees ADd

P

P = scleral suture

P

Adduction restricted by P

SCLERAL FADEN

Many different techniques - all seem to work similarly

RARE COMPLICATIONS Perforation Scarring ant to suture

THE NEW FADEN: PULLEY SUTURE

Technically difficult - the surgical anatomy of the pulley is NOT well defined even though radiological / histological anatomy is

From Clark & Demer

THE NEW FADEN: PULLEY SUTURE

Create restriction of movement through pulley by suturing muscle to the pulley

Theoretically safer - no scleral suture Technically difficult [so far] not titratable *: Will this one have a ‘small’ or ‘large’ effect? * similar with scleral Faden

No long term results

Normal Adduction

PULLEY A

B

MR insertion

Medial orbital wall

A, B : ant & post extent of pulley sleeve

If we want toimpair Adductionwithout affecting primary position…

Diagrams of pulley suture

MR insertion

A

B

MRLR

Medial orbital wall

MR

A

B

PULLEY

A, B : ant & post extent of pulley sleeve

Primary gaze 18 degrees ADd

P

P = pulley suture

P

P

Medial rectus pulley posterior fixation is as effective as scleral posterior fixation for acquired ET with high AC/A

R A. Clark, J L. Demer Am J Ophthalmol 2004

9 pts : standard BMR + scleral

faden:

2 – only scleral faden

7 – BMRc + scleral faden

Postoperatively:

6/9 – imroved stereoacuity

8/9 – no longer needed bifocals

D/N disparity av of 12∆

13 pts : BMR pulley sutures:

3 – only pulley suture

10 – BMR +pulley suture

Postoperatively:

8/13 – improved stereoacuity

12/13 – no longer needed bifocals

D/N disparity av of 14∆

Medial rectus pulley posterior fixation: a novel technique to augment recessionR A. Clark, R Ariyasu, J L. Demer JAAPOS 2004

16 pts : standard Rs and/or Rc operations with MR pulley fixation:

- 9 pts – recurrent ET with conv Xs

5 – BMR re-Rc + BMR pulley suture

4 – MR re-Rc + pulley suture +ipsi LR Rs

Postoperatively, D/N disparity decreased av of 11∆.

All pts : Dist ET ≤ 10 ∆. No pt overcorrected.

2007 / 2008

2007: 7 patients 2008: now 15 1 abandoned PS [ scleral faden] Longer follow up on some ‘07 patients

Types of patients for PS

1. Variable ET n=3 2. Convergence Xs n=7 3. Adding PS to previous BMR n=2 4. Adding PS for anticipated poor gls

compliance n=1 5. PS for face turn of LMLN n=1 6. Conv Xs in sensory ET n=1

#1 44681 CET onset 6mo. Presents @ 22mo. Delivered 33w L amblyopia ; atropine [i/mitt R ET] and

patching Cyclo +1 DS OU ET 0-40, av 5. ET’ 40-73 av. 57 [12 visits] Frequent L face turn Rx: pulley sutures

#1 POST OP ET 0-15, av 1.5 ET’ 0-45, av 27 [n=9]…was 57! BMR 4.5 3 mo: EX=0, ET’ 15 8 mo: EX / EX’ = 0. LMLN with alternating face

turns Pulley sutures inadequate as only Rx

for huge conv Xs in CET, but can add BMR as a 2ary procedure.

Variable ET

2 further pts with variable ET BMR + PS effective Dose of BMR: 1. Recent D angle 2. Average D angle

Types of patients for PS

2. Convergence Xs n=7 1. Variable ET n=3 3. Adding PS to previous BMR n=2 4. Adding PS for anticipated poor gls

compliance n=1 5. PS for face turn of LMLN n=1 6. Conv Xs in sensory ET n=1

Convergence XsET cc ET’cc ETsc BMR

doseF/up mo

Result

20 35 73 4.5 8 70”

0 25-35 40 3.5 9 straight

6-14 25-35 3.5 1 straight

40-45 85 6 7m 100”

Convergence Xs #2ETcc ET’cc ETsc BMR F/up

moResult

40 60 73 6 <1 50”

45 60 53 6 2 ET 12 ET’16

18 30 50 4 2 E/E’4

Convergence Xs

BMR + PS is a very convincing operation in this small series

Selection bias: V. lge ET’ [60,60,85] V. lge N>D [15,30,20,40+,20] Small D [0, 6-14]

Types of patients for PS

1. Convergence Xs n=7 2. Variable ET n=3 3. Adding PS to previous BMR n=2 4. Adding PS for anticipated poor gls

compliance n=1 5. PS for face turn of LMLN n=1 6. Conv Xs in sensory ET n=1

Adding PS to previous BMR for persisting conv Xs

N=2 1 worked very well 1 didn’t work @ all

Types of patients for PS 1. Convergence Xs n=7 2. Variable ET n=3 3. Adding PS to previous BMR n=2 4. PS for face turn of LMLN n=1: poor 5. Adding PS to BMR for ET with

anticipated poor gls compliance n=1: Great

6. Conv Xs in sensory ET n=1: poor

FAILED PULLEY SUTURES

#1 after previous RMR Rs.

Used scleral Faden: good result

Pulley suture 15 pts with variable ET or marked conv XS More difficult than scleral faden No long term outcomes

Promising for: Variable ET Conv Xs Where gls wear unlikely

Pulley suture : the future How much intraop restriction is enough?…too

much? Need scheme for intraoperative control of

acquired restriction & correlation with postop result

No long term results - scleral faden has 50 y history. Does PS fall apart after x years?

Long term status of pulley vs scleral suture : clinical data and histology req’d