THE MEDIAL RECTUS PULLEY SUTURE : PRELIMINARY EXPERIENCE

THE 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


Primary gaze 18 degrees ADd

P

P = scleral suture

P

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


If we want toimpair Adductionwithout affecting primary position…

Diagrams of pulley suture

MR insertion

A

B

MRLR

Medial orbital wall

MR

A

B

PULLEY


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 recession

R 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 pulley surgery [scleral faden]

• Longer follow up on many ‘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 40, ET’ 65.• Booked for surgery

Measure 2ce, cut once…..

PREOP ET PREOP ET ‘

40 65

80

0 60

0 60

0 73

25 60. Amblyopia Rx

0 40

0 70

0 45

[25] 65

0 30

0 65

Average D: 5∆, N: 57∆

ET #1

• Frequent L face turn

• Rx: pulley sutures

#1 POST OP ET ET’

0 30 - 45

0 30

0 0 -45

0 25

0 30

0 25

0 25

AverageD 0∆N 29∆

#1 POST OP

AverageD 1.5∆N 27∆

TIME p/op ET ET’

W1 0 30

W1 0 30

W2 0 0-45

M2 0 25

M2 0 25

M3 0 25

M4 0 25

M5 0 35

M6 15 30

#1 CONCLUSION

Pulley sutures inadequate as only Rx for huge conv Xs in CET

#1

• BMR 4.5• 3 mo: EX=0, ET’ 15• 8 mo: EX/ EX’ =0

• Pulley sutures inadequate as only Rx for huge conv Xs in CET, but can add BMR as a 2ary procedure

#2 45443

CET ‘since birth’.

6mo: initial exam 20 - 30∆.

Increases with multiple cover tests 35+25 = 66∆

#2. 40 60∆

#3. 35∆

#4. 35∆

All: D = N

#2

• BMR 5mm with Pulley suture

• 17 mo f/up: straight

CONCLUSION :

effective for variable ET

#3 44190

Very Variable Progressive ET• Age 11mo: few weeks of ET

• Hip problems : full body brace

• Variable ET ped’n, ped neuro, … devpt’l delay : microcephalus, ‘mixed development disorder’

DATE ET ET’

11/05 Variable 40 Variable 40

11/05 I/mitt I/mitt

12/05 0 50

1/06 I/mitt I/mitt

2/06 0 35

4/06 [20] [45]

5/06 0 30

8/06 20 45

12/06 30 45

1/07 ? 40 53

2/07 35 80!

#3 Surgery

•BMR 5mm [for largest recent D ∆] + pulley sutures

#3 postop

• Week 3: i/mitt ET’ 15∆

• Straight with 2% pilo in office

• Rx: phospholine - straight

• 3mo: requires PI to be straight

CONCLUSION: pulley suture effective for variable ET with marked conv Xs

#4 38420

Early onset variable initially intermittentn progressive ET with conv Xs

10/02 [age 26 mo]: ET ‘since birth’ • [ET, ET’] 30∆. • Some LN. CR +2 = Rx. F intorsion.• 12/02: straight• 1/03: ET 15, ET’ 25. • 3/03: 0 / 25• 10/03: [ET] 15

#4

• 10/06: now wearing +4, +2.5add OU

• ET cc 16, sc 65

• ET’ cc 45 [add 0]; sc 70

2nd visit:

ET cc 20, sc 55

ET’ cc 35 [add 6], sc 73

#4

• Dec 06: BMR 4.5 with pulley sutures

• 1w: cc XT 18, EX’ = 0. sc ET 14, ET’ 20

• 6mo: X4, X’6. Stereo 40”

• 8mo: E4. EX’=0. Stereo 70”

• CONCLUSION: pulley suture effective for marked convergence Xs

#9 4yo 45858

• Intermittent ET from 15 mo. +6 DSOU from age 18mo

• #1: cc EX=0, ET’ 35. sc ET 40. Given bifocal• #2: cc EX=0. ET’ upper 30, add 15. sc

ET 50• #3: cc EX=0. ET’ 25 / 12. Sc 65.

#9

• Surgery: BMR 3.5mm + pulley suture

• 9mo: EX/EX’ =0 with SVD

• LESSON:

• Effective for high AC/A

#10. 46756

Conv Xs

• Age 5. R+2 DS, L +3-3. L amblyopia.

• Last 3 preop measurements

• ET cc 8, 14, 6

• ET’ cc 30, 35/20, 25

• BMR R [tighter] 3mm, L 4 mm with pulley sutures

• 1mo: EX/EX’=0

#11 46047

Progressive conv Xs in a 3-4 yo• 3yo.

• ET 16, ET’ 40

• CR +0.50 DS OU

• Rx bifocal +0.50 / +3 add

• Phoria E 10, E’ 25

• 4mo later:

• ET 40, 45. ET’ 85.

#11 46047

• BMR 6 with pulley sutures

• 7mo: orthotropia D&N. BIFR 8 for D&N. 100” stereo

• LESSON:

• Effective for conv Xs

•

#12 46451

9yo with conv Xs• ET onset ?4yo. Has been 140”

• CR= pc = +3 DSOU

• ET cc 40, sc 73

• ET’ 60/ 40

• BMR 6mm with pulley sutures

• 1w followup: EX/EX’=0. 50” stereo

#13 47501

v. large ET with conv Xs and low +

• 7yo. ET since 2.5. Wearing +1.5,add +1

• ET 45, sc 53

• ET’ 60/ 53

• V 18. IO ++, SO--, F extorsion

BMR 6 + pulley sutures

ATIO OU

• 2mo: cc ET 12, ET’ 16. V=2. MR -1 OU.

#13 47501

• 7yo. ET since 2.5. Wearing +1.5,add +1

• ET 45, ET’ 60/ 53

• P/op: cc ET 12, ET’ 16. MR -1 OU.

• Conv Xs collapsed.

#15 44405

• Age 5: +4, +2.75 add 6/9+ OU

• EX=0, Near: 35/0. ET sc 45. Stereo 40”

• Age 7: ET 18, ET’ 30/14. sc ET 50.

• BMR 4 with pulley sutures

• 2 mo: E / E’ 4,

#5 45508

Recurrent ET with conv Xs after previous BMR

• 11 yo WCM

• Mild R amblyopia 6/12, 6/6

• BMR age 3

• R +2-0.75*5, L +1.75-1.75*175

#5

• cc ET 20, ET’ 30 [ sc 35 / 40]• 12/06: RLR Rs 6, RMR pulley• 2/07: EX=0, ET’ 25 [sc 20/ >>20].

• CONCLUSION: Little / no effect from pulley suture

#6

• 4yo. ET 18mo

• sc 6/8 OU.

• CR + 1.5 Ds OU

• ET 40, ET’ 40+

• Small V / IO+ / SO- / F extorsion

• BMR 5.5, ATIO OU

#6

• D3: EX =0, ET’ 25

• W4: EX=0, ET’ 20

• Given full manifest +: +0.5, +2. Then +3 add : straight D&N 80” stereo

• M6: ET 16, ET’ 40. Add EX’=0, 100”.

• M7: ET 18, ET’ 30.

#6

• Surgery. LR Rs 4, pulley suture MR OU

• M2: E7, E’5, 20”

• CONCLUSION: PERSISTING CONV XS: EFFECTIVE

#7 PHASE 1

• Born 10/03

• Presented 4/04 with head tilt to L 20-30º• CT confirmed atrophic RSO• EUA 10/04: RSO not particularly floppy• Ant Transp RIO [2mm ant to RIR insertion]• No further cyclovertical problems

#7 PHASE 2

• Post op surprise: day 9 - i/mitt ET 25^• Looking back through the notes, i/mitt small ET

sometimes noticed by Mum or me previously• Cyclo +1.5 DS OU• Trial phospholine - Didn't help• ET increased to 30^• Some latent nystagmus noted• 2/05: BMR 4.5mm• Early post op : straight for distance, i/mitt ET for very

near [12-15 inches]

#7 PHASE 3

• 6/05 I [and not Mum] notice face turn to R• Over next few weeks increases to 25-30º

• twice my notes indicate L face turn; usually to R• MRI R/O Chiari: normal

Last 2 visits:• I recognise this to be typical LMLN• R fixation : R face turn• L fixation: L face turn

#7 SYNTHESIS

• True cong SOP disrupts early binocularity sufficiently to produce LMLN which first manifests after the SOP is fixed

• Once the SOP is fixed, the cong ET presents [perhaps if the SOP wasn't fixed the ET would have presented eventually]

• When the ET is fixed the LMLN becomes symptomatic, hence the face turns

• 04/06: Pulley suture MR OU

• Day4 : face turn < 10º• M3: face turns much better - Some regression to 20º

CONCLUSION: some improvement

#8 47302

• Presents 15 mo. ET ‘since birth’• pc +4 DS OU = CR• ET cc 25, sc 35• Won’t wear his glasses• BMR 5mm for 35∆ • Add pulley suture for poor spectacle

compliance• Follow up 18w: EX/ EX’=0• Won’t wear glasses

#8

• LESSON:

• Pulley suture may lessen tendency to recur in the face of continuing esotropogenic factors [uncorrected hyperopia]

#14 41253

Sensory ET with conv Xs• PHPV. Multiple opinions. Surgery

delayed until 9mo.

• Poor visual outcome despite good compliance with refractive and amblyopia Rx

• CR other eye low +

• 7mo +2-1

#14 41253

Sensory ET with conv Xs• [ET] noted by me age 12 mo, by mother

14 mo

• Age 2: constant 30-40, more for N

• Axial length 24.4

• LMR Rc 5 with pulley suture

• LLR resect 7

• 4mo:cosmetically straight D&N

FAILED PULLEY SUTURES

• #1 44586 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

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 - does it fall apart after x years?

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

THE MEDIAL RECTUS PULLEY SUTURE : PRELIMINARY EXPERIENCE

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