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Published byRalph Hartnell Modified over 2 years ago

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Medial Rectus Pulley (Posterior Fixation) Sutures Logan Mitchell 1, Lloyd Bender 1, Avinash Mahindrakar 1, Elaine Wong 1, Elina Landa 1, Lionel Kowal 1,2 1. Royal Victorian Eye and Ear Hospital, Melbourne 2. Private Eye Clinic, Melbourne - Use in partially accommodative esotropia with convergence excess

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Accommodative Esotropia with Convergence Excess Example: ET 35, ET' 55 Surgical undercorrections common Parks' formula: distance angle + 1 mm = 6.0 mm Kushner's formula: distance angle + 10% of disparity = 7.0 mm NB = operating for near angle etc...

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Rx of Very large amounts of Convergence Excess ET 15 ET’ 50 What surgical dosage BMR? o BMR (even with augmented dose) unlikely to correct near and distance deviation

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Medial Rectus Pulley Suture A, B : ant & post extent of pulley sleeve Original MR insertion A B MR Medial orbital wall P PULLE Y MR 18 º A B P P = muscle sutured to its pulley. This now restricts full aDduction

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Medial Rectus Pulley Sutures in Accommodative Esotropia

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Faden Sutures: a revised explanation for their effect Clark et al, AJO 1999 A, B : ant & post extent of pulley sleeve Primary gaze 18 degrees ADd PULLEY MR 18 º A B P P prevents normal MR movement through MR pulley - Adduction restricted by P..as well as its effect on moment arm Original MR insertion A B MR Medial orbital wall P

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Pulley Sutures - A Melbourne experience 24 children partially accommodative esotropia near-distance disparity ≥15∆ >1 month follow-up

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Pulley Sutures - A Melbourne experience Surgery Bimedial recessions targeting average of near and distance deviations + pulley sutures +/- inferior oblique recession as needed

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Pre-operative Characteristics VariableMean Age at surgery (yrs) 5.4 Distance esodeviation (∆) 22.4 Near esodeviation (∆) 48.8 Distance-near disparity (∆) 26.8 Refraction (SE dioptres) 3.0

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Post-op outcome1-3 months3-6 months 12+ months Number 24129 Mean distance esodeviation (∆) -0.80.81.7 Distance alignment between orthophoria and 10 ∆ esotropia (%) 75 89 Mean near-distance disparity (∆) 4.82.43.6 Mean decrease in near-distance disparity (∆ (%)) 22.0 (79.7%) 23.5 (88.0%) 21.3 (87.4%) Post-operative Outcomes

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Effect on Near-Distance Disparity

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Conclusion Logical application of new understanding of orbital anatomy Safe Effective at decreasing near excess Very low risk persistent over-correction A technique to be considered in difficult cases

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Thank you

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