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 A If we want to impair Adduction without affecting MR insertion A PULLEY If we want to impair Adduction without affecting primary position… Medial orbital wall B A, B : ant & post extent of pulley sleeve

Scleral suture after Demer Primary gaze 18 degrees ADd P = scleral suture MR insertion A A PULLEY P 18º P B Medial orbital wall Adduction restricted by P MR B MR A, B : ant & post extent of pulley sleeve

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 A If we want to impair Adduction without affecting MR insertion A PULLEY If we want to impair Adduction without affecting primary position… Medial orbital wall B A, B : ant & post extent of pulley sleeve

Diagrams of pulley suture Primary gaze 18 degrees ADd P = pulley suture MR insertion A A PULLEY P P B Medial orbital wall LR MR B MR A, B : ant & post extent of pulley sleeve

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∆

16 pts : standard Rs and/or Rc operations with MR pulley fixation: 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 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 #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 Xs ET cc ET’cc ETsc BMR dose F/up mo Result 20 35 73 4.5 8 70” 25-35 40 3.5 9 straight 6-14 1 40-45 85 6 7m 100”

Convergence Xs #2 ETcc ET’cc ETsc BMR F/up mo Result 40 60 73 6 <1 50” 45 53 2 ET 12 ET’16 18 30 50 4 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 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

Used scleral Faden: good result 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