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 of mvmt

COMMON USES : TO COMPENSATE FOR INCOMITANCE Commonest use: MR: Augment effect of MR recess esp for convergence Xs. U or B. Other uses: SR: Augment effect SR recess in DVD IR: ..after contralateral blowout

SCLERAL FADEN Many different techniques - all seem to work similarly RARE COMPLICATIONS Perforation Scarring ant to suture

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 *: am I doing one with a ‘small’ or ‘large’ effect? * similar with scleral Faden No long term results

CLARKE DEMER PAPERS

#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 40, ET’ 65. Booked for surgery Measure 2ce, cut once…..

PREOP ET PREOP ET ‘ 40 65 80 60 73 25 60. Amblyopia Rx 70 45 [25] 30 60 73 25 60. Amblyopia Rx 70 45 [25] 30 Average D: 5∆, N: 57∆

ET #1 Frequent L face turn Rx: pulley sutures

#1 POST OP ET ET’ 30 - 45 30 0 -45 25 Average D 0∆ N 29∆

Pulley sutures inadequate as only Rx for huge conv Xs in CET #1 CONCLUSION Pulley sutures inadequate as only Rx for huge conv Xs in CET

#2 45443 CET ‘since birth’. 6mo: initial exam 20 - 30∆. #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 6 mo f/up: straight CONCLUSION : effective for variable ET

#3 44190 Age 11mo: few weeks of ET Hip problems : full body brace #3 44190 Age 11mo: few weeks of ET Hip problems : full body brace Variable ET  ped’n, ped neuro, … devpt’l delay : no specific cause

DATE ET ET’ 11/05 Variable 40 Variable 40 I/mitt 12/05 50 1/06 2/06 35 4/06 [20] [45] 5/06 30 8/06 20 45 12/06 1/07 ? 40 53 2/07 80!

#3 Surgery BMR 5mm, pulley sutures

#3 postop Week 3: i/mitt ET’ 15∆ Straight with 2% pilo in office Rx: phospholine - straight CONCLUSION: pulley suture effective for variable ET with marked conv Xs

#4 38420 10/02: ET ‘since birth’ [ET, ET’] 30∆. #4 38420 10/02: 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 CONCLUSION: pulley suture effective for marked convergence Xs

#5 45508 11 yo WCM Mild R amblyopia 6/12, 6/6 BMR age 3 #5 45508 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 CONCLUSION: Little / no effect from pulley suture 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 CONCLUSION: PERSISTING CONV XS: EFFECTIVE 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 CONCLUSION: some improvement 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

Pulley suture 7 pts with variable ET or marked conv XS Pulley suture possibly effective in 5 More difficult than scleral faden No long term outcomes