1. MEDIAL RECTUS PULLEY SUTURE : PRELIMINARY EXPERIENCE
LIONEL KOWAL
ELINA LANDA
RVEEH MELBOURNE

2. ‘FADEN SUTURE’ Many synonyms Long history: Germany 50 yrs ago
Frequently used in European and Latin strabismus
Lower acceptance in Anglo- American strabismus

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. 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∆

13. 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.

14. 2007 / 2008
2007: 7 patients
2008: now 15
1 abandoned PS [ scleral faden]
Longer follow up on some ‘07 patients

15. 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

16. #1 44681 CET onset 6mo. Presents @ 22mo. Delivered 33w#
CET onset 6mo. 22mo.
Delivered 33w
L amblyopia ; atropine [i/mitt R ET] and patching
Cyclo +1 DS OU
ET 0-40, av 5. ET’ av. 57 [12 visits]
Frequent L face turn
Rx: pulley sutures

17. #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.

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

19. 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

20. 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”

21. 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

22. 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]

23. 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

24. Adding PS to previous BMR for persisting conv Xs
1 worked very well
1 didn’t all

25. 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

26. Used scleral Faden: good result
FAILED PULLEY SUTURES
#1 after previous RMR Rs.
Used scleral Faden: good result

27. 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

28. 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