1. THE 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 of mvmt

4. 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

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

6. 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

7. CLARKE DEMER PAPERS

8. #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 40, ET’ 65.
Booked for surgery
Measure 2ce, cut once…..

9. PREOP ET PREOP ET ‘ 40 65 80 60 73 25 60. Amblyopia Rx 70 45 [25] 3060 73 25
60. Amblyopia Rx 70 45
[25] 30
Average
D: 5∆,
N: 57∆

10. ET #1
Frequent L face turn
Rx: pulley sutures

11. #1 POST OP ET
ET’ 30
0 -45 25
Average
D 0∆
N 29∆

12. 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

13. #2 45443 CET ‘since birth’. 6mo: initial exam 20 - 30∆.#
CET ‘since birth’.
6mo: initial exam ∆.
Increases with multiple cover tests = 66∆
#2. 40  60∆
#3. 35∆
#4. 35∆
All: D = N

14. #2 BMR 5mm with Pulley suture 6 mo f/up: straight CONCLUSION :
effective for variable ET

15. #3 44190 Age 11mo: few weeks of ET Hip problems : full body brace#
Age 11mo: few weeks of ET
Hip problems : full body brace
Variable ET  ped’n, ped neuro, … devpt’l delay : no specific cause

16. 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!

17. #3
Surgery
BMR 5mm, pulley sutures

18. #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

19. #4 38420 10/02: ET ‘since birth’ [ET, ET’] 30∆.#
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

20. #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

21. #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

22. #5 45508 11 yo WCM Mild R amblyopia 6/12, 6/6 BMR age 3#
11 yo WCM
Mild R amblyopia 6/12, 6/6
BMR age 3
R *5, L *175

23. #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

24. #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

25. #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.

26. #6 CONCLUSION: PERSISTING CONV XS: EFFECTIVE
Surgery. LR Rs 4, pulley suture MR OU
M2: E7, E’5, 20”
CONCLUSION: PERSISTING CONV XS: EFFECTIVE

27. #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

28. #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]

29. #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

30. #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

31. 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