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THE MEDIAL RECTUS PULLEY SUTURE : PRELIMINARY EXPERIENCE

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 .

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THE MEDIAL RECTUS PULLEY SUTURE : PRELIMINARY EXPERIENCE

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

  12. 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∆ 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

  13. Medial rectus pulley posterior fixation: a novel technique to augment recessionR 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 pulley surgery [scleral faden] • Longer follow up on many ‘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 • L amblyopia ; atropine [i/mitt R ET] and patching • Cyclo +1 DS OU • ET 40, ET’ 65. • Booked for surgery Measure 2ce, cut once…..

  17. Average D: 5∆, N: 57∆

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

  19. #1 POST OP Average D 0∆ N 29∆

  20. #1 POST OP Average D 1.5∆ N 27∆

  21. #1 CONCLUSION Pulley sutures inadequate as only Rx for huge conv Xs in CET

  22. #1 • BMR 4.5 • 3 mo: EX=0, ET’ 15 • 8 mo: EX/ EX’ =0 • Pulley sutures inadequate as only Rx for huge conv Xs in CET, but can add BMR as a 2ary procedure

  23. #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

  24. #2 • BMR 5mm with Pulley suture • 17 mo f/up: straight CONCLUSION : effective for variable ET

  25. #3 44190Very Variable Progressive ET • Age 11mo: few weeks of ET • Hip problems : full body brace • Variable ET  ped’n, ped neuro, … devpt’l delay : microcephalus, ‘mixed development disorder’

  26. #3 Surgery • BMR 5mm [for largest recent D ∆] + pulley sutures

  27. #3 postop • Week 3: i/mitt ET’ 15∆ • Straight with 2% pilo in office • Rx: phospholine - straight • 3mo: requires PI to be straight CONCLUSION: pulley suture effective for variable ET with marked conv Xs

  28. 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

  29. #438420Early onset variable initially intermittentn progressive ET with conv Xs 10/02 [age 26 mo]: 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

  30. #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

  31. #4 • Dec 06: BMR 4.5 with pulley sutures • 1w: cc XT 18, EX’ = 0. sc ET 14, ET’ 20 • 6mo: X4, X’6. Stereo 40” • 8mo: E4. EX’=0. Stereo 70” • CONCLUSION: pulley suture effective for marked convergence Xs

  32. #9 4yo 45858 • Intermittent ET from 15 mo. +6 DSOU from age 18mo • #1: cc EX=0, ET’ 35. sc ET 40. Given bifocal • #2: cc EX=0. ET’ upper 30, add 15. sc ET 50 • #3: cc EX=0. ET’ 25 / 12. Sc 65.

  33. #9 • Surgery: BMR 3.5mm + pulley suture • 9mo: EX/EX’ =0 with SVD • LESSON: • Effective for high AC/A

  34. #10. 46756Conv Xs • Age 5. R+2 DS, L +3-3. L amblyopia. • Last 3 preop measurements • ET cc 8, 14, 6 • ET’ cc 30, 35/20, 25 • BMR R [tighter] 3mm, L 4 mm with pulley sutures • 1mo: EX/EX’=0

  35. #11 46047Progressive conv Xs in a 3-4 yo • 3yo. • ET 16, ET’ 40 • CR +0.50 DS OU • Rx bifocal +0.50 / +3 add • Phoria E 10, E’ 25 • 4mo later: • ET 40, 45. ET’ 85.

  36. #11 46047 • BMR 6 with pulley sutures • 7mo: orthotropia D&N. BIFR 8 for D&N. 100” stereo • LESSON: • Effective for conv Xs

  37. #12 464519yo with conv Xs • ET onset ?4yo. Has been 140” • CR= pc = +3 DSOU • ET cc 40, sc 73 • ET’ 60/ 40 • BMR 6mm with pulley sutures • 1w followup: EX/EX’=0. 50” stereo

  38. #13 47501v. large ET with conv Xs and low + • 7yo. ET since 2.5. Wearing +1.5,add +1 • ET 45, sc 53 • ET’ 60/ 53 • V 18. IO ++, SO--, F extorsion BMR 6 + pulley sutures ATIO OU • 2mo: cc ET 12, ET’ 16. V=2. MR -1 OU.

  39. #13 47501 • 7yo. ET since 2.5. Wearing +1.5,add +1 • ET 45, ET’ 60/ 53 • P/op: cc ET 12, ET’ 16. MR -1 OU. • Conv Xs collapsed.

  40. #15 44405 • Age 5: +4, +2.75 add 6/9+ OU • EX=0, Near: 35/0. ET sc 45. Stereo 40” • Age 7: ET 18, ET’ 30/14. sc ET 50. • BMR 4 with pulley sutures • 2 mo: E / E’ 4,

  41. 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

  42. #5 45508Recurrent ET with conv Xs after previous BMR • 11 yo WCM • Mild R amblyopia 6/12, 6/6 • BMR age 3 • R +2-0.75*5, L +1.75-1.75*175

  43. #5 • 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

  44. #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

  45. #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.

  46. #6 • Surgery. LR Rs 4, pulley suture MR OU • M2: E7, E’5, 20” • CONCLUSION: PERSISTING CONV XS: EFFECTIVE

  47. 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 • 5. Adding PS for anticipated poor gls compliance n=1 • 6. Conv Xs in sensory ET n=1

  48. #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

  49. #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]

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