THE MEDIAL RECTUS PULLEY SUTURE : PRELIMINARY EXPERIENCE

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
B
Medial orbital wall
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 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
MR insertion
A
PULLEY
If we want to impair Adduction without affecting
primary position
B
Medial orbital wall
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
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
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 n3
• 2. Convergence Xs n7
• 3. Adding PS to previous BMR n2
• 4. Adding PS for anticipated poor gls compliance
  n1
• 5. PS for face turn of LMLN n1
• 6. Conv Xs in sensory ET n1

16
1 44681

• CET onset 6mo. Presents _at_ 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
PREOP ET PREOP ET
40 65
80
0 60
0 60
0 73
25 60. Amblyopia Rx
0 40
0 70
0 45
25 65
0 30
0 65

• Average
• D 5?,
• N 57?

18
ET 1

• Frequent L face turn
• Rx pulley sutures

19
1 POST OP
ET ET
0 30 - 45
0 30
0 0 -45
0 25
0 30
0 25
0 25
Average D 0? N 29?
20
1 POST OP
TIME p/op ET ET
W1 0 30
W1 0 30
W2 0 0-45
M2 0 25
M2 0 25
M3 0 25
M4 0 25
M5 0 35
M6 15 30
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 EX0, 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 3525 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 ? pedn, ped neuro, devptl delay
  microcephalus, mixed development disorder

26
DATE ET ET
11/05 Variable 40 Variable 40
11/05 I/mitt I/mitt
12/05 0 50
1/06 I/mitt I/mitt
2/06 0 35
4/06 20 45
5/06 0 30
8/06 20 45
12/06 30 45
1/07 ? 40 53
2/07 35 80!
27
3 Surgery

• BMR 5mm for largest recent D ? pulley sutures

28
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

29
Types of patients for PS

• 2. Convergence Xs n7
• 1. Variable ET n3
• 3. Adding PS to previous BMR n2
• 4. Adding PS for anticipated poor gls compliance
  n1
• 5. PS for face turn of LMLN n1
• 6. Conv Xs in sensory ET n1

30
4 38420Early 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

31
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

32
4

• Dec 06 BMR 4.5 with pulley sutures
• 1w cc XT 18, EX 0. sc ET 14, ET 20
• 6mo X4, X6. Stereo 40
• 8mo E4. EX0. Stereo 70
• CONCLUSION pulley suture effective for marked
  convergence Xs

33
9 4yo 45858

• Intermittent ET from 15 mo. 6 DSOU from age 18mo
• 1 cc EX0, ET 35. sc ET 40.
• Given bifocal
• 2 cc EX0. ET upper 30, add 15. sc ET 50
• 3 cc EX0. ET 25 / 12. Sc 65.

34
9

• Surgery BMR 3.5mm pulley suture
• 9mo EX/EX 0 with SVD
• LESSON
• Effective for high AC/A

35
10. 46756Conv Xs

• Age 5. R2 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/EX0

36
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.

37
11 46047

• BMR 6 with pulley sutures
• 7mo orthotropia DN. BIFR 8 for DN. 100 stereo
• LESSON
• Effective for conv Xs

38
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/EX0. 50 stereo

39
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. V2. MR -1 OU.

40
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.

41
15 44405

• Age 5 4, 2.75 add 6/9 OU
• EX0, 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,

42
Types of patients for PS

• 1. Convergence Xs n7
• 2. Variable ET n3
• 3. Adding PS to previous BMR n2
• 4. Adding PS for anticipated poor gls compliance
  n1
• 5. PS for face turn of LMLN n1
• 6. Conv Xs in sensory ET n1

43
5 45508 Recurrent ET with conv Xs after
previous BMR

• 11 yo WCM
• Mild R amblyopia 6/12, 6/6
• BMR age 3
• R 2-0.755, L 1.75-1.75175

44
5

• cc ET 20, ET 30 sc 35 / 40
• 12/06 RLR Rs 6, RMR pulley
• 2/07 EX0, ET 25 sc 20/ gtgt20.
• CONCLUSION Little / no effect from pulley suture

45
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

46
6

• D3 EX 0, ET 25
• W4 EX0, ET 20
• Given full manifest 0.5, 2. Then 3 add
  straight DN 80 stereo
• M6 ET 16, ET 40. Add EX0, 100.
• M7 ET 18, ET 30.

47
6

• Surgery. LR Rs 4, pulley suture MR OU
• M2 E7, E5, 20
• CONCLUSION PERSISTING CONV XS EFFECTIVE

48
Types of patients for PS

• 1. Convergence Xs n7
• 2. Variable ET n3
• 3. Adding PS to previous BMR n2
• 4. PS for face turn of LMLN n1
• 5. Adding PS for anticipated poor gls compliance
  n1
• 6. Conv Xs in sensory ET n1

49
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

50
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

51
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

52
7 SYNTHESIS

• 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 lt 10º
• M3 face turns much better - Some regression to
  20º
• CONCLUSION
• some improvement

53
8 47302

• Presents 15 mo. ET since birth
• pc 4 DS OU CR
• ET cc 25, sc 35
• Wont wear his glasses
• BMR 5mm for 35?
• Add pulley suture for poor spectacle compliance
• Follow up 18w EX/ EX0
• Wont wear glasses

54
8

• LESSON
• Pulley suture may lessen tendency to recur in the
  face of continuing esotropogenic factors
  uncorrected hyperopia

55
14 41253Sensory ET with conv Xs

• PHPV. Multiple opinions. Surgery delayed until
  9mo.
• Poor visual outcome despite good compliance with
  refractive and amblyopia Rx
• CR other eye low
• 7mo 2-1

56
14 41253Sensory ET with conv Xs

• ET noted by me age 12 mo, by mother 14 mo
• Age 2 constant 30-40, more for N
• Axial length 24.4
• LMR Rc 5 with pulley suture
• LLR resect 7
• 4mocosmetically straight DN

57
FAILED PULLEY SUTURES

• 1 44586 after previous RMR Rs. Used scleral
  Faden good result

58
Pulley suture

• 15 pts with variable ET or marked conv XS
• More difficult than scleral faden
• No long term outcomes

59
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 - does it fall apart after x
  years?
• Long term status of pulley vs scleral suture
  clinical data and histology reqd