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 SEMINAL PAPER

fixation sutures: a revised mechanical explanation for the fadenoperation … .

R A. Clark, J L. Demer

Am J Ophth 1999 Posterior

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

Normal Adduction

PULLEY

A

MR insertion

Medial orbital wall B A, B : ant & post extent of pulley sleeve

If we want to impair Adduction without affecting primary position…

Scleral suture

after Demer

P Primary gaze

P = scleral suture

18 degrees ADd

MR insertion

A P Medial orbital wall B MR

PULLEY

A 18 º P B MR

Adduction restricted by P

A, B : ant & post extent of pulley sleeve

SCLERAL FADEN

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

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

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

Normal Adduction

PULLEY

A

MR insertion

Medial orbital wall B A, B : ant & post extent of pulley sleeve

If we want to impair Adduction without affecting primary position…

Diagrams of pulley suture

P Primary gaze

MR insertion

A P Medial orbital wall B MR LR

P = pulley suture

18 degrees ADd

PULLEY

A P B MR A, B : ant & post extent of pulley sleeve

•

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 •

13 pts : BMR



pulley sutures:

3 – only pulley suture 10 – BMR +pulley suture •

Postoperatively

: 6/9 – imroved stereoacuity 8/9 – no longer needed bifocals  D/N disparity av of 12∆ •

Postoperatively:

8/13 – improved stereoacuity 12/13 – no longer needed bifocals  D/N disparity av of 14∆

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.

2007 / 2008

• 2007: 7 patients • 2008: now 15 • 1 abandoned pulley surgery [scleral faden] • Longer follow up on many ‘07 patients

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

#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…..

0 0 0 25 0 0 0 [25] 0 0 PREOP ET 40 40 70 45 65 30 65 PREOP ET ‘ 65 80 60 60 73 60. Amblyopia Rx

Average D: 5∆, N: 57∆

ET #1

• Frequent L face turn • Rx: pulley sutures

ET 0 0 0 0 0 0 0

#1 POST OP

ET’ 30 - 45 30 0 -45 25 30 25 25

Average D 0∆ N 29∆

TIME p/op ET W1 W1 W2 M2 0 0 0 0 M2 M3 M4 M5 M6 0 0 0 0 15

#1 POST OP

25 25 25 35 30 ET’ 30 30 0-45 25

Average D 1.5∆ N 27∆

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

#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

#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 • 17 mo f/up: straight

CONCLUSION : effective for variable ET

#3

44190

Very 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’

DATE 11/05 11/05 12/05 1/06 2/06 4/06 5/06 8/06 12/06 1/07 2/07 ET Variable 40 I/mitt 0 I/mitt 0 [20] 0 20 30 ? 40 35 30 45 45 53 80!

ET’ Variable 40 I/mitt 50 I/mitt 35 [45]

#3 Surgery

•BMR 5mm [for largest recent D

∆]

pulley sutures +

#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

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

#4 38420 Early 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

#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 • 6mo: X4, X’6. Stereo 40” • 8mo: E4. EX’=0. Stereo 70” • CONCLUSION: pulley suture effective for marked convergence Xs

#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.

#9

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

#10.

46756

Conv 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

#11

46047

Progressive 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.

#11

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

#12

46451

9yo 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

#13 47501 v. 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.

#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.

#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,

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

#5 45508 Recurrent ET with conv Xs after previous BMR

• 11 yo WCM • Mild R amblyopia 6/12, 6/6 • BMR age 3 • R +2-0.75*5, L +1.75-1.75*175

#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

#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

• Surgery. LR Rs 4, pulley suture MR OU • M2: E7, E’5, 20”

•

CONCLUSION: PERSISTING CONV XS: EFFECTIVE

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

#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 25-30 º • • twice my notes indicate L face turn; usually to R MRI R/O Chiari: normal • • • Last 2 visits: I recognise this to be R fixation : R face turn L fixation: L face turn

typical LMLN

#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 < 10 º M3: face turns much better - Some regression to 20 º

CONCLUSION: some improvement

#8

47302 • Presents 15 mo. ET ‘since birth’ • pc +4 DS OU = CR • ET cc 25, sc 35 • Won’t wear his glasses • BMR 5mm for 35∆ • Add pulley suture for poor spectacle compliance • Follow up 18w: EX/ EX’=0 • Won’t wear glasses

#8

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

#14

41253

Sensory 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

#14

41253

Sensory 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 • 4mo:cosmetically straight D&N

FAILED PULLEY SUTURES

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

Pulley suture

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

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 req’d