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 of mvmt

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

SCLERAL FADEN

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

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

CLARKE DEMER PAPERS

#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∆

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

#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 • 6 mo f/up: straight

CONCLUSION : effective for variable ET

#3

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

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, pulley sutures

#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

#4

38420 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

#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 • CONCLUSION: pulley suture effective for marked convergence Xs

#5

45508

• 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

#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

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