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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. - PowerPoint PPT Presentation
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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 R A. Clark, J L. Demer Posterior fixation sutures: a revised mechanical explanation for the fadenoperation …. Am J Ophth 1999
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
B
MR insertion
Medial orbital wall
A, B : ant & post extent of pulley sleeve
If we want toimpair Adductionwithout affecting primary position…
Scleral suture after Demer
MR insertion
A
B
MR
Medial orbital wall
MR
18º
A
B
PULLEY
A, B : ant & post extent of pulley sleeve
Primary gaze 18 degrees ADd
P
P = scleral suture
P
Adduction restricted by P
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
B
MR insertion
Medial orbital wall
A, B : ant & post extent of pulley sleeve
If we want toimpair Adductionwithout affecting primary position…
Diagrams of pulley suture
MR insertion
A
B
MRLR
Medial orbital wall
MR
A
B
PULLEY
A, B : ant & post extent of pulley sleeve
Primary gaze 18 degrees ADd
P
P = pulley suture
P
P
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∆
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.
2007 / 2008
2007: 7 patients 2008: now 15 1 abandoned PS [ scleral faden] Longer follow up on some ‘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 0-40, av 5. ET’ 40-73 av. 57 [12 visits] Frequent L face turn Rx: pulley sutures
#1 POST OP ET 0-15, av 1.5 ET’ 0-45, av 27 [n=9]…was 57! BMR 4.5 3 mo: EX=0, ET’ 15 8 mo: EX / EX’ = 0. LMLN with alternating face
turns Pulley sutures inadequate as only Rx
for huge conv Xs in CET, but can add BMR as a 2ary procedure.
Variable ET
2 further pts with variable ET BMR + PS effective Dose of BMR: 1. Recent D angle 2. Average D angle
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
Convergence XsET cc ET’cc ETsc BMR
doseF/up mo
Result
20 35 73 4.5 8 70”
0 25-35 40 3.5 9 straight
6-14 25-35 3.5 1 straight
40-45 85 6 7m 100”
Convergence Xs #2ETcc ET’cc ETsc BMR F/up
moResult
40 60 73 6 <1 50”
45 60 53 6 2 ET 12 ET’16
18 30 50 4 2 E/E’4
Convergence Xs
BMR + PS is a very convincing operation in this small series
Selection bias: V. lge ET’ [60,60,85] V. lge N>D [15,30,20,40+,20] Small D [0, 6-14]
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
Adding PS to previous BMR for persisting conv Xs
N=2 1 worked very well 1 didn’t work @ all
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: poor 5. Adding PS to BMR for ET with
anticipated poor gls compliance n=1: Great
6. Conv Xs in sensory ET n=1: poor
FAILED PULLEY SUTURES
#1 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
Promising for: Variable ET Conv Xs Where gls wear unlikely
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 - scleral faden has 50 y history. Does PS fall apart after x years?
Long term status of pulley vs scleral suture : clinical data and histology req’d