1. Medial Rectus Pulley (Posterior Fixation) Sutures
- Use in partially accommodative esotropia with convergence excess
Logan Mitchell1, Lloyd Bender1,
Avinash Mahindrakar1, Elaine Wong1,
Elina Landa1, Lionel Kowal1,2
Royal Victorian Eye and Ear Hospital, Melbourne
Private Eye Clinic, Melbourne

2. Accommodative Esotropia with Convergence Excess
Example: ET 35, ET' 55
Surgical undercorrections common
Parks' formula:
distance angle + 1 mm = 6.0 mm
Kushner's formula:
distance angle + 10% of disparity = 7.0 mm
NB = operating for near angle
etc...

3. Rx of Very large amounts of Convergence Excess
ET 15 ET’ 50
What surgical dosage BMR?
BMR (even with augmented dose) unlikely to correct near and distance deviation

4. Medial Rectus Pulley Suture
P = muscle sutured
to its pulley.
This now
restricts full aDduction
Original MR insertion A A P
18º P
PULLEY B
Medial orbital wall B MR MR
A, B : ant & post extent of pulley sleeve

5. Medial Rectus Pulley Sutures in Accommodative Esotropia

6. Faden Sutures: a revised explanation for their effect
Clark et al, AJO 1999
Primary gaze
18 degrees ADd
Original MR insertion A A
18º P P
PULLEY B B
Medial orbital wall
P prevents normal MR movement through MR pulley - Adduction
restricted
by P ..as well as its effect on moment arm MR MR
A, B : ant & post extent of pulley sleeve

7. Pulley Sutures - A Melbourne experience
24 children
partially accommodative esotropia
near-distance disparity ≥15∆
>1 month follow-up

8. Pulley Sutures - A Melbourne experience
Surgery
Bimedial recessions targeting average of near and distance deviations
+ pulley sutures
+/- inferior oblique recession as needed

9. Pre-operative Characteristics
Variable
Mean
Age at surgery
(yrs)
5.4
Distance esodeviation (∆)
22.4
Near esodeviation
(∆)
48.8
Distance-near disparity (∆)
26.8
Refraction
(SE dioptres)
3.0

10. Post-operative Outcomes
Post-op outcome
1-3 months
3-6 months
12+ months
Number 24 12 9
Mean distance esodeviation (∆)
-0.8
0.8
1.7
Distance alignment between orthophoria and 10 ∆ esotropia (%) 75 89
Mean near-distance disparity (∆)
4.8
2.4
3.6
Mean decrease in near-distance disparity (∆ (%))
22.0 (79.7%)
23.5 (88.0%)
21.3 (87.4%)

11. Effect on Near-Distance Disparity

12. Conclusion Logical application of new understanding of orbital anatomy
Safe
Effective at decreasing near excess
Very low risk persistent over-correction
A technique to be considered in difficult cases

13. Thank you