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 PAPERR 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 PULLEY A B MR insertion Medial orbital wall A, B : ant & post extent of pulley sleeve If we want to impair Adduction without affecting primary position…

6. Scleral suture after Demer MR insertion A B MR Medial orbital wall MR 18 º A B PULLEY A, B : ant & post extent of pulley sleeve Primary gaze 18 degrees ADd P P = scleral suture P P Adduction restricted by P

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 PULLEY A B MR insertion Medial orbital wall A, B : ant & post extent of pulley sleeve If we want to impair Adduction without affecting primary position…

11. Diagrams of pulley suture MR insertion A B MR LR 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

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 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.

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 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

16. #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…..

17. PREOP ETPREOP ET ‘ 4065 80 060 0 073 2560. Amblyopia Rx 040 070 045 [25]65 030 065 Average D: 5∆, N: 57∆

18. ET #1 Frequent L face turn Rx: pulley sutures

19. #1 POST OP ETET’ 030 - 45 030 00 -45 025 030 025 0 Average D 0∆ N 29∆

20. #1 POST OP Average D 1.5∆ N 27∆ TIME p/opETET’ W1030 W1030 W200-45 M2025 M2025 M3025 M4025 M5035 M61530

21. #1 CONCLUSION Pulley sutures inadequate as only Rx for huge conv Xs in CET

22. #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

23. #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

24. #2 BMR 5mm with Pulley suture 17 mo f/up: straight CONCLUSION : effective for variable ET

25. #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’

26. DATEETET’ 11/05Variable 40 11/05I/mitt 12/05050 1/06I/mitt 2/06035 4/06[20][45] 5/06030 8/062045 12/063045 1/07? 4053 2/073580!

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 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

30. #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

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, X’6. Stereo 40” 8mo: E4. EX’=0. 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 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.

34. #9 Surgery: BMR 3.5mm + pulley suture 9mo: EX/EX’ =0 with SVD LESSON: Effective for high AC/A

35. #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

36. #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.

37. #11 46047 BMR 6 with pulley sutures 7mo: orthotropia D&N. BIFR 8 for D&N. 100” stereo LESSON: Effective for conv Xs

38. #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

39. #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.

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 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,

42. 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

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 +2-0.75*5, L +1.75-1.75*175

44. #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

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: 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.

47. #6 Surgery. LR Rs 4, pulley suture MR OU M2: E7, E’5, 20” CONCLUSION: PERSISTING CONV XS: EFFECTIVE

48. 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

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 < 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 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

54. #8 LESSON: Pulley suture may lessen tendency to recur in the face of continuing esotropogenic factors [uncorrected hyperopia]

55. #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

56. #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

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 req’d