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THE MEDIAL RECTUS PULLEY SUTURE : PRELIMINARY EXPERIENCE

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 .

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THE MEDIAL RECTUS PULLEY SUTURE : PRELIMINARY EXPERIENCE

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  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 of mvmt

  4. 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

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

  6. 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

  7. CLARKE DEMER PAPERS

  8. #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…..

  9. Average D: 5∆, N: 57∆

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

  11. #1 POST OP Average D 0∆ N 29∆

  12. #1 CONCLUSION Pulley sutures inadequate as only Rx for huge conv Xs in CET

  13. #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

  14. #2 • BMR 5mm with Pulley suture • 6 mo f/up: straight CONCLUSION : effective for variable ET

  15. #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

  16. #3 • Surgery • BMR 5mm, pulley sutures

  17. #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

  18. #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

  19. #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

  20. #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

  21. #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

  22. #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

  23. #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

  24. #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.

  25. #6 • Surgery. LR Rs 4, pulley suture MR OU • M2: E7, E’5, 20” • CONCLUSION: PERSISTING CONV XS: EFFECTIVE

  26. #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

  27. #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]

  28. #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

  29. #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

  30. 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

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