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Medial Rectus Pulley (Posterior Fixation) Sutures

Medial Rectus Pulley (Posterior Fixation) Sutures. - Use in partially accommodative esotropia with convergence excess. Logan Mitchell 1 , Lloyd Bender 1 , Avinash Mahindrakar 1 , Elaine Wong 1 , Elina Landa 1 , Lionel Kowal 1,2 Royal Victorian Eye and Ear Hospital, Melbourne

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Medial Rectus Pulley (Posterior Fixation) Sutures

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  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 ofVerylarge 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

  10. Post-operative Outcomes

  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

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