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
MR insertion
PULLEY
Medial
orbital
wall
A
B
If we want to
impair Adduction
without affecting
primary position…
A, B : ant & post extent of pulley sleeve
Scleral suture
Primary gaze
after Demer
18 degrees ADd
P = scleral suture
MR
insertion
A
P
PULLEY
A
18º
P
Medial
orbital
wall
B
B
MR
MR
A, B : ant & post extent of pulley sleeve
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
MR insertion
PULLEY
Medial
orbital
wall
A
B
If we want to
impair Adduction
without affecting
primary position…
A, B : ant & post extent of pulley sleeve
Diagrams of pulley suture
P
Primary gaze
P = pulley suture
18 degrees ADd
MR
insertion
A
PULLEY
P
A
P
Medial
orbital
wall
B
LR
MR
B
MR
A, B : ant & post extent of pulley sleeve
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 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.
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 Xs
ET cc
ET’cc
ETsc
BMR
dose
F/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
ETcc
ET’cc
ETsc
BMR
40
60
73
45
60
18
30
#2
F/up
mo
Result
6
<1
50”
53
6
2
ET 12
ET’16
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
