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Medial rectus pulley posterior fixation: A novel technique to augment recession

Presented at the American Association for Pediatric Ophthalmology and Strabismus, March 31, 2004, in Washington, DC.
https://doi.org/10.1016/j.jaapos.2004.07.008Get rights and content

Purpose:Medial rectus (MR) pulley posterior fixation, a technique of suturing the pulley to its muscle without scleral sutures, may be as effective as traditional scleral posterior fixation in primary treatment of acquired esotropia (ET) with a high AC/A ratio. This study examines the effectiveness of MR pulley posterior fixation for other variants of ET. Methods:We retrospectively analyzed the pre- and postoperative alignment of 16 patients: 9 previously operated patients with excess near ET, 4 patients with sensory ET with excess near ET, and 3 patients with large-angle infantile ET. Surgeries involved extraocular muscle recessions and resections in standard doses combined with MR pulley posterior fixation. Results:All 9 reoperated patients were between 0 and 10 prism diopters of distance ET postoperatively. The excess near ET decreased from an average of 12.1 prism diopters preoperatively (range 6–20) to 1.3 prism diopters postoperatively (range, 0–4). Two of the 4 patients with sensory ET were overcorrected at distance (exotropia of 10 and 15 prism diopters, respectively). The excess near ET of these 4 patients decreased from an average of 13.5 prism diopters preoperatively (range, 10–20) to 2.5 prism diopters postoperatively (range, 0–8). In patients with large-angle infantile ET, the addition of pulley posterior fixation resulted in a greater effect than would be predicted for standard MR recessions, particularly at near. Pooling data for all groups, pulley posterior fixation was associated with a highly significant reduction of excess near esotropia postoperatively (P < 0.00001). Discussion:MR pulley posterior fixation augments MR recession with relatively greater effect at near. Surgical dosage for unilateral recessions and resections combined with MR pulley posterior fixation should be reduced in patients with poor potential for postoperative fusion.

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Subjects and methods

After obtaining approval from the Institutional Review Boards at the Southern California Permanente Medical Group and the University of California, Los Angeles, a retrospective chart review was conducted to identify all patients operated by one of us (R.A.C.), who carried the following diagnoses: recurrent ET with excess near ET after prior bilateral MR recessions, primary unilateral surgery in patients with sensory ET with excess near ET, or primary bilateral MR recessions coupled with pulley

Results

We analyzed a total of 16 patients: 9 previously operated patients with excess near ET, 4 patients with sensory ET with excess near ET, and 3 patients with large-angle infantile ET. The results for the 9 patients with recurrent ET with excess near ET after prior bilateral MR recessions are summarized in Table 1. All of the patients had esotropia originally, either acquired or infantile, and underwent bilateral MR recessions as their primary surgery. Some of the patients had undergone subsequent

Discussion

This study supports previous work by demonstrating that MR pulley posterior fixation reduces MR force during convergence, decreasing excess near ET.8 In each study group, we observed a postoperative reduction in excess near ET averaging more than 10 prism diopters, consistent with the effect found in primary MR pulley posterior fixation for acquired esotropia with a high AC/A ratio.8 Given the small numbers in each group, comparative statistics between groups are not meaningful. A further

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Cited by (22)

  • Comparison between medial rectus pulley fixation and augmented recession in children with convergence excess and variable-angle infantile esotropia

    2016, Journal of AAPOS
    Citation Excerpt :

    In the pulley group, surgeries were performed via a limbal approach, and MR muscle recession was performed with the surgical dose targeting the smallest preoperative angle; in cases where the smallest angle was 0, a bilateral 3 mm recession was performed. The muscle was then fixated to its pulley as described.12,13 Patients were examined at 1 week, 1 month, 3 months, and 6 months after surgery.

  • Bilateral lateral rectus muscle recession with medial rectus pulley fixation for divergence excess intermittent exotropia with high AC/A ratio

    2013, Journal of AAPOS
    Citation Excerpt :

    This novel technique was effective in augmenting medial rectus recession that is relatively greater at near fixation and successfully provided long-term mechanical restriction to medial rectus contraction that increases when the eye is rotated farther into adduction.6,10 They also reported that pulley posterior fixation was safer than conventional posterior fixation suture.5,6 In our experience, medial rectus pulley fixation was safer than the classic posterior scleral fixation because the pulley posterior fixation suture was not anchored to the sclera and thus there was no risk of scleral perforation.

  • New strabismus surgical techniques

    2013, Journal of AAPOS
    Citation Excerpt :

    If not, the pulley suture may need to be replaced through deeper connective tissue or more posteriorly on the muscle belly. All published studies to date have focused on pulley posterior fixation of the medial rectus muscles, either to augment a maximal recession or to treat a high accommodative convergence/accommodation ratio in esotropia.3-6 Each study has shown equivalent effects compared with either concurrent or historical results from scleral posterior fixation.

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Supported by U.S. Public Health Service, National Eye Institute: grant EY-08313 and core grant EY-00331. Joseph Demer received an unrestricted award from Research to Prevent Blindness and is David and Laraine Gerber Professor of Ophthalmology.

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