Medial Rectus Pulley Posterior Fixation Sutures Use in

Accommodative Esotropia with Convergence Excess Example: ET 35, ET' 55 Surgical undercorrections common Parks'

Rx of Very large amounts of Convergence Excess ET 15 ET’ 50 What surgical

Medial Rectus Pulley Suture Original MR insertion A P = muscle sutured to its

Medial Rectus Pulley Sutures in Accommodative Esotropia

Faden Sutures: a revised explanation for their effect Clark et al, AJO 1999 Primary

Pulley Sutures A Melbourne experience 24 children partially accommodative esotropia near-distance disparity ≥ 15∆

Pulley Sutures A Melbourne experience Surgery Bimedial recessions targeting average of near and distance

Pre-operative Characteristics Variable Mean Age at surgery (yrs) 5. 4 Distance esodeviation (∆) 22.

Post-operative Outcomes Post-op outcome Number Mean distance esodeviation (∆) Distance alignment between orthophoria and

Conclusion • Logical application of new understanding of orbital anatomy • Safe • Effective

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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 1. 2. Royal Victorian Eye and Ear Hospital, Melbourne Private Eye Clinic, Melbourne

Accommodative Esotropia with Convergence Excess Example: ET 35, ET' 55 Surgical undercorrections common Parks' formula: Kushner's formula: distance angle + 1 mm = 6. 0 mm distance angle + 10% of disparity = 7. 0 mm NB = operating for near angle etc. . .

Rx of Very large amounts of Convergence Excess ET 15 ET’ 50 What surgical dosage BMR? o BMR (even with augmented dose) unlikely to correct near and distance deviation

Medial Rectus Pulley Suture Original MR insertion A P = muscle sutured to its pulley. This now restricts full a. Dduction A P Medial orbital wall 18º P PULLE Y B MR A, B : ant & post extent of pulley sleeve

Medial Rectus Pulley Sutures in Accommodative Esotropia

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 Medial orbital wall B MR P prevents normal MR movement through MR pulley - Adduction restricted by P. . as well as its moment arm A, B : anteffect & post on extent of pulley sleeve B MR

Pulley Sutures A Melbourne experience 24 children partially accommodative esotropia near-distance disparity ≥ 15∆ >1 month follow-up

Pulley Sutures A Melbourne experience Surgery Bimedial recessions targeting average of near and distance deviations + pulley sutures +/- inferior oblique recession as needed

Pre-operative Characteristics Variable Mean Age at surgery (yrs) 5. 4 Distance esodeviation (∆) 22. 4 Near esodeviation (∆) 48. 8 Distance-near disparity (∆) 26. 8 Refraction (SE dioptres) 3. 0

Post-operative Outcomes Post-op outcome Number Mean distance esodeviation (∆) Distance alignment between orthophoria and 10 ∆ esotropia (%) Mean near-distance disparity (∆) Mean decrease in near-distance disparity (∆ (%)) 1 -3 months 3 -6 months 12+ months 24 12 9 -0. 8 1. 7 75 75 89 4. 8 2. 4 3. 6 22. 0 (79. 7%) 23. 5 (88. 0%) 21. 3 (87. 4%)

Effect on Near-Distance Disparity

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

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