Posterior fixation sutures: a revised mechanical explanation for the fadenoperation based on rectus extraocular muscle pulleys

doi:10.1016/S0002-9394(99)00356-6

American Journal of Ophthalmology

Volume 128, Issue 6, December 1999, Pages 702-714

https://doi.org/10.1016/S0002-9394(99)00356-6 Get rights and content

Abstract

PURPOSE: To determine the effect of the rectus extraocular muscle pulleys on the fadenoperation, an operation designed to fixate the posterior muscle belly to the underlying retroequatorial sclera.

METHODS: First, duction into the field of action of the operated-on muscle was quantified retrospectively after fadenoperation. Magnetic resonance imaging was then performed prospectively after surgery to verify anatomic changes. Forced duction testing was performed prospectively during surgery before and after faden placement. Finally, computed tomography in a cadaver containing radiographic markers was performed prospectively to determine the effect of fadenoperation on the position of the medial rectus insertion relative to its pulley.

RESULTS: Mean maximum adduction after medial rectus fadenoperation was 18 degrees (range, 10 to 25 degrees; 13 eyes). Fadenoperations combined with large medial rectus recessions restricted adduction more than fadenoperations combined with smaller recessions (P = .019), but even fadenoperations without recessions substantially restricted adduction. Mean maximum abduction after lateral rectus fadenoperation was 40 degrees (range, 25 to 45 degrees; four eyes). Axial magnetic resonance imaging in two eyes demonstrated a smaller loss of muscle tangency to the globe during contraction than predicted by geometric models. Forced ductions in nine patients performed immediately after faden placement demonstrated a new mechanical restriction to duction toward the operated-on muscle. Cadaveric computed tomographic scans demonstrated posterior displacement of the medial rectus pulley during adduction after fadenoperation.

CONCLUSIONS: Posterior fixation sutures do not significantly decrease muscle torque during contraction. Because posterior fixation sutures posteriorly displace the pulley sleeve during duction toward the operated-on muscle, the mechanical restriction after surgery probably represents the force deforming the pulley. This mechanical restriction may account for the limitation in duction seen after fadenoperation.

Section snippets

Subjects and methods

A retrospective analysis of surgical procedures identified patients with posterior fixation sutures placed in one or both eyes. Some of these patients had versions quantified at least 6 weeks postoperatively by means of the lateral version light-reflex test17 by an examiner unaware that the data would be used for a study. The lateral version light-reflex test uses the reflex from a 25-cm-distant light centered between the eyes to quantify ocular duction into extremes of gaze by means of a

Results

Maximum ductions were recorded by lateral version light-reflex test at least 6 weeks postoperatively in 17 muscles of 10 patients, comprising 13 medial rectus and four lateral rectus muscles. Preoperative measurements available in 10 eyes equaled or exceeded published values for the normal maximum version for the operated-on muscles.17 Clinical characteristics of these patients and their maximum ductions are summarized in Table 1. In patients with Duane syndrome, the posterior fixation suture

Discussion

An important finding of this study is the demonstration by axial magnetic resonance imaging that significant change in extraocular muscle tangency with the globe does not occur after posterior fixation of an extraocular muscle. The angular displacement from tangency, and thus the change in torque, is much less than would be predicted from geometry. Two factors contribute to maintain the contracting extraocular muscle close to tangency to the globe. First, contraction of the extraocular muscle

Acknowledgements

We thank Floyd J. Chiffer, Pharmacia & Upjohn, Simi Valley, California, for donating Healon used for the cadaveric portion of this study.

References (23)

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Cited by (72)

Treatment of partially accommodative esotropia in children using a medial rectus muscle fenestration technique
2022, Journal of AAPOS
To report the results of bilateral fenestration of the medial rectus muscle in cases of partially accommodative esotropia in pediatric patients.
In this fenestration technique, two splitting incisions are made by blunt dissection parallel to the muscle fibers on the superior and inferior borders of the medial rectus muscle, leaving a thin strip of muscle fibers on each edge. The wide, central part of the muscle is excised from its insertion to a point 5–8 mm from the insertion, depending on the angle of the esotropia. Sutures are not used in this procedure. Children with partially accommodative esotropia and no high ratio of accommodative convergence to accommodation who underwent surgery from February 2018 to August 2019 were prospectively enrolled. The success rate was defined as alignment within 8 prism diopters of orthotropia at the last follow up.
A total of 61 children were included. The procedure was well tolerated by patients and reduced the angle of esotropia for distance from 22.20^Δ ± 4.22^Δ to 2.72^Δ ± 4.71^Δ (P < 0.001) and caused no incomitance or distance-near disparity. Satisfactory horizontal alignment defined as alignment within 8^Δ of orthotropia at distance was achieved in 88% of the cases at 3-6 months’ follow-up. There were no overcorrections.
In our study cohort, the fenestration technique reduced the angle of deviation in cases of partially accommodative esotropia.
Magnetic Resonance Imaging of the Globe-Tendon Interface for Extraocular Muscles: Is There an “Arc of Contact”?
2018, American Journal of Ophthalmology
Citation Excerpt :
Fourteen strabismic subjects (6 male and 8 female) aged 19-75 (average 48.6 years) were recruited as part of an ongoing prospective imaging study: 7 subjects with chronic unilateral LR palsy, 5 subjects with horizontal strabismus status post horizontal strabismus surgery, and 2 subjects following posterior fixation suture placement. Imaging for the 2 subjects with posterior fixation sutures has been previously reported using different analytical techniques as part of a study on the mechanics of posterior fixation surgery.7 In both cases, posterior fixation was performed using interrupted permanent sutures placed through the sclera and adjacent superior and inferior poles of the operated rectus muscle far posterior to the muscle's insertion to shift the muscle's functional position of globe tangency to the location of the sutures instead of its tendinous insertion onto the globe.7
To determine if the “arc of contact” is an accurate approximation of the globe-tendon interface for the biomechanical modeling of extraocular muscle (EOM) force transfer onto the globe.
At a single academic institution, 18 normal and 14 strabismic subjects were prospectively recruited for surface-coil enhanced magnetic resonance imaging at 312- or 390-μm resolution in axial planes for horizontal EOMs (23 subjects, 26 orbits) and sagittal planes for vertical EOMs (13 subjects, 22 orbits) during large ipsiversive ductions. The measured angle at insertion and the predicted angle assuming an “arc of contact” were compared using paired t tests.
For normal EOMs, the measured angle at insertion was significantly greater than predicted assuming an “arc of contact” for the medial rectus (MR) (5.0 ± 4.8 degrees vs 0.0 ± 0.0 degrees, P = .03), lateral rectus (LR) (4.9 ± 3.0 degrees vs 0.0 ± 0.0 degrees, P = .02), inferior rectus (7.4 ± 4.8 degrees vs 1.2 ± 2.6 degrees, P = .00003), and superior rectus (0.6 ± 1.1 degrees vs 0.0 ± 0.0 degrees, P = .04). In strabismic subjects, the measured angle was significantly greater for the MR in abducens palsy (9.9 ± 4.3 degrees vs 0.5 ± 0.7 degrees, P = .0007) and after MR resection (9.0 ± 6.9 degrees vs 1.2 ± 2.4 degrees, P = .02), but not after LR recession (2.9 vs 0.0 degrees). Single subjects had comparable angles after MR recession, but markedly different angles after MR and LR posterior fixation.
Contrary to the “arc of contact” biomechanical model, normal and postsurgical EOMs are significantly non-tangent to the globe at their scleral insertions. The “arc of contact” should be replaced in biomechanical modeling by the experimentally measured angles at tendon insertions.
NOTE: Publication of this article is sponsored by the American Ophthalmological Society.
Results of combined resection-recession on a single rectus muscle for incomitant deviations—an alternative to the posterior fixation suture
2017, Journal of AAPOS
To compare outcomes of combined resection and recession on previously unoperated single horizontal or vertical rectus muscles in consecutive adult patients with acquired incomitant deviations minimal in primary gaze and maximal in an eccentric gaze position.
The surgical goal was to decrease the incomitance by 50%, expand the field of binocular single vision, and relieve diplopia. Recessions for the maximal deviations were combined with smaller resections using hang-back, nonadjustable sutures. Pre- and postoperative incomitance was compared using the paired t test.
A total of 16 adults were studied (mean age at surgery, 49.3 ± 17.5 years), 12 with incomitant vertical deviations and 4 with incomitant horizontal deviations. Eight patients had preoperative deviations of <2^Δ in primary gaze (mean, 9.2^Δ ± 10.5^Δ; range, 1^Δ-35^Δ). The mean maximum eccentric gaze deviation was 21.4^Δ ± 9.9^Δ (range, 10^Δ-48^Δ). Postoperatively, 12 patients (75%) had a decrease in incomitance of >50%, and all had expansion of the field of binocular single vision. Improvement in postoperative incomitance was highly statistically significant in the vertical incomitant group (P < 0.0001) but not statistically significant in the horizontal group (P = 0.39). The technique corrected downgaze deviations in 4 patients with canine tooth syndrome (93% ± 3.3, P < 0.0001) without worsening the hypotropia in upgaze.
Combined resection-recession single muscle surgery significantly reduces incomitance with minimal effect on primary gaze. It is most effective for treating vertical deviations worse on downgaze with primary gaze deviations of <2^Δ and for canine tooth syndrome; the technique was less successful in reducing horizontal incomitance and in cases involving gaze palsies and nystagmus.
Medial rectus pulley posterior fixation for esotropia with a high AC/A ratio
2017, Journal of AAPOS
Long-term efficacy of Fadenoperation associated to conventional surgery in the treatment of esotropia with distance-near incomitance: About 55 cases
2015, Journal Francais d'Ophtalmologie
L’objectif principal de cette étude est d’évaluer l’efficacité, à court, moyen et long termes, de la Fadenoperation associée à une chirurgie conventionnelle sur le contrôle du strabisme dans le cas d’une ésotropie avec incomitance loin-près.
C’est une étude rétrospective incluant les patients présentant une ésotropie partiellement et non accommodative accompagnée d’une incomitance loin-près et ayant subi une Fadenoperation associée à une chirurgie conventionnelle. Les valeurs angulaires de loin, de près ainsi que de l’incomitance loin-près ont été évaluées en préopératoires et postopératoires à 1, 6 et 12 ans. Un succès chirurgical a été défini par un angle de loin et une incomitance loin-près postopératoire inférieurs à 10 dioptries prismatiques (DP).
Au total, 55 patients ont été inclus. En préopératoire, les moyennes de l’angle de loin, de près et de l’incomitance loin-près étaient de 15,9 (±3,4), 29,7 (±5,8) et 13,8 (±3,1) DP, respectivement. En postopératoire, l’angle moyen de loin était de 1,6 (±0,8) DP (p < 0,001) à 1 an, de 2,8 (±1,6) DP (p < 0,005) à 6 ans et de 5,6 (±2,4) DP (p < 0,05) à 12 ans. L’angle moyen de près était de 7,8 (±2,3) DP (p < 0,001) à 1 an, de 10,5 (±3,7) DP (p < 0,005) à 6 ans et de 15,2 (±4,4) DP (p < 0,05) à 12 ans. L’incomitance moyenne loin-près était de 5,2 (±1,8) DP (p < 0,01) à 1 an, de 7,7 (±2,8) DP (p < 0,05) à 6 ans et de 9,6 (±3,2) DP (p > 0,05) à 12 ans. Le taux de succès était de 91, 78 et 58 % à 1, 6 et 12 ans, respectivement.
L’incomitance loin-près est une source d’amblyopie et exige un traitement lors de la prise en charge d’une ésotropie. Cette étude confirme l’efficacité de la Fadenoperation associée à une chirurgie conventionnelle dans la prise en charge, à court et moyen termes, de ce problème. Elle semble montrer aussi la perte progressive, quoique partielle, de cette efficacité à long terme.
The purpose of this study is to evaluate the short-, medium- and long-term efficacy of posterior fixation sutures with conventional surgery in controlling strabismus in the case of esotropia with distance-near incomitance.
This is a retrospective study of consecutive patients with partially accommodative and non-accommodative esotropia associated with distance-near incomitance who underwent posterior fixation sutures along with conventional surgery. The preoperative and postoperative distance and near deviation measurements and the distance-near incomitance were evaluated at 1, 6 and 12 years. Surgical success was defined as a postoperative distance angle and a distance-near incomitance less than 10 prism diopters (PD).
In total, 55 patients were included. Preoperatively, the mean distance deviation, near deviation and distance-near incomitance were 15.9 (±3.4), 29.7 (±5.8) and 13.8 (±3.1) PD, respectively. Postoperatively, the mean distance deviation was 1.6 (±0.8) PD (P < 0.001) at 1 year, 2.8 (±1.6) PD (P < 0.005) at 6 years and 5.6 (±2.4) PD (P < 0.05) at 12 years. The mean near deviation was 7.8 (±2.3) PD (P < 0.001) at 1 year, 10.5 (±3.7) PD (P < 0.005) at 6 years and 15.2 (±4.4) PD (P < 0.05) at 12 years. The mean distance-near incomitance was 5.2 (±1.8) PD (P < 0.01) at 1 year, 7.7 (±2.8) PD (P < 0.05) at 6 years and 9.6 (±3.2) PD (P > 0.05) at 12 years. The success rate was 91, 78 and 58% at 1, 6 and 12 years, respectively.
Distance-near incomitance is a source of amblyopia. It needs to be corrected while treating an esotropia. This study seems to confirm the short- and medium-term efficacy of posterior fixation sutures along with conventional surgery in the treatment of this problem. It also seems to show progressive, albeit partial, loss of its long-term efficacy.
Retro ecuatorial mioescleropexia combined with bimedial reccesion for the treatment of large angle esotropia: Experience with 36 cases
2015, Revista Mexicana de Oftalmologia
La mioescleropexia retroecuatorial (operación de faden) fue descrita por Cüppers en 1974. En nuestro centro este procedimiento se ha utilizado en combinación con retroimplante de músculos rectos medios para el tratamiento de esotropías con ángulos mayores a 50 dioptrías. El objetivo del presente trabajo es determinar el porcentaje de corrección obtenido al utilizar esta modalidad quirúrgica.
Se realizó un estudio retrospectivo, descriptivo, observacional en 36 pacientes con esotropía de ángulo grande (mayor a 50 dioptrías prismáticas), tratados con retroimplante de rectos medios combinado con mioescleropexia retroecuatorial. Se recabó los siguientes datos: edad, diagnóstico, ángulo de desviación preoperatoria, tipo de procedimiento efectuado según la cantidad de desviación, ángulo de desviación en el postoperatorio inmediato y realización de segundo procedimiento.
Se analizaron 36 casos, 18 de género masculino y 18 femenino. La edad media fue de 17.6 años. El promedio de desviación preoperatoria fue de 68.05 dioptrías prismáticas (rango 55-95). El porcentaje promedio de corrección postoperatoria fue del 80.57% (64.20-96.94). Del total de pacientes un 11.1% fueron sometidos a un segundo procedimiento.
The retro ecuatorial mioescleropexia (faden operation) was described by Cüppers in 1974. In our center this procedure has been used in combination with medial rectus recession for the treatment of esotropia greater than 50 prism diopters. The aim of this study is to determine the percentage of correction obtained by using this surgical modality.
We conducted a retrospective, descriptive, observational study in 36 patients with large angle esotropia (greater than 50 prism diopters), treated with medial rectus recession combined with retro ecuatorial mioescleropexia. The following data were collected: age, diagnosis, preoperative deviation angle, type of procedure performed according to the amount of deviation, deviation angle in the immediate postoperative period, performing second procedure.
We analyzed 36 cases, 18 male and 18 female. The average age was 17.6 years. The mean preoperative deviation was 68.05 prism diopters (range 55-95). The average postoperative correction was 80.57% (64.20-96.94). Of the total 11.1% patients underwent a second procedure.

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^☆: This study was supported by grants from the Heed Ophthalmic Foundation, Cleveland, Ohio; the American Ophthalmological Society–Knapp Fund, Cleveland, Ohio; the Bank of America–Giannini Foundation, San Francisco, California; and grant EY-08313 from the National Eye Institute, Bethesda, Maryland.

¹: Dr Clark is a Rosalind W. Alcott Fellow, a Heed Fellow, an American Ophthalmological Society–Knapp Fellow, and a Giannini–Bank of America Fellow.

²: Dr Demer is the recipient of a Lew R. Wasserman Merit Award from Research to Prevent Blindness, Inc, New York, New York, and is Larraine and David Gerber Professor of Ophthalmology.

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Original ArticlesPosterior fixation sutures: a revised mechanical explanation for the fadenoperation based on rectus extraocular muscle pulleys☆

Abstract

Section snippets

Subjects and methods

Results

Discussion

Acknowledgements

The so-called “fadenoperation” (surgical considerations by well-defined changes of the arc of contact)

The faden operationmechanical effects

Am Orthopt J

Constant or apparently constant congenital esotropia? A survey of 304 fadenoperations

Int Ophthalmol

An alternative approach to marginal myotomy

Am J Ophthalmol

The posterior fixation suturemechanism and indications

Int Ophthalmol Clin

Faden operation (posterior fixation sutures)

Eye

Evaluation of the posterior fixation suture plus recession operation with saccadic velocities

J Pediatr Ophthalmol Strabismus

Analysis of dosage controversy in recess-resect and Faden surgery with the Robinson Computer Model of eye movements

Doc Ophthalmol

Evidence for fibromuscular pulleys of the recti extraocular muscles

Invest Ophthalmol Vis Sci

Innervation of extraocular pulley smooth muscle in monkeys and humans

Invest Ophthalmol Vis Sci

New insights in the human orbital connective tissueresult of a new anatomical approach

Arch Ophthalmol

Original Articles
Posterior fixation sutures: a revised mechanical explanation for the fadenoperation based on rectus extraocular muscle pulleys☆