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

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.