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The Posterior Fixation Suture

(Also called the "Faden" operation: The word "faden" in German means "thread" and has been used to describe other procedures and therefore has little meaning for the procedure of Cuppers.)

The purpose of the posterior fixation suture, also called retroequatorial myopexia is to limit the action of the muscle or at least make the muscle "work harder" in its field of action while producing minimal or no effect in primary position.  The principle of the posterior fixation is to reduce the lever arm of a rectus muscle crippling the muscle somewhat in its field of action.  By "working harder", the muscle receiving the Faden "sends" increased innervation to its yoke muscle by Hering's law.

 Image01002

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Normal with full excursion moderate innervatioN 

 Image01003

After Faden, slightly limited excursion producing increased innervation

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  Image01004

Distributed Innervation

Technique of Posterior Fixation

 Image01005

Medial Rectus 13-15 mm*

Lateral Rectus 17-19 mm

Superior Rectus 17-19 mm

Inferior Rectus 15-17 mm

The borders of the rectus muscles are sutured to sclera with two or three bites and tied loosely to avoid "cheese wiring" (cutting through the belly of the muscle) using 5-0 absorbable or nonabsorbable suture.

 

 

From Limbus

 

 

*These numbers or less may be used in light of pulley information Demer.

  Image01008

For lateral rectus posterior fixation, the inferior oblique insertion must be dissected free from the lateral rectus muscle.

 

 

 Image01010

For the superior rectus, the posterior fixation suture should go behind the superior oblique. This is difficult.

Image01009 

For the inferior rectus, the inferior oblique and Lockwood's ligament must be retracted to place the posterior fixation suture.

There is no particular obstruction to deal with when doing a posterior fixation suture on the medial rectus.

Some Indications for the Posterior Fixation Suture

The main use of the posterior fixation sutures in the hands of most surgeons is to create a "laudable" secondary deviation by placing a posterior fixation suture in the fixing eye such that the extra innervation required in the fixing eye would have a "straightening" or laudable effect on the fellow eye.

No. 1

 
  Image01011 Convergence excess esotropia patients or those with high AC/A who are being taken out of bifocals can be treated with medial rectus posterior fixation bilaterally

No. 2

 
  Image01012 Some surgeons (mostly Europeans) do posterior fixation of both medial recti with or without recession of the medial recti on a routine basis for congenital esotropia. These surgeons usually perform surgery on an older child, often waiting until 5 years.

No. 3

 
  Image01013

In cases of paresis of downgaze in one eye, a posterior fixation suture can be placed on the inferior rectus of the sound eye to produce a partial crippling of downgaze in the normal eye while sending increased innervation and hopefully more action in the paretic eye.  This principle can also be applied to the medial and lateral recti.  The indication for doing this to the superior rectus may not exist. This has been called a "laudable" secondary deviation.

No. 4

 
  Image01014

In cases of DVD a few surgeons continue to perform posterior fixation of one or both superior recti.  However, most now treat DVD with large recession of one or both superior recti.  If "V" and "overaction" of the inferior obliques are seen, this can be treated with bilateral inferior oblique anterior transposition.

The main use of the posterior fixation sutures in the hands of most surgeons is to create a "laudable"" secondary deviation by placing a posterior fixation suture in the fixing eye such that the extra innervation required in the fixing eye would have a "straightening" or laudable effect on the fellow eye.

Blue Line

Example: Type I Duane OS

Primary

    Image01017     Image01017  
  Image01014 Full adduction   Image01018 Limited adduction   Image01019

Better abduction

Duane OS ET

 

Limited abduction OS

 

After posterior fixation right medial rectus

 

Blue Line

 Image01022

After placement of a posterior fixation suture, the muscle - tendon anterior to the posterior fixation may be fibrous, decreased in size, and adherent to sclera.  Some surgeons claim that this tissue can be useful at reoperation as a structure used in recession.  Most surgeons agree that reoperation after posterior fixation is difficult.

Blue Line

  Image01024

 

 

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Some surgeons perform a posterior fixation equivalent by resecting the distal muscle and tendon and then "hanging" the muscle back equal to the amount of the resection or by suturing the muscle to sclera at that point.  The muscle is then weakened in its field of action, but primary position is not changed.

Muscle hung back amount of resection or attached here.

Resection distal muscle/tendon

 

The Strabismus Minute, Vol.2, No. 23 Copyright (C) 2000 Eugene M. Helveston All Rights Reserved

Editor-in-Chief: Eugene M. Helveston, M.D.

Associate Editor: Faruk H. Orge, M.D.

Editorial Board: Bradley C. Black, M.D.

      Edward R. O'Malley, M.D.

      David A. Plager, M.D.

      Derek T. Sprunger, M.D.

      Daniel E. Neely, M.D.

      Naval Sondhi, M.D.

Senior Editorial Consultant: Gunter K. von Noorden, M.D.

Graphics: Michelle L. Harmon

Technical Support: George J. Sheplock, M.D.


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