Session: Poster session C

PULLED IN 2 SYNDROME - a case report.

TITLE

PULLED IN 2 SYNDROME – case report.

 

INTRODUCTION

Pulled in 2 syndrome (PITS) is an uncommon, but serious, complication of squint surgery, when an extraocular muscle ruptures peroperatively, potentially resulting in permanent loss of the muscle and its function

 

METHODS

We present a 58-year-old hyperopic man who presented with a consecutive right divergent squint, 40 years after surgery for a partially accommodative esotropia.

Surgery was undertaken under general anaesthetic. The horizontal recti of the divergent eye were explored, and the lateral rectus recessed. There was scarring and fat around the previously recessed medial rectus, which was cleared with a plan to pull the muscle up to the original insertion. After suturing the tendon and disinserting from the globe, the muscle split at the junction of the muscle belly and the tendon as it was pulled forwards. The muscle belly was grasped as it retracted in the orbit and sutured with a non-absorbable 5.0 suture, using a half circle needle and secured to the globe.  An intraoperative forced duction test was performed which showed a minus one restriction of the eye into abduction.

At post operative assessment he had excellent cosmesis with a small esotropia for near, with a slightly increased angle for distance and on right gaze.

 

CONCLUSION

PITS is a potentially devastating complication of squint surgery, occurring more commonly in older patients, particularly affecting the medial or inferior rectus. There is also an increased incidence in muscles affected by cranial nerve palsies, eg 3rd, 4th 6th weaknesses, which were not present in this case. Although reattachment of the muscle stump is achieved in the majority of reported cases, transposition surgery may be needed to achieve satisfactory alignment in cases where this is not possible.

This case is a typical example of this rare complication. It has been predicted that this problem will be encountered by most squint surgeons approximately once every 10 years.