Eye (1988) 2, 36-40

Faden Operation (Posterior Fixation Sutures)

BRIAN HARCOURTt
Leeds

The ocular rotational power which a rectus that of an equivalent recession when the eye
muscle exerts is a product of the muscle's is in the straightahead position, but which
force and the length of the lever arm between increases progressively as the eye moves into
the muscle's tangential point of contact with the field of action of the operated muscle. This
the globe and the centre of rotation of the eye.
A recession operation weakens a rectus
muscle because the distance between the
muscle's origin at the orbital apex and its
insertion into the surface of the globe is
decreased, so that the muscle becomes slack.
Provided that the recession does not exceed
the conventional maximum (Table I), the
length of the lever arm is not reduced. Even
when the eye moves into the field of action
of the recessed muscle, the length of the
rotational lever arm remains unchanged as the
tangential point of muscle action is still on the
surface of the globe. If the muscle is over­
recessed, not only does it become very slack
but the effective lever arm is reduced in length
and mechanical restriction of movement
ensues. The weakening effect of a con­
ventional recession operation is therefore
approximately the same in all directions of
gaze in which the muscle is active (Figs. 1 and
2).
Table I Maximum recession possible without limiting
ocular motility. Fig. I. (a) normal relationship between rectus muscle
and eyes. (b) after conventional recession, the muscle is
Superior rectus 5mm weakened by slackness but still acts through a tangential
Inferior rectus 5 mm point on the surface of the globe. (c) after excessive
Medial rectus 5 .5 mm recession the muscle is very slack and action is further
Lateral rectus 8 mm weakened as the tangential point of action is no longer at
the surface of the globe. (d) if a rectus muscle is both
recessed and resected simultaneously by the same
The faden operation was first described by amount, there is no slackness but the rotational lever
Adelstein and Ciippers. The word derives arm is shortened. (e) a faden operation works in the
from the German for a thread or suture; the same way. (f) if posterior fixation sutures are combined
with a recession, an unusually large effect is produced
more descriptive English term is posterior fix­ as all the slackness is taken up by that portion of the
ation suture. The operation aims to produce a muscle between the sutures and its origin at the orbital
weakening which is proportionately less than apex.

t Deceased.
Correspondence to: Department of Ophthalmology General Infirmary at Leeds.
 FADEN OPERATION ( POSTERIOR FIXATION SUTURES ) 37

Method
The posterior fixation sutures must be strong
and permanent; 3-0 or 4-0 Dacron or
Supramid are commonly used. Because the
lengths and orientations of the rectus muscles
differ, as do the distances of their insertions
from the limbus, the necessary fixation points
are also different (Table II). Two different
(8) (b) techniques can be employed:
� (1) The rectus muscle is attached by its edges
to the sclera using whipped sutures, each
incorporating some 115 of the total muscle
width.
(2) The muscle is detached at its insertion.
One or two circumferential mattress
(e) (d)
sutures are then applied to the sclera and
through the muscle belly, and the muscle
is reinserted.
The second method is more easily com­
bined with recession of the muscle inser­
tion. Proponents of the first technique
claim that it has some weakening effect on
the muscle even when the eye is in the
straightahead position; combination with
(e) (f) a recession is not therefore often
required.3
Fig. 2. (a & b) the normal rectus muscle exerts its Table II Approximate position for optimal posterior
action at the surface of the globe both in the primary fixation behind normal rectus muscle insertion.
position and when the eye rotates into its field of action.
(c & d) the same is true after conventional recession. (e Medial rectus 11-13 mm
& f) after application of posterior fixation sutures the Vertical recti 12-14 mm
power of the operated muscle decreases progressively as Lateral rectus 17-19 mm
the eye moves into its field of action due to increasing
shortness of the lever arm of rotation.
The operation, however performed, prob­
effect is achieved by suturing the rectus ably produces other effects. In particular, the
mu�cle to the sclera well behind the tangential heavy fixation sutures induce quite a large
point of action on the surface of the globe. area of scarring which increases the forces
When the muscle contracts and the eye resisting rotation of the eye. Another
rotates, the effective length of the lever arm mechanical effect is the holding back of the
becomes increasingly shorter. 2 Unless the orbital fat pad behind the fixation sutures.
faden operation is combined with a recession This damps rotation of the eye and it also
of the muscle insertion, the basic muscle tone helps to resist the globe retraction which is
remains essentially unchanged because the threatened by active contraction of a muscle
distance between the muscle's origin and which has been attached to the globe behind
insertion is unaltered. It is as if the muscle had its tangential point of contact.
been both recessed and resected by the same
amount. If the faden operation is combined
with a recession, the effect of the latter is Indications
enhanced as all the slackness is taken up in the A. By making use of the progressive weaken­
relatively short portion of the muscle between ing in the field of action of the operated
its origin and the points of insertion of the muscle
posterior fixation sutures (Figs. 1 & 2). Because the faden operation, unlike con-
38 BRIAN HARCOURT

ventional recession, has a progressive operated muscle's action as it turns

weakening effect when the eye is rotated the eye matches that of its con­
towards the operated muscle, but does tralateral synergist, the paresed
not change the resting position of the eye muscle, thereby inducing greater con­
to any great extent, it can usefully be comitance and an increase in the field
employed: of binocular single vision.
(1) to reduce dissociated vertical diver­ (4) in the treatment of nystagmus block­
gence (DVD). This is probably the age syndrome and essential infantile
most widely acknowledged indica­ esotropia. This is a widely used and
tion. As the dissociated eye drifts yet contentious indication for the
upwards there is a progressive weak­ operation. The rationale according to
ening of the elevating force produced continental European advocates is
by the surgery which can at least that patients with these related dis­
diminish the abnormal movement to orders exhibit a very variable angle of
an extent which makes it cosmetically strabismus due to spasmodic non­
much less noticeable. The effect is accommodative convergence excess,
more profound if combined with either as a strategy to block nystag­
muscle recession and this is especially mus or due to a developmental
necessary when asymmetrical DVD is oculomotor defect. The most appro­
associated with hypertropia of the priate operation is therefore one
non-fixing eye. The immediate effects which corrects the basic angle of
are usually encouraging, but later strabismus (by bilateral medial rectus
recurrence is quite common. recession) and inhibits spasmodic
(2) to reduce convergence excess. These convergence (by posterior fixation
patients with accommodative eso­ sutures applied to the same muscles).4
tropia exhibit, after optical correction Although many advocate this com­
of their hypermetropia, no manifest bined procedure, others state that the
esodeviation on distance fixation but edge-whipping faden technique with­
a convergent strabismus for near. If out recession gives good results.5
bifocal spectacles are considered B. When a previous maximum conventional
inappropriate, sufficient con­ recession operation has proved insufficient
ventional surgery to make their eyes There are many instances in which a maxi­
straight for near is then likely to mum conventional recession operation
induce either a mechanical impair­ alone fails to induce adequate desired
ment of convergence or a consecutive change in the position of the operated
exodeviation for distance. A faden eye. The options of reoperating on the
operation on both medial recti does same muscle are then limited. A further
not change the distance angle much direct recession will cause mechanical
but induces a marked weakening of limitation of movement. Re-recession
convergence. It may be used as a operations using hang-loose or loop
secondary procedure when previous sutures have their advocates, but usually
bilateral medial rectus recessions the muscle does not reattach indirectly to
have failed to control the strabismus. the tangential point of rotation on the
Alternatively, it may be carried out in sclera as desired, but directly and in an
isolation or combined with bilateral uncontrolled fashion where the severed
recessions as a primary procedure if insertion lies in direct contact with the
there is a significant basic angle of globe; the problems of mechanical restric­
strabismus (esophoria on distance tion again ensue. Similarly, marginal
fixation). myotomy can lead to extensive adherence
(3) to weaken the contralateral synergist of the traumatised muscle belly to the
in cases of muscle paresis. The con­ underlying sclera. In these circumstances,
sequent progressive weakening of the posterior fixation sutures whipped to the
 FADEN OPERATION ( POSTERIOR FIXATION SUTURES ) 39

edges of the previously recessed muscle may then slip up or down on the surface of
will weaken the lever arm of rotation the globe when it contracts giving rise to a
without inducing that additional muscle sudden loss of vertical stability in the pos­
slackness which follows a re-recession, ition of the eye. Scott2 suggested that this
and can be the most appropriate and could be controlled by posterior fixation
effective procedure. sutures applied to the horizontal rectus
C. To augment the effect of a conventional muscles. It is rather surprising that this
recession operation logical recommendation has not been
As already intimated, when a faden oper­ very widely taken up. However, the most
ation and recession are combined, less important consideration is to reduce the
recession of the rectus insertion is tethering effect of the tight lateral rectus.
required than normal in order to effect a This can be done by dividing the anterior
certain alteration in the resting position of portion of the muscle longitudinally,
the eye as the slackness is all taken up in recessing it and splaying out the two por­
the short length of the muscle behind the tions to give a horizontal Y-shaped
posterior fixation sutures. There is also reinsertion.6
some weakening due to damage caused to
the anterior part of the muscle belly by the
posteriorly placed sutures. In the same Problems
way, a maximum conventional recession The operation is technically more difficult
is augmented by posterior fixation sutures than conventional recession. The heavy
applied at the same time. The combined sutures must be inserted well behind the equa­
operation will lead to some limitation in tor without broaching the orbital fat pad,
ocular movement, but this may be accept­ for otherwise fat will prolapse forwards to
able in extreme gaze positions in certain produce cosmetically unacceptable subcon­
instances where recession alone gives junctival swelling, discolouration and vas­
inadequate results. The most appropriate cularisation as well as mechanical effects from
example of this is in the Kestenbaum fibrosis. The vortex veins emerge from the
operation for congenital nystagmus. It is sclera close to the required position of pos­
widely appreciated that very large terior fixation sutures whipped around the
amounts of rotation of the eyes within the edges of the vertical recti. If the alternative
muscle cones are required in order to mattress suture technique through the muscle
achieve any marked permanent change in belly is used, the sclera is very thin in those
the position of the null zone in such cases, submuscular areas; this is a special hazard in
with consequent reduction in the compen­ view of the heavy gauge permanent suture
satory head posture and increased com­ material which must be used. These sutures
fort of vision. In some instances, even a themselves induce significant local scarring,
combination of very large 'supramaximal' and if they do not the operation is probably
conventional recession and resection pro­ ineffective in the long-term. This fibrosis
cedures proves insufficient; combining means that the operation is not entirely rever­
the recessions with posterior fixation sible after the immediate post-operative heal­
sutures then adds an additional weaken­ ing period. The surgery is particularly difficult
ing effect without significantly increasing when applied to the superior rectus muscle,
the mechanical limitation of movement. usually in the treatment of DVD. Access is
O. To achieve posterior stabilisation of rectus hampered by the proximity of the orbital roof
muscle position and by the vortex veins, but principally by the
The upshoots and downshoots on superior oblique tendon which lies exactly in
attempted adduction which occur in some the area where the posterior fixation sutures
patients with Duane's syndrome have need to be inserted. This problem can be dealt
been ascribed to mechanical restriction with by deflecting the tendinous insertion
rather than anomalous innervation. The anteriorly, or less satisfactorily by passing the
lateral rectus is tight and the medial rectus scleral sutures directly through the tendon.
40 BRIAN HARCOURT

Evaluation I am indebted to my colleague, Mr Bruce Noble for

The faden operation is based on an interesting the illustrations and to my secretary, Miss Anne
Gelder for preparation of the manuscript.
theoretical concept, and its mode of action is
indeed different from that of other rectus
muscle weakening operations. It therefore References
has special applications as outlined. The 1 Adelstein FE and Clippers C: Probleme der oper­
ativen Schielbehandlung. Bericht Deutsche
degree to which it is used depends very much Ophthalmologische Gesellschaft 1968, 69: 580-
on the experience of the individual surgeon. 93.
The technical problems decrease with famil­ 2 Scott AB: The faden operation: mechanical effects.
iarity, but doubts remain about the longterm Am Orthop ] 1984,27: 44-7.
durability of the initially satisfactory results 3 de Decker W and Haase W: Results of the faden
obtained. While there is a considerable operation in alternating convergent strabismus of
the congenital type. In Balen A.Th.M. van &
number of firm adherents to the technique in
Houtman WA (eds) Documenta Ophthalmo­
continental Europe, it has not found a place logica Proceedings Series 32, 1982, pp 65-72.
worldwide in other than its rather special Junk, The Hague.
applications. In particular there is no wide­ 'Berard PVM, Mouillac-Gambarelli N, Reydy R:
spread belief that it is more effective in the Management of variable angle esotropia. In
long-term treatment of infantile esotropia Mein M. & Moore S. (eds) Orthoptics. Research
and Practice 1981, pp 233-5, Kimpton, London.
than maximal medial rectus recession oper­
ations. Many surgeons would hesitate to apply 5 de Decker W: The faden operation. When and how
to do it. Trans Ophthalmol Soc UK 1981, 101:
such heavy gauge permanent suture material 264-70.
far back on the immature infant sclera unless o Rogers GL and Bremer DL: Surgical treatment of
they were completely satisfied that there was the upshoot and downshoot in Duane's retraction
no alternative. syndrome. Ophthalmology 1984,91: 1380-3.