Novel Approaches to Surgical Correction of Strabismus Based on Current Understanding of Orbital Pulley Anatomy

Recent anatomic and functional studies of the extraocular muscles have led to a new understanding that their proper function is dependent upon a complex collagenous orbital scaffolding. This structure, for which the term "pulley system" is a useful concise designation, maintains the positions of the eye muscles relative to the globe, to each other, and to the orbit. Disruption of this system results in muscle displacement and dysfunction. Novel strabismus surgical procedures designed to utilize this new anatomic knowledge may yield powerful results while lowering ophthalmic risk. Such procedures include pulley posterior fixation, retro-equatorial myopexy, pulley sleeve fusion, angled advancement, angled resection, angled recession, advancement of a muscle's retracted or separated orbital layer, flap tear repair, pulley repair, and loop myopexy.