Surgical Technique

Modified Faden operation –A new surgical technique

Manjula Jayakumar, Suganya Vel, Amar Agarwal

Faden operation was first described in 1912. It weakens the muscle in its field of action without much Video available on:
slackening and alteration in the primary position. When combined with recession the weakening effect www.ijo.in
is more. It is a useful surgery in esotropia with high accommodative convergence, nystagmus blockage
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syndrome, dissociated vertical deviation, Duane’s retraction syndrome with up or downshoots, and in
sixth nerve paresis, where it is performed on the contralateral normal yoke muscle to increase the field of Website:
www.ijo.in
binocular vision. The conventional procedure is cumbersome due to small working space, entanglement
DOI:
of sutures, and posterior location of Faden site which is not easily accessible. We have modified the Faden 10.4103/ijo.IJO_952_18
operation by using a single 5‑0 double‑armed polyester suture, which is much easier and simpler to perform, PMID:
and have done it in a series of small angle esotropias combined with recession. This paper demonstrates the *****
surgical technique so that this surgery can be performed with ease by more surgeons. Quick Response Code:

Key words: 5‑0 double‑armed polyester suture, conventional Faden operation, modified Faden operation,
recession, small angle esotropia

Faden operation was first described by Cuppers in 1912.[1] Methods

Faden means a “suture” in German and the muscle is fixed
posteriorly 12–14 mm behind the insertion, thus creating a Six patients enrolled for this IRB‑approved surgical procedure.
new insertion. This reduces the moment arm and the force Only patients with small angle Esotropia (ET) (12 to 25 Prism
of rotation. The decrease in the force of rotation happens Dioptre [PD]) who needed one muscle (medial rectus) were
as the eye moves in the direction of the fadened muscle. included. Preoperative evaluation included best corrected visual
This is a useful surgery in esotropia with convergence acuity with glasses measured using Snellen chart, cycloplegic
excess, nystagmus blockage syndrome, Duane’s retraction refraction, measurement of angle of squint for both distance
syndrome, dissociated vertical deviation, and contralateral and near, near point of convergence (NPC) by Royal Air Force
medial rectus yoke muscle in case of sixth nerve palsies. In (RAF) ruler, stereopsis using TNO Stereoacuity Test, slitlamp
esotropias with increased accommodative convergence ratio, biomicroscopy, and dilated fundus examination. Informed
Faden operation with recession significantly reduces the consent was obtained from patient or parents, whichever
distance near disparity without much change in the distance was applicable. Fig. 1 shows the preoperative deviation and
alignment and the results are similar to those obtained with postoperative alignment in a patient with left esotropia of 20 PD.
augmented medial rectus recessions.[2] In esotropic eyes Surgical procedure [Video 1]
with unilateral poor vision, Faden combined with recession
Under general/local anesthesia, medial rectus muscle was
reduces the chances of overcorrection as opposed to a recess
secured with a three‑point fixation (a central fixation knot
resect procedure.[3] When Faden is combined with recession,
followed by locked bites at the two edges of the muscle) using a
the weakening effect is more. The conventional Faden is
single double‑armed 5‑0 polyester suture and then a scleral bite
difficult to perform and cumbersome as there is very less
of length 2 mm was taken parallel to the muscle, 5 mm posterior
operating space medially, and preplaced sutures at the Faden
to the insertion, and another bite was taken 12 mm from the
site is 12–14 mm from the insertion, which is too posterior
muscle insertion on both sides of the muscle. The suture comes
for accessibility. Hence, Faden with recession has become a
back to the muscle at the first scleral bite site (recession site) and
lesser performed surgery. In this article, we highlight the use
is passed through the edge of the muscle inwards incorporating
of a single double‑armed 5‑0 polyester suture and a modified
1/4 of muscle thickness at this site on both sides. The muscle
technique which makes the surgical procedure much easier.
We have performed this modified procedure on the medial
rectus muscle which yields the best results due to the shortest This is an open access journal, and articles are distributed under the terms of
arc of contact. the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non-commercially,
as long as appropriate credit is given and the new creations are licensed under
Dr. Agarwal’s Eye Hospital, #19, Cathedral Road, Chennai, the identical terms.
Tamil Nadu, India
Correspondence to: Dr. Manjula Jayakumar, Dr. Agarwal’s Eye For reprints contact: reprints@medknow.com
Hospital, #19, Cathedral Road, Chennai 86, Tamil Nadu, India.
E‑mail: manju_in_00@yahoo.com Cite this article as: Jayakumar M, Vel S, Agarwal A. Modified Faden
operation –A new surgical technique. Indian J Ophthalmol 2019;67:264-6.
Manuscript received: 06.06.18; Revision accepted: 17.10.18

© 2019 Indian Journal of Ophthalmology | Published by Wolters Kluwer - Medknow

 Jayakumar, et al.: Modified Faden operation
February 2019 265

insertion of posterior fixation suture.[1] Faden surgery with

or without recession has been done in esotropia with high
accommodative convergence ratio, nystagmus blockage
a
syndrome and dissociated vertical deviation,[4] and paretic
b
squints to reduce incomitance and improve the binocular
Figure 1: (a) Preoperative picture showing small left convergent squint. field of vision. Small angle esotropia have been treated with
(b) Postoperative picture after modified Faden operation
single large muscle recession but has its own disadvantages.[5]
It can affect convergence, induce incomitance in side gaze, and
there is risk of postoperative exotropia as muscle slackening is
more. We performed a “modified Faden operation” combined
with recession in a series of patients with small angle ET up
to 25 PD, using only one double‑armed 5‑0 polyester suture,
which is a novel and simple technique to perform as opposed
to the conventional method.[6] The main issue with Faden is
exposure of the surgical field and extensive dissection that
is needed. Exposure can be improved by using Desmarres
retractor. Further improvement of exposure is by retracting
the globe with a muscle hook; however, on combination with
a b recession this is not possible unless locking forceps is used
at the muscle insertion after disinsertion. The scleral bites at
the Faden site are taken perpendicular to the muscle fibres,
and because of the posterior location and poor accessibility
there is a risk of scleral perforation. The conventional Faden
also requires two sutures for recession and Faden. There are
two ways of performing the surgery.[6] One method is by
posterior fixation suture with double side stitch and rectus
muscle recession. In this procedure, two preplaced scleral
bites 2 mm in size are taken first at the proposed Faden site.
c d The recession then proceeds. After recession, 1/4 of the muscle
Figure 2: (a) Three‑point fixation of medial rectus muscle at insertion. width is incorporated at the Faden site on either side of the
(b) Two arrows showing scleral bite at recession site and Faden site. muscle and the sutures tied. In this method, encirclage of 1/4
(c) After taking scleral bite at Faden site, the suture comes back into of the muscle on either side at posterior fixation is established.
the muscle at recession site. (d) Suture tied after disinserting muscle The other method is posterior fixation suture with a single
at insertion, both recession and posterior fixation suture in situ central stitch combined with recession. In this method, after
securing the muscle by three‑point fixation, the muscle is
is cut at insertion and the central suture is tied anchoring the disinserted for recession and a central 3 mm bite is taken at
muscle posteriorly. Thereby, the muscle is recessed as well as the sclera on the Faden site as well as at the corresponding
fixed posteriorly at the Faden site by a single double‑armed 5‑0 site in the muscle (which is the distance of posterior fixation
polyester suture. Postoperatively, angle of squint for distance minus the recession), after which the recession is proceeded
and near, NPC, adduction deficit in the operated eye, and with and subsequently the central fixation suture is tied
stereopsis were assessed at 1, 3, and 6 months. at the Faden site. In this method, encirclage is not done at
either side. The muscle is fixed posteriorly and adequate
Results anchorage is brought about by the central fixation suture. In
our technique [Fig. 2], 2‑mm bites are taken on the sclera at
Six patients were operated by the modified Faden operation the recession site and then at the Faden site, both bites are
on the medial rectus muscle. All patients had satisfactory taken parallel to the muscle as opposed to perpendicular bites
postoperative alignment with maintenance of preoperative in the conventional procedure. After the second scleral pass,
NPC (mean 9 cm) postoperatively and presence of full sutures are brought back into the muscle on either side at
adduction with absent lateral incomitance on the operated side. the recession site followed by disinsertion of the muscle and
The details of these patients are presented in Table 1. then tying the suture knot. The muscle now lies recessed as
well as fadened by the appropriate measurement. The tied
Discussion suture lies at the Faden site and the muscle is anchored to
Faden surgery also known as posterior fixation suture surgery sclera by a central suture. The muscle can be maneuvered as
is used to weaken the rotational force of a rectus muscle when it is hooked and rotated away from the field until the scleral
the eye rotates in the field of action of the fadened muscle. bites are placed at both sites which provides better exposure.
When Faden is performed the basic muscle tone remains Scleral bites at both sites are of 2 mm in length and parallel to
the same because the distance between the muscle origin the muscle belly which is easier to place than perpendicular
and insertion remains the same. When Faden is combined bites as in conventional Faden. A single 5‑0 double‑armed
with a recession, the effect of recession is enhanced without polyester suture would suffice to perform this procedure
much slackening, which is otherwise observed in large compared to two sutures and entanglement that can occur
recessions as the slackening is taken up in by the relatively with conventional Faden. When Faden is performed there is
short portion of the muscle between the origin and point of lesser risk of over correction[6] It is useful in sixth nerve palsy,[7]
266 Indian Journal of Ophthalmology Volume 67 Issue 2

Table 1: Data of subjects who have undergone Faden in one eye

Patients Age/Sex Objective refraction RE Objective refraction LE

SPH CYL AXIS SPH CYL AXIS NPC

1 4/M +4.50 −1.00 180 +3.50 −1.50 180 8 cm
2 6/M +1.50 +1.25 8 cm
3 9/F +1.50 +2.50 10 cm
4 19/M −1.50 −1.00 12 cm
5 21/M 0.00 −1.00 180 0.00 −1.50 180 9 cm
6 23/M +1.50 +2.50 7 cm
Subjective refraction RE Subjective refraction LE

Patients SPH CYL AXIS VA SPH CYL AXIS VA Diagnosis

1 +4.50 −1.00 180 6/18 +3.50 −1.50 180 6/9 Partially Accomm ET RE
2 +1.50 6/12 +1.25 6/9 Intermittent Esotropia RE
3 +1.50 6/9 +2.50 6/12 Intermittent Esotropia LE
4 −1.50 6/18 −1.00 6/18 Intermittent Esotropia LE
5 0.00 −1.00 180 6/9 0.00 −1.50 180 6/9 Intermittent Esotropia RE
6 +1.50 6/12 +2.50 6/9 Intermittent Esotropia RE
Patients Stereo Angle of Squint Surgery Post OP results
1 2000”arc 16 PD BO 5 mm REC + FADEN Orthophoria
2 600”arc 16 PD BO 5 mm REC + FADEN Orthophoria
3 600”arc 16 PD BO 5 mm REC + FADEN Orthophoria
4 NO 18 PD BO 5 mm REC + FADEN Orthophoria
5 480”arc 18 PD BO 5 mm REC + FADEN Orthophoria
6 600”arc 20 PD BO 5 mm REC + FADEN Flick Esophoria
Postoperative maintenance of NPC and presence of full adduction in the operated eye was noted in all patients

unilateral dissociated vertical deviation,[8] and in nystagmus References

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