Features and outcomes of pulled-in-two syndrome
Reviewed by Fiona Rowe

Pulled-in-two (PIT) syndrome is a sudden rupture of the extraocular muscle during strabismus surgery, typically with minimal tension intraoperatively without excessive force. This is a rare occurrence and this study reports cases from a single centre over a seven-year period. Of 11,824 surgery cases, four patients had PIT syndrome giving an incidence of 0.034%. All were female with mean age at surgery of 61.75 ±8.99 years. None had previous ocular surgery and all were eso with very large angles of 100-120PD. Two had 6th nerve palsy and two were myopic strabismus. Three had medial rectus rupture and one lateral rectus. Surgical repair was required – usually muscle recovery and reattachment of the muscle, or, if the muscle was lost, a transposition surgery. Postoperative alignment was ortho to +25PD. This represents a serious complication of strabismus surgery and potential risk factors were identified as advanced age, prior surgery, cranial nerve palsy, thyroid eye disease and degenerative extraocular muscle disease.

Incidence, management and outcome of pulled-in-two syndrome associated with strabismus surgery.
Kong M, Han Y, Li J, et al.
JOURNAL OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS
2023;60(3):263-7.