Acta Scientific Ophthalmology (ISSN: 2582-3191)

Research Article Volume 5 Issue 4

Pulled in Two Syndrome (PITS), a Serious Strabismus Surgery Complication

Karim Gaballah1 and Dalal Shawky2*

1Assistant Professor of Ophthalmology, Helwan University, Egypt
2Professor of Ophthalmology, Alexandria University, Egypt

*Corresponding Author: Dalal Shawky, Professor of Ophthalmology, Alexandria University, Egypt.

Received: February 17, 2022; Published: March 22, 2022


Aim of the Study: To consider an important and rare complication that can happen during strabismus surgery, to identify the causes, the warning signs, the risk factors so as to prevent it from happening.

Subjects and Methods: This is a retrospective study, studying the files of operated cases of strabismus, and available photos, during the period from January 2010 till January 2021, searching cases of Pulled In Two Syndrome, reporting what happened and cases were this complication could be avoided.

The study included the files of 1610 patients operated by the authors from strabismus in one of the centers of Alexandria, where the details of surgery and complications are monitored, and where most of them had photos for documentation.

Results: Cases of pulled in two syndrome were six cases. This complication was shown in long standing strabismus, specially in adults, where the muscle to be operated was fibrotic, and the minimal pull of the muscle during hooking caused the muscle to be cut spontaneously at the junction of the belly and tendon of insertion. In the earlier cases, the muscle was torn, starting at one edge, and rapidly completely cut in two when pulled with the hook.

Conclusion: This complication should be considered when operating long standing strabismus, restrictive strabismus, Congenital fibrosis of extraocular muscles, and strabismus operated in older age.

Keywords: Pulled in Two Syndrome (PITS); Restrictive Strabismus; Congenital Fibrosis of Extraocular Muscles (CFEOM)


  1. Pujari Amar., et al. “Pulled into two syndrome (PITS) in a case of congenital fibrosis of the extraocular muscle”. Indian Journal of Ophthalmology7 (2019): 1229-1230.
  2. Erika M., et al. “Pulled-in-two syndrome; a multi centric survey of risk factors, management and outcomes”. Journal of AAPOS5 (2016): 387-391.
  3. Bradbury J and Taylor RH. “Pulled-in-two syndrome: A multicenter survey of risk factors, management and outcomes”. Journal of American Association for Pediatric Ophthalmology and Strabismus 21 (2017): 344.
  4. Wallace DK., et al. “Strabismus surgery complicated by ‘pulled in two syndrome’ in a case of breast carcinoma metastatic to the medial rectus muscle”. Journal AAPOS Official Publication of the American Association for Pediatric Ophthalmology and Strabismus 4 (2000): 117-119.
  5. Jones AM., et al. “Surgical technique for pulled in two syndrome: Three cases with chronic progressive external ophthalmoplegia”. Journal of Pediatric Ophthalmology and Strabismus 54 (2017): e83-87.


Citation: Karim Gaballah and Dalal Shawky. “Pulled in Two Syndrome (PITS), a Serious Strabismus Surgery Complication".Acta Scientific Ophthalmology 5.4 (2022): 47-51.


Copyright: © 2022 Karim Gaballah and Dalal Shawky. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Acceptance rate35%
Acceptance to publication20-30 days
ISI- IF1.042
JCR- IF0.24

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