This is a medial rectus recession performed on both the yes of a 10-year-old with alternating esotropia.
Surgery location: on-board the Orbis Flying Eye Hospital in Binh Dinh, Vietnam.
Surgeon: Dr Rudolph Wagner, Rutgers – New Jersey Medical School, Newark, NJ USA
DR WAGNER: And we’re just doing another medial rectus recession. Now, lift it up a little bit like that. Good. Now I’m gonna go try to cut that vessel here. Come out the back. 5.5. A little bit less of an esotropia in this case. This is — I believe it’s a congenital esotropia. But he’s older. He’s… How old? 10? Yeah. Has big large angle esotropia, but not quite as big as the last case. Okay. Hold it straight up like that. That’s good. Tight. What’s that? All right. You’ve got to hold it like… When you hold this… Let go. Now hold the stick. Get both of these tight. In your hand. Press it so that they’re tight. Good. Keep it straight. Okay. It should be good. Okay. Let that go back there. A little bleeding here. But that’s okay. What’s that? Are we okay? Just slide that back in there. Cautery, please. Thank you. Just leave that one there. That’s good. Okay. Here we go. I’ll get it. Nice big vessel there. It’s hot. A couple little ones there. That’s better, I guess. All right. Let’s see. So let me try that same — I’m gonna show you how I was doing it before, with the locking forceps. Are they still here? We have them? Yeah. Okay, good. Okay. So I’ll do the upper one first — lower one first. So I’ll put this one on the lower pole. Like that. Okay. And I’ll do the upper. Because it’s a little bit easier, when you’re passing the suture, if you’re controlling the opposite one. Not directly opposite, but I guess diagonally opposite. I’m gonna grab onto here like this. Okay. Let me see that. 5.5 is good? Okay. So let’s put it… I like to measure from the posterior edge of the insertion. I’ve been in places where everybody measures from the anterior. So what I would call a 5.5-millimeter recession would be 7.5 to somebody else. So you have to be careful that you understand you’re talking the same amount. That’s good. We’re fine. Can I have the opposite one? I don’t think so. Let me see. Yeah, maybe. Huh? No. Well, let’s check. No, we’re okay. Let me have that caliper back again. Meals. I’m not sure what she was concerned about. Whoa. Is she okay? Is everything all right? Good.
>> So you measure from the behind of the muscle insertion?
DR WAGNER: Oh, you mean where I measure from? That’s okay. Closer. I see what you mean. Closer to the limbus, she means? You mean closer to the limbus? Yeah. A little higher. Yeah. Oh. Okay. I’ll move it over this way more. Yeah. I did it a little bit lower. Let me have that again. Caliper again. So what I’ll do… I’ll just go over here more. That’ll balance it a little bit better. Okay, good. Push it back. That’s good. You can take it out. Take it out. It’s easier for me to get my hand flat if it’s not there. But see, what I’m saying is like — when I was talking about the bridge of the nose, it’s easy for me here — there’s plenty of room. If it’s higher and larger in the nose area, it’s sometimes difficult to get your hand flat for this part. And that’s actually one of the reasons why some people will use a hangback sometimes, because it’s easier — you know, better positioning. Maybe I’ll try to cut this the old way here. Yeah. Right. Yeah, semi… Actually, you can cut that for me here. Cut it here. I’m gonna tie it the rest of the regular way. Needle. Needle, needle. The question is about using a hemihangback. In other words, if you want to do a 10-millimeter recession, could you — instead of putting it from the limbus, hang it back? Sure. The only time that I feel you have to do it from the limbus is — or from the insertion — is if you’re gonna do, like, an adjustable suture. Then you want to be more anterior, so that you can control it better. Right? I think. So… I want the plain suture next. Did they understand that? Good. Okay.
>> Can you say this again?
DR WAGNER: Okay. Plain suture. So we could… We could cut it, but give us about… Yeah. That’s good. What’s this? Oh yeah. Thank you. We cut this a little shorter, Doctor… Yeah. What’s going on here? Are you describing the hangback?
DR WAGNER: But, I mean, sometimes the positioning is so difficult that that’s the best thing to do. I think most of the studies show that the hangback can be just as effective as scleral fixation recession. As far as the results that you get. I don’t think I have the edge here, do I? Yeah, I guess I do. No? Is that the… We’ll find out. We’ll test it. You think it’s Tenon’s? Yeah, you might be right there. Yeah. I think that’s good. Can we have that marcaine? I’ll infusion a little bit of it. If it’s ready to go. Here we go. Got a lot of it now. Nice big — we’re gonna infuse a little marcaine again. Microphone? I think the infusion got loose. Yeah, we probably cut it too short. I hope there’s enough in the other eye. I think when I infused a little bit of marcaine… Trying to save as much suture as possible here. I think we’ll have enough. Good. There you go. Okay. Halfway done. Load that silk suture up for us again, please. And we’ll adjust the light. Have enough room that way? Can you wet it? It’s white, right? That’s phenylephrine. Did the job in this case. Pupil’s not even that dilated yet. So… Usually gets dilated as you work more along, because I think it takes more time and penetrates a little bit better. Okay. What’s going on? Oh, just moving the camera? Good. Very good. Just get the bite of episclera and conj. I have this. Get it out of the way. Should have good view now. So Dr. Hai is making a limbal incision again here. Make sure it’s… You have… I think that’s big enough. Yeah. Careful there. Because you’re a little bit medial. So don’t go… Yeah, that’s it. Yeah. That was good. Okay, Dr. Hai. Here you go. Okay. So let’s see how that looks. It looks pretty good. So you hold it that way. You’re gonna hold it flat toward you this way. Keep a little tension on it. I’m gonna go with one small hook here. One small hook here. And you’re gonna… Cây kéo? Is that what it is? Cây kéo?
DR WAGNER: I learned that yesterday. Tampon. Cotton tip. It means cotton tip applicator. Q-Tip. That’s good. Okay. I’ll hold this for you while you’re getting ready. Ready for a double-armed suture. Trim? Good. A small hook. And what do you want to do? There a little bit. Trim that. You have everything. Yeah. You want… Let me see. Let me get this over here first. Pull that and lift up a little bit. There you go. Give you a little bit more room. There you go. Right at the edge. Very good. Right here. Good, good. Gotta always get good exposure. Now… That’s through. Okay. Okay. Wait a minute. Let me help you a second. Get the position a little bit better. Stretch it. I’m gonna do something… I’m gonna take the hook out now and put it back in. Because there’s a little loop there. That’s not a problem. I just want to make sure that it’s not in the way when we try to cut the suture off. Good. You can try that. You’ve locked it, right? The locking bite? And when you do the locking bite, make sure you go all the way through. That’s it. Yeah. Perpendicular. Right? Dive straight through it. So that locks. This one was a little flat, but I think it’s okay.
>> Dr. Wagner, can I ask that you speak just a little bit louder? We’re trying to learn along with your hands-on trainee. Thank you.
DR WAGNER: Sure. How is that? Better?
DR WAGNER: Good. So I’m keeping the tension — the sutures tight. And make sure everything is good here. Let me look at this. Always make sure it’s spread nicely, and it is. The muscle looks great. Good. So now we’re gonna… We’ll keep this one here. This one there. I’m gonna do this for a second. The bleeding that’s coming from the muscle, I’m just gonna — yeah, that’s it. You do exactly… Just keep one in there. Put the other one in there. Keep it tighter. Hold on a second. I just want to get it in there, so it’s… Get it cauterized. So we think on the next case we’re gonna do a similar procedure, but we’re gonna use the microscope. 3D microscope. One there. Which I think is gonna be kind of interesting. One spot. A couple little spots there.
>> Excuse me. There is an online question for you. Why do you not use the fornix incision?
DR WAGNER: Why not a fornix incision? Is that what the question was? Just personal preference in this particular case. Over the years, I tend to do more fornix incisions on the lateral rectus muscles than I do on the medial rectus muscle. And — let me have the cautery one second — and I think it’s just a little bit easier medially, sometimes, to the limbal, to get a little bit better exposure. I do a lot of little babies, younger kids, and it’s difficult sometimes to get the exposure that you want. So I believe in making it, you know — what’s easiest to get your visualization. That’s the most important thing, that you’re happy with — that you can see everything. Get the other one there. You’ve got a little too tight grip. I’ve got to straighten that out for you. Let me fix that up for you. Don’t worry about it. That’s okay. Don’t worry about it. We’ll fix this. She’s doing a very, very good job. She’s got a good strong grip. I think that’ll work. Let me load it for you. I locked it. So if you want to unlock it, you can — wait. Let me dry it for you. Wait, wait, wait, wait, wait. Let me put a marker here again. Yeah. I think I’ll do it from the right posterior edge, like that. Okay. Good. You okay? That’s very good. Back it up a little bit. And then go a little bit deeper. A little tiny — that’s good. Keep going. You’re okay. A little bit more. The question is: How much do I resect for the inferior rectus recession? Well, I mean, I use the rule of 2 millimeters per — 2 to 3 prism diopters per millimeter. So, you know, it depends. The lid — you worry about the lid position changes. And it often happens in thyroid cases. I’ll mark it again for you. So I’ve tried different ways to avoid that. We’re talking about lid position changes with inferior rectus recessions. And I’ve tried different ways to avoid that. But sometimes you get it. Even with smaller recessions. But mostly I try to keep the capsulopalpebral ligament, we call it, intact. But that’s a whole other topic. That’s good. That’s fine. You’re good. Now, before you move it, make sure it’s flat. That’s it. See? So this way it doesn’t turn or twist. If it twists, then it cuts on the side. Then you don’t want that. You might lose your tunnel. But I think it looks perfect, where we want it. Let’s dry it. It looks good. Now, why don’t we cut one of these? And I’ll tie it. Right? We’ll cut this one. Good. You know what? While we’re at it, let me have that marcaine. You have that marcaine there? Marcaine? Yeah. I’m sorry. I’ll pull it out of the way for you. Just grab it. Go — you’re okay. Oh, want it again? Good. Tighten it a little bit. Good. Very good. Another one. Okay. Before you cut that, let me have that marcaine. Let’s put this in now. It’s a little easier. Don’t have to worry about the conjunctiva. Go down here. Not getting it. Got some in there. Good. Okay, good. Looks good. Now, remove those locking forceps. Okay? Got a little… I think when I infused, I got a little bleeding from the infusion of the marcaine. But that’s okay. I think you got it. Good. Looks great. I’m gonna cut it. I’m sorry. Let me get the scissor. Uh-oh. It came loose. I thought it was too short. We’ve got to do it again. Dr. Hai. It came loose. Let me try it again. Hold on. It came out. See? A little stitch there. Wait. Let me get the right one here. I think it might have been Tenon’s anyway. That’s better. Go right through… Let me lift that up for you. Good. Right here. That’s better. Do another one. Okay, good. Now cut it longer. Good. Now one more here. Let’s see where it goes. Try to grab it. That’s good. Good. I think that looks very good. Let’s see. We’ve already infused, so we’re done with that part. We should be ready to go. Looks good. Can I have the scissor? Can I have the Westcott one more time? Thanks. Sorry. Needle. Good. Very good. Clean this up a little bit. Very good, Dr. Hai. Thank you. Looks great. Wait. I want to see something. I see… I see six. Good. We’ve got them all. They’re all here. Yes. You have the magnetic sweeper? You have all that stuff? Yeah. I’ve seen that done a few times. Very good. Very good. Thanks.