This is a standard medial rectus recession surgery performed on the right eye of a patient, using a limbal approach.
Surgery location: on-board the Orbis Flying Eye Hospital in Can Tho, Vietnam.
Surgeon: Dr Rudolph Wagner, Rutgers – New Jersey Medical School, Newark, NJ USA
This is a case of a right medial rectus muscle recession, and we’re going to use a limbal conjunctival peritomy or a limbal approach in order to isolate the muscle. You can see that we have the lid speculum in place and the eye is exposed.
I’m now passing a four zero silk traction suture through the episclera and conjunctiva at six and twelve o’clock in order to position the eye properly for surgery.
We attach the silk suture to a clamp and clamp it to the lateral area to expose the medial conjunctival area. Now I’m making a peritomy and extending it pretty much inferiorly to the edge of the sutures.
I make a relaxing incision both superiorly and inferiorly to widen the opening.
Now I make a tunnel in order to hook the muscle.
You don’t need to cut when you make the tunnel, just advance these scissors, and spread, but avoid going into the other muscles and avoid the muscle itself. The hook is passed and the muscles begin to be isolated.
Once I’m sure that I have the muscle in its entirety, We use two small hooks or in this case one initially and there’s the other to lift the tenons capsule and connective tissue above the muscle, then carefully dissect away the connective tissue in order to isolate the muscle tissue itself and prepare it for the surgical procedure or recession.
We go back far enough to isolate the muscle, but not to pass through the fat pad or the tenons capsule site where the muscle extends through the tenons into the anterior area.
Now, we’re using a 5’0 vicryl suture to secure the muscle.
Pass the muscle at partial thickness to come out the edge from one side, retrieve the needle and pass a locking bite on the edge, the second bite has to be perpendicular through and through the muscle. The needle is then picked up through the through a loop of suture and locked.
In the opposite direction, the second arm of the double arm suture is passed once again remaining within the muscle tissue and is retrieved.
We now make a locking bite once again perpendicular through and through, pick up the needle, and secure the muscle.
Muscles then is dissected using a blunt Westcott scissor, paying careful attention to the location of the sutures, so as not to cut them.
You check to see that the muscle is oriented properly.
And in this case, we will apply a locking force on both the superior and inferior pole of the insertion.
Once the area is clear, we use a caliper to measure the distance. In this case, we’re doing a five millimeter recession.
And we passed the needles within the sclera to make a tunnel for suture.
We’d like to visualize the needle the whole time within the sclera to ensure that we have the proper depth, but not too deep.
We then do the same with the other end of the suture.
And in this case directing them where they will meet at a point centrally closer to the limbus.
Once both sutures have been passed, we advance the muscle up to the needle entry area, and tie the muscle down in its proper anatomic position, therefore creating the recession of this medial rectus muscle for five point o millimetres.
We usually do two throws and then two more individual single throws in order to lock the suture.
It’s very important after the first suture is down that you pay attention to not disturbing this knot, by by putting tension on the sutures. So, you bring the knot down to the original knot that was made.
This locks it.
Then the final locking suture has been passed. Check to make sure it’s spread well, and then we can cut the free ends of the suture above the knot.
We then reposition the conjunctival incision, and I usually like to leave it somewhat recessed from the limbus to allow for the eye to go to its central position with the conjunctiva not overlapping on the cornea.
We use six o plane suture for this.
And you can see the conjunctiva brought up.
It usually only requires two sutures, one superiorly and one inferiorly.
Again, we use the two one surgical technique, two throws and then two single throws.
We use the plain suture non dyed, so that it is not perceived as a foreign body by the patient or their family.
We then remove the silk suture.
In this case, we’ve decided to give an injection of anaesthetic agent to allow for better recovery in the post operative period. This is given in a sub tenon’s location.