Surgery: Inferior Rectus Recession

So this, young boy presented with an esotropia but also a hypotropia.

What was interesting is is that his deviation got worse when he looked up.

As you look under anesthesia, it’s hard to tell what the position is. So the most important thing is is that we prepped both eyes, and so we’re gonna do force reduction testing. So we’ll start on the unaffected eye, and then we’ll grab and I can elevate that eye just fine.

And I can adduct it, and I can AB duct it, and I can depress it. Now this eye, you can see look at there’s a little bit of eso bias. It’s already going in.

The eye is going down a little bit. I wonder if the anesthesia just got a little bit lighter there for a second. Because look at how the eye has changed since we first started. When you see a change in eye position, that usually means there’s some change in the gas.

But you can see this eye now is still more down than this eye. You get a little bit of tonic contraction.

So now I’m gonna push this eye. No problem.

No problem.

The eye is going down, so, you know, that’s not gonna be a problem.

But then when you go to look up, it doesn’t wanna go up. It doesn’t wanna go up in any direction.

This is your classic monocular elevation deficiency or double elevator palsy.

So the treatment for that is relaxing the tight inferior rectus, which is what our our surgical plan is going to be.

When you are working on the inferior rectus, you don’t have to make your incision right at the limbus. You can go down a little bit closer to the insertion.

So what’s the main condition that’s in the differential diagnosis of monocular elevation deficiency?

What’s a colorful name? It’s Brown syndrome.

So Brown syndrome also be called as superior oblique tendon in the cheek syndrome is where you cannot elevate the eye in a deduction.

But in Brown syndrome, you can elevate the eye in a b duction.

The difference is is that in monocular elevation deficiency or double elevator palsy, the eye won’t go up in either a deduction or a deduction.

What’s interesting here, there’s a lot of blood vessels around this.

When you operate on the inferior rectus, one of the most important things to consider is its connections to the other paravergal tissue. This is particularly important when you do large recessions on inferior rectus when you’re doing thyroid eye disease.

Look at this white adhesions between the periorbital.

See those adhesions there?

You wanna just cut those away so that you don’t get retraction of the lower lid when you’re doing, like, a thyroid case.

What is this look way down at the base here. Vortex vein. That’s right. And so that’s why when you’re doing your dissection of the quadrants, that’s why I like to do my dissections this way, not this way. Because you can imagine if I did this, if I stuck this in, I would tear that vortex vein.

And if you tear the vortex vein, it makes a mess, but it’s not dangerous. It doesn’t cause any damage. It doesn’t damage the eyeball.

It just makes it very ugly.

The insertion itself looks a little bit fibrotic.

Again, we’re gonna put imbricate our muscle the same way.

How will a child with Brown syndrome present?

They’ll have a abnormal head position sometimes. Right?

So if they have a hypotropia, what position will they take when they come to your clinic?

You know? Kids don’t complain about the topopoeia very much, but they will come in with a anomalous head position.

So what will their head position be?

Will it be chin up or chin down?

Chin up.

Because the eye won’t go up, so they have to lift their chin up to avoid the double vision.

You confirmed the diagnosis of Brown syndrome actually in the operating room by doing the forced actions.

What’s different than what the forced duction we just saw is is that you would notice that there’d be an inability to lift up the eye only in adduction. You’d be able to lift up the eye fine when it was in abduction.

So we can see we have the muscle indicated in the usual fashion.

Now you see how I’m making small snips?

If this is a thyroid case, if it was a thyroid case, long standing, strong, stiff muscles can make the square very thin, and you could inadvertently cut through the square.

Now the other thing that’s important to know in this case, this child, he had a ten percent doctor hypotropia. He also had about a ten percent doctor esotropia.

Now when you have a tight inferior rectus, you can also have esotropia.

So after we take care of this tight inferior rectus, is esotropia will go away as well.

And so what we’ll do now just to convince ourselves that indeed that was the problem with the muscle, we’re gonna just do our force duction again.

And see how the eye goes up? Easy. So that proves that that was the the culprit. That was the the issue.

Look at how quickly that it’s changing there because the the the sclerostin right there. And that’s where where I wanna put my suture, so I make it look more better.

When you do your square bites, you don’t have to rush. I’m gonna take your time.

And you can see it’s a little bit deeper in that one.

Horizontal strabismus where we have surgical tables.

Vertical, the tables aren’t so good. But the bottom line is you get about three diopters of shift for every millimeter you do.

He measured about a ten prism diopter hypotropia, so we’re gonna do a four millimeter recession.

I tie this securely. I’m gonna just put a bow knot here, and I wanna repeat my forced duction.

I wanna make sure it’s still loose so I can still elevate the eye.

So now that I’m satisfied, I’m gonna tie it securely. So I’m gonna take the bow out. So if I do a super oblique tonotomy, they will no longer have a hypotropia.

They’ll come in a week later, and they’ll have what?

They’d have a hypertropia now because I’ve given them a fourth nerve palsy.

So some people, when they do a Brown syndrome, they’ll do a superior oblique tenotomy, but at the same time, they will do a inferior oblique myectomy.

Some people do that at the same time. Some people do that sequentially.

Some people for Brown syndrome, instead of doing the superior oblique tonotomy, they will put a superior oblique expander, where they cut the tendon and then sew silicone band in between the cut ends. So it lengthens the superior oblique tendon without completely paralyzing it.

We’re looking at his, fornix. We wonder if this is related to his muscle problem.

Yeah. You don’t want to do too much recession ever on a inferior rectus because it can lead to problems in down gaze, and they will have problems walking.

You never wanna recess the infarrectus more than about six or seven millimeters.

We’re just looking at the vortex. See here, he’s got a deep sulcus there.

Look at this. So it looks like he has OCP, and hopefully, he would not need that relaxed.

I’m not gonna cut it because his lid wasn’t his problem.

It makes you wanna just go but if you did that, you would probably have to put amniotic membrane, you know, to prevent it from scarring because it would scar if you just cut it.