Surgery: Bilateral Lateral Rectus Recession in a Large Exotropia

This video demonstrates a lateral recession surgery in both eyes in a patient with a large exotropia.

Surgery Location: on-board the Orbis Flying Eye Hospital, Accra, Ghana
Surgeon: Dr. Harry O’Halloran, Rady Children’s Hospital, San Diego, USA



So this is a patient who has a large exotropia. His eyes drift outwards. He has no pattern to his exotropia. He has a large deviation. I think he measured around 50 prism diopters. So he had in his pre-op evaluation — they did what we call prism adaptation for him, to see how much of his deviation to actually correct, and we found that if we corrected him for the full 45 diopters of exotropia, he would have double vision, and he’s 16 or 17. In some of those patients, the double vision never goes away. So you have to do a prism adaptation test and make sure there’s no double vision. And because of that, we’re gonna correct him for 35 diopters instead of 45, because that’s what he tolerated. We’ve done a conjunctival incision. We’ve gone in and isolated the lateral rectus muscle. I know that a couple of things — I know I have the lateral rectus muscle here, because when I pull on this muscle, the globe moves over in its entirety. And to know that I have the whole muscle, if I push back the conjunctival tissue on this side, you can see bare sclera here. So there’s no residual muscle up here. And then I push it on this side. There’s bare sclera on this side. So I know that I have the whole muscle here. And you can actually — if I lift this tissue up — you can see the inferior oblique right down there. We like to use a double ended vicryl suture, so that we can pass in at least two locking sutures. One on either side of the muscle. I’m gonna go through my loop here. Catch the needle. And pull it through, so that side is locked. What you’re trying to make sure here is that you get the whole muscle in, and that you achieve hemostasis. So on this side, I’m just gonna do it slightly differently to show you. I’m gonna come in from underneath, and come through the muscle again, and that way, I know that it’s a full thickness pass through the muscle, and I have the entire muscle. Again, we’re gonna lock it down. Pick up both vicryl sutures in one hand. And what I always say to people who are learning is: Always hold what you are gonna suture, and always hold what you are gonna cut. So I’m gonna cut myself, but I’m holding the muscle in the muscle hook, and I’m holding the sutures in my hand. If by accident we cut the sutures here, we know that the lateral rectus muscle is still attached to the inferior oblique muscle. So this muscle won’t slip behind the globe. The only muscle that will do that is the medial rectus muscle. We have evaluated the patient preoperatively. We know how much deviation we want to correct. There are formulas. Just use the formula to see how far back you want to go. And then pass through. So again, it’s not where the needle goes in. It’s where the needle comes out that matters. And then you can see that I’m holding this needle flat to the globe, and I’m exerting a little bit of downward pressure from the blade of the needle, onto the globe. That pushes the sclera underneath the needle down, and gives me a little sort of hill of sclera right in front, to advance into. You do not want to point the needle down into the globe like this, because the only place for that needle to go then is basically into the eye. Again, flat to the globe. You can see almost a little indentation that it makes. We’re gonna advance it. Again, it doesn’t matter where it comes out. It matters where it goes in. Right here, I can see that needle the whole way through the sclera. So I know for sure that I have not gone too deep. When we pull gently on the sutures here, you can see that the muscle comes all the way up to where I made my mark. Not where the needles come out. And then we’re gonna just hand tie here. A lot of strabismus surgeons like to instrument tie. I think just hand tying is just easier and it’s more efficient for me. But we all have our little quirks. Again, we’re gonna leave this a little bit long, because it is covered by conjunctival tissue. Now we want to close the conj. So I like to get two pickups, and just sort of look and see what makes it neatest. And if you did a nice incision to open, you’re usually able to close with just one suture. So I think that looks pretty nice there. I’m gonna put our suture through. And we’re gonna hold that conjunctival tissue with the needle driver. Pick up the other side. Pass it through on the conj here. That’s a little bit of a small bite. A better bite. And then I’m gonna pinch the two pieces together. And then pass my needle through, and that way I hopefully will not have to regrasp and just make a whole bunch of extra movements. Here’s my needle. Pull it through. And then we’re gonna tie this one again. We tie short, because it sits right on the surface of the eyeball, and we don’t want it to cause mechanical irritation. A lot of people describe after strabismus surgery that they feel like they have sand in their eyes. Which is a pretty reasonable description. And probably part of that sandy feeling is the suture. So we’re gonna cut it short. So in this case here, you can see that we have a nice closure on that side. We’re gonna give a subconjunctival injection again of Marcaine. We want the injection to be away if possible from the surgical site. Because you’ll see this is gonna cause a big bubble, and I don’t want to put stress on the suture. You can see the start of the bubble. I rest the syringe on the nose, because a little tendency here is once people see the bubble start to form, they like to advance the needle in and in and in, which clearly can be a problem. I like to rotate the head a little bit, just to suit myself. Pick up the tissue. And we’re gonna make a little snip. And I like to say: Make every movement count. So we’re gonna go in with the Westcotts, and spread a little bit. We’re gonna go in with one blade here of the Westcotts. I haven’t cut. And then I’m going to cut. And then I’m gonna rotate my hand around, as I cut. And that gives you a really nice peritomy, with just two movements of your hand. I want to spread down between the inferior rectus and the lateral rectus. I do not want to spread over the muscle. Because if I do, it will bleed. And I pass down, and then at the end, we just open it up with a little bit of pressure on the Westcotts right there. Jameson hook. I like these, because they have a ball on the end, which means the end of the hook is blunt. So you’re less likely to just tear the tissue as you go through. You can see when I pull on this the whole eyeball moves over. So I know that I have the lateral rectus muscle there. It is possible that I will have some fibers of the inferior oblique, and we’re gonna look for that. Now, I want to clean off that muscle hook. So just using my pickups, pull the Tenon’s off with the pickups, because Tenon’s is sort of tough and elastic. And then we just do this Q-Tip dissection. And it just pushes all the tissue away. And see that Tenon’s — because he’s a young, healthy man, his Tenon’s is pretty sort of elastic. And I don’t have as nice a clearance yet as I want. These Q-Tips only work if they’re dry. And I still have a little bit of tissue here. So I’m gonna just snip it. I’m holding the muscle. So I’m gonna snip parallel to the muscle. So I’m unlikely to cut any muscle fibers. And then I’m gonna get my Q-Tip again, and push that. My Ghanaian assistant is going to isolate this muscle for me and recess it. So again, she’s holding the muscle with her non-dominant hand. You want to clearly pass the suture through the muscle with your dominant hand. She’s passing the needle through in a way that she can catch it again. And then reuse the needle without having to reposition the needle for herself. We used, again, some phenylephrine, right when the patient was induced. That basically cuts down substantially on your bleeding. We’re gonna do another locking pass from the other side. So you’ve got inferior and superior. And because you lock these, even if one side was to break, because the suture is locked, it’s unlikely to slip. We always say: Make little snips. You can see how thin the sclera is right in that area. The thinnest sclera on the globe is right behind the insertion of the muscle. And you can see a teeny little black mark right there. She’s pushing the blood out of the way with the edge of the blade. And right there, that little black mark. And that shows you how thin the sclera really is in that area. Again, a really nice pass. She holds the blade flat to the globe. That was a long pass, but you can see the pathway the whole way through. And again, people sometimes get confused, and they say… Well, wait a second. That’s not a 7 millimeter recession. Again, it doesn’t matter where your needle comes out, which is probably 2 millimeters. It matters where it went in, which is back here at 7 millimeters. You know, there are multiple surgical planning tables out there now, so what we say to people is: Look, everybody’s technique is a little bit different. So pick the tables that you like, but stick with the same tables. And then adjust based upon your own postoperative results. Right before we tie this down, you can see that the muscle, the knot, is not on the globe. So we retie the first knot on the surface of the globe. That way, we know that our recession is an accurate amount of recession. You can see here the patient is getting his subconjunctival injection on the other side. And then we’re gonna give him a little bit of Maxitrol ointment.

November 21, 2019

Last Updated: October 31, 2022

Leave a Comment