This video demonstrates bilateral medial rectus recession in a 4-year-old girl with esotropia.
Surgery location: on-board the Orbis Flying Eye Hospital in Binh Dinh, Vietnam.
Surgeon: Dr. Rudolph Wagner, Rutgers New Jersey Medical School
DR WAGNER: So this is a really interesting little girl here. Her name is Li. And she has esotropia, bilaterally. She has probably a restrictive component to it. You can see, when I open her eyelids a little bit, that even under this anesthesia, her eyes are significantly esotropic. Which usually is not the case in most kids that don’t have a restrictive component. They’ll go exotropic. The eyes will go out or they’ll go straight. If you want to translate that, that would be great. Yeah. Not too bad, though. But it’s better than I thought. Sometimes they won’t even move. So I’m doing a traction test. Forced duction test. I’m grasping the conjunctiva at the limbus. And I’m gonna try to move the eye. Into adduction. And now into abduction. It is restricted. It won’t go — it should go farther, all the way over. But it won’t. Yeah. So that means that we’re gonna probably encounter a little bit of a restrictive component. But we’ll find out after we disinsert the muscle what we can do. Yeah. It’s hard to position this, right? So we’ll put the traction suture in here. You have to make sure you have a pretty good bite, because when it’s restricted, if you just get superficially, the traction suture will come right out. Okay. So I’m going to make an incision, a limbal incision, through the conjunctiva. And what we did today — we put a little bit of phenylephrine in there. For some vasoconstriction. A nice tunnel in there. Making a tunnel. And we’ll make one over here. You want to avoid the muscles, because that’s when you get the bleeding. Now, this is gonna tell us a lot now, how easy it is to hook it or move it. We’ve got the muscle. And I would say — I would say this is definitely restricted. Hold that. There. Try it. See what I mean? That’s tight. It’s tight. We should be able to move that eye all the way over, you know? So this is the appearance of a muscle that has a restrictive component to it. You’ll see it. Sometimes you’ll see it in cases like thyroid. Or they’ll have similar findings. You can hold that hook for me. I’m gonna take a small hook… And a Westcott scissor. Do you have that smaller one? Is this the one I asked for? I wanted to try it and see. That’s as small as they come, huh? You sure? I guess it is. Let me see that one. Yeah, this is a little bit too big. This is a little smaller. Right. A little bit… Very good. Now, let’s go here. Now we’re gonna cut that. We’re gonna go here. Losing it a little bit here. Wait a minute. Gonna go back. Yeah. Bring it that way. Get the connective tissue. This is just connective tissue here. Maybe some bands, like, attaching the muscle there. Let’s see about this. You can go with the cotton tip in there. This is not exactly normal anatomy, because it’s very restricted. Right? So I’m using the cotton tip. I don’t feel like cutting anything that I might need later. So gently just pull this away. Sort of like the retina people do it. The retina doctors like to do this. They like to shove the cotton tips in there. Let’s see how that works. Now… That’s better. But it’s very tight. So sometimes the challenge is getting the suture in. There’s a couple different ways to do it. You don’t happen to have the hook with the groove in it, do you? See if we can trim that off. Let me see what that looks like. Let’s trim this off. Get the Westcott, Dr. Phan. I want you to just trim that for me, okay? Good. Okay. Let me see this hook with the groove. Let’s see how it looks. No. Yeah, okay. So the other way to do this is this. There’s a couple ways. This is — normally when you do a case like this, a muscle — and you’ll see on the next case — you can move it all around. You can get plenty of room to put your suture through. But this is difficult, because it’s very, very tight. So there’s a couple ways to improve that ability. One is to take a small hook like this — a Stevens hook. And pull it that way, toward you. You hold the small hook in your hand, okay? And that’s gonna give me a little bit more room to put my sutures through. Let me see that. I can’t see it. Yeah. A groove. That might work. Yeah, let’s try that. Okay. We’re gonna try something here that we have. It’s a hook that has a groove in it. A groove. Do you know what that is? You’ll see. No, you see this? I can put that under muscle, and then the suture — you don’t have to worry about going into the sclera. It might be too big. It’s not bad. You’re gonna hold that for me, right? Okay. Like that. It might work okay. A groove. A groove. G-R-O-O-V-E. Groove. Now, let me have the suture, please. Okay. So you see… I can go in the muscle like this. One minute. There we go. So you see the advantage of this. Why I’m using it. Normally — I mean, it would be very hard to get underneath that muscle without going into the sclera. So I’m gonna go like this, underneath. In the groove. Like that. And I’m protected. Yeah. So do you understand why I’m doing this? I mean, everybody understand…
>> Yes, we understand that. Yes. Because the…
DR WAGNER: Because it’s hard to do this…
>> You protect the sclera.
DR WAGNER: Yeah. Now, let’s slide it over this way a little bit. Okay. Okay. Now we’re gonna go back in the groove again. Coming out the other side. All right. So whenever I’m gonna do a thyroid case, thyroid muscle, I ask for that groove to be ready to go. Sometimes you need it. Sometimes you don’t. I don’t know what’s going on here. So I think we got it. Pretty well. Now we’re gonna take this hook out, because it’s too hard to cut with that hook. Okay. Good. So if I didn’t have that instrument — why don’t you hold that tight that way? What I would have done is used a small hook — Westcott, please. The scissor. No, no, no. I’m saying what I would have done. It’s hard. You have to be careful. Go this way. Little bites is always safer in a case like this. Go back this way a little bit. I like this way better. It’s easier to see it. Make sure the sclera is okay in the niche there. Get those little “foot processes”, we call them. And let’s see what we’ve got. So it’s not so easy, see? Everybody is breathing. But we have it nicely. But it’s hard. It’s still tight. Yeah. Yeah. Let’s see. Let that dry a little bit. Let me have the cautery. Let me clean that up a little bit. Ooh, that’s a hot one. But that’s good. When it’s real hot, what you do is you press it, get it hot, take your finger off, and then use it. See what I mean? What I did?
>> Is it a handheld cautery?
DR WAGNER: Off. Still hot enough. You have to know that ahead of time. Otherwise you’ll have a little trouble.
>> Is it a handheld cautery? No?
DR WAGNER: Look at how even in the sclera — look at that dark band there. That means the muscle is really adherent. It was tight. It was plastered there. So let’s see how it moves now. If you hand me the forceps — okay. I’ll grab it here. That’s better. It’s definitely better. I think in this case, though, we may be better off to hang it back. I think it’s a little safer. So rather than… So look at the sclera there. You can see it. How thin it is. The dark band. Rather than have to deal with that, we’re gonna put the sutures through the original insertion, and let it hang back so many millimeters. I’m still thinking about how many millimeters. You’re not gonna find any textbook that’s gonna tell you what to do right now. This is just from experience, deciding to make it less tight. So let me see. But usually, since it still is… It can move much better. You can see that. We couldn’t get anything like that before. So… Clean it up a little more, that sclera, with the cautery again. I want to just get this real nice. Gotta be real careful with this one. That’s good. That’s better. Okay. Good. All right. So let’s see. So now we’re gonna… So we’ve decided we’re gonna hang this back. And I think that… About 6. 6.5. Yeah. I think that’ll be a good number for this. Yeah. And I’ll have the needle holder back. We don’t need that yet, until we let it hang back. Right? I just need the — my needle holder back. I want to poke the suture. So… Okay. So what we’re gonna do… Is we’re gonna reattach it. And I need a little bit more room over this way. So this is almost like a congenital fibrosis of the medial rectus muscle, or could be a type of Duane syndrome. But there’s different types of Duane syndrome, and this would be a restrictive type. So I’m gonna go right into the insertion here. This is where it’s thicker here. Okay? I’m gonna go back here. Make sure I have enough tissue. Doing this by feel. I don’t want to go too deep. But I’ve got to get enough to hold it. Let’s see. I think what I’m gonna have you do is… Well, let’s see. Now, if I grab it there, I’ll be okay. Just got to make sure I have enough traction to move it. You know? That’s gonna work. Good. That’s good. I always check it like this. If I lift up and it feels like I have a substantial bite, then I’m okay. I’ll get the other one. Okay. Let’s go about here.
>> Dr. Wagner, as a reminder, we have a translator who’s working quite hard up here to keep up with you. So when you’re speaking, if you could just pause after a sentence or two, that would be great.
DR WAGNER: Sure. Even the sclera is not 100% normal here. You know, this is all… It’s thick. It’s fibrosed. So okay. So now we have — we decided to go through the original insertion, to bring it up. So now we can decide — look how much it wants to go back. So I have to advance it. Like this. So now we’re gonna… I think I’ll throw my first loop in there. Then we’ll put it where we want it to be. It still wants to go back. Right? This is a hard decision. You know? So I’m gonna make one loop. And then we’re gonna figure out where to put it. Okay? Now, let’s see. Okay. So let’s get the caliper. Let me release… I’m gonna release this… Well, I don’t have to release it. Let’s see. Let me… Get a little bit of a view here, where it is. I’m gonna bring it over. It’s gotta come up, right? That’s more than 6.5, it looks like, to me. Although I would measure… I’ll tell you where I would measure it from, Dr. Phan. I think, when we measure it, let’s measure it from…
>> The limbus?
DR WAGNER: No. I think it was attached — that was probably effective insertion. A little bit behind the insertion. So we’ll measure 6 from there. So let me bring it up this way. It’s still far back. Let’s see. I don’t want to get in the way of the camera here. Let’s see. That’s probably pretty good. Let’s see how that is. Yeah. Get that free. Yeah. If you can break that little adhesion there. So we’re gonna take… That’s pretty good. About where it is. It’s a little uneven. A little bit more there. That’s good there. But this one I want back a little bit. Right? So let me have the needle holder. We’ll do this. If we can. I think that’s maybe gonna be better. A little bit. Gotta be careful. You don’t want to weaken the suture either, you know what I mean? But I think that’s pretty good now. What do you think? Yeah, a little bit more. Okay. Let’s check it again. That’s gonna be good, though. Let’s go from the middle there. We could go back a touch. Right? But not too much more.
>> Reduce the calipers?
DR WAGNER: We don’t need them anymore. Right now… That’s perfect. That’s good. Okay. So now I have one loop down. So it shouldn’t slip. And I’ll put a second one in. There we go. Tie that up. And one more. Gotta come underneath. Okay. This is a good knot.
>> How many knots do you use?
DR WAGNER: I did 2-1-1-1. Sometimes I do 2… Most of the time I do 2-1-1. But this is a tight one. Okay. Here we go. Now, let me take a look at the conjunctiva. Can I have the other forceps? Thank you. I’m gonna recess it a little bit. I’m gonna cover the knot, though. Gonna recess the conj. There, like that. And I’ll tuck it under. Something like that. So I’m not gonna… I don’t wanna recess it too much. I want… We’ll be okay. Yeah. Sometimes… We’re discussing whether we should recess the conjunctiva a little bit. But because I had to put the suture so anterior, I’m gonna just… I want to cover the knot. So I’m ready for a plain suture. I think that’s pretty good. Yeah. That’s better. You can see the pupil dilates — we used phenylephrine, and it helped. Helped quite well. To stop the bleeding, preventively. Some people like to do the phenylephrine too, because when you do that, if you need — want to take a look at the end of the case, for whatever reason, you could get an indirect ophthalmoscope, and look at the retina, if you wanted to. So let’s go over here. I’m not gonna go all the way up. I’m gonna bring it here. Like this. What’s that? Oh yeah. Maybe. But some people want the pupil dilated a little bit. Okay. I got caught up a little bit on the conj. There we are. I’m not even sure if that’s… I want to make sure that’s not Tenon’s there. I don’t know if I like that. I’ll take that out. I want to look at this. I’m gonna wet this. And now we can see — by wetting it, now we can see what’s connective tissue and what’s… Still not 100% convinced. Let me get both edges of it. It’s hard to tell. This is where it’s gonna be, right? Yeah. I’m gonna hold it. You hold that for me. Okay? Good. Good. Then I’ll put that to here. Okay? Oops. Other way. It goes like this, always. I’m trying to get it. There we go. Okay. So let me take a bite here. Okay. And right here… Let’s hope that’s gonna work. I think so. So a little trick is to wet the conjunctiva with the BSS, and if it’s the Tenon’s capsule, it fluffs up. It looks different than conjunctiva. Like, there’s a little bit of Tenon’s there. But that we’ll probably tuck under. We can always cut it off, too. Okay. We need a little trim there. Very good. Now, bring that over this way a little bit more. So I can see better. Let’s do the same thing. So I’m gonna load this up again. I’m gonna need that in a minute. Let me see where it’s gonna go. I think that’s good. Right? You hold this one. This time.
>> Excuse me. There are some questions for you. These are online questions. Excuse me?
DR WAGNER: Yes. I’m listening.
>> Okay. The first question is: What do you think is causing the restriction in this case?
DR WAGNER: Okay. Well, that’s a good question. There’s a few different possibilities. Okay? One of the things that this child had, that we saw today, when we were evaluating her again, is that there’s a little bit of an upshoot in the adducted position, in both eyes, when she attempts to adduct. You got that? So that makes a distinct possibility of it being a type of variant — of, like, a Duane syndrome. Possibly.
>> Twin? Twin syndrome?
DR WAGNER: But it seems to be that there’s more of an esotropia than you normally would get in Duane syndrome. So I’m not 100% sure that that’s what it is. It could be a type of congenital fibrosis that occurs, because that was a very, very restricted and tight muscle also. I don’t know. What do you think? I see the vessel, but I’m not sure. I think it’s just a blood vessel. I’m not sure. We’ll see the other way.
>> You had another question. Which is cosmetically better? Limbal conjunctival incision and conjunctival incision over muscle insertion?
DR WAGNER: Which is better for the incision, you said?
>> The limbal incision and the…
DR WAGNER: Which is cosmetically better? It depends. In this case, if we would have tried — you know, look, the limbal incision can be fine in medial cases. In laterals, I like to do sometimes a cul-de-sac or a fornix incision. But I have to tell you, if we tried anything but a limbal incision in this case, we would have had to go do a limbal incision anyway. We were not gonna be able to do that through a cul-de-sac incision, because of the tightness of the muscle, the conjunctival tightness — it would have been difficult. So you have to be able to — you can’t just say which is better or which one you want to use. You have to know how to do all of them, and you have to pick the right one, on the right patient. And this is one where we needed exposure as the most important thing. We want to see what we’re doing well. And this was the best way for that to happen. You can use the same one. That’s okay. She’s still not straight, but that’s okay. But I definitely would not resect the lateral muscles in this case. That’s too much to do. So we got better movement here. And I’m happy with everything I was able to do. In that eye — we’re gonna do the same thing in the left. You know, when you watch this kind of surgery, all strabismus surgery is not the same. If you watch the next case, you’re gonna see a big difference in the ease of hooking the muscle and passing the suture. This is a difficult case for those reasons, because of the restriction. Do you think we can adjust the lights a little bit, maybe, to this eye, if we can? Even the conjunctiva is, like, thicker. Yeah. Firmer. It’s like… Everything is just a little bit different, in this case. You know? Like, it’s hard to go through, even. It’s not, like, a smooth needle. It’s hard. But that’s good. Got what we wanted to do.
>> Another question.
DR WAGNER: Yes?
>> Okay. When you suture the muscle’s tendon, you do this very near to the insertion. Why?
DR WAGNER: I’m sorry. I didn’t hear your question.
>> Okay. I’ll ask it again. When you outer the muscle tendon, you do this very near to the insertion. Why? This is an online question.
>> She said you inserted the suture very near to the insertion.
DR WAGNER: Why did I do it near the insertion? Oh, because I wanted to let the muscle hang back. I thought it would be more difficult to position the eye to pass it through the suture — I mean through the sclera — posteriorly, and I didn’t like the way the sclera looked. It was thin. It was — you know, it was more dangerous. So many people, when they do surgery, they just hang them all back. They always attach it at the insertion, and just let the muscle hang back. I tend to modify it depending on what I need to do. What I feel is best for the individual patient. But that was the reason in this case. It was harder. You want to — and I’m not worried about that muscle coming forward, because it’s so tight that it’s not gonna… It’s gonna stay back. Wherever I put it, it’s gonna stay there. So I expect to find the same thing here. And it’s just as tight.
>> And the last question is: What is the maximum medial rectus recession you do in your practice?
DR WAGNER: It’s very tight.
>> The question is: How maximum the recession of the medial rectus —
DR WAGNER: Can you do? In general, I don’t like to do more than 6.5 in anybody. Maybe I’ve done 7 in some cases. 7 millimeters. But I always measure from the posterior edge of the insertion. We’d use the small hooks. But in this case, we just decided to do 6.5, just based on the tightness and what was going on. You have to be careful with these kinds of restricted cases. If you do too much, and it happens to be a Duane syndrome, we’ll end up with an exotropia, because of the minor adduction problem that she may have, that we can’t even see yet, because her eye’s never been in a position to determine that. That’s better. Now I’m gonna try to… You can take those two out. You can take those hooks out. I’m gonna clean off a little bit anterior to the insertion. Hold that hook like that for me. Okay? So we’re really encountering the same thing. It’s really restricted. You know? Get a little better visualization this way. Okay. Now… So we’ve used that grooved hook. We’ll probably use it again. But I want to show you — the other way you could do it is… Dry it like that. And you can put this small hook in here and spread it. You see what I mean? So if you hold that, then I could get my suture in there. But since I have the groove, I’m gonna use it. Because it’s safer. This could be the most useful instrument in all of Vietnam, if you get one. Because when you have — if you have a case like this, with thyroid cases, it’s very useful. And it has grooves on both sides. So you can use it either way. See? Which is really nice. You want to get that out of there. Very good. Ready for a suture? Double-armed vicryl. Gotta get the light a little bit better. No, that’s good. I think you’re blocking a little bit. That’s okay. Stay… If you’re right there… Just come more superior than inferior. Okay, good. Now I’m gonna go… I’ve got it. I’m gonna go like this. I’m gonna stay in the groove. Go this way. I can’t get it. If you hold it for me, that would be great. Let’s see. I think it will be easier. Always better if you have a good assistant. I’ve got a good one. Okay. Let me see. Now I’ve got to hold — I’m gonna come from the side more. I’m gonna go right here. This will work here. Okay. About halfway through. Now I’m gonna lock it. In the groove. Behind it. And make sure I’m… You’ve got to really make sure you’re below the muscle, you know? That’s it. Of course, when you lock it… That’s too much. That’s better. That’s good. Pick it up through the loop. And that should lock it. That’s good. I’m gonna get rid of that eyelash. Don’t want that. Okay, good. I can’t really see the groove. Let me hold it this way again. Let’s see. Let me dry it. I have it. I just want to dry it a little bit. Okay. There’s the groove. Now I see it. Good. I’m gonna try this way. So this is a nice instrument, isn’t it? It really saves you a lot of stress. I’m glad you had it here. I should have thought to ask for it ahead of time. But I didn’t realize how tight it was gonna be. But I always tell people that when you operate on Orbis, you can’t think of anything you would want that they don’t have. And I think that’s kind of true. Today, anyway. Gonna go behind it. Go deep. And come out. Good. That’s good. So that’s easy. But it’s — it’s easier, but it’s still not easy to just disinsert this muscle. Because you don’t have, really, much room to cut, between the sclera and the suture. But I’m gonna go with a big hook, again. The regular hook. Because it’s too hard to cut through that grooved duct. So I’m gonna hold it like… Let’s see. I’m gonna have you hold the sutures like that. Now I just need a… Scissor. Okay, good. So let’s get under it a little bit. Just being very careful. Nice and slow. And when I have the residents — I’m teaching the residents — they all like to go… One shot! And it’s not a good idea. They say it’s not… They say this can’t be harder than a cataract surgery. So I can do it any way I want. But they learn fast. Always do it carefully. I always like to feel what I’m cutting. I’ll dry it a little bit. The light’s not so good there for a second. Let’s see. That’s better. I think we got it. Right? Look how thin, right? Yeah. I mean, you know, it’s really, really, really hard. Look at that sclera. Blue sclera. Thin, again. It’s from that tight muscle, pulling on there. And just weakening the sclera. You know? Look at that. See that? Yeah. Let me have that cautery. I certainly don’t want to cauterize over that blue area. That’s for sure. Let’s see. Yeah. See what I’m doing? I take my finger off before I touch anything. I don’t wanna start a fire in here. That looks good. So we can work with that. Let’s see how… Yeah. It moves better. It’s better. I’ll grab it and see if I can move it a little bit more, just to show everyone. Here we go. Here and here. I mean, it’s better, but it’s still not like normal. You know what I mean? But it’s much better. So probably I would put this more in a category of, like, a fibrosis. Congenital fibrosis of the muscle. Yeah. And those… More often, that type of — those types of case involve the medial — I mean the inferior rectus muscle in kids. Sometimes I have a lot of those fibrosis cases. And there’s actually some thought — and I’ve seen this published, and I’ve seen cases where I might believe it — that sometimes with the fibrosis cases, the mother had thyroid disease.
>> The mother had thyroid disease?
DR WAGNER: I don’t know about this case. I’m not saying that in this case. But it’s a postulated mechanism for fibrosis. Congenital fibrosis. Because, you know, the Graves’ disease gives you a really fibrotic strabismus.
>> And it can affect the baby?
DR WAGNER: There’s a condition called Mobius syndrome. M-O-B-I-U-S. Which presents similarly to this, with really restricted muscles. But they often have facial nerve palsy too. Kind of close. But I don’t think there’s any other option than to put the suture there. I can’t go farther back, you know? Right? It’ll be too — I want to get in the substantial tissue. So let’s see how that looks. Look where it wants to go. It wants to go way back. Maybe I’ll leave this one back a little bit farther. I don’t know. I guess we’ll do the same. We’ll go 6.5 again, right? I mean… So let’s see. Let me put a loop in here first. See, if you weaken the medial too much, you can really produce adduction difficulties. Even in a case like this. So it’s a decision we just have to make, how much we want to do. And… Let’s see. Okay. Lift that up. Let’s bring it up a little bit. That’s probably okay. But we’ll measure it again. Needle holder again. So the same thing — it makes much more sense to let it hang back and put it where we want to put it than to try… It might be you have to come bring it up a little bit. I don’t know. It looks like it maybe has to come up a little bit more, huh? Let’s see where that is. I mean, it’s even hard to get a look in there. Can I have the caliper? Let’s see. Can’t even get it flat in there. So, you know…
>> It’s a little bit big.
DR WAGNER: Yeah. That’s not a straight way of measuring it, but I think if I do the 6, I think it’s gonna be okay that way. I think that’s where it should be. Can we pull up a little bit? Yeah, that’s good. See it now? Yeah. Let’s leave it right there. Good. Okay. I’m just gonna… When I lift up, I don’t care if the knot moves. Because it’s gonna slide back to where it needs to go anyway. So… Let’s get this back here a minute. Okay. It came up. No. I don’t wanna do that. I’ll move it back before I cinch it. Yeah. Let me grab the insertion. I want to adjust it the way I want it to be. You know, in an adult, something like this — you could consider adjustable suture. But even that’s difficult when they’re very tight, the muscles. You know what I mean? You can’t adjust a kid unless you brought them back to the operating room. Let me cut the needles off. Because I want to do something with this. I’m gonna tie it another way. I don’t wanna tie it my regular way. There’s one. I’ll get the other one in a minute. You got that? We’ll go the conventional way for had. A little easier. It won’t move any more, the muscle. That’s good. Okay.
>> So there is a question for you.
DR WAGNER: Yes.
>> In case of undercorrection, this may mean the patient —
DR WAGNER: Oh, that’s a tough one.
>> What should you do?
DR WAGNER: Well, you’d have to really — the question is, if the patient still has an esotropia after this, what would you do? Well, I wouldn’t do anything very quickly. Because even if it was a little bit eso, it wouldn’t surprise me if it… Because we weakened the adduction so much that it got better over time a little bit, but if I had to go back, and it was still there, I think you could resect the lateral, but it’s really hard. Because you might produce a restriction if you do that. If it’s a Duane syndrome. So I think what’s gonna happen… And I’ll talk slowly on this… Go ahead. You can say what I’ve said, and then I’ll say what I think in a minute. I’ll stuff that under, when I attach it. I think I can get it this way. Let me have the plain suture, please. So anyway, so to answer the question, so then let’s say there still is esotropia over time, and you have to do something else. You’d have a better idea what she really is, now that at least her eye can be more centered, so we’ll at least know more clearly what condition she had, or what approach we might use.
>> How about lateral rectus resection?
DR WAGNER: Yeah, that’s what you think about. The only thing is, you have to be careful. Because if it happened to be a Duane syndrome, you can produce more retraction. I don’t think so. I don’t think that would be the case. I think most likely I would do a lateral rectus resection, if that were the case. But, again, you might go in there, and the muscle might be tight too. It might be a similar situation that we’re encountering here. It might be not a normal muscle. So we’ll see. I’m hoping this will do quite enough for her, and I think it will.
>> Okay. But… I’ll wait for the question. I’ll be able to tighten that. A little near. Yeah. One of my assistants here has asked me if I thought maybe the insertion was a little bit closer than the normal 5.5. Yes. I do think so. But it’s a smaller eye, you know. And sometimes you’ll see that. Usually, when she’s awake and she goes a little bit eso, it’ll be covered. I mean, I could bring it up more. Let me see. We only have one more suture. Let me cover it. Plain. Oh, by the way, Doc, we only have 3 minutes. Okay? I think I’d rather use that ointment. Yeah. I don’t want to do anything back under there that would interfere with what we did. Because she has — not a loose suture, but a suture that’s long and still present. That’s gonna cover it. So there’s the needle. So I think we did what we wanted to do. I think we’re gonna help her a lot. I don’t know that she’s gonna have full abduction after this. Because of the restrictive component of this strabismus. But I think we’re gonna put her in a position that’s gonna be much better for her, as far as binocularity and the position of her eyes and the ability to use them together. And we should be okay. So I think it looks much, much better. I think we’re — considering when we started — and the other thing is, what she has, which is — you know, a lot of Asian kids have, and Latin American and American — a lot of kids have this. Where the bridge of the nose is very wide and flat. So whatever you do, they often have a pseudostrabismus or pseudoesotropia. As they grow older, sometimes it gets a little bit narrower. But it does — it is a common finding. And I spend a lot of my time explaining to my patients that their eyes don’t really cross. But they have the appearance of it. And people nowadays, with cell phone cameras, that’s the most common picture they bring in. They’ll say — is this crossing? Because the eyes — they see a little white in the corner of the eyes. Right? Okay. So I think we’re completed. If she stayed here, I certainly would be… Yeah. And the anesthetic. Do we have that? I mean, if she stays in this position, I would be very happy.