This video demonstrates a bilateral MR recession surgery in a five year old boy 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
DR WAGNER: So this is a little boy with an alternating esotropia, similar to the case I just did. But he has full movements of his eyes. No disruption of his versions or ductions. So he’s gonna have bimedial — we’re gonna recess the right and left medial rectus muscles on him. Clamp. So I’m gonna do a limbal incision on him. I’ll start right in the limbus. Then I just dissect away. Stay away from the muscles. As long as you stay anteriorly, you don’t have to worry about hitting the muscle. Make a little relaxing incision here. And here. Now I’m gonna make a tunnel. Here. You want to always stay away from the muscle as much as you can when you’re doing your inception. Try to hook it. Should have all of it. Now I’m gonna have Dr. Hai, who is assisting me, take two small hooks, one in her right hand, and the other one in her left hand, get in there… You want to get under the connective tissue, like that. Hold it up. Okay, good. Then, since I can’t quite see where the muscle is yet, I just kind of make a small cut, and just sort of dissect it a little bit. Until I’m sure where the muscle is. If I’m really not sure, and I want to know, I’ll sometimes do a little maneuver, where I separate it with the cotton tip, until I see what is definitely recognizable as muscle. Can I have another large hook, please? I want to make sure I have everything here. So I’m gonna go behind this one. Now I do for sure. And we’ll go right there. I think we have everything. Right? You can put your hook a little deeper here. Good. That’s good. A little adhesion. Here. Get in there deeper. That’s good. I think that’s very good. That’s pretty clear now. Okay, good. So now I’m ready for a double-armed vicryl suture. So a lot different from the last case. I can hold it myself. I can position it. I like to hold it, if I can, because you can work it both ways, if you want to position it. But if you recall, anyone who watched the previous case will see that I couldn’t do this by myself. There’s no way. Weave it in the muscle and come out the edge, if you can. Get this one out of the way. Pick up the needle the way I want it. Thank you. Let’s see. Deciding which way I want to go with this. We’ll go this way. So here’s my locking bite, perpendicular through the muscle. Pick it up in a loop. And you want to stay away from grabbing the needles at the tip. You never want to do that. Because it dulls the needle for the most important part. When you have to put it through the sclera. Got that, translator? That’s an important point.
>> Can you say it again?
DR WAGNER: You never want to grab the needle — pick up the needle at the tip of the needle. It weakens the needle. It dulls the tip. So then when you need the needle to go through the sclera, it’s not — it’s not sharp enough. And it might be more difficult.
>> So you mean that I should grab the needle at the… I don’t understand it.
DR WAGNER: I like to do this — what I’m doing now. I like to hold the hook and have the sutures secured tightly like that. Then I feel comfortable when I disinsert it. I can see it better. You know? So in here… Now, you can see this is a big difference from the last case. I mean, here we can see what we’re doing. It’s good position. The view is easy. Easier. Never really easy. But… Not so easy. There we go. Now we have good orientation of the muscle. We’re okay. Connective tissue’s gotta go. So what I’m gonna do is… I’ll get the suture. Thank you. You want to keep it out of the way. You don’t want to get those… So now I’m gonna do this one again. Get it hot. Take my finger off. And then… That’s a hot one, right? Okay. So now let’s take a look. Where is the original? I don’t know if we’re gonna use the… Where is the original insertion here? I’ve got to get a little bit better look at it. Let’s see. I’m gonna dry it. That’s connective tissue. So I think it’s… I got pretty close when I cut it. I think that’s it there. And here. Right? Would you say? Yes. That’s the insertion there. So… What I want next is the caliper. And I want it set at 6. I want good exposure so we can see where we’re gonna put it. Can you get that? Just make sure it’s 6. Okay. It’s 6? Thank you. Needle holder. Needle driver. Good. Okay. Don’t want that one. Okay. Good. I need you to keep that out of the way. Thank you. So I’m gonna go very flat. Engage the sclera. Nice and flat. I can see it the whole time within the sclera, when I advance it. A little bit more. Come out. That’s good. Sometimes I like to cross them a little bit more. But it more depends on the position of what’s most comfortable at that time. Sometimes it’s too difficult to put your hand a certain way. So you want to just make sure you have a good attachment for the sclera. That’s right. I’ve got it. Now I’ve got it. So I’m about a third of the way back. That’s okay. I’m gonna once again engage the sclera at the mark.
>> Can I ask a question? How many deviation?
DR WAGNER: 45 prism diopters. It looks good. Let’s see. This is pretty good, because it’s a pretty nice width. Spreads the insertion… Connective tissue there. Good. That’s good. Can I have the hook in there? Okay, good. Thanks. That’s good, right? Now, you don’t have to… You’re not gonna have to hand tie this. You can cut it wherever you want.
>> So you do 2-1-1 knot?
DR WAGNER: Yeah. There’s one. Nice and flat. Now, the key thing is, when that first knot is down, you cannot change anything. You have to go — all your tying, manipulating, has to be above the knot, so you don’t loosen it. What’s she saying? It’s not all the way up? I think it is. Because the tract is longer. It’s only going up to where the entry point is, right? You see? Yeah, yeah. Yeah. See? But that’s the thing you have to pay attention to. Okay? Gotta cut that. Now we’re ready for the plain suture. Good. Two needles went back there? That looks pretty good, like that. Is that Tenon’s? That is. See? That’s a little Tenon’s. See that? Let me tell you again. If I put this back here, that’s Tenon’s. You look at it sometimes, you’re not sure. But if I let it go, it’ll go underneath. And there’s the conjunctiva there, the way we want it. Right? So I don’t really need to recess this. I’m just gonna put it back here and here. I think it’ll be fine. So let me have a suture, please. Okay. I’ll try to get it on there a little bit. Yeah. Watch your hand there. It’s making it flat. Yeah, thanks. This needle holder is a little bit too big for the… Yeah. It’s too big. See? It’s a little too heavy for that, for what I’m trying to do here. Yeah. That’ll be better. Okay. Get it toward me like that. Make it easier to cut. Very good. Once again, make sure I have the conjunctiva. That looks like it, right? That’s the edge. I think that’s good. I’m not sure. This needle is actually a little small, too. For what we’re trying to do. I usually use a little larger, longer needle. That’s probably why I’m having trouble with the suture. I want to make sure I’m okay. Yeah. We’re okay. That’s good. Too much, you think? You know what? You’ll see. When it goes back to the primary position, it’s gonna be fine. Don’t forget the eye is pulled way over. Okay? You’ll see in a minute. Needle. See what I mean? It’s okay. A little bit — that’s okay. I like it a little bit recessed. Let me take this out. Okay. That looks very good. I think we’re okay. Good. Now, where would you like to sit? Would you like to sit at the head? Would you like to sit there? Or would you like… Which one? She wants to stay right there? Good. Okay, that’s good. Okay. Okay. So we’ve got one done. We’re gonna do the other. And we need the silk suture back again. Here’s the forceps for you. Sometimes the eye rotates a little bit. Let’s see where we are here. So…
>> Excuse me. Can you adjust the camera? Excuse me?
DR WAGNER: Yes?
>> Can you adjust the camera?
DR WAGNER: Sure. Oh yeah.
>> Okay. Thank you.
DR WAGNER: Okay. The needle is a little bit — loaded a little far. Okay, good. Let me bring it up to you again. Then you regrab. Okay? See what I mean? Something is dull about those needles. I don’t know. Same trouble. Yeah. It feels like it’s too… You’re fine. Just advance a little bit more. It’s good. Same thing that I noticed. The needle just is a little… It seems like it’s difficult going through that tissue. Okay. Put it right there. Very good. That was better. That was good. So you got the right spot. A little clamp. So we have equal sutures here. That’s good. I’ll load this all up for you. Hanging down there for you like that. Dry it. So you can start about here. That’s good. And then enter. Very good. One in and one out. Just like we do. You can less go and regrab closer. It’ll be easier. Good. Still have to go farther that way. Good. It’s better to have a bigger incision, so you can see exactly what you’re doing. Especially in older kids, where the muscle is wider. That’s good. I’ll make a little tunnel. So turn the scissors over when you make the tunnel. You have to do that. Good. You know what I mean? No. Turn them over. Like this. It’s easier. That’s why they’re curved. They’re helpful that way. Just spread. Don’t cut. I think you have to go a little bit more… You might have to cut a little bit. And when you do, make it easy. I’m gonna show you. Direct it this way. See? So that you’re not going to the muscle at all. You’re safer there. Yeah. Nice tunnel. So make another one up there too. I’ll help you with that. I think what I would do here — wait a minute. I would make a little… I want you to cut right here. Make a relaxing incision. Not over here. Cut the conj. Right there. Good. That’s better. See? Now you have more space. Head more that way. So you don’t go through the muscle. That’s it. Actually, even more like this. This direction. And then you avoid hitting any of the muscles. That’s good. I think that should be good. Good. And whichever way you want to hook it. I think you have a hole, though. There’s the hole. See it? Good. You’re doing great. You’re doing very, very well. Okay. Okay, now. Here’s what you’re gonna do here. That’s it. You grab — you get it flat like this. Okay? Make sure you have it. Bring it back a little bit. And then just go farther. So we don’t quite come out the hole there, right? Try again. There might not be a hole, so we might not be able to get through it. You know what I mean? Let’s see. Wait a minute. You’re good. You’re in good shape. Let me just feel it. You can tell by feel. So now what you do is you keep the tip — there you go. Good. Perfect. So now you hold that straight, like that, toward you. In your left hand. Hold it. And you get a Westcott scissor in your right hand. Okay? You hold that. And now you pull it toward you a little bit… Okay? I’m gonna go this way. Keep it flat. Now, there’s a lot of connective tissue there, so I want to make sure we see what we’re doing. Hold on a second. I’m a little worried there. I don’t want to cut anything until we see where we are exactly. A little connective tissue to cut. Put that — yeah, that’s better. That’s definitely not muscle. Okay. I see the muscle there. So now you have an opening there. You can go through that. That’s nothing. He has really, really a lot of connective tissue, right? So it’s hard to find the muscle. Keep it pulled toward you tight. That’s it. That’s the way to do it. Just between that a little bit. Now you can see there… Here… In there… Pretty good. Now… There’s still connective tissue here. So what we’ll do is… I’ll hold it for you while you do it. Okay? You might want to get a little forceps, maybe. Okay? Get the muscle really clean. So I’m gonna lift it up for you here. We’ll go through that. Let’s see if we need to clean any more. Let me use the cotton tip again. You’re doing great. Just want to get… So that we can see what we’re doing. Now… I’m gonna try something here again. Trying to see if we need to clear off any tissue to see… I want to make it a little easier to see the tendon, where the suture goes. But I don’t want to go too deep into it. Because then it causes other problems. But let me see if I can get… You could trim that. Good, good, good. That looks pretty good, right? That’s better. Let me dry it for you again. Suture ready? Good. That’s good. So I’m gonna hold this a little tighter. You want me to hold the hook? Or you want to hold it? Ask her. Whatever she wants. Good, good. Very, very good. That’s good. Stay within the muscle. This is a very wide muscle. This is one that you would have trouble — you want to catch the edge. I’ll hold it while you get ready. Good. That’s good. Perpendicular through and through. Advance a little bit more. I’m trying to help you as much as I can here. There you go. That’s good. Let it go. Pick it up again. Doing very well. Okay. Is that locked? Make sure it’s locked. It’s locked? Good. Let me dry it for you. See what you’re doing. I want to give you better exposure. Wait a minute. Wait a minute. That’s good. Let go a second with your hand like this. That’s good. I want to position it better for you like this. So you can see it better. Good. Let me dry that. Let’s dry it. Let’s see how it looks. I’m not sure that this one’s locked. I don’t see a loop on there. See it? I’ll spread it for you a little bit. Make it easier for you to see it. There you go. There you go. That’ll be perfect. This needle holder is a little bit… They’re all a little bit big. The ones I have at home are a little finer as far as picking up the sutures. The needles. Perfect. Now… So… That’s all right. I’ll hold it, because it’s easier that way. So I’m gonna hold the sutures for you. Okay. Okay. Be careful of the short one, though. Okay, good. Feel more comfortable that way. That’s good. I do too. I like to hold it myself. Cutting, just like you like… Careful, there. Okay. It’s locked. Good. The suture in the middle. That’s fine. Okay, good. Now… Might need a little bit of that cautery there. We’ll see. Now… You want to use that cautery? Be careful. You saw what I was doing. It’s really hot. So you just go… Get it hot and then take your finger off. Good. That’s good. That’s very good. A little bit more there. You might have something over here more. Let’s see. There. Over here. Right there. This is very good. This is… What we want to do. Good. I think that’s good. The other is just gonna be oozing a little bit. Not gonna be a problem by the time we get rolling. So… Okay, now… So now we’re good, as far as the position. So when you… When I do this with people, sometimes, when I teach the residents, sometimes I have them hold one of the poles of the insertion. I hold the other. That’s probably the best way to do it. Make sure we cross it a little bit. The shorter one is the lower one. Right. Okay. We could do that. We could put one here. You want to do it? You can do it. Lock it. That’s good. This is a good instrument, the locking forceps. Especially if you’re on your own or you can do it… If you’re doing surgery by yourself, without an assistant, that can really help you. It works really much better. Just gonna keep those oriented down. Now, what I’m gonna do to help you with this… Looks good. I see them. Might go away, but… You have it. That’s good. Okay. And now… So I’ve got to be careful of that hook. I don’t want you to have any trouble with your exposure. Switched over. Did it bend? All right. We’re gonna fix that. You were grabbing too tight. That’s okay. Let’s see. I’m staying away from the tip, but I’m trying to get the shape back. I think this will work. You know, the problem is the locking one. It’s a little harder when it locks. Wait. Let me help you. It’s too hard. There’s not enough room in there. But I see it. Don’t press on it. With these, you have to… Wait a minute. Just lift. Let me dry it for you. So you can see it better. Wait a minute. Hold on. Wait, wait, wait. I want you to see it. Okay, good. Nice and flat. That’s good. A little bit more. That’s good. I think I would come out — that needle — I don’t know how. She’s fine. Yeah, good. Good. Now… A couple things that will make this easier. When you use these, you don’t want to push down like that. You want to hold them up. I’m gonna hold one. You hold one. Just hold one of them. Because when you hold one, it gives you much more room to see what you’re doing. See what I mean? In fact, when I do it, when I hold on, I usually tell the residents that I want to… I call it “proptose” the globe. I want the globe to come up a little bit toward me, so that I can see it better. See the mark? Good, good. Then I’m gonna reach over here. Like that. And I’m gonna take a small hook. Get that out of your way. And yeah… You okay? That’s it. That’s better, right? I can see it better. Good. Nice and easy. You’re not too deep. You’re good.
>> Dr. Wagner, we can’t see at the moment.
DR WAGNER: All right. Well, this is a critical part. I don’t wanna do anything right this second. Well, too bad you didn’t see it, because she did a great job. Wait a minute.
>> No, we’re good now.
DR WAGNER: Can you see it now?
>> Yep, perfect.
DR WAGNER: Good. Let’s see. I want to get rid of that connective tissue that’s in our way a little bit. Good. So that’s much better. Beautiful. That’s spread very nicely. I like it when it’s widely spread like that. So you can cut one, if you’d like to cut it. It’s easier to tie. Right? I mean, like I said, I do those hand ties sometimes. It’s just — sometimes I just want to do something different. And I’ll change my mind. It’s not… No way is better than the other. That’s how you have to do it. Notice how she grabbed — when she went to regrab, it goes closer, so then you can get the knot flatter, like she just did. Perfect. Slide down. Same thing. Really close. Tie the knot. Good. That’s good. A little more. And then we’ll be done. Right? Very nicely done. Good. So this is great. Muscles in a great position. Remove these two. Let’s see how it looks. The conjunctiva. We’ll bring it up a little closer for you, because she doesn’t want it to hang back. So… You can bring it… You want to put it like that? All right? Good. So we need the plain suture, please. We just have anesthesia. We have three… We have four minutes to go, I’d say. Four. Five, four minutes, max. So… I think she’s okay with that. Want me to lift that up for you there? Here. See what I mean? That’s a very small needle. Yeah. Yeah. It’s bigger than — regrab it again. Yeah. Grab it again. That’s what I told her. The needle is very small on this plain. The plain I have at home has that same… It has a bigger needle. I don’t know if there is another one. I didn’t look at it. Can you check? What is it called? Okay. Maybe we’ll try that one. On the other… Yeah. This one’s a little smaller than that needle. But we’ll try the other one on the next case. Westcott. Thank you. Now… Make it a little easier. Bring this over this way. And then you can see what you’re doing better. We want to go here. You want to do that? Go over there? Good. So you think you have a good assistant?
DR WAGNER: Oh, yes. That’s gonna look perfect, because it’s gonna come right up close… Like before. Looks nice. I usually cut it. Then you can take them out. Very good. I think we have it done. Yeah. Let’s infuse a little bit in there. Let’s try it this time. Yeah. We’re gonna infuse a little in there. What they want to do, Dr. Hai, they want to infuse a little bit of… Looks nice, huh? A little sub-Tenon’s in there. Let me put the speculum back in. I’ll put the speculum back in. You can do it here. It’s easier to see it. You’re gonna go right inside there. Just in there. Okay? What’s she saying? What are you saying? Oh, oh, here, like that. No, the suture’s there. Yeah. We just cut it nice and short. That’s all. Here. I’ll do it from this… That’s fine.
>> So, Dr. Wagner, we have a couple questions, if you are able to answer.
DR WAGNER: Oh, getting it out? There we go. Not too much room for it in there. You can try the other one here. What’s that?
>> Are you okay with us asking a couple questions from the online audience?
DR WAGNER: Yeah. Here you go. That’s better. That’s good. What I’m worried about… That’s probably enough. What I’m worried about… I had a little prolapse of the Tenon’s. I want to make sure that that’s not… See what I mean? You gotta snip it? Can I have the Westcott? You wanna get rid of that? Yeah. That’s better. I think we’ll be good. Right? Good. Perfect. Good job. Very good. But I’m gonna show you when we do the next case, with Dr. Phan, Dr. Hai, I’m gonna show you how we do the — prolapse the — lift the eye up so that it’s really easy to pass the scleral suture. You’ve got to keep it up. So what you do is you grab the insertion, and the back of your hand goes down, and the front comes up, and that proptoses the eye, and then it makes it much easier to position it.