This video demonstrates a bilateral medial recession + inferior oblique recession surgery in a 13-year-old female patient, who had a V-Pattern 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 we’re gonna start in the left eye. This is a nine-year-old with alternating esotropia that also has a V pattern, due to overaction of both inferior oblique muscles. So we’re going to recess each inferior oblique muscle. I’m gonna do what’s called a 14-millimeter recession, which means you look for the inferior temporal vortex vein, and you put it there. And then we’re gonna do the regular recession that we would do of the medial muscle. So we usually do the inferior oblique first, just because it’s… It makes sense to do it on these cases. It’s a little bit easier, I think, than doing the medial first. So I’m gonna have my assistant grab the eye at the limbus and bring it up into elevation and adduction, like that. Not yet. We’re gonna take a second. I’m gonna make an incision first. We need another forceps in the… There we go. And what I’m gonna do is make an incision… I just put the scissors open… We’re gonna take it in a minute. I’m gonna cut through the conjunctiva. Extend it. Extend it this way a little bit. And now I have a hole through the conj. I’m gonna lift up the conjunctiva a little bit. Now go through the Tenon’s capsule, the connective tissue. And the next step — I’m gonna hook the lateral rectus muscle. Large hook. What? It’s not on? They sent everybody for lunch? Okay, good. This is kind of tight. Okay. I’m a little bit too far away. Going too far, right? There it is. Now I’m gonna put the fixation suture. Now I’m gonna take it… So this is what I was talking about the other day. You don’t want to engage any tissue. You want to go… Below the muscle. Like that. See? I’m not hitting anything. And come out the other side. And that should be just the lateral. Right? So let’s hook it and bring it up here. So what I want to do is I’m gonna take two large hooks. Another one. There we go. And we put one hook below the lateral rectus muscle, like that. And one hook over here. And you are gonna hold… Actually, you could reach under and hold that for me, right? And I’m gonna look for the inferior oblique in the inferior temporal quadrant here. Usually use two hooks. Go down in here. Usually you can see the fleshy color of it. And I think I got it right there. I think that’s it. Don’t you think? It’s definitely overacting, because it’s big. You know what I mean? It’s a bigger muscle than it normally looks. Just want to get some of the connective tissue. Now, let’s see. I’m in pretty well. I’ll come underneath. Spread. Yeah. I’m gonna put another hook in there. Put that one in there. That looks great, right? So now we’re gonna switch this a little bit. I’m gonna put this hook in the same hole. And I’m gonna go back down to where the lateral is, like that. So you’re gonna use this hook, and just lift it up like that. Okay? So let’s make it look nice, so we can see it a little bit better. Okay? Keep the hook flat down like that. How do we know? In this case, I can tell. I mean… Well, I don’t know. Let’s see. I’m sure we do. I’d be surprised if we didn’t. It doesn’t… Well, I don’t know. There’s something there? There’s one little slip of it. There’s a big… This is a really big muscle. I don’t think so. Yeah. I think it just looks… It looks so nice here that I think we’re okay. We’ll see when we cut it off, anyway. Okay, now… Hold that down there. And I think we’re okay. So let me have a small hook, again. I have one ready for me. Like that. Okay. So I’m gonna just pass the suture, just anterior to it there. So I’ve got double-armed vicryl I’m ready for. Now, in this case, you can go through with one pass. Right? Because it’s not very wide. Right? Come on. Come over here, stitch. Suture. Keeps wanting to go away. Sometimes I do this. There we go. So I come from behind, just to unlock it, like this. I think that’s pretty good. Okay. So… So this answers your question about how close you want to get. I left enough there — so it still has the hook there. So it’s still safe. Okay? I’ll cut it over the hook. The hook is protecting me from cutting too deep. Right? There you go. But look. When I let it go, it doesn’t go anywhere.
>>They said that the inferior oblique is so big, so we’re going to clamp it? Or to —
DR WAGNER: Watch that. Get that lash out of there. See that? I’m sorry. What did you say? To do what?
>> Are we going to want cautery, when we cut? Are we afraid of bleeding?
DR WAGNER: Yeah. This one, we didn’t have to, this time. It was okay. We got lucky, maybe. But there it is. That’s all of it.
>> And how do we identify the start? The cycle of the muscle?
DR WAGNER: What do you mean? If we have all of it?
>> When we’re cutting, if we have the top, upside… The right side…
DR WAGNER: Oh, whether it rotates? Yeah. I felt… I could tell. When I pick it up, I’ll be able to tell. So now I have the inferior rectus here. And I’m just gonna bring the conjunctiva over the top here. And we’re gonna look down that quadrant. Sometimes we can use a Desmarres retractor, possibly. Let me see. We should see the vortex. There’s the vortex vein. See it? Right there. Right in front of my… See the vortex vein? It’s right in front of my applicator. It’s just that, right there. That dark vein. Put the Desmarres in there. Yeah. Go ahead. If you can. Like this. There it is. That dark… That’s it right there.
>> Oh, this one?
DR WAGNER: Yeah. That’s how it looks. Sometimes it looks like a big vein. Sometimes it just is a small part coming out. That’s it, though. Yeah. See? Now you can see behind it. See? Going back? Where it exits? Right there? I don’t wanna cut it or to hit it, but that’s it. Yeah. Okay, good. Now… Might as well keep it in there, because I have to put my… Let me go a little deeper here. Like that. That’s better. Okay. So this is the more medial one. Push that back in there. And dry it. Thanks. What is your question? Go ahead.
>> We couldn’t identify the medial on the —
DR WAGNER: Yeah. I know the longer suture in this case was the medial one. So I’m just gonna go right by the vortex vein. Right in front of it.
>> So this is for when…
DR WAGNER: When you go to the vortex vein, they call that a 14 millimeter. A 14. Right. I’m sorry. Yeah.
>> But the overaction is 1+ or 2+ or 3+?
DR WAGNER: Yeah, this is a pretty significant one. There’s another thing you can do, which I haven’t really done in a long time, where they call it a denervation and extirpation. Did you ever hear about that? Where you actually go way back. Get another cotton tip. A dry one. But I don’t… That’s good. I’m just gonna go next to it here. You don’t really… That’s not much of a bite. I didn’t do much of a bite. But I don’t worry about that too much with the inferior oblique. It’ll usually stay where we want it. Okay. Let’s see. So… Hold this hook with your right hand. Good. See what I mean? That’s good. So I’m gonna cut one. Yeah. A little easier to tie the more conventional way here. Very good. Now we’re getting a little bit of the bleeding. So is anybody really watching this out there? Or not really? Nobody? Yeah. Sorry. I don’t think anybody is really watching all this.
>> It’s just the project manager and myself. And online.
DR WAGNER: Oh, online. Oh, okay. Then we’ve got to keep talking, then. Sorry about that, online participants. We’ve got some information that we weren’t sure about. So there’s the inferior oblique. There’s the inferior rectus. And we put it right next to it. When I release the hook, you’ll see that it’s right there, at the vortex vein. Okay. So now, this incision will close before we go to the medial. We’ll take this again. And I would like some plain suture now. Plain, please. Yeah. When you close, do you usually use two or one suture on the… Excuse me? No, but when you close it, do you usually close it with two sutures or one? Like a cul-de-sac incision or a fornix incision? When you close it? With the plain? Two or three? Yeah. I mean, sometimes you use one. I’ll tell you, what I’ve seen happen a few times is, when they have a lot of Tenon’s, and the kids around here seem to have it, it’ll prolapse through the wound, and then you have a reaction there. Yeah. In fact, I have a picture on my cell phone of one like that. Some woman called me and said — I think there’s a reaction or something going on. Sent me a picture. You can see a little granuloma right where the suture was.
>> Dr. Wagner, there is a question on Cybersight. Do you feel cauterization of distal part of the inferior oblique is unnecessary?
DR WAGNER: You can cut it in half. Oh, it’s all one suture? Oh, well, we’re gonna use it four times. But yeah. Cut it there. We’ll just be careful. I’ll put two. I think two is gonna work okay.
>> Can you hear me, Dr. Wagner?
DR WAGNER: Now I can.
>> There is a question on Cybersight.
DR WAGNER: Sure. Go ahead.
>> Do you feel cauterization of the distal part of the inferior oblique is unnecessary?
DR WAGNER: Do I think… Anteriorization?
DR WAGNER: Cauterization. We were asking that in here too. You know, I don’t always cauterize it. When I put the suture, I don’t want to get too close to possibly burning the suture. You know what I mean? So I don’t think that it has to be done in all cases. But sometimes they will bleed more than others, so you have to pay attention to it. I have to put one more there. Okay. So this needle is a little bit bigger, but it’s okay for what we’re doing. I wouldn’t want to attach it to the sclera. Right? But if we’re going conj to conj, we’re okay. Good. I think we’re okay there. I don’t know. It’s a little bit of a gap, but… What do you think? Should I close it? We can wet it again. Let’s see. It’s okay. I don’t know. I think it’s okay. There you go. Put that back. Now I’ll take that silk suture back again. Thank you. So now I can do the medial muscle. I just, from doing this for a long time, I just got in the practice of doing the medials through a limbal incision, and the laterals and inferior obliques I often do through a fornix incision. And I can’t say that there’s a tremendous reason why I do one versus the other, except that I found that in a lot of the very small babies that have esotropia, I think there’s a little bit better exposure in a lot of the cases, when you do the limbal incision. Sometimes — especially when you’re teaching residents and things like that — sometimes it’s a little bit more difficult. So I like to have a good opening that I can see what I’m doing a little bit better. But I can’t say that one way is better than the other. It’s just a question of personal preference, or sometimes you tailor it to the individual patient too. Out here. Make a little tunnel. And what I was trying to show you, Dr. Hai — the inferior is here. The medial is here. I like to go between the two. If you go in there, it’s pretty good. It’s pretty safe. You don’t get much of a muscle there. Same thing here. I’ll try to do the same. And notice I’m not cutting anything. I’m just advancing and opening up the sutures to make a bigger hole there. Thank you. Keep the tip on the globe. I always exaggerate it to make sure I’m where I want to be. Go through here. Get the two small hooks. There’s another hook… I don’t know if you guys have it here. I don’t really use it that much. But I just wanted to mention it. There’s a hook that’s a double… Yeah, a double hook. It has one… I think Dr. Helveston, who did a lot with Orbis over the years, introduced that, if I’m not mistaken. Did you ever meet Dr. Helveston? Is Jackie here?
>> Does he not come anymore?
DR WAGNER: I think he’s retired. He actually started the Cybersight program, Dr. Helveston. So that’s appropriate for what we’re doing here today. I think that looks pretty good. Big muscle, huh? Okay. There’s a little bit of connective tissue I want to remove. You can take those hooks out. And then get the Westcott scissor, and I’d like my assistant, Dr. Phan, to just trim these for me. Let me see. It’s okay. We’ll hit that easily. That’s not a problem. That’s why I let you do that instead of me. So we’ll see. Hit the cautery with that now, so it makes the field cleaner. Hold it on there. Take it off. Good. That’s good. This still has a little funny shape to it, there. It almost looks like… Yes, that’s the double hook. I don’t need it right now. But you could use that instead of the two hooks. And then you have one hand free. Yeah. Everything you ask for shows up, right? Okay. So now we’re gonna go here. This needle, it just feels big in my hand. I guess I must… That’s okay. I was just saying that the needle holder feels large. Bigger than the one I use at home. So… This time I’ll try to get past the blood vessel. Good. So when I knew they were doing this case on live broadcast, I tried to get, like, my wife or a couple of my kids to watch it. But they said it was too late. It was too… Where I’m from, it’s on — the live broadcast of this case is going on, like, probably 4:00 in the morning now. Or I guess 3:00. It’s 12 hours. 13 hours, I think, difference, from Vietnam to where my home is. So I couldn’t convince anybody to get up in the middle of the night and watch the surgery, for my family. That looks pretty good. I think we have it nicely, right? That looks nice. Let’s go over here. Cautery, please, again. Cautery. I think we’re good, right? We’re good. So anyway, what I’m gonna show you is — when I was talking about positioning, to put the sutures through, what you want to do, if you have an assistant, you should grab the insertion, and you should bring your hands back like this. Get it flat. And then — see how nice that surface is? It gives you a big surface to operate on. Plenty of room. No issues with it. So if you do it yourself, you can kind of do the same thing. But if you’re gonna assist somebody, that’s a really good way to do it. I actually learned that from a guy named Joe Calhoun, who was at Wills Eye Hospital. Thank you. Just afraid to really hit it with this cautery, because of how hot it is. There. That time we got it. Now I’ve got to go back here again. That’s better. Okay, good. Now, the caliper I need at 6 millimeters. Okay? That was a hot one that time. It looks like 6 to me. That’s good. All right. Let me grasp here. I’m gonna go right there. Good. We can do one of these. That’s better. I’m fine. I’ll take it again. I’ll mark the other one. Sometimes I wait and mark the other one after, because it’s easier to… Okay, good. So I’m gonna enter here. You have to dip in a little bit, engage the sclera, and then advance it. Within the sclera… That’s pretty good. Could be… It’s all right. It could be a little deeper and still be safe. But it’s okay. I’ll look at it again. Make sure it still says 6. Is that right? A little bit deeper. A little bit more. That second one is better for me. I’ve got to get it this way. Good. You can take that out of there. Because I can get my hand a little flatter now. That’s good. Should be spread pretty well. Could be wider. But that’s okay. Good. Let’s cut this one.
>> Dr. Wagner, we have another question.
DR WAGNER: Sure.
>> In case of esotropia, regarding surgical outcomes, which is better? Bimedial MR recession, or unilateral?
DR WAGNER: To answer that question, it totally depends on how much — how large the deviation is. How much the eye is turning. In other words, there’s only so much you can correct with one muscle, in some cases. So you could have good results with either, but it depends how large the deviation is. So usually, if it’s more than… I don’t know… More than 20, maybe, 18 or 20, you need to do two muscles, bimedial recession. Does that answer it? That should help. Plain suture again. Yeah, that was kind of a long one, right? Sometimes they’re double-armed, and you can use half and half, right? But not in this case. This one I don’t have to do much at all. Just a little bit. Only got one there. That’s okay. Let’s see. One, two, three. Good. Very good. Needle. Take this out. So we’re halfway done. Where would you prefer to sit, Dr. Phan? Where do you want to sit? Do you want to sit where you are? Do you want to come to the front? Yeah. I think it is easier. Yeah. Okay. So we can move. We can switch. No, we can switch. I’ll just come around. Yeah. Here. Yeah. And you’ll do the inferior oblique first, right? Did you want to stay on this side? Oh. Stay right here? Yeah. And I’ll come on this side. Good. Good. It’s easier for me to be assisting on this side anyway. For this. Okay. Good. So we’re gonna go like this. Like that. Let me have the cautery for a second. Yeah. I don’t know if that’s gonna work or not. The very nice. You can make it a little bit bigger, if you want. A little bit. Sometimes it’s hard to get the lateral. Okay. So let’s try to hook the lateral muscle. Don’t go too far back. I made a mistake. It’s closer than you think. There you go. Yeah. So hold it up. Straight up like that. And then get the suture. The silk suture. Go in there. Be very careful. Just to stay away from the sclera. Good. Good. So for the elevation and adduction, you’re gonna clamp it on there somewhere. I’d like the two large hooks. The other one. The other large hook. And one goes under the lateral rectus, like this. And one goes down in here, in the quadrant, like that. And you should be able to see it. I think that’s it. You’re in the right spot. The incision is a little small. You know what’s easier? I think it’s easier to go that way. Turn the hook the other way. Like that. And then get behind it and then rotate it toward me. I think that works a little bit better. We’ve got a lot of stuff there. There’s definitely the muscle. And whether we have all of it or not I’m not sure. I think so. Let me have the Westcott scissor, please. Okay. I think that’s better. Lift up a little bit. I don’t know if there’s a hole there. Lift the… Yeah. There you go. Try that. Let it go. Sorry. It’s not quite a hole that we want there, is it? There’s the hole there. There you go. I believe you have all of it. If we look at it, we’ll see, but… That same hole. Good. So the way you can tell is if we really want to go really nicely and isolate the insertion, we’ll be able to tell. You can actually dissect around it. Yeah, yeah, yeah. So what you’re gonna do is… Here. Take a Westcott. Okay? Let me have the hook. Sorry. I’m gonna get that tissue away. Trim through there. He’s got a lot of Tenon’s. Very much so. That’s just connective tissue. Right? You can cut through that. Good. I think so. That’s connective tissue. That’s nothing. That’s the full muscle. Okay, good. So then let me hold this up. Switch this up. I think that’s better. No. We’re good. I’ll hold it up for you, like that, if you like. I mean, if you want… Let me see. I’ve got to twist a little bit. I think that’s fine. I don’t think we can do any better than that. That’s just connective tissue on there.
>> Dr. Wagner, would you mind speaking up just a little bit?
DR WAGNER: I’m sorry. We’re fine. We’re just positioning the inferior oblique here. Want to make sure we have all of it.
>> Great, thank you.
DR WAGNER: I see both edges of it. It looks okay. Let’s put the suture through there. No sense doing more dissection if we don’t need to. Okay? So… I can hold this for you. You can get a forceps, if you like, or you can… Do it with another hook. If you want to hold onto one of the hooks. Whatever you feel most comfortable with. Good. You can go pretty close to this, right? Because we’re safe. That’s good. So we’re just passing the suture through. Sometimes I actually disinsert the muscle and then place the suture in after it’s already loose. Because as opposed to all the other muscles, it really doesn’t go anywhere. You really can’t worry about — you wouldn’t worry about losing a muscle because you disinserted it. It’s the only muscle you can try that with. We don’t recommend it with anything else. Good. I’ll try to get it out of your way. It’s got tissue drag here. There we go. That’s better. So we have this — the inferior oblique — isolated pretty well. I’m inside your loop, though. So I’ll get out of there. That should be good. We lift it up here. You have plenty of room to cut it. So don’t forget: Most of the time — we definitely have the whole muscle. That’s for sure. But most of the time, when you get bleeding, it’s because you’re doing a myectomy or a myotomy. In this case, we have the sutures there pretty well, so I don’t think we’re gonna get as much bleeding. So I don’t really worry about cauterizing it. And what I was saying is if you cauterize it now, you might burn the suture anyway. And then you’re gonna have to replace it or do it again. So that looks great.
>> Dr. Wagner, we do have another question. So does traction of the IO not injure the macula?
DR WAGNER: Does traction… Well, we don’t go right into — we cut it off… Go ahead. You can hook it. We disinsert it or cut it off — we leave a little space in there. So we’re not right up against where would be the macula. We’re in that area, but we’re not getting that close into the sclera that we would worry about damage occurring that way. But you have to be careful. That’s why we do it under direct visualization. Sometimes some people don’t — will just hook it and start proceeding. But I think it’s better to see it — can I have the Desmarres retractor, please? Marion? Thank you. Now, let’s really find… What do you call it here? The vortex vein. There it is. Now you can really see that one. See it? So you’re gonna… I call it straddle it. Right there. You can really see… I think you can see on the camera. Hopefully you can. Let me push it away. It’s right there. There’s a little connective tissue around it. So I don’t feel like dissecting that away. But… We don’t have to. It’s there, though. All right? So now… Am I helping you? I don’t know if I get it this way. That’s good. Okay. So let’s try it. Good. So you’re gonna go… Just on both sides of it. Right anterior to it. Okay? Hold it way up this way. Hold that there and keep it flat. I’ll hold it for you like that. And you can get set. What you want to do. Yeah, that’s good. Lift it up. Lift it up. I think that’s the lateral one you have now. Yeah. You want to dry it. Where is the vortex? Let’s see. Have to dry it again. Right there. So be careful. You have to get very flat. If I’m in your way… You’ve got too much of an angle. Go flatter. Yeah. If you have to do it, just direct it toward the… Direct it medially toward you, when you enter. It’s easier. Then you don’t have to position your hand… That’s okay. If you can get it. If it’s too hard… You can just go flat and… That’s okay. That’s good. Yeah, that’s good. That’s all you need. Very little. I’m more worried about the inferior oblique getting loose and coming forward than I am about it going backward. Yeah, that’s good. Now… You might want to try it, maybe. I guess you’re okay. As long as you can see it. Good. That’s good. Yep. Just in and out. Good enough. Very good. So we call it a 14-millimeter recession when we go just anterior to the vortex vein. Cut that. Good. A small hook. Okay. You’re good. You can tie it up. Good. Very, very good. Good position. Sutures. The lateral. You need the plain suture again for the third or the fourth time. I’ll hold this. I will take one of those for you. Just get you the suture. Very nice. The incision closes very nicely. It really looks good. Almost all of them, the next day, though, often they have a subconj hemorrhage. Not so much from when you do the inferior oblique, but when you do the lateral rectus, you almost always have a subconjunctival hemorrhage, a big one. But it’s no effect or anything. Not a problem. So this is going very well. I’m very happy with the way the muscle looks here. Is there enough in there? Looks like it’s caught. You can close a couple with that one. There’s enough. Yeah. We may need a little more for the other. Oops. I think it’s gonna come out. I don’t know why. Is it long enough? Did you fix it? Yeah, you did. Okay. Yeah. I was gonna tell you, when you pick it up, it’s always easier when you… Let me just show you something. When you pick up suture, it’s always easier to turn it this way. In other words, I’ll usually grab it, sometimes, the way — whatever I think is easier at the time, but it’s always easier, if I want to pick up something, to use the needle holders that way. As opposed to this way. And same thing when you pick up a needle. You want to — when you pick up the needle, you want to be able to go forward or backward. Follow the curve. Like that. Usually pick it up. Just a simple thing that’s not a big deal. But every little thing adds up and makes things just a little bit easier, as you go along. And then… You don’t have to worry. Well, we have one more muscle to do. So it’ll be another 15, 20 minutes, right? There it is right there. Good. We’re gonna take that silk suture next again. If it’s still there.
DR WAGNER: Yep. Here we go. Needle holder. Load it up. It’s okay. Looks good. Go here and here. Good. No. Usually what we… You know what? I don’t either. But we don’t usually use the locking forceps. What you have to do, when you use them, is unlock it, when you pass it. You know what I mean? You don’t want to really… I don’t like to pass it when it’s locked, because you don’t have… I think it’s too tight. You don’t have that good control over it. You don’t have that feel. The eye is in a good position. Sometimes you have to regrab it to get at the right spot, but this looks good. Can I have a clamp, please? Thanks. Good. I got it. I have it. Okay. Okay. So I’m gonna slide behind you. These are nice chairs, though. They can move around easily enough. It’s not so easy sometimes. I’ll make a little tunnel. Very nice. Here I’m not sure where it is. Go more that way. It’s safer. Because it’s a big muscle. Good. Let me try that double hook. Did you leave it on the tray there with you? Did you leave that… Oh, no, if you didn’t open it up, that’s all right. I don’t really need it. That’s okay. I’m fine with this. I wasn’t sure if you opened it up. If you didn’t open it, don’t worry. Okay. Now… Scissors. Good. Center it like that. So that I can see where I’m assisting you. And hold on. I’ll lift up all this. Make sure this… That looks pretty good. Maybe we’re gonna clean up the front part again. I’ll lift it up for you. Can I have cautery, please? That’s because we want to clean it a little bit too much. That’s what happens when you clean it. But it’s better, because you can see — I’d rather see where we’re putting the suture. It’s a little bit easier. So we’re okay. Yeah. I’ll hold it for you. Are you ready? I’m gonna pull it this way. For the left eye, sometimes it’s harder to get the exposure that you want. But you’re fine. That’s it. So if you pick it up — if you’ve switched it in your hand before you picked it up, you could have been ready to pass it. You know what I mean? Save you one more step. Good. Very good. So there you go. Now, push it farther. All the way. Now, turn your needle holder around. Yeah, like that. Okay? Yeah. Good, good, good. I like that. Looks good. Except that rotated on you. Be careful. Yeah, you’re fine. All this stuff — all these little things, when you have the basic techniques down, then you start thinking about all that little stuff that makes it a little more efficient. Cuts off a little anesthesia time. All kinds of things. Good things. She needs the Westcott scissor. Good, good. You can lift up both sutures to check it, to make sure you have everything that you want. Here you go. We’re gonna take care of this in one second. Okay. Let’s see. We’re gonna do one of these maneuvers. Okay. See where it’s coming from there? Big vessel there. See that? We’ve got to get that one. Cautery again, please. One giant vessel. I got it. That’s a big vessel. That was all the problem, that one. We didn’t even do anything. We just removed the muscle. That was just a blood vessel in the wrong place. Okay. I think that’s okay. So… Okay. No bleeding. A little from the muscle? Yeah. We’ll try to hit it. Can I have the cautery again? I want to be careful, though. I don’t want to cut the suture. So go… I know where to go. Let it go a second. Let me see where it’s coming from. Let go a second. Good. Yeah, I think so too. Yeah. I left the tension off. We’ll worry about that in a minute. Let me see. Let me hold it up here. Might be able to get it on this side. Cautery again. Just another shot at it. I don’t want to get the suture. So I think we’re good. That’s good. Just leave it. Good. It’s just gonna ooze a little bit. By the time we get ready to go here, and mark everything, we’ll be fine. Okay. So we need the caliper again. Okay? Same. 6 again. Right by that darn vessel. We might have to get rid of that blood vessel. That’s good. And let me grab it here for you. Good. I can still see it. You see it there? I’m gonna get rid of that blood vessel. Give me that cautery again. I’m just being careful, because that’s… So hot. There it is. Right? I’ll put another mark there for you, so you can see it better, though. The caliper again. Oh, she’s got it. Good. Very good. Good. Now, you can hold onto one. And this is… Let me help you another way. Wait a minute. Two-point fixation sometimes works better. Let me have the caliper again. Looks good, right? That’s a good depth. I like it. A little bit more. That’s good. Put another mark there for you. You can grab it. Go ahead. I think that’s good. Good. Let’s see. Let’s get this… We’ll cut one of those. That’s good, right? Yeah. It’s okay. Good. Okay. Westcott. Cut one of those for you. Oh, you want to tie it? I’m not gonna cut it. I just pushed it down. Good. Needle. Okay. Now it’s gonna be three minutes. That’s it. Okay? Good. They were there. That’s the whole thing, right? I’ll tell you,people make a mistake sometimes, and bring that up, and then you have a big scar there. Okay. Good. So we’re just closing the conjunctiva, for anybody who’s still watching. And this will be the end of the procedure. It broke. It was too fragile. When it gets dry, the suture, it gets brittle, and it’s hard sometimes to… It’ll break or fray. Okay. One more suture, and we’re done. Where is that gonna go? Like, there to there? Good.
>> We’re missing a needle.
DR WAGNER: We have one needle here.
DR WAGNER: And we actually have another needle, right?
>> So there’s two on the table. Yes. Then we’ve got —
DR WAGNER: Here comes one. Here comes the other one. That’s it?
DR WAGNER: Great. Good. You like that? Okay. So we’ve completed the case, if anybody is still observing. And this case went very well. We did the obliques, did the medial rectus recessions. And the interesting thing is — look. Even now, under anesthesia, it looks the same as when we started, right? So you can’t really… You really can’t make a decision based on the position of the eyes, how they look, once they’re under anesthesia. All these decisions were made prior to that. Unless you have a restrictive problem with a strabismus. Yeah. Good.