This video demonstrates a medial rectus recession surgery in a 15-year-old patient with esotropia. The MR recession was done in both eyes but only the right eye is demonstrated here. Dr. Wagner performed this MR recession through a limbal incision.
Surgeon: Dr. Rudolph Wagner, Rutgers – New Jersey Medical School, Newark, NJ USA
DR WAGNER: This is a patient with 65 prism diopters of esotropia that will undergo a 6.5-millimeter recession of the right and left medial rectus muscles. A 4-0 silk traction suture will be passed through the conjunctiva at the limbus, superiorly and inferiorly, to move the eye into a position of adduction. As you know, there are other sutures available to isolate the muscle. Many people will use a fornix incision. Sometimes called a cul-de-sac incision. Which avoids dissection of the limbus. However, a good strabismus surgeon needs to know how to do multiple procedures, since you may not be able to do what you have planned, because there has been a reoperation or scarring. It may interfere with your ability to do one particular type of incision. So a limbal incision is very useful for reoperations, and I like to use them in medial rectus recessions, because of the better visualization, especially if there is a small child with a narrow fissure. Lateral rectus recessions through a cul-de-sac incision or fornix-based incision are easier to perform. We grasp the conjunctiva and some of the episclera and pass the needle into the tissue, trying not to incorporate too much of the conjunctiva, which would then pull over the cornea when the traction suture is positioned properly. In this case, we will attach the traction suture to a straight clamp to keep the eye in the abducted position. A limbal incision through the conjunctiva will then be made, beginning superiorly and extending along the limbus inferiorly. Careful dissection is made subconjunctivally to avoid the insertion of the medial rectus muscle. A relaxing incision can be made on the inferior extent of the conjunctival incision. This can also be made superiorly, and a tunnel is then made along the globe, being careful to be between the inferior and medial rectus muscles and the superior and medial rectus muscles. Careful dissection of the subcutaneous tissue is then performed. When a hole has been created, a large muscle hook can then be passed — in this case, inferiorly — to hook the medial rectus muscle. The tip of the hook is exaggerated superiorly to make sure that the entire width of the insertion is included. In this case, you can see some connective tissue surrounding the tip of the muscle hook. Small Stevens tenotomy hooks are used to elevate the connective tissue and intramuscular membrane, and careful dissection is performed along the margins of the muscle to isolate the entire width of the muscle. The muscle hooks elevate the tissue nicely, so that you can avoid cutting the muscle as you dissect the surrounding connective tissue and Tenon’s capsule. you don’t need to extend the dissection very far posteriorly when you are doing a recession, as will be done in this case. Here we are making sure that the hook is free of any connective tissue along the muscle margin. You can see very well the anterior ciliary vessels within the muscle extending through the subconjunctival tissue toward the limbus. We are now passing an S-14 needle attached to 5-0 vicryl suture, although a 6-0 vicryl suture can be used just as easily. We like to pass the suture about 3/4 of the width of the muscle, and to remain within the muscle tissue, with the first passage. The needle is then grasped, and a locking bite is done, which must be perpendicular through the muscle, coming out in this case behind the insertion, and picked up through the loop to lock the suture on the muscle. This needle can be passed either anteriorly or posteriorly, depending on the positioning and surgical preference. The other end of this S-14 double-armed suture is passed through the width of the muscle, extended in this case inferiorly. And once again, a locking bite is made, perpendicular through the muscle, coming out posteriorly through the full thickness and then picked up through the loop, in order to lock the suture on the muscle. Once this is accomplished, the muscle can be safely disinserted. We like to leave at least a millimeter of space between the globe and the suture. In this case, you can see that it is easy to disinsert the muscle, and to avoid the attached locking sutures. We will use some cautery to control the bleeding, which is occurring where the muscle has been disinserted. The bleeding will stop eventually, but it’s nice to be able to control the bleeding, so you have better visualization of the operative field for the next part of the procedure, which will be the recession and reattachment of the medial rectus muscle. You need to be careful to maintain the proper orientation of the sutures and locate the superior suture and inferior suture, because these may twist when the muscle is disinserted. Some of the bleeding comes from the muscle itself, which I’m not concerned with. Generally, as we tie the muscle to its proper position, the bleeding will stop. Notice we have grasped the insertion with locking 0.5 forceps, which can free up the surgeon’s hand and can also be held by the assistant, in order to position the globe. It’s always a good idea to leave enough of the insertional tissue that you have something to grasp when you use your forceps to position the eye. You don’t need much, and sometimes if you leave too much, you can always shave it off at the end. You can sort of see the bluish color of the sclera behind the insertion, which is typical in many cases, indicating that you are dealing with a fairly thin sclera. Here we’re using a caliper to measure 6.5 millimeters from the original insertion. Some people put a little dye on the caliper from a marking pen, but usually the dehydration that occurs in the sclera is enough to visualize your mark. I like to grasp the needle about 1/3 away from the tip, so that I have good control of the needle as I pass it through the sclera, which is the most critical part of the operation. You can get very flat, although you must engage the sclera slightly in order for it to have a proper depth within the sclera. In that case, I didn’t like the depth, so I’m gonna repeat it. And re-mark. I like to hold one of the insertional forceps in my hand, in order to control the eye movement as I pass the suture. In this case, I’m aiming to cross the sutures, so that the exit point at the tip of the sclera will be in close proximity, allowing the knot to be tied flat on the sclera. During the entire width of the incision, you can see — or length of the incision — you can see the needle within the sclera. Which is important, because it shows that you’re not too deep. So now we’re going to pass the superior needle. Once again, I like to grasp about a third of the way back from the tip, in order to better control the needle. Re-mark. So that we have the correct position. Enter the sclera. You must dip it in very slightly, I call it, into the sclera, in order to engage it, and then get flat immediately, and advance it while flat. Otherwise it’ll rip forward and come out of the sclera, and not produce a tunnel. Here you can see very nicely within the tunnel that we’re producing with the needle, and I’m gonna exit very close to the exit point of the first suture. Try to avoid it — I have actually seen cases where you can cut the suture with the needle. And some people leave the first needle in the sclera while they pass the second, in order to avoid that occurrence. So we have the insertion spread nicely. And we’re happy with the exit point of the vicryl sutures. In this case, we’ll use an instrument tie to close the — or to lock the sutures and to secure the muscle to the sclera. When I was originally taught to do this, I used — and still use very frequently — a hand tie. You have to be careful not to disturb the second knot. Because if you lift up on the first, you will move the position of the knot, and you could change the effect of your suture placement. I usually do two throws, then an additional one and one, and lock the suture. I like to leave a tail on the sutures when I cut them, so I’m not as worried about slippage, if they’re not as tight as I’d like it to be. And in this case, we’re going to advance our conjunctiva back over the original insertion, and attach it to the more limbal conjunctiva. I don’t like to pull it all the way over, in some cases, because when the eye returns to its central position, you may have an overlap of the conjunctiva, which can create some bulk there. And sometimes you can even get a dellen formation. So as I said, I like to slightly recess it, in some cases. If it’s a restrictive problem, I will even recess the conjunctiva and reattach it at the original muscle insertion, in order to augment the effect of the recession. You always want to make sure you’re grasping the edge of the conjunctiva, not the edge of the Tenon’s capsule, which would be a problem. In this case, we’re using a 6-0 plain suture, non-dyed, which is not easy to visualize, but it doesn’t present as a foreign body to the person who would have the surgery done. You want to make sure that there is no prolapse of Tenon’s tissue through this area where the wound is closed, as this can cause a granuloma formation, which may need to be excised in the future. If you want to check to make sure that you have it closed properly, you can infuse some BSS right at the wound site, and the Tenon’s will fluff up and be well visualized and differentiated from the conjunctival tissue. This suture came loose, which probably means it was cut a little bit too short. So we will repeat this, in order to get the conjunctiva tighter and closed. It’s one of the reasons I leave the tails on the sutures that are attached to the muscle, when I attach it to the sclera. Because I like to have the security of knowing that we have some suture above the knot, which makes me feel that the knot is tied down. And unlikely to unravel or unfold when cut. On the conjunctiva, of course, it’s not as critical, because you are not gonna have a problem if it slips. Initially, you should be able to recognize it. Now we’ll close the superior incision, using the same technique. Now we are passing the 6-0 plain suture through the conjunctiva, superiorly, to once again reattach it to the conjunctiva more proximal to the limbus. Once again, I use two loops on the needle holder, then two additional sutures, one in each direction, to lock the suture. Or lock the knot. So there we’ve completed the recession of the right medial rectus muscle, and you can see the conjunctiva is well positioned. Not right on the limbus, but very close to it.