This video is a medial rectus recession surgery in a 15-year-old boy with esotropia.

Surgery location: on-board the Orbis Flying Eye Hospital in Binh Dinh, Vietnam.

Surgeon: Dr Rudolph Wagner, Rutgers – New Jersey Medical School, Newark, NJ USA

Transcript

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DR WAGNER: This is a 14-year-old girl with probably congenital or infantile esotropia. I just hooked the muscle. You can see that. You hold that for me, please. So in this case what I’m gonna do — to dissect it a little bit more easily — I’m gonna use the small hook. I’m gonna use the small hook myself. And lift up the conjunctiva so I can see the connective tissue that I want to clean.

>> Doctor, excuse me. Sorry. The microscope is a little to the side.

DR WAGNER: Maybe somebody could fix it for me? I don’t know how to do that. Yeah, I definitely see it. Well, it’s definitely easier to avoid blood vessels. Yeah. Yeah. Right. So you can avoid them. Pretty good?

>> Yeah. It looks great.

DR WAGNER: Good.

>> I’ll ask you to speak up just a little bit.

DR WAGNER: I’m gonna hold the muscle hook like this.

>> Perfect, thank you.

DR WAGNER: And I’m gonna just clear away some of the blood vessels here this way. So I can see it better. And I’m gonna take the suture now, the double-armed vicryl. So this time… I can see the vessels very well. Going right through the vessel. But it seems okay. I’ll get them all right. And I can’t tell how much to go on it. But this is what I talked about, going perpendicular. So you’ve got to go through the — front to back. Because if you don’t do that, you don’t have a lock, a proper lock. And now we do. There’s the needle. Go the other way. Put this through here. We’ll try to lock this one. Didn’t get anything. Can you grab that? Thank you. Now we’re gonna take a Westcott scissor, please. It’s gonna look gigantic under the microscope. Right? It looks big. Those are little foot processes, we call them. Foot plates. Just to break them. Okay. Let me dry that a little bit first, before I do anything. Yeah. I’m gonna bust that there. Good. Put a little pressure on there. Okay. Let me have the cautery. Are you okay? I’m gonna reach around here. And now you’re gonna see the fire here.

>> What pressure are you talking about?

DR WAGNER: How much? We’re talking about 6.5. Not bad. This one’s pretty good. This one’s not as hot, this cautery. I can work it a little bit better. I think that’s good. Okay. Now, I think I’ll use the locking on here. Oh, this is a different type of lock. That’s okay, though. We’re going put one here. Okay. Another forceps. A little cautery again. For a second. I’m not getting it hot enough. Good. Little one here. Okay, good. Now… Let’s have a look at the caliper. Let me see. Once the caliper itself is calibrated, it should be okay. In other words — you know what I mean? If it reads 5, 6.5… That’s good. Okay. So le put a little mark here. I think that’s okay. Okay. Now… That one. I’ll have to dry that. I think I’ll be okay if I dry it. There’s my mark right there. Right? This is a little different for me, because I’m not used to knowing how… A little shallow, right? Okay. So let me — let me put my finger here. I’ll feel more comfortable with it tight in there. Dry that for me, that spot, again. And where is the entry point? I kind of lost it. Yeah. There. I got it. Okay? Good. So I have to dive in a little bit here. Like this. Okay. So we’re gonna do the suture now. I think that’s better. I want to see it through the sclera. I’m being super careful, because it’s just a little bit different view for me than I’m used to. But I think I’m fine. Yeah. I’m fine. I can see it. There’s the other one. Yeah, mark it again. I think I can give you a spot there. Another mark. You know, the caliper, the way it works, it just dehydrates the sclera. So that will… Rotate the eye a little bit inferiorly for me, if you can. That’s pretty good. So I’m really gonna do the cross here. Yeah. Don’t want to hit that suture. Thank you. Okay. Dry that. Put a little pressure on it. I think we’re okay. We’ll have to cut — definitely gonna tie these with a regular tying method. Gonna cut these here. And I need my needle holder again. Thank you. It looks good. Okay. Now I’ve got to wrap it. Now I’ve got to wrap it one more time. It’s just a little bit different, because I’m used to the whole view of the suture. So you have to be a little more careful with your wrapping. I think we’re good. Ready to cut? Very good. There it goes. And I’m ready for the plain suture. So let’s reposition the conjunctiva. That certainly will be easier with the microscope, to know where you are. Yeah. There’s the Tenon’s. See? I think that’s okay like that. So how’s the view out there of this procedure? Is it okay?

>> Yeah. We can see pretty well.

DR WAGNER: Good. Well… I’m gonna put it this way: I’m not really a very young, young guy. But this is the first time I’ve ever done a muscle with the microscope. That’s what I told you. I’m always willing to learn something new. As everybody should be. Right, right, right. That’s right. I mean, I’ve used the microscope for many things. But not for muscle surgery. Oops. Yeah. That’s not bad. But it’s not bad. Having a little trouble here with the conj. But we’ll get that. Okay. There we go. Now, you may have to tilt that down a little bit for me. Oops. A little came out. Yeah. I thought that was gonna come out. Just didn’t quite have that knot the way I wanted. Yeah. I don’t know. Those are little things that we’re not used to seeing how it’s supposed to really look. You know? Let me go back the other way. So I guess the hard part’s just getting the sutures a little lower. And the visualization under the scope. I think that will be about right there. I think I didn’t do two. One, two. I think that will help. One. Yeah. I think I only — yeah. Didn’t do enough. That’s gonna stick. But cut it longer anyway. Good. Good. Okay? Might feel it a little bit, but that’s okay. Won’t be that bad. Where to grab it… I think I’ll go about here. There’s the Tenon’s. Let that flip back. Very good.

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June 2, 2017

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