Surgery: Lateral Rectus and Superior Rectus Recession using Hang-back Suture

This video demonstrates lateral rectus and superior rectus recession surgery using a fixed scleral suture technique on the lateral rectus and a hang-back suture technique on the superior rectus of both eyes of a 2-year-old child, who presented with large angle exotropia and dissociated vertical deviation (DVD) in both eyes.

Surgery Location: on-board the Orbis Flying Eye Hospital, Mandalay, Myanmar
Surgeon: Dr. Monte Del Monte, University of Michigan, USA


>> Well, we have a two-year-old child here who has large angle exotropia and dissociated vertical deviation, or DVD, in both eyes. So we’re going to recess the lateral rectus in both eyes. We’re gonna recess the superior rectus in both eyes. Using a hangback technique. And we’re gonna do this through a fornix incision. It’s a little bit darker red here. This is a lateral rectus. You can see the superior rectus is right here. You can see the ciliary vessels a little bit. So we’re gonna make our incision in the fornix, about 8 millimeters posterior to the limbus. The scissor is gonna be parallel with the speculum. Push against the sclera and squeeze. You don’t want to get too far posterior, because this becomes — this gets into the upper lid. So we’re gonna enlarge the incision by grabbing one end, and then just slitting the conjunctiva just a little bit. Now we’re gonna go perpendicular to that wound, pressing hard against the sclera, to make an incision in through Tenon’s, down to the bare sclera. And we’ll see if we went through. All right. And now, this is called spreading. We’re gonna close the scissor, go in the incision, let the scissor open, and pull it up. Now we can see the bare sclera here. So this is a Stevens hook. We’re gonna use this to hook the superior rectus. We’re gonna recess the superior rectus first, because it’s gonna be on a hangback suture. So there’s gonna be no tension on it. So now I’ve got the edge. Just the edge of the superior rectus. This is a Jameson hook. Underneath the superior rectus. And we’re gonna sweep it forward. If we can get it up to the limbus, normally that means we’ve got the whole muscle. Now, we’re gonna peel the conjunctiva off the top of the muscle. And there’s the superior rectus exposed. We’re going to see if we’ve got the whole muscle. So we put the tip of the Stevens hook behind. And we’re gonna sweep around the end to make sure we have the whole muscle. And there we can see the end of the insertion right there. So we know we have the whole muscle. We’re gonna clean the Tenon’s off the insertion. There’s the insertion. To clean Tenon’s, we’re going to open the scissors. We’re going to go anterior to the muscle, to cut this Tenon’s tissue. By pressing hard against the sclera, like that. Our goal here is not to cut the ciliary vessel. So we’re staying well in front of the muscle. The tissue we’re cutting goes all the way to the limbus. So there’s no reason to cut towards the muscle. For vertical muscles, we have to clean posteriorly. The intramuscular septum. Or else we’ll change lid position. And there’s the superior rectus. There’s an adhesion of the Tenon’s capsule to the muscle. It’s oblique. We call it the falciform ligament. We’re gonna start off by getting into that ligament. And we’re gonna clean the edge of the muscle. And we want to clean it fairly far back. All the way back to the pulley. The reason is that we don’t want any tissue that connects to the upper lid to remain. Otherwise it will pull the eyelid higher and give you lid retraction when you recess it. We’re gonna be doing a very large recession here. So I’m getting the intramuscular septum on both sides. You have to be very careful, because the superior oblique tendon is right underneath here. We’re only cutting tissue that comes off the top of the muscle or off the edges. Nothing that goes underneath. Now, you can see we’re pretty far back. I’m gonna secure the muscle. And again, there’s many ways to do this. This is the Parks crossed swords technique. So we’re gonna go about two thirds of the way across the muscle. Half thickness. We need to come out very close to the insertion here. This is a 6-0 vicryl with an S-29 needle, a very fine wire needle. Now we’re gonna go full thickness, about one third width, and lock. And that’s how we’re going to secure this pole. Trying to avoid the ciliary vessels. A little bit of bleeding, always, when you do that posterior dissection. And we lock it. And then we’re gonna make sure that we can see our incision. All right. Same thing now on the other side. We have to make sure we’re in the muscle. It’s a fairly thin muscle. Sometimes we kind of weave this up and down to make sure you stay in the muscle. And then the lock bite. And I’m pulling it towards the insertion to lock it. So it locks a millimeter from the sclera. We don’t want to resect any of the muscle. So we want it to be very close to the sclera. Take about half the muscle off. And then we try and secure the insertion with a locking forceps. All right. There’s one in. Okay. There’s our muscle. So now we’re gonna grab the other end of the insertion. Now we’re gonna secure the muscle back to the original insertion site. And we’re gonna recess it by hanging it back. You want to go in very close to the end of the insertion, so we don’t narrow the muscle. Which changes its physiology, changes its vector force. This is called the crossed swords technique. We’re gonna try to make these cross in the center. Now, that was the nasal pull. Now we’re gonna do the temporal pull. And you want these to exit as close as possible together. So press the back point against the sclera. I’m gonna clamp right at the 5.5 millimeter point. And now we’re gonna tie the suture on top of the clamp. This is going to allow 5.5 millimeters of suture, which we can use to hang the muscle posteriorly. So 2-1-1, our throws here, to make our knot. And then we’re gonna cut the suture. We cut it long. Now we’re gonna let this hang back. This is called a hangback recession. You can see why. It hangs back. And when the knot makes tight contact, we’re basically hung back 5.5 millimeters. We do this for a couple reasons. One, the superior oblique tendon is underneath here. We don’t want to tie that tendon down. This allows that tendon to slide underneath. All right. Now we’re gonna do the lateral rectus. So through the same incision — again, the nice advantage of the fornix incision. You work through the same incision. I’m gonna hook the lateral rectus. Again, if I can get the tip of the hook to the limbus, I know I have the whole muscle.

January 10, 2020

Last Updated: October 31, 2022

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