PREOPERATIVE DIAGNOSIS: Right exotropia.
POSTOPERATIVE DIAGNOSES:
1. Right exotropia.
2. Scar tissue and restricted ocular mobility, right eye.
PROCEDURES PERFORMED:
1. Resection of right medial rectus, 5.5 mm.
2. Isolation of previously operated upon right lateral rectus with lysis of scar tissue and adhesions with recession to 17-18 mm posterior to the limbus.
3. Lysis of adhesions of the inferior oblique in the inferotemporal quadrant.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal anesthesia.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: Attention was directed to the right eye after it was prepped and draped in the usual sterile ophthalmic fashion. A lid speculum was inserted, and the conjunctiva was marked nasally for reapproximation later. A patch of scleromalacia was visible anterior to the location of the medial rectus insertion, and he had some scarring of the conjunctiva to the sclera anteriorly. As esotropia is more common than exotropia, assume that there had been a medial rectus recession in the past. Thus, we made a radial fornix incision inferonasally and cleaned in the inferonasal quadrant with blunt dissection. The medial rectus muscle was then isolated with a small and then large muscle hook, and L-shape peritomy was then carried superiorly and the conjunctiva was dissected off the sclera. There was surprisingly little scar tissue from surgery, but there was some from early pinguecula and solar conjunctival damage.
The muscle was attached to the globe 6-6.5 mm posterior to the limbus. It was really difficult to tell if there had been, in fact, any previous surgery to the right medial rectus, which we had thought because of the apparent scleromalacia anterior to where the insertion would be. However, it is difficult to tell if there was in fact any surgery there. The muscle was then gathered up and cleaned posteriorly. A second Green hook was inserted at 180 degrees to the first hook. This was used to expose the posterior muscle belly. The muscle was then resected 5.5 mm after suture was passed through the muscle belly and through the upper and lower borders of the muscle just posterior to a point marked at 5.5 mm posterior to the insertion. The muscle was then cross-clamped and transected at the 5.5 mm mark. The muscle stump was disinserted from the globe. The muscle was then advanced just anterior to the 6.5 mm mark, in a more physiologic position about 5.5 mm posterior to the limbus. The muscle was then left unsecured there and the sutures placed to side for exploration of the right lateral rectus.
Attention was then directed to the right lateral rectus through a radial fornix incision winged inferotemporally. There was obvious conjunctival scarring, and clearly, there had been eye muscle surgery there. The conjunctiva was quite adherent from a combination of both old surgery and from solar conjunctival damage. The incision was carried superiorly, somewhat posterior to the limbus, as it was obvious that the muscle had been recessed. The lateral rectus muscle was quite posterior and small and then large muscle hooks were used to secure the muscle. We could not get a great hold of it and was worried whether the inferior oblique was imbricated into the previously recessed muscle.
Thus, we carried the incision of the conjunctiva and winged it superotemporally as well and hooked the lateral rectus from above successfully, clearly, without imbrication of the inferior oblique. The muscle was then cleaned over its superior aspect as it extended posteriorly. There was a pseudotendon that extended to about 8 mm posterior to the limbus, but this was quite diaphanous, and there was clearly no muscle tissue in it. The muscle itself was in good shape but was located 15 mm posterior to the limbus. There was a copious amount of scar tissue inferotemporally and forced ductions were positive with mild-to-moderate restriction to passive adduction of the eye. The scar tissue was cleaned in the inferotemporal quadrant, and the muscle was then finally freed. Even with this, however, the forced ductions were not completely free. The muscle was then gathered up on double-armed 6-0 Vicryl suture using the real insertion.
The anterior pseudotendon was excised. The muscle was then carefully disinserted from the globe. Forced ductions were not yet free, however, as there was scar tissue underneath the lateral rectus and also between the inferior oblique and the inferotemporal quadrant. The inferior oblique was isolated and cleaned of its scar tissue as was the adhesions of the inferior border of the lateral rectus muscle into the inferotemporal quadrant. After lysis of scar tissue, the forced ductions were freed both with the muscle disinserted and with the muscle reattached. As the muscle had been previously recessed quite a bit, we reattached it between 17 and 18 mm posterior to the limbus in a scleral fixation pattern using the double-armed 6-0 Vicryl suture, which had been previously placed. The conjunctiva was then carefully closed with simple interrupted 8-0 Vicryl sutures temporally.
Attention was then directed to the right medial rectus and the previously resected muscle was then pulled up to its new insertion and tied firmly in place. The conjunctiva was closed with simple interrupted 8-0 Vicryl suture. TobraDex eye ointment was instilled onto the conjunctivae, and the patient was awakened from anesthesia and taken to the recovery room in stable condition. There were no complications.
