Adjustable lateral rectus muscle recession
In this video we demonstrate a lateral rectus muscle recession with adjustable sutures. The lower border of the muscle is towards the top of the screen and the upper border towards the lower part of the screen. We begin with the conjunctival peritomy. The conjunctival layer is grasped with toothed forceps just posterior to the limbus and below the lateral rectus muscle insertion and a radial incision is made with curved Westcott scissors. The conjunctival and Tenonís layers are then grasped and Tenonís capsule is penetrated by cutting in a posterior direction onto the sclera. The closed blades of the scissors are inserted into the sub-Tenonís space and advanced towards the upper edge of the muscle insertion in a direction parallel to the limbus, underneath Tenonís and the conjunctiva. The posterior blade of the scissors is then placed in the sub-Tenonís space and a limbal peritomy is done. A second radial incision is performed at the upper end of the incision. An opening is made through the Tenonís capsule in a posterior direction above the muscle insertion. A Jameson muscle hook is passed along the scleral surface posterior to the muscle insertion superiorly and the muscle is isolated on the hook. A second opening is made through Tenonís below the muscle insertion, and a second hook slipped around the insertion. Using blunt and sharp dissection, check ligaments are separated from the outer surface of the muscle and intermuscular membranes are dissected away from the upper and lower borders of the muscle. The muscle is stabilized at its insertion using conjunctival forceps and a double-armed 6-0 vicryl suture with spatula needles is woven through the full width of the muscle adjacent to the insertion site. The suture is locked to both the upper and lower borders of the muscle. The muscle is then disinserted from the globe. The security of the sutures is verified prior to complete disinsertion. Bleeding vessels at the insertion site are cauterized with a low-temperature disposable cautery.. The muscle is then reinserted using partial thickness scleral bites at the original insertion site. The lateral rectus muscle is allowed to hang back in a recessed position and then the two ends of the suture are tied in a ďhalfĒ bow. This will allow for further adjustment in muscle position after the ophthalmoplegic effects of the retrobulbar anesthetic have worn off, or after the patient has fully awakened from general anaesthesia. The conjunctiva is then reinserted in a recessed position 4 mm back from the limbus and sutured in place using 6-0 vicryl interrupted sutures.