Inferior Oblique Myectomy

Inferior oblique myectomy is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by transecting it. The patient is a four old with a history of inferior oblique overaction and vertical strabismus, which can be corrected by resection of the inferior oblique muscle.

The ointment was applied to the cornea. Forced ductions were performed and identified restriction of the inferior oblique. A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the Inferior Oblique. The inferior oblique muscle is isolated using a Stevens tenotomy hook followed by Jameson muscle hooks. The inferior rectus was identified on a steven’s hook medially to the inferior oblique. The lateral rectus was then identified on a steven’s hook laterally to the inferior oblique. This was done to ensure that neither muscle was incorporated with the portions of the inferior oblique muscle to be cut. Wescott scissors were used to cut both ends of the muscle. Bipolar cautery forceps were used to cauterize the resected proximal and distal ends of the inferior oblique muscle. The two ends were released and the remaining muscle ends were allowed to retract into the orbit. The conjunctiva was closed using a plain gut suture.

No complications arose during the procedure. Postoperatively, the patient had a subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the one follow-up, the redness and pain had resolved.

Inferior oblique myectomy effectively treats inferior oblique overaction and vertical strabismus associated with this condition.

Superior Rectus Recession

Introduction

Muscle recession is a type of strabismus surgical procedure that aims to weaken an extraocular muscle by adjusting its insertion posteriorly closer to its origin. The patient is a 14-year-old with dissociated vertical deviation, which can be corrected with recession of the superior rectus muscle.

Methods

A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the superior rectus muscle. The superior rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. After the remaining Tenon’s attachments are cleared, the muscle is secured at both poles with a double-armed 6-0 VicrylTM suture and double-locking bites. The muscle is then disinserted from the sclera with Manson-Aebli scissors. A caliper is used to mark the predetermined distance of muscle reinsertion. Next, the muscle is reattached to the sclera with partial thickness bites and then tied down to its new location. The conjunctival incision is closed with 6-0 plain gut sutures.

Results

No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the three-month follow up, the redness had resolved. The dissociated vertical deviation had improved.

Conclusion

Superior rectus recession is a safe procedure that can effectively treat vertical strabismus.

By: Michelle Huynh

College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

mhuynh@uams.edu

Surgeons:

Brita Rook, MD

Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA

BSRook@uams.edu

Joseph Fong, MD

Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

JFong@uams.edu

Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.

Lateral Rectus Plication

Introduction

Muscle plication is a type of strabismus surgery that aims to tighten an extraocular muscle by partially folding the muscle under or over itself without disinsertion. The patient is a 14-year-old with alternating esotropia, who previously had a medial rectus recession. Therefore, she underwent plication of the lateral rectus muscle for this procedure.

Methods

A conjunctival incision is made in the fornix. Tenon’s capsule is dissected to expose the lateral rectus muscle. The lateral rectus muscle is isolated using a Stevens tenotomy hook followed by a Jameson muscle hook. A Stevens tenotomy hook is used to sweep around the muscle to confirm the location of the muscle pole. A caliper is used to mark the predetermined amount of plication, starting at the muscle insertion and marking further posteriorly on the muscle. The muscle is then secured at the location marked by the caliper with a double-armed 6-0 VicrylTM suture with a central bite and double-locking bites at each pole of the muscle. Plication is achieved by bringing the muscle anteriorly and attaching it to the sclera adjacent to the muscle insertion with half-scleral depth bites in crossed-swords fashion. The muscle is tied down to its new location and 6-0 plain gut sutures are used to close the conjunctival incision.

Results

No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and pain that decreased over the following week. Neomycin-polymyxin-dexamethasone drops were applied daily to prevent infection and inflammation. At the three-month follow up, the redness had resolved. The alternating esotropia had improved.

Conclusion

Lateral rectus plication is a safe procedure that can effectively treat esotropia.

By: Michelle Huynh

College of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

mhuynh@uams.edu

Surgeons:

Brita Rook, MD

Arkansas Children’s Hospital – Department of Ophthalmology, Little Rock, Arkansas, USA

BSRook@uams.edu

Joseph Fong, MD

Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA

JFong@uams.edu

Video was performed at Arkansas Children’s Hospital, Little Rock, AR, USA.

Ahmed® Glaucoma Valve for Treatment of Refractory Glaucoma

Introduction
Intraocular pressure is the single modifiable risk factor resulting in progression of various subtypes of glaucoma. Intraocular pressure control is often achieved with topical medications, outpatient laser procedures, or minimally-invasive glaucoma surgery (MIGS). This patient is a 63-year-old with traumatic glaucoma in the right eye with elevated intraocular pressure sub-optimally controlled despite maximum medical therapy (29 mmHg). His intraocular pressure must be controlled with incisional glaucoma surgery – in this case, with placement of an Ahmed Model FP7 glaucoma valve. An advantage of valved glaucoma shunts is lower risk of postoperative hypotony-related complications compared to non-valved glaucoma shunts.

Methods
The 10 and 12 o’clock meridians are marked with a marking pen to define the borders of the conjunctival peritomy. A limbal traction 6-0 Vicryl suture is placed superotemporally in the cornea at the limbus. The conjunctival peritomy is then completed using Westcott scissors along the predetermined marks. The peritomy is extended posteriorly with blunt dissection using Stevens tenotomy scissors. Wet field cautery is used to achieve hemostasis of the scleral bed. A Stevens tenotomy hook is used to identify the superior rectus muscle and a marking pen is used to mark its border. The Ahmed Model FP7 tube shunt is then introduced onto the surgical field. Balanced salt solution is injected into the tip of the tube using a 30-gauge cannula to ensure adequate patency of the valve. The Ahmed plate is then sutured to the sclera approximately 8 mm posterior to the limbus using 5-0 Nylon suture. A corneal paracentesis is made at the 8 o’clock position, and viscoelastic is injected to deepen the anterior chamber. A 23-gauge needle attached to the Healon syringe is then used to tunnel from a point 2.0 mm posterior to the limbus into the anterior chamber. The needle tract is anterior and parallel to the plane of the iris and the surgeon must ensure that the tube does not contact the iris or corneal endothelium after insertion. The implant tube is then laid flush with the cornea and shortened with Westcott scissors with an oblique cut, bevel up. Healon is injected as the needle is withdrawn. Non-toothed forceps are then used to insert the tube into the anterior chamber. A single 8-0 Vicryl suture is used to secure the tube to the underlying sclera. A corneal patch graft is cut to fit the site of tube implantation and secured with a single 8-0 Vicryl horizontal cross mattress suture. The conjunctival peritomy is then closed with a running 8-0 Vicryl suture on a BV needle. Anchoring sutures incorporating the conjunctiva and the episclera to firmly secure the corners of the peritomy to the limbus. A 9-0 Nylon suture is used to re-approximate the limbal conjunctiva. At the conclusion of the case, the eye is returned to a neutral position, the traction suture is removed, and satisfactory intraocular pressure is confirmed by palpation.

Results
No complications arose during the procedure. Postoperatively, the patient had subconjunctival hemorrhage, injection, and mild pain that decreased over the following week. Prednisolone acetate drops were applied six times daily to prevent inflammation and moxifloxacin drops were applied four times daily to prevent infection. At the three-month follow up, the eye was quiet and intraocular pressure was measured to be 9 mmHg.

Conclusion
Implantation of an Ahmed glaucoma tube shunt is a safe procedure that can effectively treat various subtypes of glaucoma with sub-optimally controlled intraocular pressure despite maximum medical therapy.

Joseph W. Fong, MD
Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
JFong@uams.edu

Ahmed A. Sallam, MD, PhD
Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
ASallam@uams.edu

Surgery was performed at University of Arkansas for Medical Sciences, Little Rock, AR, USA.

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