PREOPERATIVE DIAGNOSIS: Thyroid eye disease with severe esotropia and left hypertropia; limitation of elevation and abduction, both eyes.
POSTOPERATIVE DIAGNOSIS: Thyroid eye disease with severe esotropia and left hypertropia; limitation of elevation and abduction, both eyes.
OPERATION PERFORMED: Bilateral medial rectus recession, right inferior rectus recession, isolation, and attempted recession of the left inferior rectus.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
INDICATIONS FOR OPERATION: This patient has a history of severe thyroid eye disease and has minus 6 limitation of abduction of the right eye with minus 4 limitation of elevation of the right eye. On the left eye, the left eye is frozen in adduction and depression with only the superior limbus visible above the lower lid margin. Eye muscle surgery was undertaken to improve alignment, promote binocularity, as well as to alleviate diplopia.
DESCRIPTION OF OPERATION: Attention was first directed to the right eye after it was prepped and draped in the usual sterile ophthalmic fashion. Forced duction revealed that there was marked limitation of abduction and elevation of the eye to passive ductions. A radial fornix incision was made inferotemporally, along the lateral border of the inferior rectus muscle. The muscle was then isolated with a small and then large muscle hook, and forced duction of the muscle on the hook revealed that it was markedly tight. The conjunctival peritomy was then carried along the inferior limbus and winged, inferonasally. The inferior rectus muscle was then carefully dissected posteriorly, and the lower lid retractors were removed from the inferior part of the muscle belly. The muscle was then secured with a double-armed 6-0 white Dacron suture, which was difficult to place because of the marked restriction of the inferior rectus. The muscle was then very carefully disinserted from the globe, with great care taken not to imbricate sclera. After the muscle was off, there was still some resistance to passive elevation of the eye.
Attention was then directed to the medial rectus muscle, which was isolated with small and then large muscle hooks. The conjunctiva was then winged along the nasal limbus superiorly. The muscle was isolated with small and then large muscle hooks, and passive forced ductions revealed marked restriction of that muscle as well. The muscle was difficult to isolate because it was so tight. A double-armed 6-0 Dacron was once again used to isolate and secure the muscle. The muscle was then carefully disinserted from the globe with Aebli scissors with great difficulty because of the marked restriction. After the medial rectus muscle was off, it was somewhat easier to elevate the eye.
The inferior rectus was then reattached 4 mm posterior to the old insertion with one-half tendon with nasal transposition. Once the inferior rectus was reattached to the globe, this caused an increase in resistance to passive abduction of the eye due the abducting action of the inferior rectus. The medial rectus was next sutured to the eye in a scleral fixation hang-back fashion giving a recession of 0.5 mm. The ends of the sutures were then trimmed, and the conjunctiva was then closed with simple interrupted 8-0 Vicryl sutures. The lids needed to be taped shut on the right side for attention to be directed to the left side, as there was greater amount of lagophthalmos.
Next, drapes were opened on the left side and a lid speculum was inserted. Even under anesthesia, the eye was still frozen in adduction and depression. It was not possible to get the inferonasal conjunctiva, so superior nasal incision had been made between the medial rectus and superior rectus. The conjunctival peritomy was then carried inferiorly and the medial rectus was isolated with some difficulty because of its extremely adducted position.
A small hook was then exchanged for a large hook and the medial rectus was eventually isolated. Because the eye was frozen in adduction and depression, it was difficult to even place hooks. The muscle was then secured with a double-armed 6-0 Dacron suture, and with great difficulty, the muscle was disinserted from the globe. After the muscle was disinserted from the globe, attention was then directed to isolation of the inferior rectus on the left side. A variety of lid speculums were tried to get better exposure of the inferior rectus. The conjunctiva was then incised along the inferior limbus in order to try to gain better exposure. Even after cleaning the inferonasal quadrant, it was still not possible to visualize the inferior borders of the inferior rectus insertion.
Next, a Barbie retractor was used to pull down the nasal lid against the inferior orbital rim. With this and some great difficulty and pressing along the orbital rim with a small hook, it was sometimes possible to hook the nasal border of the inferior rectus. However, it was readily apparent that the inferior rectus was so tight that the inferior rectus inserted posterior to the equator of the globe. Thus, access could not be gained to the inferior rectus insertion. The case was discussed with Dr. Jane Doe and we elected to perform an orbitotomy at a later date to gain access to this very severely restricted inferior rectus due to thyroid eye disease. The medial rectus muscle was then recessed 7 mm on a hang-back suture and the conjunctiva was exposed carefully, as possible, given the severe amount of restriction of the globe.
The conjunctiva was closed with simple interrupted 8-0 Vicryl sutures. TobraDex eye ointment was then instilled to the left eye. TobraDex ointment was instilled to the right eye after the half-inch Steri-Strips were removed from the lids, which had been holding it closed. The patient was awakened from anesthesia and taken to the recovery room in stable condition. There were no complications.
