Partially accommodative esotropia with convergence excess is managed with surgery,1 which includes recession of both medial rectus muscles to control distance deviation combined with strategies to control distance-near disparity, such as posterior scleral fixation2 or pully fixation sutures.1 However, medial rectus recession followed by posterior scleral fixation is associated with poor access and increased difficulty. We report a modification of the conventional surgical technique in which the posterior scleral fixation suture is preplaced through both sclera and muscle before medial rectus recession, with considerable improvement in surgical accessibility and ease.
Under general anesthesia, a limbal conjunctival incision is made and the medial rectus muscle is hooked and freed from Tenon’s capsule and the intermuscular septa. The hooked muscle is used to rotate the globe in order to explore the retroequatorial space. At the upper muscle border, the caliper is adjusted to the distance required for posterior fixation suture placement (here, 12 mm posterior to the muscle insertion) and a surgical pen is used to mark the sclera. First, the needle of nonabsorbable 5-0 polyester suture is used to anchor the sclera at that location. From the scleral suture, the position of muscle suture placement is measured anteriorly according to the amount of the planned medial rectus recession (here, 6 mm), and the same needle is passed through the peripheral one-third of the medial rectus muscle. A Bulldog clamp is used to secure the suture. The same steps are then repeated at the lower border of medial rectus muscle. The insertion site of the medial rectus muscle tendon is then secured using double armed 6-0 polyglactin 910 sutures. The muscle is then disinserted from the sclera and recessed using a hangback technique. After recession, the scleral and muscle suture passes at each muscle border should be at the same distance from the original insertion. These sutures are simply tied without further manipulation, thus fixing the peripheral part of the muscle to the sclera at a location 12 mm posterior to the original muscle insertion. Finally, the conjunctiva is closed using interrupted 8-0 polyglactin 910 suture. |
