Medial rectus recession — assistant's view

A fornix case needs four hands. The fornix approach is only the right choice when the assistant can do this reliably — so this is worth learning properly early.

What the assistant does

1. Position the globe. Grasp conjunctiva and Tenon’s in the quadrant, rotate the eye away from the target muscle, and lift it forward into the fissure so the surgeon can work behind the insertion. Hold that position steadily rather than re-gripping.
2. Present the plane. For the second-plane cut, take Tenon’s with fine forceps opposite the surgeon and tent it into a ridge parallel to the first incision.
3. Hold the hooks where they’re useful. Lift hooks away from sclera and toward the orbital rim to display borders; don’t press them into the globe.
4. Keep the field visible. Retract conjunctiva off the scleral exit points during suture passes, and keep the wound dry enough that the surgeon can see the needle through sclera.
5. Watch the pole sutures. During disinsertion they are the thing standing between you and a lost muscle. If a pole goes slack, say so immediately.
6. Follow the globe during the scleral passes without countering the surgeon’s rotation.

Pearl: Set the exposure once and hold it. The surgeon calibrates every movement to where the globe is, so each re-grip moves the target and crushes another piece of conjunctiva. The scleral pass is when this matters most: a needle is traveling through sclera about 0.3 mm thick, and that is not the moment to improve your grip. If you have to move, say so first and wait until the needle is out.

Pearl: Your traction is what slows the heart. Pulling on a muscle or the globe sets off the oculocardiac reflex in a large share of strabismus cases — 37% in one series — and it is often the assistant’s hand doing the pulling. When anesthesia calls a drop in heart rate, let go of the tension at once without waiting to be asked, let the rate recover, then take it up again gently.

Pitfalls to avoid

• Rotating the eye the wrong way, or letting it drift mid-pass.
• Pressing hooks against sclera and tamponading the field you’re trying to show.
• Letting a fold of conjunctiva sit over a hook tip, which is how buttonholes happen.

Further reading

• Del Monte MA, Archer SM. Atlas of Pediatric Ophthalmology and Strabismus Surgery. Churchill Livingstone, 1993. Ch. 2, “General Surgical Considerations” (Archer), pp. 15–24.
• Same atlas, Ch. 5, “Rectus Muscle Weakening Procedures” (Del Monte and Archer), pp. 51–62.
• Lai YH, Hsu HT, Wang HZ, Cheng KI, Wu KY. The oculocardiac reflex during strabismus surgery: its relationship to preoperative clinical eye findings and subsequent postoperative emesis. J AAPOS. 2014;18(2):151–155. doi:10.1016/j.jaapos.2013.11.024