Hooking and isolating the muscle · Rectus Muscle Surgery Fundamentals

The aim is the whole insertion on the hook, bare of fascia, with no split tendon and no fibers left behind.

Key steps

Through a fornix wound, put a Stevens hook in, rotate it back against sclera and sweep to catch one pole of the muscle — not the whole insertion at once. Don’t sweep far posteriorly: inferotemporally that finds the inferior oblique, superotemporally the superior oblique.
Lift the heel of the Stevens hook to open a tunnel, then pass a large Green or Jameson hook under the whole insertion.
Verify the pass. Rotate the large hook until its tip reaches the limbus. If it hangs up 5–6 mm out, you have split the muscle — reposition and repeat.
Reflect conjunctiva and as much Tenon’s as possible over the hook tip with small anteroposterior sweeps, walking the large hook toward the wound to deliver the insertion.
Cut the intermuscular septum next to the hook tip, then pass a small hook through that hole to clear the septal remnant off the tip.
Pole test. Pass a second Stevens hook through the septal hole, down to bare sclera behind the insertion, and sweep up and forward around where the far pole should be. A clean sweep with the tip riding sclera the whole way means the full insertion is captured, and that pole should be directly visible. Any snag means unhooked fibers — lift them onto the large hook and repeat.
Clear the remaining anterior Tenon’s in as few cuts as possible; it is hard to re-catch once it retracts. Cut perpendicular to sclera and stay off the long anterior ciliary vessels.
Cauterize any cut vessel before sutures go in — hot cautery near a placed suture melts it.

Pearl: The hook is for holding, not for pulling. Pulled-in-two syndrome — the muscle rupturing under tension — is rare but real. In a multicenter series of 40 cases the medial and inferior rectus accounted for nearly nine in ten, 70% of the patients were 50 or older, previous surgery and cranial nerve palsy were the leading risk factors, and in 30% the muscle was never recovered. In an older patient, a reoperation or a palsied muscle, lift only enough to see, and make sure your assistant knows to do the same.

Pearl: Tell anesthesia before the first firm lift. Traction on a rectus muscle is the trigger for the oculocardiac reflex, which turned up in 37% of patients in one series — and a patient who drops their heart rate on the first muscle is likely to do it again on the second. If the rate falls, let the hook go slack and wait for it to recover before you carry on.

Pearl: Through an inferotemporal incision the inferior oblique lies just behind the lower border of the lateral rectus. Keep the hook tip on sclera and turn it forward toward the insertion rather than sweeping back. A lateral rectus that looks unusually wide or bulky on the hook has probably brought the inferior oblique up with it — take the hook out and start again.

Pitfalls to avoid

A split tendon that passes unnoticed until the muscle behaves oddly at the end.
Buttonholing conjunctiva by leaving a fold over the hook tip.
Sutures placed through capsule because the insertion was never fully bared.

Key steps

Pitfalls to avoid

Further reading