We're going to talk a little bit about surgical techniques, planning, anesthesia, a little bit about Botox and complications. Surgical planning is kind of the mystery that drives a lot of residents nuts when we talk about doing eye muscle surgery in terms of figuring out what to do, what procedure, how much, and how to go about accomplishing it. Now, types of surgical procedures, these are a variety of weakening procedures, recession, myotomy, myectomy, recession with anteriorization, tenotomy, tenectomy, and some of these are more appropriate for some muscles than others. When we talk about tenotomies, we occasionally do them for superior oblique tendons, recession with anteriorization. This, let's see, is this, yeah, there we are, mainly refers to the inferior oblique muscle. Myectomy also, usually for the inferior oblique muscle, as with myotomy, recessions, usually we're talking about rectus muscles, sometimes the inferior oblique muscle. Denervation and extirpation is a weakening procedure I would not recommend you try to do. It basically is what happens when what you've done to the inferior oblique hasn't worked in a big way, but usually those issues are due to scarring in the area, and in my experience, this procedure doesn't add anything. For purposes of OCAPs, boards, it is an inferior oblique weakening procedure done when everything else has failed. Posture fixation suture, and there should be another one added here, and for some reason it did not come up when I pulled up this talk because I modified it last night. Posture fixation suture is a weakening procedure that has more effect in the direction of action of the muscle with medial rectus muscles at near. There's another procedure that has come into vogue similar to this, which is called a recession and resection procedure, not meaning recessing one muscle, resecting the other, but what we do is take a muscle, say the medial rectus muscle, and then we remove a five millimeter section, and we tack it down to the wall of the eye, five millimeters posterior to the insertion. That also has an effect greater in the direction of action of the muscle. We usually gear it at kids who have esotropia that is greater at near than a distance that we can't correct by other means, and they wanna get out of bifocals. It also is useful at times after orbital trauma with an inferior rectus muscle that isn't working well, and what we're trying to do is recruit the fellow inferior rectus muscle so you remove a small section of the muscle, tack it down, an equal amount posterior to the insertion, and that's been shown in some studies to work just about as well as doing a posterior fixation suture. Technically, it's a lot easier to do. Now, strengthening procedures, and when you look at length tension curves, basically what you're doing is shortening and tethering, not strengthening. The muscle hasn't gotten any stronger, but that's the term that is currently in vogue. Resection is the mainstay advancement of a previously recessed muscle or a tuck, mainly again geared at the supere bleak historically, but again, recently people have started folding horizontal rectus muscles. Instead of doing a resection, it turns out, again, it's not a terribly difficult procedure to do, and it is a procedure that can help preserve the blood flow through the muscle, which provides blood supply to the interior segment. Now, special procedures, adjustable sutures, well, those are something that you should do if you've had experience doing them and otherwise I would not suggest it, so the first time you're gonna try one, get one of your colleagues who's done one before who had experience doing it, do it with you. Transpositions of muscles, again, can be a lot more difficult than doing straightforward horizontal surgery, but if you've had experience doing them, can be very helpful to patients. And then we talk about vertical shifts, either for vertical misalignment, if I have hypotropia, my right eye, shifting both the medial and the lateral up to rotate the eye up at the same time we're doing horizontal surgery. The other circumstance is vertical shifts for an A or V pattern, A and V patterns refer to circumstances, again, where we have more or less horizontal misalignment and upper down gaze. If I have esotropia, 50 prism diopters in up gaze, 30 prism diopters in primary, and I'm ortho in down gaze, that's an A pattern, whereas the child who's 50 prism diopters of esotropia in down gaze, 30 in primary, and they're ortho in up gaze, and they've got an inferior oblique overaction, that's a V pattern. Now, what about anesthesia and how do we approach it? You notice that most of the eye muscle surgeries that we do here, we do a general anesthesia that isn't just because that's what somebody happened to do, it is with some thought and planning. The idea is that when we do general anesthesia, we have the opportunity to be able to operate on both eyes.  It is not appropriate in any circumstance to do bilateral simultaneous retro-ball bar blocks. I have done retro-ball bars when there was no general anesthesia available and an eight-year-old is the youngest I've done doing one eye in the morning and one eye in the afternoon, doing horizontal strabismus surgery to correct esotropia because both eyes were tight. The other thing you can't do if you're doing a retro-ball bar on one eye is very reliably check for reductions in the operating room, which a lot of the re-operations and complicated things that we deal with here is very helpful to do that. So I'm a strong advocate of doing general anesthesia where it's appropriate and for most of the patients that we operate on it, that turns out to be the case. But keep in mind, you can do eye muscle surgery with a retro-ball bar block. You can also do eye muscle surgery with topical, I've done it with topical anesthetic. In that point, you have to realize that what you're not gonna be able to make numb with topical anesthesia is any tugging. So you have to be very gentle pulling on muscles because where those muscles attach back the annulus is in, those muscles, that's gonna be very uncomfortable if you pull on that. So you have to carefully select things. If you're doing a small recession to one muscle, you can get away with it. If you're trying to do an eight or nine millimeter resection of a muscle and you try to do it under topical anesthesia, you're gonna have a very, very uncomfortable patient. Now, when we talk about general considerations, what am I trying to accomplish for the patient? And that turns out to be an issue, is it possible to make the patient binocular? One of the things to ask the patient is, what bothers you about your eyes? There's a big difference between I'm seeing double and my colleagues ask me whether I'm looking at them or I'm looking over here across the room because my eyes are turned out and it's affecting how I feel about myself. Either of those, dyplopia or the misalignment and the social consequences can be a perfectly reasonable reason to operate on a patient, but I think it absolutely have to be clear, patient has to be clear as well on why we're doing what we're doing and that may change what we're trying to accomplish. If you take a patient who has dramatically decreased vision in one eye, say I have optic nerve hypoplasia in my right eye, we wanna make the eyes straight, you say gee, I think if I did a little bit on each eye I'd probably get a better result, but because I don't wanna risk the child's only good seeing eye, I'm gonna limit what I'm doing to the eye with the optic nerve hypoplasia. And that is again something to think about ahead of time and talk to the family about. Now what is comatence? Who can tell me what that means? You're having a similar deviation in all areas of gaze. That's right. And if the deviation is comatent, that's great, but let's say it's not. You need to have as clearly as possible in your own mind an explanation for why it's not comatent, whether it is due to weakness of a muscle with a six nerve palsy or due to tight muscle subconjunctival tissues, conjunctiva scarring due to previous surgery. Those are issues to take into account when planning surgery because ideally we would like things to be as well lined up as possible. Sometimes on the other hand, it is the circumstance that a patient comes in and their issue is I'm seeing double when I look way over here, but when I'm looking straight ahead, everything's fine. I look down to read, walk around, everything's fine. And I go out here a ways and suddenly it's double out there and I want you to fix that. Sometimes our obligation isn't to plan a surgery, is to tell the patient why they shouldn't have surgery in your opinion because you never wanna sacrifice good alignment, primary position, reading position, walking around vision, going up downstairs for something that's happening in some very peripheral field of gaze if that's the only thing that's going on. So part of our job may be to tell the patient that they shouldn't have surgery. Now, equality of visual acuity I touched on and I think that if there is something that prevents an eye from seeing well, you may wanna think about operating on that eye. Sometimes on the other hand due to restriction or other issues, cranial nerve palsies that affect the only good seeing eye, it is necessary to operate in the only good seeing eye at which point you need to have a thorough discussion with the patient about your rationale in recommending that to them. Torsion, the things look tilted. Remember, misalignment can occur both vertically, horizontally and torsionally and we can deal with torsion either primarily by operating on a muscle that is usually the culprit in causing the torsional misalignment. The other things though that can be done is to offset other muscles. Muscles tend to wanna go back where they normally sit. So if I take my right medial rectus muscle and I recess it at the same time, I shift it up.  Now, if you're offsetting the muscle for some other reason, it's useful to think about that and say, well, gee, is the patient gonna notice if I give her some torsion? That's something to be aware of and so you wanna think about what effect you're likely to create. You can also use that information to fix torsion. Let's say the patient has had something done to an inferior oblique muscle like a myectomy where big piece of the muscle's gone. You can't go back and re-operate on it now and what they've caused at the time, they did that basically, is some encyclotortion and we're gonna be working on another muscle. Let's say at the same time that eye is now hypertropic, we're gonna recess the inferior rectus muscle and we've got some encyclotopia, which is what you might see with an inferior rectus parisus, which is what one creates when you chop out a large section of it and if we take our inferior rectus muscle and we recess it, we can shift it nasally or temporally as we reattach it to affect the torsion. And again, if we wanna take care of it, we wanna cause an encyclotation, what we're gonna do is take that inferior rectus and transpose it temporally and you need to think about this and I find it useful to think about my own eyes when I'm thinking about this in terms of which way things are gonna go. If I'm gonna move the inferior rectus muscle back and I temporally transpose it when it comes in, it's gonna rotate that 12 o'clock position out, encyclotation, so it's gonna go in the correct direction. Can you quantitate it? No, not very easily, but often if you get things in a range where the patient can pull things together, it's gonna take care of itself. Now, the other issue are surgeon-specific issues and those are the issues. It is a different circumstance. If Sophia now getting well into her fellowship has had a fair amount of experience doing eye muscle surgery and so if she's doing something that in the choices, do I operate on a previously operated muscle or a muscle that's had no surgery, her answer may be different than your answer if you've done what you did here as a resident on the service and that's all the eye muscle surgery you've done, chances are you're almost always gonna be better off operating on an unoperated muscle. The anatomy is gonna be easier to deal with and you're gonna feel better about it at the end of the day where is the answer for her may well be that she needs to kinda look at where am I gonna get the best result, the largest area of competence and make this just as good as it possibly can be and so you need to have an honest assessment of how comfortable am I, have I ever seen the superior bleak muscle before? Figure that out before you go in to operate on it and I did that when I was a resident, we went in and nobody in the room had ever seen the superior bleak before, I thought that the attending had but turns out he'd been assigned to the case and he hadn't either and I had my copy of Grant's Anatomy Atlas out looking in a picture of where we should find the superior bleak but it was not a pleasant experience for all involved, particularly me so you wanna think about those things ahead of time and again, before surgery you wanna talk to the family and the patient about what's in it for them, is it a matter of in an adult getting rid of diplopia or is it a matter of trying to give a child a decreased risk of developing amblyopia or not having it recur after it's been treated or to improve their chance of having normal binocularity and then there are mitigating factors, developmental delay, neurologic disease, proptosis, developmental delay, if a child is horribly developmentally delayed and they are not interacting with their peers, they're in a self-contained classroom fixing their exotropia in a teenager may make absolutely no difference in how people interact with them. On the other hand, in an otherwise developmentally normal child, it may make a world of difference in terms of their ongoing self-esteem and social development. Progressive neurologic disease can sometimes be a reason not to operate but often we go ahead and try to get things fixed so a patient can enjoy and enjoy a better quality of life but you need to understand that when you're operating on a patient who's got miastinia gravis, who's got Parkinson's disease, things that can affect strabismus, your chance of getting the best possible outcome decreases and that is something that you must discuss with the patient ahead of time. Now, this is an issue just to think about a little bit and realize that when we talk about weakening horizontal muscles, the eye, when we move a medial rectus muscle back comes forward a bit.  Conversely, if you resect a muscle, you're gonna cause the eye to move posteriorly just a bit, a slight amount of enophilus. Now, if a patient has preexisting mild ptosis, you push the eye forward just a little bit, the lid's gonna come up, things are gonna look better. Conversely, they've got ptosis and you do a huge resection on that medial rectus muscle and you decide to do two muscles on one eye for exotropia rather than one muscle on each eye. You're likely to cause ptosis to look worse.  That can be complicated but it is something you need to think about. The other one you never wanna forget if you do vertical muscle surgeries to talk to a patient about ahead of time is the effect of vertical muscle recession, usually recession more than resection on the lid position. If you do a successful inferior rectus recession for thyroid disease, even when you try to separate all the attachments between the inferior rectus and the lower eyelid retractors with Lockwood's ligament, what you wind up doing is causing the lid to come down a bit. And so when we do that for patients with thyroid disease, we have discussion ahead of time about the likelihood of precipitating the need for some eyelid surgery so that they don't have dramatic increase in their exposure symptoms because they're usually already proptotic and we're making that situation worse as well. The other is with superior rectus recessions and when you do superior rectus recessions in kids, most commonly done for dissociated vertical deviation where you don't have associated inferior bleak overaction, when you do a six or eight millimeter recession of a superior rectus muscle, they always have this really wide-eyed look for a few weeks, sometimes two or three months, it usually settles down. Where it can be a problem is if you do very, very asymmetric surgery. So think about it particularly if you're doing a unilateral superior rectus recession. Again, you wanna consider how you're gonna create problems before you do. Patients are always much more appreciative and they think you're smarter if you say, I think I may cause this problem when I do your surgery instead of walking in the room for that first post-op business saying, gosh, I've never seen that before. That's a new one on me. People don't like that. Now, what about the issue of cosmetic eye muscle surgery? I'm a strong fan of the concept that there is no such thing as cosmetic eye muscle surgery. Cosmetic surgery is when you take something that looks perfectly acceptable and you make it look prettier because it meets some social standard. Correction of a deformity is when you take something that is not the way that it's supposed to be and you make it more like it's supposed to be. And that is where almost all eye muscle surgery that people sometimes call cosmetic really fits. Correction of a deformity. There is a significant body of evidence now that both children and adults with strabismus do better in terms of opportunities for playmates, school positions, jobs, advancement, relationships, if their eyes are straight. Evelyn Pacy is a colleague of mine at Baylor, took a series of digital photographs and altered them and both kids and adults. With the kids, I believe they were five-year-olds, made them ET or XT, and then showed the kid with straight eyes, the kid with misaligned eyes to preschoolers and said, who would you like to play with? They picked the kid with straight eyes every time. She did the same thing with adults and showed it to a series of human resources professionals who by law are not allowed to discriminate on that basis, but they still did, picking the individual with straight eyes. And so we can't improve people's quality of life. And again, if you look into that, I mean there are now a number of publications and I know that Dr. Feng has some information and has done some work in this area as far as adults and adult strabismus surgery. And I think that it's something to consider, it is something to consider as well when you're getting informed consent. And informed consent is different as you are hopefully all aware than having a patient sign a piece of paper saying, I'm gonna have eye muscle surgery on one or both eyes. It means that you've talked to them about the diagnosis the options for treatment. If you're talking about surgery, what options are there to consider? What are the pluses, minuses? How might you get them into trouble? And the likely outcome of the surgery, possible need for additional surgery. How it's gonna affect their life both short-term and long-term. And I talked to them at the same time about the post-op care restrictions of activities and for follow-up. Now with some surgeries, this turns out to be more important, not with eye muscle surgery, when we see an infant with a cataract, have a conversation with the parents, in addition to talking about the surgery and getting consent for that, I basically tell them that it is my expectation that they will bring that child to somebody like me or me until that child has grown for regular care. That's their end of the deal and are agreeing to operate in the child. And similar discussion often takes place in terms of parents, kids who have strabismus who are in the amblyogenic age range, saying our job isn't done when we get little Susie's eyes straightened out. We have to follow her to make sure that her vision is developing normally. She's using the two eyes together to get the best possible outcome. Now, what about in the OR before you get to the muscle? What do we do? This is one of the only things that's been shown to actually have any effect. Sherwin Eisenberg published some very interesting information. It came from a pediatric ophthalmologist looking at number of species and colony forming units after putting in two and a half percent Povidone iodine in the eye prior to surgery and found that that was the single thing that actually appeared to have a dramatic effect on that. So, iodine, Povidone iodine does matter and I'd urge you to put it in before surgery. I usually use traction sutures. Conjunctival incisions you will see with either myself or my colleagues here, a variety of conjunctival incisions approaches to get to muscles. The two common variants are either a limbal incision or a forex incision. They have their pluses and minuses. With a limbal incision, you can more easily deal with scarring. It's easier to do reoperations. On the other hand, with a forex incision, the advantage is the incision is a bit hidden out of the way. There is less obvious redness, irritation, and misery right after surgery. And for some muscles, they're more appropriate than others. But you'll see both here if for those of you who have not been on our service already. Now, surgeon positioning, lighting, and magnification, you need to think about and as you're going through this in your rotations as a resident, look at where the attending sitting, doing things a certain way, where they have the assistant sitting. You want to get that in your own mind as far as how you want to organize things when you're out and you're trying to do your first eye muscle operation, saying, well, where do I want to sit and all that? And like a lot of things in sports and other things, if you kind of visualize yourself doing things and go through in your own mind the steps in the surgery and kind of see it from that surgeon's perspective, I think that's very helpful. As far as lighting and magnification, all of you hopefully have loops that you can use for eye muscle surgery. I think that if you go in other parts of the world, you'll see an awful lot of eye muscle surgery, horizontal surgery done through an operating microscope. And you can do horizontal eye muscle surgery well through an operating microscope. It is very difficult to do vertical surgery, to do obliques. And I think you can position your head better using loops. And I'm a strong advocate of using these battery-powered headlights. I think they're absolutely wonderful to get good visualization right where you need to see from your perspective and it always moves with you. But if you're trying to use the microscope, there are some people that are predominant. I think advocate here in the U.S. is a guy named John Simon, he's a pediatric ophthalmologist at one of the State University of New York programs in Albany. And John has been using the microscope, feels strongly it's the only way to do eye muscle surgery. So it's good there's some disparity it causes in a good discussion. But I've actually switched people from using the microscope to using loops in a lot of the programs I work with internationally if they're gonna go beyond doing just straightforward horizontal muscles. You know, the advantage is they don't need a conditional equipment when they use the microscope and they can do it in the same flow of patients when they are doing anterior segment surgery. So it works for them in that regard. Now, if we go through and these tables are in your books but basically you can look up numbers that will give you information about how much to recess a medial and resect a lateral for a given amount of esotropia. These are Marshall Park's original numbers and these are from my mentor folks I trained with Gene Helveston and Gerald Ellis. These are measurements of the amount of recession and resection and this would be like a bimedial recession of four for 25 prison doctors. Whereas these measurements are from the limbis. So this is you recess the medial to eight and a half millimeters in the limbis under a year of age nine over a year of age nine and a half and 10 and a half. So it's kind of a small medium and large approach to eye muscle surgery. It seems to work pretty darn well. Now, Hiran Hardesty is a guy who followed a whole series of intermittent dextropia patients for many years and these are his numbers that he derived looking at a very large extended data pool that I think was over about 25 years. And this Dr. Park's numbers for the same things and these I think this is being recorded so you can have these to use and use these when you start out and then what you need to do is look at how your results vary from these because as you go from one attending to another here you'll see different ways of placing suture, different ways of doing resections and so these numbers are only a rough guide because people's technique differs.  When it comes to A and V patterns again you can decrease the amount of dextropia in up gaze with bilateral inferior oblique weakening. Shouldn't be any change in primary position but you will see a bit of an ESO shift if you're doing bilateral superior oblique tenotomies for an A pattern exotropia. Vertical surgery, you can decrease the vertical, the ipsilateral hypertropia by about 10 to 15 prism diapters in primary position, up to 25 prism diapters in the field of action meaning the gaze down and in towards the nose the involved ipsilateral superior oblique if we're going to tuck that. So gaze if my right superior oblique is involved that would be that gaze down and left. You can get up to 25 prism diapters of correction. That's a very powerful procedure, something you don't want to take lightly and you can vary the amount of inferior superior rectus precession that you do to get at most probably 15 prism diapters. If you're talking about a situation that doesn't involve restriction, if you put restriction in there like a tight inferior rectus and thyroid patient then those numbers go out the window because the restriction itself is causing a significant amount of that misaligned. And again with exotropia doing a recess resect procedure these are again are Dr. Parks's numbers and then complications to touch on this stuff and then I want to look at some patient examples. The alignment issues, most common problem after eye muscle surgery is that we didn't accomplish what we set out to do and there's still enough misalignment to either be noticeable to the patient or to cause diplopia. We can also see usually temporarily refractive air changes when you do a significant resection you can see a significant amount of a stigmatism show up in the short term but if you watch that patient over two or three months as sutures absorb that will often go away. Perforation of sclera is one that everybody dreads. I've also in my career seen sclera perforated a number of times I have seen large sections of sclera excised with someone pulling up firmly on a muscle while pushing down with scissors trying to disinsert the muscle. That always is a major, oh gosh I wish I didn't do that lots of bad words are said. And then you put in a sclera patch graft and do what you were gonna do with the muscle. I've never seen anyone lose an eye from either perforating sclera or removing part of the wall of the eye but it does require some reconstructive work with the sclera removed. And if you were, we are in the operating room right now. And I were making a pass and suddenly things seemed to lighten up and the needle jumped forward and it's kind of heading for the middle of the vitreous. What would you do? Any ideas? I mean besides saying gosh I wish I hadn't just done that and you'd probably tell me you wish I'd been aiming the needle not towards the vitreous and keeping the needle flat on the globe like I kind of hound some of you folks to do. Well, if, I mean the needle can go a variety of places, right? It still could be interscleral but not likely. It could be in the supercoil of space at which point you probably not cause any problems. But let's say you've gone, you look at it for a second and you're trying to decide did I really just do that and you kind of push gently in the area and you see some clear kind of gooey stuff come out through there. It looks like you got a little bit of vitreous. If you've got vitreous coming out of the wound what does that tell you? You know you went through retina, okay? I mean that's how the vitreous is coming out through that hole. And so then what do we do? Any ideas? We've got a hole in the retina and it's basically asleep in the operating room. Do some laser cryo. So the first thing you do is you get some dilating drops in that eye and you get the indirect defilmoscope and you take a look and you see where it is and what's going on. And if you laser works very well to laser around the hole you've just created like any retinal tear you can call the elegant solution is to get one of your retina colleagues to come take a look and help you out with it. I've been in a circumstance where that's happened in my OR and we haven't had a retina person available. They're all off doing various things and so you also can use a cryo machine if it's something very peripheral and you can't get to it with laser. Don't go hog wild with the cryo.  So don't be over aggressive with the cryo. But I think from my perspective if you think there has been a deep passer perforation you are obligated to take a look personally in the back of the eye, you don't close up and say I want you to see my retina colleagues next week. You take a look back there right there and then and then when we've had something like that happen what else should happen as a result? Let's say there is a hole, you need to laser, you need to cryo. You have to disclose that to the family or the parents. You have to have a discussion with them. The other part is to let your leadership and risk management know about it because they wanna be involved to try to help the patient and I mean their own selfish interest and the hospital's selfish interest are at heart too that they wanna minimize the chance that somebody is gonna take legal action and if someone's been harmed by something that we've done they wanna help them get it taken care of so that that isn't something that's necessary for the patient to consider. Now what about infections? And by definition from my perspective we've done eye muscle surgery and you get cellulitis. It is orbital cellulitis. I mean you've created an opening. You're postural orbital septum. You know that is orbital cellulitis. It's not preceptile cellulitis if we've done eye muscle surgery and so I think that we need to think of it in that vein. It can be potentially very serious. Usually though these are caused by pathogens that were on the lids, lashes, things that respond very well to treatment with systemic antibiotics. Topical antibiotics usually take care of a lot of it. There's probably a pheromonic contamination that goes on that either the body takes care of or we take care of what we're doing at the end of surgery. What about intraocular infection? Anybody seen an alfamitis after eye muscle surgery? That probably the only case you'll ever see if you've seen one because it is an incredibly rare occurrence but in a patient who has dramatically increased pain, decreased vision after eye muscle surgery you need to consider that and you have to look and you need to have a high index of suspicion because early treatment is the thing that's most associated with a good outcome. You know the type of bug that's in there obviously is a big deal as well. Now, suture granulomas. We use absorbable suture. The type of absorbable suture you use will to some extent direct how vigorous the responses, the body's responses to the suture. Vicaral is pretty well tolerated and tends to last usually two to three weeks with the superficial ADO sutures we put in conjunctiva, two to three months with a deeper 6-0 vicaral that we put in the muscle but you will find patients who have an unusually robust immune system who'll develop a granuloma, they usually calm down either with taking the suture out if that's appropriate, it's certainly with conjunctival sutures. If they've got enough healing going on to occur to granuloma, you can easily get to the suture, take it out. The other option is to use topical steroids. Conjunctival cysts occur when you have tissue that should be making fluid and dumping it onto the surface of the conjunctiva become buried and what they're making goes beneath the conjunctiva. Most of those conjunctival cysts will open up and go away all on their own if you watch them. Don't let the patient try to pop them with a pin. I have had people try to do that, it is not a good thing. Patient jumps and the needle winds up someplace it's not supposed to be. But you can also go back and if it isn't going away, if it is causing symptoms and very easily just reopen your conjunctival wound, lift that up, clean out as much of the cyst wall as you can and they almost always do well. I've never had one recurred. Scarring is best dealt with by not creating it, by treating tissues nicely, by staying out of the fat, by trying to minimize bleeding. Sometimes it is not possible either in trauma or with previous surgery to get around that. So we irrigate steroid at the end of surgery in the operative area. It is also for some patients appropriate to put them on topical. Immunosuppressive medication usually steroids to try to decrease inflammation after surgery. And restricted motility after surgery can be in the short term either because there's something tight like conjunctiva or an overly resected muscle limiting movement. The thing you worry about when things progressively become more misaligned and limited with movement is fat adherence. If you get an orbital fat and it is adherent to the globe, it is going to limit movement of the eye and that is very difficult to rectify. Numerous approaches have been tried, none of them were perfect or everyone would be doing it. So again, the main take home for that is to avoid getting into the fat. We talked before a little bit about eyelid position. What about slipped and lost muscles? Anybody here been involved in looking for a slipped or a lost muscle ever? You know, if you do enough eye muscle surgery, you will be and I get called often if one of my colleagues has an issue with something like that. Often, you know, the call is something like drop whatever you're doing and come to the operating room right now and need your help. And there are a number of things having been on numerous missions to find lost muscles, having talked with at least one of my partners over the telephone from out of town into finding a lost muscle is that muscles very reproducibly go the same places and that's where you will find them and all of the digging around posterior to the globe won't help you. You need to go to the right place to find them. Typically, horizontal rectus muscles and it's the medial that's most commonly lost go through the sleeve and posterior tenons that the muscle exits to before it comes up with the gloves. It comes anteriorly and the muscle will retract through there. So the key is to follow the blood. If this occurred acutely and you find the blood, you take a non-toothed forceps, close it, reach through that opening and tenons, open the forceps, go a little farther close and you'll pull the muscle up just like pulling a rabbit out of a hat. And everybody will think you're a hero, it works. And if you're stuck and you're in that situation, remember this conversation and call me and I'll talk you through doing it. The other places I've seen these commonly are in trauma with fingers and various things, disasserting muscles. I've seen it occur in the operating room. The worst circumstance is when someone does a huge resection on a medial rectus muscle and either sutures pull out or they cut on the wrong side of the sutures. And then you've got a very short muscle way back in the orbit. Those are very, very, very difficult to find. That's the one circumstance where I don't have an easy answer that people have come up with very elaborate ways of going in and taking out part of the medial orbital wall, finding the muscle posteriorly, and then threading suture up along the medial orbital wall. That can be done, the surgeries are successful and from the standpoint of accomplishing it, does it ever give relatively normal motility again? I've not seen that part of it work out quite as well as the end of surgery video showing suture attached to a muscle being attached to something on the globe. In that part of it they can do, but it isn't a good outcome. So be careful when you put sutures in, you want the muscle to be sutured securely every time. That keeps it from slipping posteriorly in its sheath. And again, just be alert in the operating room and if you think something is happening with the muscle, the thing to do is to grab the muscle with a force up while you're sorting out what to do if suture's actively pulling out. I have seen people cut suture when just inserting a muscle numerous times and if you grab the muscle, control the muscle, get suture back in it, it can have a happy ending. So you just want to be alert, be aware of what's going on. Now what about the octetocardiac reflex? Has anybody here ever had to run a code in the operating room because of the octetocardiac reflex? Me either, but I have had some anesthesiologists have to go change after several screens of asystole in adults in our OR here. And so we have an amazing ability to bring the heart to a standstill. I like to listen to the monitor in the operating room. I listen to the heart tones and I haven't turned up so I can hear it. And certain when we're about ready to pull, particularly on superectus muscle, I usually alert the anesthesiologists that they may see a precipitous drop, particularly young people, so they're not surprised. I learned that because that gasp when they, you know, suddenly jump out of the chair and they realize they're looking at a blank screen saying, oh my gosh, what are you doing? And, you know, typically just letting go of the muscle for a minute will cause the heart rate to come right back. I've never seen anybody have to be resuscitated beyond doing that or, you know, giving atropine or their atropine ligations. Nausea and vomiting after surgery is a problem combination of eye-muscle surgery, general anesthesia, and particularly in teenage girls or hormonal issues, nausea and vomiting is huge. Anesthesia will go to great lengths to try to minimize that there isn't anything other than doing a neat, tidy job of the surgery that's gonna alter that, but think about that in terms of the possible need for anti-iometics after surgery. Anybody here ever been involved in an MH case, an active, willing in hypothermia case? I've been involved in one in my career. They're not common, but it is not good. And it occurs more frequently in patients who have strabismus, patients who have ptosis. And so it's something you always, you know, when you schedule a patient for surgery, you're talking with general anesthesia, it's useful to just ask them simple question, has anybody in the family ever died during anesthesia? Have you ever heard the words malignant hypothermia? And those two questions, if they know the disorder, chances are somebody's mentioned it to them and anesthetic deaths in the family are a red flag to start looking into that. Now, what else we got here? Botox, we're gonna talk about. Actually, what I'd like to do is, we're gonna hold off on Botox, and I wanna shift gears here for a second. How do I get out of this? Escape? And for a couple of minutes, just look at a couple of other things that we've got here. You guys are running out of time, you know. We'll see if this works again. There we go. So we're gonna flip through just a couple of these examples here for the last couple of minutes. So, you all know the three-step test, and you need to be able to think through, realizing we usually use a three-step test to confirm what we already know that the patient has a fourth nerve palsy. But what about when it's not a super oblique palsy? And this is an example of how we sort through that. This is a patient who has a left hypertropia, and it's a left hypertropia that is greater in left gaze. Now, if I had a left fourth nerve palsy, I'd have a left hyper that's worse in right gaze and on left head tilt, wouldn't I? So here, what we have is we've got a left hyper that is worse in left gaze. That we're looking at the patient, this is primary right gaze, left gaze, and it's worse on left head tilt. And so, let's sort through this. So first, if we think about this, you gotta remember that the obliques are the elevator, depressor, and abduction, rectus muscles, elevator, and depressor, and abduction. And if we're talking about muscle weakness, which muscles on each eye could cause a left hyper? Well, either the down pulling muscles on this left eye or the up pulling muscles on the right eye will cause a left hypertropia, correct? Stop me if it isn't making sense. And now, if we're saying, well, is it, so we're saying which eye is up? That's the first step, right? The second one is, is it worse in left or right gaze? It's worse in left gaze. And of that, that's what these lines represent. So we're talking about either the right inferior oblique or the left inferior rectus muscles so far. And then, what we're gonna do is say, is it worse on left head tilt or right head tilt? And it's worse on left head tilt, which causes us to put this arrow in here. And if you forget which of these, which way do I draw this last arrow with the head tilt? If you tip your own head, you say, well, I've got, it's worse on left head tilt and I have to x-cyclotort my right eye and in-cyclotort the left eye to keep the rural level. Which muscles are doing that? You're gonna find that this is where you wind up with left head tilt. And so then the next question is, is there any muscle here that is in blue that has both lines? And that would be our right inferior oblique muscle. So this is an example of a left hypertropia due to a right inferior oblique paracus. This is how you sort through these things quickly. This is, and these do show up on OCAS. Now, and there's our right arrow. And what about this patient right here? We've got this nine-month-old who's been E.T. since birth. He's got equal fixation, behavior, equal vision, full ductions and versions. What's the diagnosis? Genitalia? Yeah, infantile or congenital yeast tropia. So what is a, what would you do surgically to fix this? These are the kind of questions you'll see when they say, and it's not the absolute, one of them will be more reasonable than others. What do you see? Give me it, let's make it multiple choice. Superior oblique tuck by lateral. Recess lateral rectus muscles, OU. Recess medial rectus muscle, OU. Yeah, is that reasonable? You recess the medial rectus muscles. That's gonna decrease these tropia, one, up with straighter eyes. And that would probably be what they would come up with. You also, I mean, if you could do a recession of one medial, resection of the lateral, and the way they try to trick you at this of the tests are to say, well, you know, and do a recess, resect in the wrong direction for yeast tropia. And throw that in there just to make life interesting. And then now what we've thrown in here is a V pattern. We've got more yeast tropia in down gaze, less than up gaze. And so let's say we're still gonna recess the medial rectus muscles, but the OCAP question would be, which way do you shift those muscles? Down, correct. And towards the apex of the V or the A, with medials, the opposite for the laterals, worth remembering. And then if we have the same patient, but the patient has this right hyper and left gaze, left hyper and right gaze, because of this inferior oblique overaction. And so we've got a V pattern with inferior oblique overaction and the message here is when you've got inferior oblique overaction with a V pattern, you're gonna weaken the inferior obliques. That'll decrease that hyper and lateral gaze. It'll also collapse the pattern and you still operate for the primary position measurements. So you're gonna do medial rectus recession both eyes, inferior oblique recession both eyes. And then just, and we'll close with this because you guys need to get to where you're going. We've got constant leftisotropia, optic nerve hypoplasia, strong preference for fixation with the right eye. And you've got 45 prison diapters of leftisotropia distance in the air. The parents want the eyes straightened out. At nine months of age, what procedure would you do? Persect on the left eye of the poor museum. Good. It's a little bit of a tricky question though. The question is should you do that? And if they've got very, very, very limited vision with optic nerve hypoplasia, you're not gonna give them a better chance of maintaining good vision or establishing binocularity. So the better thing is to just not operate and try to stall them as long as you can. But if they're just they want it done and grandma's beating the door down wanting to get the kids eyes straightened out, that is what you do a recess, resect procedure on that eye. Recess the medial, resect the lateral. I would do it before they start school and usually the summer before they start kindergarten is a good time to do it. That's about the age where kids really start to get picked on. And that's what I tell the parents. And I say, the reason we do surgery early on is because we wanna give your child a better chance of maintaining good vision of binocularity. This eye isn't gonna do that. These eyes aren't gonna work together and the risks are slightly greater doing anesthesia at nine months of age, say as opposed to four years of age. And so that's the, and then they say, yeah, but my insurance runs out next week. What do you do, doctor? They say, well, you'll have some more by the time child's four. And where the safety glasses, that's the most important thing to do. Now let's say we have a three year old who's got 40 prism doctors of ET, distance and near, without correction, full ductions and versions. And this is their psychopathic refraction. Is this still infantile isotropia? It's accommodative isotropia. And this is four months in that, this is acquired four month history. It was noticed that they appeared to suddenly cross four months ago.  And they wanted to know if they needed an MRI scan. That's number one on their list.  And both of the answers to those are no, at least not from this. And then the issue is, what do we do with this child? And the question on OCAPS, so it would be what surgical procedure and usually way down the list is glasses, no surgery now. And that is absolutely what you must do with this child. There are some people who have questionable ethics who operate on kids in this circumstance, rather than putting them in glasses. Why? Well, it's because they have a car payment or a boat payment or something else to do. Not because it isn't the patient's best interest. So in closing, you think about these things from the standpoint of how is what I'm thinking about doing gonna help the patient and is that the best thing to be doing for the patient? Makes sense? Cool. Have a good day.