In addition to optimised body posturing, an ideal eye position is imperative for ophthalmic surgeries for a smooth intraoperative course. In situations of long-term eso/exotropia with subsequent muscle contractures, centring the patient’s eye becomes tedious. Such instances are unswerving to retro/peribulbar blocks (Fig. 1a). The usual norm resorted to in such situations is to grasp and pull the opposite limbal conjunctiva with a toothed forceps, with each surgical step, increasing the risk of conjunctival tearing and bleeding (Fig. 1b, c) due to the resistance mounted by the contracted rectus and tight conjunctiva. It also compromises the surgeon’s dexterity in addition. An attempt to centre the eye with in-situ intracameral/intravitreal instruments can be tried, but may not always succeed (Fig. 1d). All these result in surgeon discomfiture, laborious manipulations, compromised glow and visibility.

Fig. 1
figure 1

a Case of esotropia with extreme nasalisation even after administration of peribulbar block. b Surgeon’s non-dominant hand used to grasp and pull the temporal limbal conjunctiva with Lim’s forceps to aid centration. Note the tearing of conjunctiva at the site held (black arrow). Surgeon’s dominant hand used to inject intracameral air bubble. c Difficulty in capsulorhexis due to the poor glow and limited manoeuvrability. d Inadequate centration despite appropriate intracameral instrumentation. Difficulty in accessing the nasal lens fibres highlighted

To the rescue of the above, the contracted horizontal rectus muscle can be bridled with long cotton/silk sutures and clamped to the opposite territory of the sterile drape, giving a tight traction, centring the eye. After rotating the eye to the opposite gaze, the interested tendon can be grasped with superior rectus holding forceps (Fig. 2a), and bridled using Arruga’s needle holder. The mean distance from the anterior limbus to the mid-point of insertions of the medial rectus and lateral rectus is 5.3 ± 0.7 and 6.9 ± 0.7 mm, respectively [1]. Hence, the respective tendons can be grasped 6 mm from the nasal and 7.6 mm from the temporal limbus. The motility of the eye corresponding to the movement of the grasped tendon confirms that the muscle has been rightly picked up. This manoeuvre not just centres the eye, but also frees the surgeon’s hand and provides unrestricted room for manipulation. It maybe of undue help in lenticular and vireo-retinal surgeries, where a co-axial view is vital. In the former, by fetching maximum possible illumination and a worthy red glow, it aids in a confident capsulorhexis, phaco-aspiration of lens matter and assessment of the posterior capsular status [2], while in the latter it offers the view of posterior pole.

Fig. 2
figure 2

a Medial rectus tendon held with superior rectus holding forceps and pulled temporally to confirm lateral movement of the eyeball. b Cotton suture used to bridle the medial rectus and traction applied temporally by clamping along with the sterile drape. Note the centration of the eyeball and resultant ease to proceed the surgery

In simple cases, a peribulbar or retrobulbar block may avert this, however, in cases of long-term strabismus where the root cause is a muscle contracture, an extra mile is deemed necessary. Bridling the superior rectus is a time tested technique used for cataract and glaucoma surgeries [3, 4], which is even now resorted in difficult situations. Similarly, bridling the horizontal rectus may be adopted to centre the eyeball in cases with contractured horizontal recti (Fig. 2b).

The possible complications of this technique include bleeding, subconjunctival haemorrhage, soft tissue bridling, muscle haematoma, muscle damage and scleral perforation. However, given the familiarity and ease of this age-old technique, their chances are meagre. Also, being a one-time transconjunctival technique, the risk of overt bleeding is minimal.

In conclusion, bridling the vertical recti for cataract surgeries is well known. We extend this idea to the horizontal recti, to manage cases of long-term horizontal strabismus with tight forced duction test providing a simple solution to centre the eye and combat surgical complexity.