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.
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.
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.
References
Apt L. An anatomical reevaluation of rectus muscle insertions. Trans Am Ophthalmol Soc. 1980;78:365–75.
Sethi HS, Dada T, Rai HK, Sethi P. Closed chamber globe stabilization and needle capsulorhexis using irrigation hand piece of bimanual irrigation and aspiration system. BMC Ophthalmol. 2005;5:21.
Loeffler M, Solomon LD, Renaud M. Postcataract extraction ptosis: effect of the bridle suture. J Cataract Refract Surg. 1990;16(4):501–4.
Gupta D. Glaucoma Diagnosis and Management. Lippincott Williams & Wilkins, USA; 2005. 378 p.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no competing interests.
Rights and permissions
About this article
Cite this article
Selvan, H., Gupta, S. Transconjunctival rectus muscle bridle: an adjunct in surgical exposure. Eye 32, 1151–1153 (2018). https://doi.org/10.1038/s41433-018-0020-8
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/s41433-018-0020-8