Many years of working on such cases where prior
surgeries were done , the surgeons are not
known , the operative details are exactly
unknown and the results are not good taught me
it is best to deal with the patient more of less
as a "new" patient.
Based on the above, this young man has a huge Lt.
XT, the 2 MR are possibly
recessed and the 2 LR are possibly resected.
These cases require decisions be made in the
operating room depending on what is found and on the
operative scinario.
I did a large recession for the
previously resected left LR putting the muscle at or
very near the equator. I found the lateral conjunctiva is
tight , so I slightly recessed it. Then I advanced
and resected the previously recessed Lt MR as much as I can without pulling forward
tissues of the medial orbit , the MR is sutured
nearly at its original insertion ( 5.5 mm of the limbus
)
In cases like this, the big challenge of the surgeon
is the fibrosis of the periorbital tissue, I always be sure to do forced ductions before and after detaching the
muscles to asses this fibrosis . Fibrosis of the
periorbital tissue is the main cause of limited
ductions following previous orbital surgeries, it is
also the main cause of disappointing undercorrection
of these patients . So, forced ductions will
be a clue as to what you can expect from this part
of the operation. Also, be sure to avoid inclusion of the inferior oblique
in the left lateral rectus.
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