Simultaneous Harada-Ito and superior oblique tendon tuck
February 10, 2016
Hi, this is Matt Weed, the pediatric ophthalmology fellow at the University of Iowa (2015-2016). This video shows a surgical technique for performing simultaneous Harada-Ito and superior oblique tendon tuck. This was done bilaterally for bilateral superior oblique palsy.
Here we mark the vertical poles on the eyelids and next we mark the same poles on the cornea. Now, a Cionni ring, set to the angle of half of this patient's objective torsion, is also used to mark the cornea. Bipolar cautery is applied in the superotemporal quadrant 8 mm posterior to the limbus. Westcott scissors are then used to create a fornix peritomy which is carried down to the sclera.
The superior rectus muscle is then hooked, taking care not to incorporate any superior oblique. A small hook is then used to separate the anterior 1/4 of the fibers of the superior oblique tendon.
The tendon tucker is then used to create a fold big enough such that when you lift up on the instrument, there is only about 1 mm of space between it and the globe.
6-0 nonabsorbable polyester suture is then passed in a vertical mattress fashion beneath the arms of the Bishop tendon tucker. The ends are tied down and trimmed. A hook is used to make sure the suture is tight, and forced ductions are performed to verify restriction when the inferior limbus elevates above the canthal angle.
Now, for the Harada-Ito. A modified Hartmann clamp has been applied to the anterior 1/4 of the fibers near their insertion, and Westcott scissors are used to disinsert those anterior fibers.
Here, we have now hooked the lateral rectus, and a mark has been made 8 mm posterior to the superior pole of the lateral rectus insertion. Now, the surgeon passes a double-armed 6-0 Vicryl suture a few mm back from the insertion of these anterior fibers and creates a lock bite on either end.
Having cut off these anterior fibers at their insertion and removed the excess tendon, the surgeon now passes each arm of this 6-0 suture through a point 8 mm posterior to the superior head of the lateral rectus. Be careful not to go too deep with your scleral pass here, as you're very close to the macula.
The suture is tied down in temporary bow-tie fashion. Though the patient's excyclotorsion has improved, we realize we still have more to go, so the bow tie is taken out, and those anterior superior oblique tendon fibers are further advanced. Torsional alignment is again assessed and this time, felt to be perfect. The bow is cut, and the suture is tied down in a permanent fashion.
This extra tail from the tendon tuck is trimmed short and the conjunctiva is closed.