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David K. Coats, MD , is from Texas Children's Hospital, Houston, Texas.
William P. Madigan, MD , is from Children's National Medical Center, Washington, DC.
Avery H. Weiss, MD , is from Seattle Children's Hospital, Seattle, Washington.
Moderator: Rudolph S. Wagner, MD
Drs. Coats, Madigan, and Weiss have no financial or proprietary interest in the materials presented herein. Dr. Wagner is on the speaker's bureau of Alcon Laboratories.
Wagner:
During a bilateral recession of the left medial rectus muscle performed by a resident in a 1-year-old child with infantile esotropia, you notice a small perforation of the globe with a small bleb of vitreous present during the second scleral suture passage in that left medial rectus muscle. You already completed the surgery on the right eye. What is your immediate action in a case like this?
Weiss:
I routinely dilate the pupil in all cases so that if something does occur then I'm able to respond appropriately. Perforations are common, but if it was associated with vitreous presentation, I would use the indirect ophthalmoscope to confirm the perforation. In this case I would do a limited vitrectomy followed by cryotherapy over the area. Then I would place a suture close to the wound to prevent endophthalmitis.
Madigan:
I always feel like I know when the eye has been perforated. I see the needle going too deep and sometimes the resident doesn't stop in time. Once it happens, I have the resident back the needle out but complete the pass just at the correct depth because I think bringing the muscle down onto that perforation is a good thing. I'm not going to do a separate repair of the scleral puncture. I think just putting it in at the correct depth and pulling the muscle up is a normal part of your operation. It provides adequate closure of that area.
Coats:
First of all, we should preface this discussion by stating that there's no evidence to support anything we're suggesting and we're all doing what we think is best based on what we think is common sense. Having said that, you were doing a bilateral medial rectus recession and the first eye has already been done. If the perforation had occurred with the first eye,...