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Panelists: Michael S. Abrams, MD, Miles J. Burke, MD, William P. Madigan, MD
Michael S. Abrams, MD, is from Excel Eye Center, Orem, Utah.
Miles J. Burke, MD, is in private practice, Cincinnati, Ohio.
William P. Madigan, MD, is from Children's National Medical Center, Washington, DC.
Wagner: Our topic is strabismus surgery and I'll start with a general question. What has been a major change in your surgical technique for horizontal rectus muscle recession since your fellowship?
Burke: My original approach to the medial rectus muscle was the cul-de-sac incision. For approximately 3 years as a teacher of residents, I found that residents had a hard time visualizing from the fornix approach and so I changed it to a limbal approach. As far as the medial rectus muscle is concerned, I think the information that we have learned about the pulley system, particularly in reoperations, has helped me identify the anatomy that I previously didn't understand. I don't go as far back in my dissection and, when I see that pulley system, I'm much more careful around it.
Wagner: You're referring to the point where you can see the muscle penetrate the Tenon's capsule?
Burke: Absolutely. You can actually see that much thicker structure underneath the muscle. In primary cases I'm not that far back, but in reoperations I almost always am.
Wagner: Dr. Madigan, is there anything specific about the technique that you first started with that you might have changed?
Madigan: Not for the medial rectus. I learned it as a resident from Norman Katz, who was one of Marshall Parks' fellows, and then I was Marshall Parks' fellow.
Wagner: What about the incision that you use?
Madigan: I still use the fornix-based incision, but I agree with Dr. Burke that it's hard for the residents to learn initially. They have a hard time visualizing what you want and this is probably the hardest part of the operation for them, much harder than putting the suture to the muscle or cutting it off or reattaching it to the globe. It's the initial entry that's difficult, but I ask our fellows at the end of the year when they've been exposed to a variety of approaches and by and large they say they...