Educational diagram and intraoperative clinical photographs illustrating adjustable suture techniques in strabismus surgery. Figure A depicts a recession of the lateral rectus muscle using a hang-back technique. The muscle is disinserted and secured to the scleral insertion point with a single-loop bow-tie suture, allowing for postoperative adjustment. A 4-0 Vicryl bolster suture is placed below the bow-tie to facilitate easy untying, and a 6-0 Vicryl traction suture is anchored near the insertion site for exposure. Figure B shows a resection of the medial rectus muscle. The resected muscle is suspended approximately 2 mm posterior to the original insertion site, secured again with a single-loop bow-tie and bolster suture. This suspension creates necessary space for potential muscle advancement during the adjustment phase. The medical illustrations are paired with small clinical photographs of the respective surgical fields, highlighting the 'bow-tie' suture configuration used for fine-tuning ocular alignment postoperatively under topical anesthesia.

This composite of clinical photographs documents the surgical management of severe restrictive strabismus in a patient with Graves' ophthalmopathy. Panel (a) shows the preoperative presentation of extreme bilateral esotropia and hypotropia, with significant globe deviation and restricted visibility of the pupils. Panels (b), (c), and (e) illustrate intraoperative stages of extraocular muscle release and recession. Specifically, (b) displays the identification and isolation of the inferior rectus muscle using a squint hook through a transconjunctival approach. Panel (c) shows the globe in a corrected primary position after the release of the inferior and medial rectus muscles, with non-absorbable sutures and a speculum visible. Panel (d) demonstrates the asymmetrical interim results one week after surgery on the left eye only. Finally, panel (f) depicts the three-month postoperative outcome, showing restored vertical and horizontal primary alignment in both eyes, despite mild persistent exophthalmos and conjunctival hyperemia. This sequence highlights the effectiveness of extraocular muscle repositioning for correcting fixed globe deviation in advanced autoimmune thyroid eye disease.

A four-step surgical diagram illustrating the Augmented Partial Rectus Muscle Transposition (APRMT) combined with horizontal muscle recession-resection, specifically for treating superior rectus muscle paralysis. Step 1 shows the longitudinal splitting (division) of the medial rectus and lateral rectus muscles into upper and lower halves. Step 2 depicts the shortening of the upper halves of both muscles using sutures. Step 3 illustrates the transposition of these shortened upper muscle segments to the nasal and temporal aspects of the superior rectus insertion point. Step 4 demonstrates the final stage involving the recession and resection of the remaining lower halves of the medial and lateral rectus muscles to correct concomitant horizontal strabismus. The diagram highlights anatomical relationships between the extraocular muscles on the globe and the specific surgical manipulations of muscle splitting, shortening, transposition, and recession-resection used in complex strabismus management.

This intraoperative clinical photograph captures a surgical field during an ophthalmologic procedure, specifically a strabismus surgery involving the lateral rectus muscle. The central focus is on the lateral rectus muscle, which displays a characteristic striated, reddish-pink appearance and has been isolated and retracted. The surgical site is held open by metallic wire retractors (Desmarres or similar), providing exposure of the extraocular muscle and the underlying sclera. A notable round, nodular mass is visible attached to the belly of the muscle, representing a cyst associated with fat necrosis or foreign material such as silicone oil. Surgical sutures (likely 6-0 Vicryl or similar) are present, looped across the muscle to facilitate recession or resection manipulation. The surrounding conjunctiva and Tenon's capsule show expected surgical trauma, including minor hemorrhage and edema consistent with active dissection. This image serves as a teaching tool for identifying extraocular muscle anatomy and visualizing the surgical management of peri-muscular cystic lesions.

Two side-by-side intraoperative clinical photographs illustrating strabismus surgery using the relaxed muscle positioning technique. Image (a) shows the inferior rectus muscle under manipulation. A wire speculum provides ocular exposure while a surgeon's gloved hand uses forceps to grasp the muscle belly near its insertion. The surgical field exhibits expected conjunctival hyperaemia and minor hemorrhage typical of extraocular muscle dissection. Image (b) shows the medial rectus muscle during a similar procedure. The sclera is visible with dark gentian violet markings indicating the planned recession point for muscle reattachment. A surgical suture is visible traversing the field, and a muscle hook or forceps is used to stabilize the tissue. These images demonstrate the 'relaxed muscle positioning' method where the tendon is released, allowed to retract naturally, and then sutured to the globe at a precise marked point to correct restrictive strabismus or thyroid eye disease-related deviations.

This clinical photograph captures a close-up, intraoperative view of an ophthalmic surgical procedure, specifically a strabismus surgery involving the extraocular muscle. The image demonstrates the application of pressure at the muscle-sclera interface following the use of iso-amyl cyanoacrylate (IAC) bioadhesive. The white scleral bed is clearly exposed, with the reddish extraocular muscle being held in apposition to the intended recession site. Key surgical instruments visible include a metallic speculum retracting the eyelids and forceps applying localized pressure to facilitate the adhesive 'take.' A blood-stained cellulose strip is used for drying the site, and fine, dark-colored sutures (6-0 Vicryl) are present, serving as backup traction or hang-back sutures. The photograph illustrates the surgical technique for sutureless muscle reattachment, focusing on the mechanical stabilization of the tissue-adhesive interface to ensure secure bonding before closure. This material is intended for educational use in ophthalmology and ophthalmic surgery training.

This intraoperative clinical photograph captures a surgical procedure on the extraocular muscles, specifically focusing on the lateral rectus muscle. The operative field is retracted using metal speculums and forceps, revealing a vascularized, erythematous surgical site. The primary finding is the presence of numerous small, whitish, spherical to ovoid cystic lesions embedded within and attached to the substance of the lateral rectus muscle. These cysts appear translucent and are distributed densely along the muscle fibers. The surrounding orbital tissues show evidence of surgical manipulation and mild hemorrhage. The visual demonstrates a rare complication where foreign material (such as silicone oil) or fat necrosis presents as multinodular cystic masses within the extraocular muscle tissue. This image is relevant for ophthalmology and strabismus surgery education, illustrating atypical anatomical findings during rectus muscle recession or resection.

This intraoperative clinical photograph captures a surgical complication known as 'pulled-in-two syndrome' during strabismus surgery. The image shows the medial rectus (MR) muscle of the right eye, which has suffered a complete rupture at the muscle belly, approximately 5mm posterior to its scleral insertion. Two black horizontal arrows highlight the distal ruptured stump of the MR muscle. The surgical field displays exposed sclera and periocular connective tissue with visible focal hemorrhage and irrigation fluid. A pair of strabismus forceps is positioned in the lower right quadrant of the frame, currently manipulating the anterior segment of the muscle tissue. The image demonstrates the catastrophic failure of a contracted extraocular muscle under tension during a recession procedure, illustrating a rare but significant intraoperative risk in patients with high myopia or myopic strabismus fixus.

This intraoperative clinical photograph captures a surgical complication known as 'pulled-in-two syndrome' during strabismus surgery. The image shows the medial rectus (MR) muscle of the right eye, which has suffered a complete rupture at the muscle belly, approximately 5mm posterior to its scleral insertion. Two black horizontal arrows highlight the distal ruptured stump of the MR muscle. The surgical field displays exposed sclera and periocular connective tissue with visible focal hemorrhage and irrigation fluid. A pair of strabismus forceps is positioned in the lower right quadrant of the frame, currently manipulating the anterior segment of the muscle tissue. The image demonstrates the catastrophic failure of a contracted extraocular muscle under tension during a recession procedure, illustrating a rare but significant intraoperative risk in patients with high myopia or myopic strabismus fixus.

Educational diagram and intraoperative clinical photographs illustrating adjustable suture techniques in strabismus surgery. Figure A depicts a recession of the lateral rectus muscle using a hang-back technique. The muscle is disinserted and secured to the scleral insertion point with a single-loop bow-tie suture, allowing for postoperative adjustment. A 4-0 Vicryl bolster suture is placed below the bow-tie to facilitate easy untying, and a 6-0 Vicryl traction suture is anchored near the insertion site for exposure. Figure B shows a resection of the medial rectus muscle. The resected muscle is suspended approximately 2 mm posterior to the original insertion site, secured again with a single-loop bow-tie and bolster suture. This suspension creates necessary space for potential muscle advancement during the adjustment phase. The medical illustrations are paired with small clinical photographs of the respective surgical fields, highlighting the 'bow-tie' suture configuration used for fine-tuning ocular alignment postoperatively under topical anesthesia.

This clinical photograph captures a close-up, intraoperative view of an ophthalmic surgical procedure, specifically a strabismus surgery involving the extraocular muscle. The image demonstrates the application of pressure at the muscle-sclera interface following the use of iso-amyl cyanoacrylate (IAC) bioadhesive. The white scleral bed is clearly exposed, with the reddish extraocular muscle being held in apposition to the intended recession site. Key surgical instruments visible include a metallic speculum retracting the eyelids and forceps applying localized pressure to facilitate the adhesive 'take.' A blood-stained cellulose strip is used for drying the site, and fine, dark-colored sutures (6-0 Vicryl) are present, serving as backup traction or hang-back sutures. The photograph illustrates the surgical technique for sutureless muscle reattachment, focusing on the mechanical stabilization of the tissue-adhesive interface to ensure secure bonding before closure. This material is intended for educational use in ophthalmology and ophthalmic surgery training.

This clinical photograph captures an intraoperative view of an ophthalmic surgical procedure, specifically a biopsy of a mass located near the lateral rectus muscle. The surgical field demonstrates several specialized instruments in use: a strabismus muscle hook is utilized to retract and suspend the muscle belly away from the globe, while fine dissection scissors are seen isolating and excising a sample of tissue. The visible anatomy includes the extraocular muscle, characterized by its reddish-pink longitudinal muscle fibers, and the surrounding scleral surface of the eye globe. The biopsy technique shown involves the longitudinal division of fibers to obtain a superficial sample from the orbital surface of the rectus muscle. Hemorrhagic staining and surgical manipulation of the conjunctiva and muscle capsule are evident, reflecting the active dissection. This image serves as a teaching tool for oculoplastic or strabismus surgery, illustrating the precise instrumentation and anatomical handling required for extraocular muscle tissue sampling while minimizing mechanical complications.

This clinical intraoperative photograph illustrates a surgical procedure on a human eye, likely a strabismus correction. An eyelid speculum is in place to provide surgical exposure of the globe and sclera. The surgical field demonstrates a disinserted extraocular muscle being prepared for recession. Metal surgical forceps are visible, retracting the conjunctiva and stabilizing the globe. A 25-gauge needle is positioned at the cut edge of the muscle belly, applying a clear liquid bioadhesive, specifically iso-amyl cyanoacrylate, to facilitate sutureless reattachment to the sclera. Key anatomical landmarks include the white scleral surface, the vascularized conjunctival edges, and the reddish muscle tissue. Pre-placed 6-0 Vicryl sutures are visible at the muscle edge, serving as a safety measure for the adhesion process. A blood-stained cellulose sponge is located adjacent to the surgical site for moisture control. This image serves as an educational resource for ophthalmic surgeons and students, demonstrating alternative tissue-fixation techniques in extraocular muscle surgery.

Two side-by-side intraoperative clinical photographs (A and B) demonstrating a medial rectus (MR) muscle resection on a left eye, a procedure typically used in ophthalmic surgery to correct strabismus or muscle palsy. Panel A shows the initial surgical exposure with the medial rectus muscle identified; the muscle appears notably thin and atrophic, a pathological state following a previous orbital injury or hematoma. The surgical field is maintained using eyelid speculums and muscle hooks, with moderate focal hemorrhage visible on the scleral surface. Panel B depicts the same anatomical region after a 6 mm resection of the MR muscle has been performed. In this view, the muscle is shortened and repositioned, appearing relatively thicker and more compact compared to the pre-resection state. Suture material is visible where the muscle has been reattached to the sclera. These images illustrate the surgical management of muscular atrophy to restore binocular alignment (orthophoria) and resolve diplopia.

Educational diagram and intraoperative clinical photographs illustrating adjustable suture techniques in strabismus surgery. Figure A depicts a recession of the lateral rectus muscle using a hang-back technique. The muscle is disinserted and secured to the scleral insertion point with a single-loop bow-tie suture, allowing for postoperative adjustment. A 4-0 Vicryl bolster suture is placed below the bow-tie to facilitate easy untying, and a 6-0 Vicryl traction suture is anchored near the insertion site for exposure. Figure B shows a resection of the medial rectus muscle. The resected muscle is suspended approximately 2 mm posterior to the original insertion site, secured again with a single-loop bow-tie and bolster suture. This suspension creates necessary space for potential muscle advancement during the adjustment phase. The medical illustrations are paired with small clinical photographs of the respective surgical fields, highlighting the 'bow-tie' suture configuration used for fine-tuning ocular alignment postoperatively under topical anesthesia.

A composite of six perioperative clinical photographs demonstrating the surgical correction of strabismus in two pediatric patients. The images are arranged in two columns (A-C and D-F) representing pre-operative, intra-operative, and one-week post-operative stages. Column A-C features a patient with esotropia (inward deviation of the eye); panel A shows the initial deviation, B shows the intra-operative adjustable suture technique with a corneal light reflex test, cotton swab, and visible sutures, and C shows successful orthophoric alignment (straight eyes). Column D-F features a patient with exotropia (outward deviation); panel D shows the pre-operative state, E captures the intra-operative adjustment phase showing conjunctival hyperemia and eyelid retraction, and F demonstrates postoperative orthophoria. The images illustrate the clinical application of a modified adjustable suture technique to achieve precise ocular alignment, emphasizing the use of the Hirschberg test (corneal light reflex) for intra-operative decision-making in ophthalmology.

This three-panel diagnostic clinical photograph set demonstrates the arthroscopic technique for linking an anterior cruciate ligament (ACL) grasping suture to an adjustable femoral loop during a Bridge-Enhanced ACL Repair (BEAR) procedure in a left knee. Panel A illustrates the initial configuration where one limb of the blue/white ACL-grasping suture is passed through the white adjustable loop. Key landmarks include the lateral femoral condyle (LFC), internal brace sutures, and the TigerWire countertraction suture. Panel B shows the use of a metal switching stick inserted through the far anteromedial portal to maintain spacing while the ACL-grasping suture is tied to the adjustable loop, ensuring smooth loop sliding. Panel C displays the completed sequence where the adjustable loop has been shortened to eliminate slack in the grasping suture, bringing the ACL stump into proximity with the femoral notch. The medial femoral condyle (MFC) and a tibial shuttling suture are visible in this final panel, representing successful linkage and tensioning of the repair construct.

This series of six laparoscopic clinical photographs (a-f) documents the surgical removal of uterine compression sutures in a postpartum patient. Image (a) depicts the initial stage of the procedure, with laparoscopic forceps grasping a violet-colored suture thread. Panels (b) and (c) show the lower uterine segment before suture removal, characterized by visible violet compression sutures and tissue that appears dark and congested, suggesting focal ischemia. Panel (d) illustrates the same lower uterine segment immediately following suture removal, showing a reduction in dark discoloration. Panels (e) and (f) provide a comparative visual inspection of the anterior uterine wall. In (e), the wall exhibits a darker, congested hue prior to suture release. In (f), the anterior uterine wall shows a distinct transition to a pinkish-white and pinkish-red color, indicating improved tissue perfusion and the resolution of venous congestion. This educational material demonstrates the laparoscopic management of suspected uterine ischemia following B-Lynch or similar compression suturing techniques used for postpartum hemorrhage.