MMCR with burying of suture knots under conjunctiva
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This is Richard Allen at the University of Iowa.
This video demonstrates a Muller muscle – conjunctival resection (MMCR) with burying of the knot of the suture.
4-0 silk sutures are placed at the upper eyelid margin to provide traction. The upper eyelid is then everted over a Desmarres retractor. The central third of the superior border of the tarsus is then marked with the monopolar cautery. This will be an 8 mm resection, thus, marks are made 4 mm superior to the previous made markings. Paufique forceps are then used to grasp the conjunctiva at the superior markings. A suture could be used if preferred. The Putterman clamp is then placed over the conjunctiva and Muller muscle to be resected to the superior border of the tarsus. The clamp is tightened. Westcott scissors are then used to excise a piece of conjunctiva lateral to the clamp. This will allow the knot of the suture to recess into this excision in order for it not to irritate the eye post-operatively. This will obviate the use of a contact lens. The 6-0 chromic suture is then placed to enter this area of the excision and exit out the adjacent conjunctiva. The suture is then placed in a running mattress fashion at the superior border of the tarsus and therefore the edge of the clamp. This is placed lateral to medial along the length of the clamp and then turned around to be placed medial to lateral in the same running mattress fashion. Laterally, the final placement of the suture will be made to exit out the area of the excised conjunctiva. This results in both ends of the suture exiting the area of the resected conjunctiva. A 15 blade is then used to make "metal on metal" contact with the Putterman clamp to resect the conjunctiva and Muller muscle. It is important to make metal on metal contact in order to avoid cutting the suture. The suture is then tied, allowing the knot to retract under the conjunctiva, thus burying it and avoiding post-operative irritation. This will then avoid the use of a bandage contact lens post-operatively. At the conclusion of the case, ophthalmic antibiotic ointment is used three times per day, and the patient returns in one week for reevaluation.