title: A small-incision muscle hook for the Parks cul-de- sac approach for strabismus surgery.
abstract: BACKGROUND
  One of Dr. Marshall Parks' most valuable contributions to strabology was his cul-de-sac ("fornix") approach to strabismus surgery. This approach provides better comfort, faster healing and less conjunctival scarring than previous approaches. Tearing of the conjunctiva can occur, however, especially in older patients with thin and friable conjunctival tissues.
  
  
  METHODS
  To facilitate the cul-de-sc approach through a small incision, especially in older patients, I designed a new "small-incision" muscle hook.
  
  
  RESULTS
  A new sharp second bend combined with sharpening of the bend in the heel (creating literally an "S" bend) in the Jameson style eye muscle hook enables burying of the knee or heel of the hook in the wound, allowing reflection of the conjunctiva over the ball or toe of the hook without tearing. I have used and treasured this hook for over six years, routinely using the cul-de-sac approach to strabismus surgery in both children and adults.
  
  
  CONCLUSIONS
  This new small- incision muscle hook complements the cul-de-sac approach to strabismus surgery by allowing the use of a smaller incision while significantly decreasing the risk of conjunctival tearing.
authors.affiliation: The Krieger Children's Eye Center at Wilmer Institute, The Johns Hopkins University School of Medicine, Baltimore, MD 21287-9028, USA.
authors.forename: David L
authors.initials: DL
authors.lastname: Guyton
mesh_terms: D004867:Equipment Design; D006801:Humans; D019060:Minimally Invasive Surgical Procedures; D009801:Oculomotor Muscles / Q000601:surgery*; D013508:Ophthalmologic Surgical Procedures / Q000295:instrumentation*; D013285:Strabismus / Q000601:surgery*