Re: “Localizing the Lost Rectus Muscle Using the Connective Tissue Framework

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Jordan et al1 describe their results in a small series of patients, finding lost rectus muscles by dissecting through the intraconal fat, along the muscle pathway. Their technique takes advantage of attachments between the muscle and surrounding intramuscular septum.
It is encouraging that they were able to find the muscle within the anterior orbital fat in all their cases. However, for most surgeons, this is a difficult dissection; the orbital fat tends to spill in the field, and the landmarks of the muscle “tunnels” may not be easy to find.
A consistent relationship exists between the extraocular muscle belly and the bony orbital wall: in the mid-orbit, the muscle is easily identified in this space (Fig. A). In fact, for the orbital surgeon, the problem is often not that the muscle is hard to find but rather that it is hard to work around when trying to access the intraconal space.
The space between the medial rectus and lamina papyracea can be accessed transconjunctivally2–4 or, with additional time and equipment, endoscopically.5,6 This approach should be familiar to the orbital surgeon (Fig. B and Supplemental Digital Content 1, I believe that the orbital wall approach will be faster and more predictable for the average surgeon. At University of California Los Angeles, we have been successful in finding the muscle in more than 20 cases over the past 25 years. At least, as the authors note, it should be utilized if an initial search anteriorly within the fat proves unsuccessful.
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