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

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We thank Dr. Goldberg for his commentary about our technique to localize a lost rectus muscle.1 We are pleased to provide a response as we believe that more informed dialogue will educate fellow surgeons and ultimately improve patient care. Although we think a closer reading of the article will clarify most of the issues raised, we are happy to provide additional information.
Dr. Goldberg stated that we were trying to “find lost rectus muscles by dissecting through the intraconal fat, along the muscle pathway.” However, we did not suggest there is dissection through the intraconal fat. In our article, we stated: “The aim of the retrieval procedure is to maximize exposure without further violating the integrity of Tenon’s capsule. It is of utmost importance to respect fascial planes rather than transecting them and avoid excessive manipulation of the tissue (i.e., fat) when retractors are placed as this may lead to bleeding which obscures the view.” “Disruption of fascial planes may also result in fat adherence and scar tissue which may compromise any subsequent muscle surgery.” Furthermore, “blindly fishing into the orbit for the lost muscle with forceps or other instruments should be avoided as this will further traumatize posterior Tenon’s capsule and may produce scarring and a fat adherence syndrome from the extraconal fat prolapse into sub-Tenon’s space.”
For accuracy and clarification, the technique we described is simple, easy to follow, and based on a thorough knowledge of the orbital connective tissue framework. It recognizes the intricate detail and expanse of the orbital connective tissue framework throughout the entire orbit that we promoted in this article and other papers the authors have written on similar subjects.2,3 This tissue framework is an extensive system of interconnected fibrous septa that allows compartmentalization and support of orbital structures.2–5 Some fibrous elements suspend and support delicate orbital vessels and nerves, whereas others are aligned with the extraocular muscles and are designed to resist displacement of the latter during contraction. All orbital structures including the periorbita, globe, optic nerve, and extraocular muscles are involved in the organization and suspension of these extensive connective tissue septal systems.2–5 The extensive interconnected fibrous septa making up the connective framework is well illustrated in Figures 1a,b, and c of our paper.4 Knowledge of these interconnections is vital to understanding why our technique works, and using them to one’s advantage rather than violating them to allow fat spillage in the operative is one of the keys to success with our technique.
It should be emphasized that our technique is not for the rectus muscle that was lost 6 or 12 weeks earlier; it is for use in the acute muscle loss setting. Our technique also assumes that the orbital connective tissue framework is still relatively intact. If the orbital surgeon is faced with intraconal fat in the operative field from excess tissue manipulation, then our technique may not be appropriate as the connective tissue framework may have been too disrupted. An alternative technique may be better to use in this situation as we point out in the article: “if the muscle cannot be identified clearly, one can switch to an alternative technique.”4 The alternate technique we prefer is the one that Dr. Goldberg has nicely described in his commentary and in previous publications.6 However, if there is no fat billowing out from tissue manipulation, as in the cases we describe, and when the check ligaments attaching the muscle sheath to Tenon’s capsule remain intact, our technique is simpler, more effective, and quicker, and it avoids an additional incision through the caruncle.
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