Year : 1987 | Volume
: 35 | Issue : 4 | Page : 211--213
Paralimbal conjuntival incision in squint surgery
Prem Praksh, R Sihota, VM Menon
The conjunctival incision in squint surgery contributes in large measure to the case of surgery, postoperative cosmesis and later function of the operated muscle. We describe a paralimbal conjunctival incision which utilizes the fusion of the Tenon«SQ»s capsule and conjunctiva within 3 mm of the limbus to allow minimal disturbance of these importance layers It also ensures adequate exposure and minimal trauma to the muscle, as all steps are performed under direct observation.
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Praksh P, Sihota R, Menon V M. Paralimbal conjuntival incision in squint surgery.Indian J Ophthalmol 1987;35:211-213
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Praksh P, Sihota R, Menon V M. Paralimbal conjuntival incision in squint surgery. Indian J Ophthalmol [serial online] 1987 [cited 2023 Jan 30 ];35:211-213
Available from: https://www.ijo.in/text.asp?1987/35/4/211/26185
The conjunctival incision is one of the major components of squint surgery, contributing greatly to the ease of performance, post operative cosmetic and later function of the operated muscle.
Each surgeon uses his own variation of this incision based on three described techniques, iee the conjunctival incision in the palpebral area described by Swan F, Talbot, a conjunctival incision in the fornix advocated by Parks, and a limbal conjunctiva) incision, popularized by von Noorden. A newer technique of incision is described in this communication.
The method utilizes the fusion of the Tenon s capsule and conjunctiva within 3 mm or the limbus to allow minimal disturbance of these important layers. It also ensures adequate exposures and minimal trauma to the muscle, as all the steps are performed under direct observation.
Traction sutures through the fused conjunctiva and Tenon's capsule are applied 2 mm and 4 mm from the limbus in the axis of the muscle for surgery[Figure 1]. Using these sutures, the conjunctiva. Tenon is tented and incised parallel to the limbus with Westcott Scissors, approximately 5 mm in either direction.
The traction suture at the limbus is utilized to rotate the eye ball away from the field of surgery and also to protect the cornea during the surgery as a wad of wet cotton can be placed below the suture. The other traction suture allows a good separation of the reticular episcieral tissue from the muscle sheath and anterior sclera under direct visualization. When the borders of the muscle have been identified, the muscle is hooked Adequate exposure with a Desmarre's retractor and gentle traction on the muscle hook, allows a meticulous dissection of the check ligaments and intramuscular membrane which is essential for good post-operative mobility of the muscle as well as ease of resurgery, in case required Any type of muscle surgery to any extent can be carried out with ease, as the exposure is very adequate. The incision is sutured in just one layer, using 6'0 silk and a continuous E pattern of suturing to ensure total conjunctival apposition.
The para limbal incision fulfils all the criteria for an ideal conjunctival incision in squint surgery. It is technically simple and provides adequate exposure for ease of operation There is an absence of significant adhesions between the Tenon's capsule, muscle and sclera, although minimal cicatrization is found along the line of the incision which does not hinder freedom of movement of the conjunctiva over the sclera and muscle. Only a faint scar is visible within a few weeks of the surgery. Recession to allow relaxation of a tight restrictive conjunctiva is easily achieved but to a lesser extent as compared to a timbal incision Adjustable sutures can also be easily applied with such a conjunctival opening Situated a reasonable distance from the cornea, this incision decreases the incidence of corneal dellen formation.
The two traction sutures are an important step in surgery. Initially, tenting of the conjunctiva allows a single snip with the scissors to cut both the conjunctiva and Tenon s fascia without damage to the episcieral vessels.
In addition to the above, they minimize the necessity for a trained assistant as the eye is easily rotated, bringing the field of operation into direct view, and adequate exposure is ensured. Protection of the cornea is assured by the presence of wet cotton beneath the suture. The presence of these two sutures also allows an exact reapposition of the conjunctiva during suturing.
We advocate the use of this incision after having used it ourselves in hundreds of cases with a follow up exceeding ten years Our results have been extremely gratifying[Table 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5]
|1||Swan, KC and Talbot T. Recession under Tenon's capsule, Arch. Ophthalmol Vol 51 32-41, 1954.|
|2||Parks, MM : Fomix incision for horizontal rectus muscle surgery. Am J.Ophthalmol Vo. 65 (6) 907-915,1968.|
|3||Von Noorden, CL K The timbal approach to surgery of the rectus muscles, Arch. Ophthalmol 80: 94-97, 1968.|
|4||Von Noorden, QK Modification of the Umbal approach to surgery of the rectus muscles Arch. Ophthalmol 82: 349-350, 1969.|