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Fascia of the Temporalis Muscle in Scleral Buckling and Keratoprosthesis Operations
FASCIA O F T H E T E M P O R A L I S MUSCLE IN SCLERAL BUCKLING AND KERATOPROSTHESIS OPERATIONS G. CHILARIS, M.D.,
AND S. LIARICOS,
M.D.
Athens, Greece
We have successfully used the strong, fibrous fascia of the temporalis muscle to create a buckle in retinal detachment opera tions1 and to reinforce the cornea prior to in sertion of a keratoprosthesis,2 thereby, in creasing its ability to retain the implant. Temporalis fascia is also useful in those cases in which it is necessary to reinforce or to replace the sciera, for example, in scleromalacia perforans, in sclerectasic myopia, and in scierai injuries and burns. We have gained experience in the use of fascia in or bital decompressions for malignant exophthalmos,3 done in cooperation with the Neurosurgical Department of St. Savvas Hospi tal. There are several advantages in the use of temporalis fascia in ocular surgery: (1) it provides an autogenous graft of strong collagenous, fibrous tissue; (2) its source is close to the eye ; ( 3 ) it can be easily and rap idly removed in any size or shape desired; and (4) it is easily handled during surgery.
Fig. 1 (Chilaris and Liaricos). Note the thickness of the area from which the fascia is removed.
REMOVAL
The temporalis fascia extends over the temporal fossa, covers the temporalis muscle, and inserts along the superior border of the zygomatic arch (Fig. 1). After surgical preparation of the scalp, a linç is drawn midway between the eyebrow and the top of the ipsilateral ear lobe (Fig. 2). A 1.5-cm incision is made 1 cm above this line. The sheen of the fascia makes its identification easy. Scissors is used to sepa rate it from the underlying muscle. After ob taining a piece of fascia that will meet the requirements of the surgical procedure at hand, the skin incision is closed with 4-0
Fig. 2 (Chilaris and Liaricos). The incision two weeks after the removal of temporalis fascia for a scierai buckling operation on the left eye.
black silk sutures. Hair growth will soon hide the scar. PRIMARY RETINAL DETACHMENTS
We use the Schepens technique for the re pair of retinal detachments, substituting temporalis fascia for a silicone implant. Su turing the fascia to the edges of the scierai bed lengthens the absorption time (Fig. 3). Temporalis fascia grafts can be used intrasclerally or on full-thickness sciera. When used on full-thickness sciera, one must be careful to suture the graft to Tenon's capsule
From the Department of Ophthalmology, St. Savvas Hospital, Athens, Greece. Reprint requests to George A. Chilaris, M.D. 14 Navarinou Street, Athens, Greece. 35
36
AMERICAN JOURNAL OF OPHTHALMOLOGY
JULY, 1973
flap is sutured to the temporalis fascia graft. Three weeks later, an opening is made in the conjunctiva corresponding to the anterior opening of the optical cylinder (Fig. 4 ) . DISCUSSION
Fig. 3 (Chilaris and Liaricos). The temporalis fascia graft is sutured to the scierai bed.
Temporalis fascia possesses advantages over other absorbable implants used in scierai buckling procedures. The globe's tol eration of the fascia is excellent. The mate rial is close at hand, and its removal is easy. The fascia is a strong, fibrous tissue that can successfully replace both absorbable and nonabsorbable implants. Further, it can be used in encircling procedures for retinal de tachment, as well as to reinforce badly dam aged corneas so that they will be able to re tain a keratoprosthesis. SUMMARY
and the conjunctiva. Another use for tempo ralis fascia is to produce segmental indenta tion in encircling procedures. KERATOPROSTHESES
When chemical burns or disease severely alter the collagen structure of the cornea, the extrusion rate of prothèses is markedly in creased. Autogenous temporalis fascia grafts will improve the collagen structure of the cornea and increase the probability of kera toprosthesis retention. A 1.5 X 1.5-cm piece of fascia is obtained by the technique described. The epithelium and the superficial scar tissue are removed from the diseased cornea. A periotomy is performed and the scar tissue is removed 2 mm beyond the corneal limbus. The graft is sutured to the sciera 120 degrees around the corneal limbus. After trephination in the center of the cornea, a small incision is made at the corre sponding center of the graft. The implant is placed in the pocket formed by the cornea and the graft and is carefully maneuvered until the trephine opening engages the cylin der of the prosthesis. To insure better nutrition, a conjunctival
Temporalis fascia was used to reinforce the cornea prior to insertion of a kerato prosthesis, and to create a buckle in retinal detachment procedures. This fibrous tissue was strong, autogenous graft material, and the procedures in which it was used were successful.
Fig. 4 (Chilaris and Liaricos). The cornea was reinforced with an autogenous temporalis fascia graft covered by a sliding conjunctival flap before implantation of a Cardona keratoprosthesis.
VOL. 76, NO. 1
TEMPORALIS FASCIA IN SCLERAL BUCKLING REFERENCES
1. Chilaris, G. : Temporalis fascia grafts in retinal detachment surgery. Delt. Hellinic Ophth. Etair. 40: 1972. 2. Chilaris G, and Liaricos, S. : Improvement of
37
keratoprosthesis by autogenous grafts of temporalis fascia. Presented before the VI Panhellenic Congress of Ophthalmology, Corfu, 1972. 3. Chilaris, G., and Taptas, J. : Surgical treatment of malignant exophthalmos. Arch. Ophth. Etair, Bor. Hellenic, 14:169, 1965.
OPHTHALMIC MINIATURE
Who would think otherwise than that the elephant, which far sur passes all terrestrial animals as to the huge mass of its body, especially of the head, also should surpass them as to the solid mass of its eye? But, all the same, the eye of a grown-up male elephant from Ceylon, dissected by my father at Kassel, hardly equals a bovine eye as to size. But you will have to wonder so much the more that the stupendous mass of the ocular muscles rather seems adjusted to the whole body than to the eye ; for each of the musculi recti is more than four inches long and one and a half broad, while the eyeball, which they embrace, hardly measures one and a half inches in horizontal diameter and is rather compressed in front and behind ; but they do not merely consist of flesh, as is normal for other muscles, but their muscular fibres proper are wrapped and mixed into some coarser connective tissue in order to fill out the space of the immense socket. The sclerotica, forming a most solid case textured from very strong and almost sinewy white fibres, is found to be of such a thickness as can not be observed in the eye of any of the terrestrial animals known to me, so that it is not surpassed by those of any other than the sea-beasts, namely the whales. As with the latter, it becomes more delicate beneath the tendons of the musculi recti, being very thick at the fundas, so closely packed there with connective tissue, so dense, so cohesive and surrounding the optic nerve with ciliary nerves and vessels and mixing its fibres so densely, that one can separate it entirely. Detmar Wilhelm Soemmerring, De oculorum hominis animaliumque sectione horizontali commentatio, University of Göttingen Thesis, 1818. (Translated by H. D. Schepelern, Acta Ophtal., September, 110, Copenhagen, 1971.)
AND S. LIARICOS,
M.D.
Athens, Greece
We have successfully used the strong, fibrous fascia of the temporalis muscle to create a buckle in retinal detachment opera tions1 and to reinforce the cornea prior to in sertion of a keratoprosthesis,2 thereby, in creasing its ability to retain the implant. Temporalis fascia is also useful in those cases in which it is necessary to reinforce or to replace the sciera, for example, in scleromalacia perforans, in sclerectasic myopia, and in scierai injuries and burns. We have gained experience in the use of fascia in or bital decompressions for malignant exophthalmos,3 done in cooperation with the Neurosurgical Department of St. Savvas Hospi tal. There are several advantages in the use of temporalis fascia in ocular surgery: (1) it provides an autogenous graft of strong collagenous, fibrous tissue; (2) its source is close to the eye ; ( 3 ) it can be easily and rap idly removed in any size or shape desired; and (4) it is easily handled during surgery.
Fig. 1 (Chilaris and Liaricos). Note the thickness of the area from which the fascia is removed.
REMOVAL
The temporalis fascia extends over the temporal fossa, covers the temporalis muscle, and inserts along the superior border of the zygomatic arch (Fig. 1). After surgical preparation of the scalp, a linç is drawn midway between the eyebrow and the top of the ipsilateral ear lobe (Fig. 2). A 1.5-cm incision is made 1 cm above this line. The sheen of the fascia makes its identification easy. Scissors is used to sepa rate it from the underlying muscle. After ob taining a piece of fascia that will meet the requirements of the surgical procedure at hand, the skin incision is closed with 4-0
Fig. 2 (Chilaris and Liaricos). The incision two weeks after the removal of temporalis fascia for a scierai buckling operation on the left eye.
black silk sutures. Hair growth will soon hide the scar. PRIMARY RETINAL DETACHMENTS
We use the Schepens technique for the re pair of retinal detachments, substituting temporalis fascia for a silicone implant. Su turing the fascia to the edges of the scierai bed lengthens the absorption time (Fig. 3). Temporalis fascia grafts can be used intrasclerally or on full-thickness sciera. When used on full-thickness sciera, one must be careful to suture the graft to Tenon's capsule
From the Department of Ophthalmology, St. Savvas Hospital, Athens, Greece. Reprint requests to George A. Chilaris, M.D. 14 Navarinou Street, Athens, Greece. 35
36
AMERICAN JOURNAL OF OPHTHALMOLOGY
JULY, 1973
flap is sutured to the temporalis fascia graft. Three weeks later, an opening is made in the conjunctiva corresponding to the anterior opening of the optical cylinder (Fig. 4 ) . DISCUSSION
Fig. 3 (Chilaris and Liaricos). The temporalis fascia graft is sutured to the scierai bed.
Temporalis fascia possesses advantages over other absorbable implants used in scierai buckling procedures. The globe's tol eration of the fascia is excellent. The mate rial is close at hand, and its removal is easy. The fascia is a strong, fibrous tissue that can successfully replace both absorbable and nonabsorbable implants. Further, it can be used in encircling procedures for retinal de tachment, as well as to reinforce badly dam aged corneas so that they will be able to re tain a keratoprosthesis. SUMMARY
and the conjunctiva. Another use for tempo ralis fascia is to produce segmental indenta tion in encircling procedures. KERATOPROSTHESES
When chemical burns or disease severely alter the collagen structure of the cornea, the extrusion rate of prothèses is markedly in creased. Autogenous temporalis fascia grafts will improve the collagen structure of the cornea and increase the probability of kera toprosthesis retention. A 1.5 X 1.5-cm piece of fascia is obtained by the technique described. The epithelium and the superficial scar tissue are removed from the diseased cornea. A periotomy is performed and the scar tissue is removed 2 mm beyond the corneal limbus. The graft is sutured to the sciera 120 degrees around the corneal limbus. After trephination in the center of the cornea, a small incision is made at the corre sponding center of the graft. The implant is placed in the pocket formed by the cornea and the graft and is carefully maneuvered until the trephine opening engages the cylin der of the prosthesis. To insure better nutrition, a conjunctival
Temporalis fascia was used to reinforce the cornea prior to insertion of a kerato prosthesis, and to create a buckle in retinal detachment procedures. This fibrous tissue was strong, autogenous graft material, and the procedures in which it was used were successful.
Fig. 4 (Chilaris and Liaricos). The cornea was reinforced with an autogenous temporalis fascia graft covered by a sliding conjunctival flap before implantation of a Cardona keratoprosthesis.
VOL. 76, NO. 1
TEMPORALIS FASCIA IN SCLERAL BUCKLING REFERENCES
1. Chilaris, G. : Temporalis fascia grafts in retinal detachment surgery. Delt. Hellinic Ophth. Etair. 40: 1972. 2. Chilaris G, and Liaricos, S. : Improvement of
37
keratoprosthesis by autogenous grafts of temporalis fascia. Presented before the VI Panhellenic Congress of Ophthalmology, Corfu, 1972. 3. Chilaris, G., and Taptas, J. : Surgical treatment of malignant exophthalmos. Arch. Ophth. Etair, Bor. Hellenic, 14:169, 1965.
OPHTHALMIC MINIATURE
Who would think otherwise than that the elephant, which far sur passes all terrestrial animals as to the huge mass of its body, especially of the head, also should surpass them as to the solid mass of its eye? But, all the same, the eye of a grown-up male elephant from Ceylon, dissected by my father at Kassel, hardly equals a bovine eye as to size. But you will have to wonder so much the more that the stupendous mass of the ocular muscles rather seems adjusted to the whole body than to the eye ; for each of the musculi recti is more than four inches long and one and a half broad, while the eyeball, which they embrace, hardly measures one and a half inches in horizontal diameter and is rather compressed in front and behind ; but they do not merely consist of flesh, as is normal for other muscles, but their muscular fibres proper are wrapped and mixed into some coarser connective tissue in order to fill out the space of the immense socket. The sclerotica, forming a most solid case textured from very strong and almost sinewy white fibres, is found to be of such a thickness as can not be observed in the eye of any of the terrestrial animals known to me, so that it is not surpassed by those of any other than the sea-beasts, namely the whales. As with the latter, it becomes more delicate beneath the tendons of the musculi recti, being very thick at the fundas, so closely packed there with connective tissue, so dense, so cohesive and surrounding the optic nerve with ciliary nerves and vessels and mixing its fibres so densely, that one can separate it entirely. Detmar Wilhelm Soemmerring, De oculorum hominis animaliumque sectione horizontali commentatio, University of Göttingen Thesis, 1818. (Translated by H. D. Schepelern, Acta Ophtal., September, 110, Copenhagen, 1971.)