![]() ![]() Care must be exercised to prevent accidental damage to the vortex vein. Four of these vortex veins are present on either side of the vertical recti, i.e., 1,5,7 and 11 clock hours. They take a 2 to 4 mm intrascleral course in the posterior direction before exiting the sclera around 14 to 18 mm posterior to the limbus. Viii) There are seven vortex veins with at least one in each quadrant. The scleral suture should be placed at least 1mm posterior to the spiral of Tillaux to prevent the exoplant from rubbing against the muscle at the site of their insertion, which can cause damage to these vessels and the anterior segment ischemia. These vessels contribute to the formation of several vascular plexuses, which are responsible for the blood supply of the anterior segment of the eye. Vii) The anterior ciliary arteries exit the recti near their respective insertions. The thickness at the eyeball equator (5mm chord length posterior to the spiral of Tillaux) is approximately 1 mm. It is the thinnest, just behind the recti insertions. Vi) The scleral thickness varies according to the location. The LR muscle can be hooked from the superior side to reduce the chances of inadvertently engaging and/or damaging the IO muscle. The surgeon must be cautious while hooking the LR muscle to prevent engaging and/or damaging the IO tendon. V) The inferior oblique (IO) muscle passes under the lateral rectus (LR) muscle. The surgeon must be cautious while hooking the SR muscle to prevent engaging and/or damaging the SO tendon and the vortex vein. One vortex vein is usually present under the temporal edge of the SO insertion. Iv) The superior oblique (SO) muscle travels under the superior rectus (SR) muscle and gets inserted 12-14mm posterior to the limbus. Iii) The vitreous base inside the eye lies around 2-3mm chord length posterior to the spiral of Tillaux outside. Ii) Ora serrata inside the eye corresponds to the spiral of Tillaux outside, i.e., site of recti insertion. It must be remembered that these ligaments are functionally important for muscle action. However, care is necessary to avoid damage to the recti and their ligaments. The intermuscular septum has to be divided and stripped off to ensure easy passage of the exoplants and scleral suture placement. ![]() These sleeves connect to the intermuscular septum, which is another layer of fascia present between the recti insertions. The extraocular muscles pierce the fascia and get covered by a glove-like sleeve of fascia that extends anteriorly untll the site of insertion. It extends from the limbus to the optic nerve. I) Tenon’s capsule is a layer of the fascia that envelops the globe. It is essential to discuss the relevant anatomy to understand SB. SB continues to be a great tool in the armamentarium of a vitreoretinal surgeon. This dangerous trend can potentially make SB a “dead art.” It is imperative to mention that the anatomical and functional outcomes of SB for the management of primary RRD are almost comparable to PPV. Even the vitreoretinal training programs have shifted their focus away from teaching SB. This has led to a drastic reduction in the number of SB procedures. Vitrectomy has gained popularity worldwide over the last few decades due to its better ergonomics. The surgical approaches for the treatment of RRD include pneumatic retinopexy, SB, and pars plana vitrectomy (PPV). He also did not drain SRF in almost any case. He introduced using a silicone sponge instead of a polyviol exoplant, cryotherapy (for creating chorioretinal adhesions) instead of diathermy, and a spatula needle (for scleral suturing). Lincoff (1965) made multiple modifications to the Custodis procedure. He used a polyviol exoplant and did not drain SRF. The three principles of RRD surgery are:Ĭreation of appositional closure between the retinal break(s) and the RPEĮrnst Custodis performed the first scleral buckling (SB) surgery in 1949. He also established the principles of RRD surgery that are valid even today. He also developed the first successful surgery for RRD, i.e., “Ignipuncture.” The surgery included break(s) localization, subretinal fluid (SRF) drainage through a 2 to 3 mm long scleral incision constructed beneath the retinal break, and direct thermocautery to the breakthrough of the drainage sclerostomy. RRD was considered an untreatable disease until Jules Gonin proved that it is caused by retinal break(s) and not vice versa. The history of successful management of RRD starts with Jules Gonin. Its incidence is reportedly around 6.3 to 17.9 per 100,000 population. It causes a sudden painless loss of vision. Rhegmatogenous RD (RRD) is characterized by the passage of fluid from the vitreous cavity into the potential space between the NSR and the RPE through a full-thickness retinal break. Retinal detachment (RD) is defined as the separation of the neurosensory retina (NSR) from the underlying retinal pigment epithelium (RPE) layer. ![]()
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