Avoiding pre-placed recti sutures in enucleation
Reviewed by James Hsuan

This is a retrospective review of 40 patients who underwent enucleation using a non-conventional technique in which the recti muscles were detached from the sclera without pre-placing any sutures to secure the cut muscle ends. The surgery was only performed in patients without a prior history of squint, orbital or retinal detachment surgery which may have disrupted the orbital septa. Following a 360 degree periotomy and blunt dissection of the quadrants, only the proximal part of the recti were cleared of fascial attachments, preserving the check ligaments. The muscles were then cut at their insertions, and the globe removed after cutting the obliques and the optic nerve. Haemostasis was achieved and an implant inserted. Identifying the cut recti ends was managed by simple retraction of the conjunctiva and Tenon’s either side of the muscle head with skin hooks. This allowed the muscle to be easily visualised, and then sutured to the implant if required, but the authors imply this is optional and closure can be limited to Tenon’s and conjunctiva. A review of 40 patients undergoing this technique found no intraoperative or postoperative complications. The authors argue that the traditional belief that the muscle will retract irretrievably is incorrect as they are still attached to the connective tissue framework of the orbit. They had no instances of being unable to locate the muscle heads. The previous reports of lost muscles occur when the muscle belly has been aggressively stripped or subjected to trauma. The authors argue their technique is easier than pre-placing sutures, and avoids the risk of inadvertent globe penetration in the presence of an ocular tumour. This is an interesting article by respected authors which contradicts traditional teaching. 

The hook and release technique during enucleation surgery.
Jordan DR, Stoica B, Dutton JJ.
OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY
2018;34:31-6.