The role of the fascia in muscle surgery

Mishandling of the fascial tissues during surgery on the extraocular muscles accounts for unsatisfactory alignment of the eye in the primary position; restricted movement of the globe; scarred, injected, heaped conjunctiva; and changes in the normal eyelid level. These hardships may be impossible to overcome by performing secondary surgery. The most serious and frequently recurring abuse of the fascia during muscle surgery is the needless penetration of the Tenon's capsule beyond 10 mm. from the limbus, which results in prolapse of the fat cushion into the spaces that are normally between the movable fascial planes and sclera. The prolapsed fat infiltrates into the sclera and muscle capsules and undergoes fibrofatty proliferation; with time, cicatrization of these scarred tissues pulls the eye to a deviated position, restricting its normal movement. Also, the fat cushion migrates forward under the conjunctiva toward the limbus, causing the unsightly appearance of injected yellowish fleshy tissue near the limbus. A patient's ocular motility can be ruined for life and his appearance deformed because of a surgeon's disrespect for the important role Tenon's capsule plays in the motility of the globe.