© 2017 Wichtg Publishing EJO ISSN 1120-6721 Eur J Ophthalmol 2017; 27 (5): 614-616 surgical technique capsule is cleared from the muscle belly using a sharp and a blunt dissecton. A modifed 1/4� × 7-3/4� Zalkind Ribbon Malleable Retractor (Sklar Surgical Instruments Corp., West Chester, PA, USA) is inserted between the muscle belly and the globe between 6 and 8 millimeters posterior to its in- serton (Fig. 1A). This modifed malleable retractor is de- signed specifcally to protect the sclera during the handling of the EOM. Uni-Punch (Premier Surgical, Plymouth Meet- ing, PA, USA) 3.0 mm, a disposable biopsy punch, is used to incise and extract the middle part of the muscle belly above the modifed malleable retractor (Fig. 1B), whereby a full- thickness 3-mm punch biopsy of the middle of the EOM is obtained (Fig. 1C). Subsequently, the conjunctva is closed in standard fashion with 8-0 Vicryl sutures (Ethicon, Somerville, NJ, USA). results We performed this procedure on a 34-year-old man. The patent had pain in his right eye. On examinaton, a positve relatve aferent pupillary defect was noted in the right eye. There was restricton in abducton and upper and lower gaze of the right eye, and unremarkable fndings on biomicroscopic examinaton. Routne laboratory tests were normal, including thyroid, rheumatologic, and tumor marker panels. Cerebrospinal fuid was clear on lumbar puncture. No pathologic fndings were observed on imag- ing studies, except bilateral medial rectus enlargement on magnetc resonance imaging. At this stage, a muscle biopsy was performed. The patent was orthophoric before and afer the biopsy was taken. No worsening of abducton, muscle weakness, bleeding, or cosmetc defects were noted postoperatvely. The pathologic result of the biopsy described striated muscle and mild edema with no evidence of lymphoma (Fig. 2). Leu- kocyte common antgen immunohistochemical stain showed sparse leukocytes. DOI: 10.5301/ejo.5000933 sutureless extraocular muscle biopsy technique Tom Kornhauser, Ahed Imtrat, Jaime Levy, Erez Tsumi Department of Ophthalmology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva - Israel Introducton Muscle biopsy has an important role in the diagnostc process of idiopathic infammatory myopathies, congenital muscular dystrophies, and metabolic disorders, among oth- ers, according to the literature (1-3). In cases of infltratve or atypical infammatory eye dis- ease, when abnormal muscle structure is seen on imag- ing studies of inconclusive etology, a full-thickness biopsy of an extraocular muscle (EOM) is warranted in order to make a fnal diagnosis (1, 4, 5). The biopsy technique has not thoroughly been depicted except by Hertle and Wilson (4), who described an approach to obtain an adequate sam- ple of an EOM or a tendon while avoiding postoperatve strabismus by dividing the muscle belly into longitudinal thirds between 2 self-retaining muscle hooks and isolatng a 8-to-10-mm central segment of muscle for biopsy. We present a modifcaton of that technique that is simple, precise, and sutureless, without compromising muscle functonality. Methods The tendon of the EOM is approached and isolated us- ing either a limbus or fornix incision approach. The muscle abstract Purpose: To describe a simple and novel technique of obtaining an extraocular muscle (EOM) biopsy. Methods: Our sutureless method involves obtaining a full-thickness 3-mm EOM specimen using a disposable punch biopsy. results: The procedure was performed successfully, with no worsening of eye movement, muscle weakness, or cosmetc defects postoperatvely. The acquired full-thickness specimen was sufcient for analysis. conclusions: This technique to obtain an EOM biopsy allows a straightorward sutureless method, providing an adequate sample for tssue scrutny. Keywords: Biopsy, Extraocular muscle, Technique accepted: January 9, 2017 Published online: January 25, 2017 corresponding author: Tom Kornhauser, MD Department of Ophthalmology Soroka University Medical Center P.O. Box 151 84101 Beer Sheva, Israel tomchook@gmail.com