Retrieval of lost medial rectus muscles with a combined ophthalmologic and otolaryngologic surgical approach

Simplification of the complex: Successful management of large-angle exodeviation after endoscopic sinus surgery

PURPOSE

To report the clinical characteristics and successful management of large-angle exodeviation due to medial rectus muscle (MR) transection incurred during endoscopic sinus surgery (ESS).

METHODS

The medical records of 5 consecutive inpatients with MR complete transection following ESS resulting in large-angle paralytic exodeviation between November 2014 and June 2021 were reviewed. The type of muscle injury, clinical characteristics, surgical procedure and dosage, and long-term outcomes were evaluated.

RESULTS

All 5 patients manifested exodeviations of 72 PD to >133 PD with no adduction capacity (graded -4); all of them had proven orbital trauma and complete MR transection with a ≥20 mm distal (globe attached) stump based on CT scans and/or MRI imaging. They underwent a supra-maximal recession (10-12 mm) of the lateral rectus and resection (10-15 mm) of the medial rectus on the affected eye. At least 1 year (1 to 5 years) following the corrective surgery, the patients still maintained orthophoria or had a small angle of exotropia (≤ 8 PD) in primary gaze with successful fusion, and 3 of them (Case 3, 4, and 5) exhibited a certain degree of stereopsis. In addition, appreciable adduction occurred (graded -1 to -3).

CONCLUSIONS

A supra-maximal recession/resection shows favorable outcomes in patients with proven complete transection MR with a ≥20 mm distal (globe attached) stump. It can help to achieve good ocular alignment and even yield improvements in adduction over time.

Medial Rectus Anastomosis Under Endoscopic Endonasal Orbital Approach With Image-Guided Navigation: A New Way of Repairing a Ruptured Medial Rectus

BACKGROUND

With the extensive development of endoscopic sinus surgery, iatrogenic medial rectus muscle injury should be treated with caution. Traditional methods to repair a ruptured medial rectus need an anterior orbitotomy approach, with more injury and difficulty in finding the posterior end of the ruptured medial rectus.

OBJECTIVE

To explore a new method to repair a ruptured medial rectus.

METHODS

Eight cases of iatrogenic medial rectus rupture after endoscopic sinus surgery were reviewed from July 2015 to January 2019. Assisted by image-guided navigation, the ruptured medial rectus was sutured under an endoscopic endonasal orbital approach. Two methods were designed to suture the ruptured medial rectus. Optic nerve and orbital decompression were performed in 5 cases with visual impairment. The extent of exotropia and diplopia were followed up for 5 to 33 months after surgery.

RESULTS

With the help of image guidance, the posterior and anterior ends of the ruptured medial rectus of all patients were pinpointed, and operations using medial rectus anastomosis were successfully completed in 7 patients. The exotropia of these patients was corrected, and they have recovered. The vision of 2 patients recovered. There were no minor or major complications intraoperatively or postoperatively.

CONCLUSION

Assisted by image-guided navigation, medial rectus anastomosis under an endoscopic endonasal orbital approach is a feasible method. The key to preventing orbital complications is strict professional training, including identification of the Onodi air cell and correct application of powered instrumentation.

Medial rectus muscle loss: Is immediate lateral rectus disinsertion a solution? A case report with review of the literature

Purpose

To report a case of medial rectus (MR) muscle loss during the strabismus surgery with a late successful management and review of the literature.

Methods

The left MR was lost during resection in a 14-year-old girl who had undergone strabismus surgery elsewhere. The surgeon disinserted the antagonist lateral rectus (LR) muscle in the same session following unsuccessful attempts to retrieve the lost muscle. She was referred to our clinic two months later with a large angle exotropia and a complete lack of adduction. We performed a half-tendon transposition of vertical rectus muscles to the MR insertion and attached the residual fibers of the LR to the orbital periosteum.

Results

She was orthotropic after the surgery and remained stable until 6 months with a significant improvement of the adduction.

Conclusions

Simultaneous LR disinsertion is not a solution for MR loss. Half-tendon transposition of the vertical recti to the original insertion of the lost MR and periosteal fixation of the LR are good options as a second-stage operation in patients with MR loss during strabismus surgery.

Localizing the Lost Rectus Muscle Using the Connective Tissue Framework: Revisiting the Tunnel Technique

PURPOSE

To describe a technique for localizing a lost rectus muscle during strabismus or retinal surgery or following trauma.

METHODS

In this single center, retrospective chart review, 5 patients were identified between January 2012 and June 2016 with a lost rectus muscle; 3 during strabismus surgery and 2 post trauma. The inclusion criteria included a lost rectus muscle during strabismus surgery, or a disinserted/lacerated rectus muscle following ocular/orbital trauma. The primary outcome measure was successful reattachment of the rectus muscle.

RESULTS

The lost rectus muscle was identified in each patient and reattached to the globe by gently applying traction anteriorly at the conjunctiva/Tenon edge using double-pronged skin hooks and following the path of the rectus muscle through its Tenon capsule tunnel where it remained attached by suspensory ligaments. There was no instance where orbital fat was obscuring or blocking the view of the lost rectus muscles. There were no other complications associated with the procedure.

CONCLUSIONS

The authors describe a simple and effective method in 5 patients to localize a lost rectus muscle based on knowledge of the orbital connective tissue framework.

The Hook and Release Technique During Enucleation Surgery

PURPOSE

To describe the results and potential benefit of direct muscle release from the globe during enucleation surgery without identifying sutures in the rectus muscle insertion sites, a technique referred to as the hook and release technique.

METHODS

Single center, retrospective chart review of patients who underwent enucleation with direct removal of the rectus muscles without identifying sutures in their insertion sites between January 2011 and September 2015 was carried out. The inclusion criteria were primary enucleation without previous strabismus surgery, retinal detachment surgery, or orbital surgery that entered the fibrous connective tissue framework. Forty charts of enucleated patients that had direct release of their extraocular muscles without identifying sutures before releasing them from the globe were identified and reviewed. The primary outcome measure was intraoperative or immediate postoperative complications. This retrospective chart review was performed with research ethics board approval and in compliance with the Declaration of Helsinki.

RESULTS

Data show that following the hook and release technique, the rectus muscles were easily located and reconnected to the orbital implant wrap. The oblique muscles were not reattached. In each of the 40 patients, the 4 rectus muscles were easily located by gently applying traction anteriorly at the conjunctiva/Tenons' edge using double-pronged skin hooks. There was no instance of a lost or slipped muscle following the hook and release technique.

CONCLUSION

The hook and release technique is a simple and efficient method to remove the 4 rectus muscles from the globe and still easily locate them. They are not "lost" and do not "slip out of position" but held in place by the orbital connective tissue framework and the extraocular muscle pulley system. This technique has been very helpful teaching resident staff how to do enucleation surgery as it avoids the more time consuming placement of double-armed locking sutures through the rectus muscle insertions and the potential risk of globe penetration while the muscles remain attached to the eye. If the surgeon desires to attach the muscles to the orbital implant, then sutures are passed after the eye is removed, thus eliminating the worry of globe penetration and avoiding accidentally cutting preplaced extraocular muscle sutures during the remaining enucleation procedure.

An Approach to Some Aspects of Strabismus from Ocular and Orbital Trauma

Strabismus caused by ocular or orbital trauma can be the result of localized acute soft tissue swelling or may follow orbital fractures, partial or complete loss of extraocular muscle (EOM) and/or cranial nerve function, or damage to surrounding tissues causing mechanical restriction. The strabismus is frequently incomitant and can be difficult, if not impossible to completely correct. The resulting diplopia can affect the individual's ability to function at work, in sports and in common tasks of daily living like driving. The preoperative evaluation should include an assessment of the degree of limitation, muscle function and the condition of the surrounding tissue. In most cases, high resolution computed tomography and/or surface coil dynamic magnetic resonance imaging are required to determine the extent and nature of suspected bony or EOM injury, as well as muscle contractility. If the scan reveals an intact but paretic muscle or only minor muscle injury, surgical intervention is based on the degree of muscle recovery 6 months after the initial insult. If a rectus muscle has been lacerated, and the proximal stump is functional, retrieval should be attempted, either by a direct conjunctival approach if located anteriorly, or by an anterior medial orbitotomy if located deep in the orbit. If a damaged muscle cannot be found, recovered or repaired at any time, then muscle transposition should be considered. If multiple muscles are damaged or scar tissue is excessive, a tether procedure may be indicated. This paper will present an approach to some aspects of strabismus in this setting.

Isolated Total Rupture of Extraocular Muscles

Total rupture of extraocular muscles is an infrequent clinical finding. Here we conducted this retrospective study to evaluate their causes of injury, clinical features, imaging, surgical management, and final outcomes in cases of isolated extraocular muscle rupture at a tertiary center in China. Thirty-six patients were identified (24 men and 12 women). Mean age was 34 years (range 2-60). The right eye was involved in 21 patients and the left 1 in 15. A sharp object or metal hook was the cause of this lesion in 16 patients, sinus surgery in 14 patients, traffic accident in 3 patients, orbital surgery in 2 patients, and conjunctive tumor surgery in 1 patient. The most commonly involved muscles were medial (18 patients) and inferior rectus muscles (13 patients). The function of the ruptured muscles revealed a scale of -3 to -4 defect of ocular motility and the amount of deviation in primary position varied from 10 to 140 PD (prism diopter). Computerized tomography (CT) confirmed the presence of ruptured muscles. An end-to-end muscle anastomosis was performed and 3 to 5 mm of muscle was resected in 23 patients. When the posterior border of the injured muscle could not be identified (13 patients), a partial tendon transposition was performed, together with recession of the antagonist in most patients, whereas a recession of the antagonist muscle plus a resection of the involved muscle with or without nasal periosteal fixation was performed in the remaining patients. After an average of 16.42 months of follow-up an excellent result was achieved in 23 patients and results of 13 patients were considered as a failure. In most patients, the posterior border of the ruptured muscle can be identified and an early surgery can be performed to restore function. Alternatively, a partial tendon transposition should be performed. When muscular rupture is suspected, an early orbital CT is required to confirm this possibility, which can then verify the necessity for an early surgical intervention.

Medial Rectus Muscle Injuries after Functional Endoscopic Sinus Surgery

In recent years, functional endoscopic sinus surgery (FESS) has improved the treatment of sinus disorders. However, various orbital complications have been reported, including optic nerve damage, orbital hemorrhage, infection, lacrimal drainage system injury, and strabismus. Complications are rare but may cause severe morbidity. We describe two patients who underwent endoscopic sinus surgery procedures that resulted in trauma to the medial rectus muscle. The first patient had medial rectus paresia due to contusional trauma and showed spontaneous resolution in a month. The other patient had an orbital medial wall defect with medial rectus injury and he underwent orbitotomy. Medial rectus innervation returned at postoperative 8 months. Several extraocular muscles may be traumatized during FESS. Timing and method of treatment are based on the severity and type of injury and the number of muscles involved. Treatment strategies are dependent on accurate interpretation of magnetic resonance imaging scans.

What information can we give to the patient about the risks of strabismus surgery

I hope to report the type, incidence, and clinical outcomes of severe complications from strabismus surgery in the United Kingdom and to help in the discussions involved in the consent process. The main part of the talk will revolve around a BOSU (British Ophthalmic Survey Unit) investigation. Cases were identified prospectively between 1 September 2008 and 31 August 2010. Questionnaire data were requested at the time of the complication recognition and at 6 months' follow-up. Outcome was graded I-V, with a poor or very poor outcome meaning either loss of corrected visual acuity or primary position double vision. A total of 60 completed reports of adverse events and complications were received during the study period. During the same time, ∼24 000 strabismus surgeries were carried out in the United Kingdom, yielding an overall incidence of 1 in 400 operations (95% binomial confidence, 1 per 333-500 operations). The most commonly reported complication was perforation of the globe (19 (0.08%)), followed by a suspected slipped muscle (16 (0.067%)), severe infection (14 (0.06%)), scleritis (6 (0.02%)), and lost muscle (5 (0.02%)). Overall, complications were reported in adults and children in equal numbers; however, scleritis was significantly more common in adults. A poor or very poor clinical outcome was recorded as 1 operation per 2400. The study limitations are as follows: the denominator was extrapolated from the number of surgeries in England, and there was an almost certain underreporting of cases. Complications with the potential for a poor outcome are relatively common, but the final clinical outcome is good in the majority of cases.

Retrieval of ruptured medial rectus muscle with an endoscopic endonasal orbital approach. A case report and indication for surgical technique

INTRODUCTION

Rupture of the extraocular muscle is extremely rare, and a traumatic event is especially uncommon. Although retrieval of an injured MRM is usually performed by an anterior approach by an ophthalmologist, missing muscles in the orbital retrobulbar space are sometimes difficult to identify. This is the first report to demonstrate direct muscle to muscle anastomosis by an endoscopic endonasal orbital approach by a single otolaryngologist.

CASE REPORT

A 67-year-old man presented with left medial rectus muscle (MRM) rupture due to a traffic accident 4 months after injury. The MRM was completely ruptured, and the muscle was repaired by an endoscopic endonasal orbital approach. After surgery, his eye abduction was improved in the primary position, and adduction ability was markedly restored on right gaze without diplopia.

CONCLUSIONS

Our endonasal endoscopic approach provides excellent access to the MRM in the orbital retrobulbar space and avoids a facial scar. We could suture both ends of the muscle together by an endonasal endoscopic approach and could obtain a good result without any complications.

A conventional strabismus surgical approach for lost medial rectus muscles

We present 3 cases of successful conventional strabismus surgery to retrieve lost medial rectus (MR) muscles. In all cases the lost MR muscle was retrieved and re-attached to the intended scleral point. Two patients had residual exotropia, while the third case was orthophoric after surgery. The retrieval of lost MR muscle using conventional strabismus surgery technique can be successfully achieved if the lost MR muscle is recognized early and the re-operation is performed by an experienced surgeon.

Function of transected or avulsed rectus muscles following recovery using an anterior orbitotomy approach

PURPOSE

To assess the function of muscles retrieved from a retrobulbar location using an anterior orbitotomy approach and to identify the prognostic factors favoring a good outcome.

METHODS

The records of all patients undergoing anterior orbitotomy for the retrieval of a transected or avulsed muscle in a retrobulbar location were reviewed. Ocular motility, before and after retrieval (with ductions scaled from -4 to +4), was evaluated.

RESULTS

Record review identified 11 patients who had suffered trauma to 12 muscles (5 inferior, 6 medial, and 1 lateral rectus muscle). Ductions improved from -4 ± 0.4 preoperatively to -2.7 ± 0.9 postoperatively (P = 0.002); mean primary position deviation improved from 34(Δ) ± 14(Δ)-15(Δ) ± 9(Δ) (P < 0.001), and mean deviation in the field of action improved from 47(Δ) ± 20(Δ)-20(Δ) ± 22(Δ) (P = 0.02). Ductions improved by at least two units in three patients, all of whom had medial rectus trauma. Single binocular vision in primary gaze was achieved in 6 patients. Patients with medial rectus muscle injury and patients injured by sinus surgery had the lowest likelihood of recovering single binocular vision.

CONCLUSIONS

Our results are similar to historical series in which muscles were not retrieved and transpositions performed; however, muscle retrieval avoids risks associated with transposition surgeries such as anterior segment ischemia. Muscle recovery via the anterior orbitotomy approach may be reasonable to consider in those cases with a reasonable possibility of having active force generation postoperatively.

The effect of horizontal strabismus surgery on the vertical palpebral fissure width

PURPOSE

To compare vertical lid fissure width before and after medial or lateral rectus muscle recessions for horizontal strabismus.

METHODS

In this prospective, noninterventional case series, vertical eyelid fissure width measurements were compared before and after treatment in consecutive patients undergoing extraocular muscle recessions for esotropia or exotropia. Digital imaging analysis was used to measure vertical lid fissure width. Each measurement was an average of three separate images.

RESULTS

A total of 59 subjects were enrolled, including 42 for esotropia and 17 for exotropia. Mean postoperative vertical palpebral fissure width increased by 0.96 mm (11.9%; range, 0.64-2.5 mm) in esotropia patients and 1.00 mm (11.8%; range, 0.19-3.23 mm) in exotropia patients (P < 0.0001 in both groups.)

CONCLUSIONS

Recession of a rectus muscle for comitant horizontal strabismus may result in vertical widening of the palpebral fissure.

Functional endoscopic sinus surgery: indications and complications in the ophthalmic field

Functional Endoscopic Sinus Surgery (FESS) is a highly sophisticated type of surgery, which has revolutionized the surgical management of chronic sinus diseases. In the ophthalmic field, FESS plays a crucial role in the management of a few conditions, but not without risks. Ophthalmic complications associated with FESS are well documented. They mainly occur due to the shared common anatomic areas between ophthalmology and otolaryngology. Ophthalmic complications can vary in severity from very trivial cases such as localized hematoma collection, which is not very problematic to very devastating cases, such as optic nerve damage, which can lead to complete blindness. In order to minimize such complications, safety measures need to be considered prio to the surgery, these include; precise knowledge of detailed anatomy, the operating surgeon's ability to interpret precisely the para nasal sinus CT scan and experienced procedural surgical skills.

Endoscopically assisted strabismus surgery

BACKGROUND

Strabismus surgery involving open exploration of the posterior orbit is difficult. Exploration is sometimes avoided by considering alternative procedures (transposition and weakening other muscles). Although the use of endoscopic sinus surgery (ESS) to retrieve medial rectus (MR) muscles lost in the posterior orbit has been described, the use of an endoscopic approach to the posterior orbit in elective strabismus surgery has never been reported.

METHODS

A patient with thyroid orbitopathy had severe bilateral restrictive strabismus with bilateral esohypotropia, rendering him functionally blind. The MR was inaccessible via the anterior approach. We describe a transnasal endoscopic approach to the posterior orbit where the MR was identified, sectioned, and reattached to the globe. We also describe two other patients who had endoscopic posterior orbit exploration after ESS-related MR injury.

RESULTS

In patient 1, repositioning of the medial rectus muscles facilitated follow-up conventional strabismus surgery and dramatically improved ocular alignment. In patient 2, the medial rectus muscle was severely disrupted. A temporary traction suture was placed endoscapically. Follow-up transposition strabimus resulted in satisfactory alignment. In patient 3, endoscopic exploration and freeing of adhesions was done in anticipation of follow-up strabismus surgery.

CONCLUSION

These cases illustrate the expanding frontiers of ESS. The endoscopic approach to the posterior orbit allows enhanced posterior orbit access in elective strabismus surgery and posttraumatic exploration of the MR.

Ophthalmic complications of endoscopic sinus surgery

The intimate anatomical relationship between the orbit and the paranasal sinuses places the orbit and its contents at risk of harm from primary pathologic processes of the sinuses. In the absence of ophthalmic signs or symptoms, ophthalmologists are not routinely involved in the management of patients with sinus disease. Occasionally, some patients may develop ophthalmic complaints after surgical intervention. The orbit, optic nerve, extraocular muscles, and lacrimal drainage system are susceptible to injury during endoscopic sinus surgery. The risk of injury is related to the skill of the sinus surgeon, history of previous surgery, extent and severity of disease, and anatomic variation. Furthermore, recent advances in endoscopic sinus surgery, in particular the use of powered cutting instruments, has resulted in a novel mechanism of injury to the ocular structures.

Medial rectus muscle injuries associated with functional endoscopic sinus surgery: characterization and management

OBJECTIVE

To characterize and evaluate treatment options for medial rectus muscle (MR) injury associated with functional endoscopic sinus surgery (FESS).

DESIGN

Retrospective interventional case series.

PARTICIPANTS

A total of 30 cases were gathered from 10 centers.

METHODS

Cases of orbital MR injury associated with FESS surgery were solicited from members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) through an e-mail discussion group.

MAIN OUTCOME MEASURES

Variables assessed included patient demographics, computerized tomography and operative findings, extent of MR injury and entrapment, secondary orbital/ocular injuries, initial and final ocular alignment and ductions, and interventions.

RESULTS

A spectrum of MR injury ranging from simple contusion to complete MR transection, with and without entrapment, was observed. Four general patterns of presentation and corresponding injury were categorized.

CONCLUSIONS

Medial rectus muscle injury as a complication of FESS can vary markedly. Proper characterization and treatment are important, particularly with reference to the degree of direct MR injury (muscle tissue loss) and entrapment. Patients with severe MR disruption can benefit from intervention but continue to show persistent limitation of ocular motility and functional impairment. Prevention and early recognition and treatment of these injuries are emphasized.

The use of an image guidance system in retrieving lost medial rectus muscles

INTRODUCTION

Finding a lost medial rectus muscle can be difficult. We present 2 patients in whom image guidance technology assisted in the recovery of a lost medial rectus muscle.

METHODS

Two patients (ages 19 and 33), both with lost medial rectus muscles, underwent computerized tomography of their heads, faces, and orbits. The muscles were both lost after strabismus surgery 7 and 19 years ago, respectively. These images were then loaded into an image guidance system (LandmarX, Xomed Co, Jacksonville, Fla) and served as a "map" to locate the lost medial rectus muscle intraoperatively. Using a transnasal endoscopic approach, the lamina papyracea was exposed. The area of the lamina closest to the lost medial rectus was identified using a guidance probe. After the periorbita was exposed, the guidance probe was used to confirm the location of the medial rectus muscle. The muscle was then isolated transnasally and passed into the orbit using forceps. It was then sutured onto the globe.

RESULTS

The medial rectus was identified transnasally and reattached to the globe in both cases. Adduction improved from complete deficits in both patients to 80% and 50% adduction deficits, respectively.

DISCUSSION

The transnasal endoscopic approach to retrieve the medial rectus has been described before. For these patients, image guidance technology successfully identified the appropriate areas for the surgeons to locate the lost muscle. The use of this technique decreased operative times and reduced the extent of the dissection required, which should also reduce long-term scarring.

CONCLUSION

Image guidance technology, with its capability of 3-dimensional images, can be used to assist surgeons in finding lost medial rectus muscles.