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.

Putting the Pieces Back Together: Optimizing Function and Appearance after Orbital Surgery

Objectives  To describe medical and surgical options and techniques for functional and aesthetic abnormalities after orbital surgery and multidisciplinary approaches that include the orbit. Design  A review of current management options in outpatient clinics and ambulatory surgery centers with selected illustrative cases. The rationale for choosing specific medical and surgical interventions will be discussed with a focus on eyelid malposition and double vision. Setting  Outpatient clinics and ambulatory surgery centers. Participants  Patients with eyelid, orbital, eye muscle, and scalp contour abnormalities as a result of medical and surgical interventions for brain and/or orbital tumors. Main Outcome Measures  Descriptive outcomes. Results  A variety of medical and surgical options are available to optimize eyelid, orbit, extraocular muscle, and scalp structure and function.

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.

Avoiding complications in endoscopic skull base surgery

PURPOSE OF REVIEW

Endoscopic skull base surgery has become an established approach for the removal of tumors and cerebrospinal fluid fistulae repair. Compared with external approaches, it provides better aesthetic results and quality of life postoperatively. However, as it becomes popular and expands its indications possible complications should be reassessed in terms of incidence and variability in order to confirm its efficacy and safety. This article reviews the recent literature describing the main categories of possible complications suggesting strategies to minimize their incidence.

RECENT FINDINGS

Detailed preoperative planning based on imaging and histology can prevent major complications. Intraoperative use of image guidance and meticulous hemostasis provide the surgical field needed to avoid complications. Postoperative patient counseling, along with close and detailed nasal postoperative care are significant factors for an optimal outcome.

SUMMARY

Monitoring of complications after endoscopic skull base surgery is necessary in order to standardize protocols of management and improve our surgical techniques. The presence of late onset complications underlines the need of a special focus in postoperative care and follow-up.

Challenging Management of Double Vision After Functional Endoscopic Sinus Surgery-A Series of 6 Cases

PURPOSE

To present 6 cases of orbital trauma, diplopia and strabismus after functional endoscopic sinus surgery (FESS).

DESIGN

Retrospective observational case series.

METHODS

The medical charts of suitable patients were reviewed for information on medical examination, imaging studies, the type of corrective surgery, and surgical outcomes.

STUDY POPULATION

All patients with diplopia and strabismus after undergoing FESS who were treated or consulted at our institution between 2008 and 2017 were included.

MAIN OUTCOME MEASURES

The presence and extent of strabismus and double vision at the end of follow-up.

RESULTS

Six patients complained of diplopia after FESS; all of them had proven orbital trauma. In Cases 1-5, patients suffered medial rectus (MR) muscle transection and subsequent exotropia. Their prognosis was guarded despite prompt surgical intervention, and ranged from large exotropia when direct recovery of the MR was attempted, to primary gaze orthotropia but with minimal adduction capacity, during which vertical recti transposition was attempted. Patient 6 sustained transient diplopia, although all of his extraocular muscles appeared intact on imaging. His eye position and movement were completely resolved with conservative measures only.

CONCLUSIONS

Our experience was that immediate recovery procedures to reattach the muscle in cases with proven transection of the MR muscle are futile, and that definitive corrective strabismus surgery (ie, vertical muscle transposition) has a better chance to achieve favorable results.

Long-term therapeutic outcome of ophthalmic complications following endoscopic sinus surgery

Ophthalmic complications associated with endoscopic sinus surgery (ESS) are quite rare. There is a paucity of reliable data and limited experience on the clinical findings and treatments of these injuries. Our study here is to characterize the types of orbital injury following ESS, in particular extraocular muscle injury, and to evaluate the long-term therapeutic outcomes as compiled from a relatively large sample of Chinese patients.A series of 27 patients (21 males and 6 females; mean age = 42.6 years, ranges: 10-60 years) were retrospectively reviewed. The mean duration of orbital complication was 6.6 months (ranges: 1 day to 24 months). The right eye was affected in 19 patients and the left in 8 patients. All patients had various extraocular muscle dysfunction, including contusion, oculomotor nerve damage, muscle entrapment, muscle transection, and muscle destruction. All patients subjected to strabismus surgery showed an obvious reduction in deviation. Three patients achieved orthophoria without any surgery during the period of observation. All patients displayed mild to complicated orbital hemorrhage that often disappeared within 2 weeks. Optic nerve injury occurred in 29.6% of patients and vision damage in these patients was often irreversible.All patients with ophthalmic complications after ESS had strabismus and extraocular muscle dysfunction. Timing and type of strabismus surgery performed depended on the severity and number of muscles involved as well as the type of injury. This surgery is less effective in cases of restriction factor adhesion and/or entrapment as compared to that of patients with other types of strabismus. Orbital hemorrhages were usually resolved spontaneously, but optic nerve injury was mostly irreversible.

Iatrogenic diplopia [corrected]

Diplopia is a very disturbing condition that has been reported as a complication of several surgical procedures. The following review aims to identify the ocular and nonocular surgical techniques more often associated with this undesirable result. Diplopia is reported as an adverse outcome of some neurosurgical procedures, dental procedures, endoscopic paranasal sinus surgery, and several ophthalmic procedures. The most common patterns and some recommendations in order to prevent and treat this frustrating outcome are also given.

Periorbital globe fixation after severe extraocular muscle injury

Endoscopic sinus surgery is a popular surgical treatment for chronic sinus disease. Despite improved surgical techniques, postoperative orbital complications can occur, including extraocular muscle injury. We report the case of a 62-year-old woman who suffered from medial rectus muscle transection after transnasal endoscopic ethmoidectomy. She was successfully managed with periorbital globe fixation.

Prevention and management of medial rectus injury

Medial rectus injury is an uncommon but often devastating complication of functional endoscopic sinus surgery. Prevention of these types of injuries is predicated on a thorough preoperative assessment of the position and integrity of the medial orbital wall coupled with excellent surgical technique. The use of powered instrumentation has led to more severe injuries and thus should be used with caution near critical structures such as the lamina papyracea. Early recognition and management of medial rectus and associated orbital injuries is critical to improve outcomes and prevent associated complications. Despite optimal surgical and medical interventions, the prognosis is relatively poor and patients should be counseled that the primary goal of these interventions is to reestablish a binocular single visual field.

Management of orbital complications in endoscopic sinus surgery

PURPOSE OF REVIEW

Minor and major complications can occur during endoscopic sinus surgery. Even though major complications are rare, orbital complication is one of the more common major complications that can lead to devastating consequences. This article summarizes the orbital complications that can occur during endoscopic sinus surgery, how to manage the complication when it occurs, and more importantly how to avoid these complications.

RECENT FINDINGS

One of the orbital complications during endoscopic sinus surgery is retrobulbar hematoma. Retrobulbar hematoma can be classified as spontaneous, traumatic, and iatrogenic. Iatrogenic hematoma, which can be caused by endoscopic sinus surgery, is more likely to have an arterial source, so these hematomas have higher tonometric pressure and may require more aggressive management. However, medical management can be an option for some of these iatrogenic retrobulbar hematomas. Tonometric pressure may be the best indicator to decide which intervention to use for this complication. Another distressing orbital complication is injury to the oculomotor muscles. With prompt medical and surgical intervention, the ocular dysmotility can be compensated.

SUMMARY

Consequences of orbital injury during endoscopic sinus surgery can be devastating; however, with proper medical or surgical treatment potential morbidities can be minimized.

Ophthalmic complications of endoscopic ethmoidectomy: a case report

Damage to ethmoid structures following removal of nasal polyps can cause severe complications. A patient aged 48 years with damage to right orbital structures sustained in the course of transnasal endoscopic surgery for ethmoid polyps was operated. After operation were complications.

Orbital approach for retrieval of transected extraocular muscles

Transection of an extraocular muscle can occur from orbital and facial trauma, or as a complication of surgery. The injury can occur either near the muscle insertion or in the muscle belly. Identification of the proximal end of the muscle in the orbit may be difficult, especially if the transection occurs a farther distance from the insertion, and, in these cases, the muscle is often considered lost. We present two patients who suffered from traumatic transections of an extraocular muscle more than 10 mm from the insertion. Both patients underwent transconjunctival orbitotomy to retrieve and secure the severed extraocular muscle. Both patients achieved good primary gaze alignment postoperatively. Preoperative imaging should be considered in cases of traumatic extraocular muscle transection.