外直肌折叠眶骨膜固定术治疗固定性内斜视

目的 探讨固定性内斜视的手术治疗方法及手术效果.方法 对10例12只眼固定性内斜视采用内直肌完全断腱,外直肌折叠眶骨膜固定术治疗固定性内斜视.结果 术后第2～4天,12只眼水平位斜视完全矫正,1只眼残余下斜视约5°.术后随访3月至5年,患者9只眼正位,3只眼残余水平斜视5°～10°,其中2只眼同时残余下斜视5°～10°.10例患者外观明显改善,术眼视物功能部分恢复.结论 采用内直肌完全断腱,外直肌折叠眶骨膜固定术治疗固定性内斜视,手术操作简单、安全、创伤小,效果较满意,是对其治疗方法的一种有益改进.

Abstract：

Objective To investigate surgical methods and treatment effect for esotropia fixus.Methods Ten cases of 12 eyes with esotropia fixus were treated by severing of medial rectus muscle, folding of lateral rectus muscle combined orbital periosteum fixation and made the eye overcorrection for 5-10. Results Followed-up 3 months to 5 years, 9 eyes gained normotopia and 3 eyes were undercorrection. All patients' visual function and appearance obtained amelioration. Conclusions Severance of medial rectus muscle, foldback of lateral rectus muscle and orbital periosteum fixation can make satisfied result in most patients of esotropia fixus.     

Unaugmented Vertical Muscle Transposition Surgery for Chronic Sixth Nerve Paralysis

Introduction: Chronic sixth nerve palsy can cause incapacitating diplopia requiring vertical muscle transposition surgery. Augmentation of surgery, with lateral fixation sutures, medial rectus recession or botulinum toxin injection, is associated with an increased risk of complications. Purpose: Our aim was to evaluate the efficacy and safety of unaugmented full-tendon vertical rectus transposition in chronic sixth nerve paralysis. Methods:Longitudinal study of 21 patients with chronic sixth nerve paralysis of longer than 6 months duration, who underwent superior and inferior recti transposition surgery without medial rectus recession or botulinum toxin injection. Details of surgery, preoperative and postoperative examinations including full orthoptic examination were obtained from an electronic database. Outcomes included the change in angle of deviation, the requirement for further surgery to the medial rectus and postoperative improvement in diplopia. SPSS software (Version 12.0.1, SPSS Inc. Chicago, IL) was used to summarize baseline characteristics and outcomes and to compare preoperative and postoperative deviation (paired t-test). Results: Twenty-one patients (10 (47.6%) men and 11 (52.4%) women) with a mean age of 41 years (range 4 to 74 years) were operated in the period between April 1998 and November 2000. Eighteen patients had unilateral and three had bilateral acquired sixth nerve palsy. Nineteen patients required unilateral surgery and two had bilateral transposition procedures. In patients with unilateral sixth nerve palsy, mean esotropia in primary position before surgery was 46.7 prism-diopters (PD) (95% CI 35.9–57.4 PD) and improved to 14.6 PD after surgery (95% CI 6.4–22.7 PD). The angle of deviation was significantly reduced by an average of 32.1 PD (p < 0.001, paired t-test; 95 % CI 22.6–41.6 PD). Over all, 10 patients (55.6%) had a well-controlled esophoria with a postoperative alignment of within 10 PD of orthophoria without diplopia in the primary position, for distance and near. A further six patients (28.6%) required additional medial rectus recessions to achieve success. The only complication observed was slippage of the inferior rectus in one patient (4.2%), who consequently required further surgery. Conclusion: Botulinum toxin infiltration of the medial rectus in vertical rectus transposition surgery may be unnecessary, incurring cost, additional attendances and interventions for patients. Less than a third of all patients in our series required additional medial rectus recession later.     

Acquired Esotropia in Cerebellar Disease: A Case Series Illustrating Misdiagnosis as Isolated Lateral Rectus Paresis and Progression Over Time

We highlight an under-recognised cause of acquired esotropia with this prospective observational case series of adults with diplopia secondary to cerebellar dysfunction. We also show deterioration of cerebellar esotropia over time, which has not been previously described. Seven adults (four women) developed diplopia at a median age of 63 years (range: 31–75 years), as the initial manifestation of the underlying cerebellar disorder. Causes of cerebellar dysfunction were familial cerebellar ataxia of unknown mutation (two patients), idiopathic cerebellar ataxia (four patients), and spinocerebellar ataxia 3 (one patient). At onset, three patients had unilateral and four had bilateral lateral rectus under-action. These were initially diagnosed as lateral rectus paresis, but the diagnosis was revised, as our examination showed no slowing of abducting saccades assessed clinically and full abduction with gaze-evoked nystagmus. Esotropia was concomitant and worse for distance, although at onset one patient’s esotropia was equal for near and distance. There was a trend of worsening esotropia over time, following a median interval follow-up of 4 years (range: 1–18). All patients were first observed to have cerebellar eye signs after a median interval of 5 years (range: 1–30) from presentation, i.e., impaired pursuit (7/7 patients), gaze-evoked nystagmus (7/7), hypometric saccades (3/7), downbeat nystagmus (2/7), and skew deviation (4/7). Only two patients have not developed non-ocular cerebellar eye signs, after 5 and 8 years from diplopia onset, respectively; the other five patients had gait ataxia, which could be mild. The patients were successfully treated with prisms (7/7), botulinum toxin injections (1/7), and strabismus surgery (1/7).     

Adult Medial Orbital Wall Trapdoor Fracture with Missing Medial Rectus Muscle

We report the case of a 28-year-old man presenting with a medial orbital wall trapdoor fracture with a missing medial rectus muscle. We believe this to be the first case report of an adult medial orbital wall trapdoor fracture. Trapdoor fractures most commonly occur in the pediatric population, and those involving the medial orbital wall generally occur in areas with less developed ethmoid air cells. Since the present case followed neither pattern, a different injury mechanism was considered. The ethmoid air cells in this case were well developed, which may have played an important role in the pathogenesis of this adult medial orbital wall trapdoor fracture. Based on our findings, we propose a possible mechanism for a medial orbital wall trapdoor fracture in an adult. The cellular frames enable the medial bone to shift just minimally, regardless of the high orbital pressure during a blow. The excess volume of the orbital content escapes into the cells through narrow cracks; therefore, after a blow, it cannot move back completely into the orbit. Consequently, it pushes the shifted bone towards the orbit, becoming trapped in a manner similar to that of a check-valve mechanism.     

Lateral rectus resection versus medial rectus re-recession for residual esotropia: early results of a randomized clinical trial

PURPOSE: To compare lateral rectus muscle resection with medial rectus muscle re-recession for patients with residual esotropia. METHODS: This randomized controlled clinical trial included 25 patients (mean age, 18.8 +/- 8.7 years) with residual esotropia who were candidates for reoperation. They were randomly assigned into two groups: re-recession group (n = 12), in which the medial rectus muscle was recessed again, and the resection group (n = 13), in which lateral rectus muscle resection was performed. Postoperative deviation < or =10 prism dioptres was considered to be treatment success. RESULTS: The success rate of the re-recession group and the resection group was 67% and 54%, respectively; this difference was not statistically significant. Each 1 mm of medial rectus re-recession and lateral rectus resection corrected 7.5 +/- 1.2 and 2.5 +/- 0.5 prism dioptres of residual esotropia, respectively. In 50% of the re-recession group, mild medial rectus muscle underaction occurred; however, only 16.5% developed an increase in the near point of convergence. Major intraoperative and postoperative complications, including overcorrection and slippage or a lost muscle, did not occur in any of the patients. CONCLUSIONS: Medial rectus muscle re-recession can be a substitute for lateral rectus muscle resection in patients with residual esotropia. The resultant underaction of the medial rectus muscle after re-recession is relatively mild and causes no major problems.     

眶下壁骨折后下直肌麻痹的手术治疗

目的 探讨眶壁骨折后,或眶壁骨折修复手术后发生单独的下直肌麻痹斜视患者的诊断和最佳手术治疗方案.方法 回颐分析诊治的8例下直肌麻痹斜视患者,均有眶壁骨折或眶壁骨折修复手术病史,6例患者正前方垂直斜度小于20△,下方斜度显著,行下直肌缩短加强手术,缩短量从3.5mm到6mm;2例患者正前方垂直斜度大于20△,上转、外转、下转时垂直斜度均较显著,行下直肌缩短联合同侧上直肌后徙手术.手术采用术中调整缝线的方法.结果 5例患者术后正前方正位,复视和代偿头位消失,远期随访眼位维持稳定,2例患者正前方过矫2△,远期随访正前方正位,复视和代偿头位消失.1例患者正前方欠矫4△,复视消失,头位改善.所有8例患者正前方和下方阅读距离视野复视消失.结论 下直肌缩短加强手术对于眶壁骨折后下直肌麻痹斜视患者消除复视,代偿头位是有效的,如果正前方斜度大,并且斜视累及上方视野,可行下直肌缩短联合同侧上直肌后徙手术,可有效增大双眼单视野.

Abstract：

Objective To study the diagnosis and surgical management of isolated inferior rectus paralysis following orbital trauma or caused by contusion at the time of surgical repair of a blow out orbital fracture.Methods In 8 patients with isolated inferior rectus paralysis,all of which had orbital fracture and 7 of them had history of surgical repair for orbital fracture,3.5mm～6mm resection of the paralyzed inferior rectus was done in 6 patients whose vertical deviation was less than 20△ in primary position;resection of inferior rectus combined with ipsilateral recession of superior rectus was done in other 2 patients whose vertical deviation was over 20△.Adjustable suture technique was used during surgery.The patients were followed up for more than 6 months.Results Postoperatively,5 patients were orthophoria without diplopia or abnormal head position,2 patients were 2△ over correction in primary position which became orthophoria during follow up,I patient was 4△ less correction with no diplopia and improved head position.Diplopia in primary and downward gaze position was disappeared in all the patients.Conclusions Resection of paralyzed inferior rectus is effective to correct vertical deviation both in primary and in downward gaze position for isolated inferior rectus paralysis.When the deviation is most pronounced in both downward and upward gaze position and the deviation in primary position is over 20△ resection and recession is effective to increase single binocular vision.     

Case Report and Literature Review of Inferior Rectus Muscle Aplasia in 16 Japanese Patients

Purpose: To describe clinical features of inferior rectus muscle aplasia in Japanese patients and to gain insight into its pathogenesis. Methods: Case presentation and literature review of 16 Japanese patients with inferior rectus muscle aplasia. Results: The age at presentation of 16 patients (9 females, 4 males, and 3 with unknown gender) varied from 7 months to 73 years (mean, 21.8 years). The inferior rectus muscle was absent on the right side in 10 patients, on the left side in 4 patients, and on both sides in 2 patients. Structural anomalies of the eye globe, such as microphthalmos, microcornea, and coloboma of varying degrees, were present on the ipsilateral side of the inferior rectus muscle aplasia in 4 patients and on the contralateral side in 1 patient. As surgical findings, anomalous inferiorly located insertion of the medial rectus muscle was discovered in 5 patients: 1 patient in association with microcornea and iris coloboma. Frequent surgical procedures were recession or tenotomy of the superior rectus muscle, combined with downward transposition of the entire or partial tendons of the medial rectus and lateral rectus muscle to the medial and lateral end, respectively, of the putative inferior rectus muscle insertion. Conclusions: The association of coloboma with inferior rectus muscle aplasia suggests that abnormal optic fissure closure during embryogenesis might underlie the muscle aplasia.     

Recession–resection combined with intraoperative botulinum toxin A chemodenervation for exotropia following subtotal ruptured of medial rectus muscle

Background Ruptured extraocular muscle loses its function and shows severe restriction of eye movement even after muscle-to-muscle anastomosis or muscle transposition surgery. We present the case of a patient who developed a large exotropia after near-total rupture of the medial rectus muscle following a blowout fracture.Methods Case report.Results A 12-year-old girl presented at our clinic with 45 prism diopters’ exotropia after a blunt trauma. A forced duction test was unrestricted, and orbital computed tomography showed a medial orbital wall fracture and an impinged medial rectus muscle. Upon surgical exploration, an almost totally ruptured medial rectus muscle was found. The median margin of the ruptured muscle was 6.0 mm from its insertion, and the distal end that we could examine was 15.0 mm from the limbus. Recession–resection surgery combined with intraoperative botulinum toxin A chemodenervation to the ipsilateral lateral rectus muscle achieved a good primary alignment and binocular single visual field, even at a 9-month follow-up.Conclusions Recession–resection surgery augmented by intraoperative botulinum toxin A chemodenervation to the ipsilateral rectus muscle appears to be highly effective in the treatment of a large exotropia produced by subtotal rectus muscle rupture following orbital wall fracture, with a lower risk of anterior segment ischemia.     

内直肌超常量后徙治疗共同性内斜视疗效观察

目的观察内直肌超常量后徙治疗共同性内斜的手术效果。方法对不同类型的共同性内斜均采用超常量内直肌后徙，根据斜视度不同，单眼或双眼内直肌后徙6-9mm。结果术后眼位矫正良好，无明显内转及辐辏受限现象，术后经视功能训练，有部分患者恢复Ⅲ级视功能。结论内直肌超常量后徙是治疗共同性内斜的一种安全可行的办法。     

A rare case of Moebius sequence

We report a case of an 18-year-old male who presented with watering and inability to close the left eye completely since 6 months and inability to move both eyes outward and to close the mouth since childhood. Ocular, facial, and systemic examination revealed that the patient had bilateral complete lateral rectus and bilateral incomplete medial rectus palsy, left-sided facial nerve paralysis, thickening of lower lip and inability to close the mouth, along with other common musculoskeletal abnormalities. This is a typical presentation of Moebius syndrome which is a very rare congenital neurological disorder characterized by bilateral facial and abducens nerve paralysis. This patient had bilateral incomplete medial rectus palsy which is suggestive of the presence of horizontal gaze palsy or occulomotor nerve involvement as a component of Moebius sequence.     

上直肌转位联合内直肌后徙术在治疗外展神经全麻痹中的应用

目的探讨上直肌颞侧转位联合内直肌后徙术治疗外展神经全麻痹内斜视的疗效。方法回顾性病例研究。分析11例就诊于天津市眼科医院或徐州市第一人民医院眼科的外展神经全麻痹患者术前、术后末次随访时的斜视度、代偿头位角度、受累眼外转和内转受限的程度。11例患者均行上直肌颞侧转位手术,其中8例同期联合内直肌后徙术。内直肌后徙手术采用术中调整缝线方法,根据术中眼位,确定内直肌后徙的位置。平均随访6个月以上。采用配对t检验比较术前、术后第一眼位内斜度、代偿头位角度、外转及内转受限的程度。结果10例患者一次手术矫正至正位,患者代偿头位和复视消失,患者均对手术结果满意。1例患者上直肌全肌腹转位联合内直肌后徙术后欠矫,残余代偿头位及复视,3个月后行下直肌颞侧转位术,头位及复视消除。11例患者内斜视从术前31.2°±13.7°矫正至术后3.4°±1.7°（t=7.28,P<0.01）;代偿头位从术前26.1°±7.7°矫正至术后0.9°±3.0°（t=10.75,P<0.01）;外转受限从术前-4.8±0.9矫正至术后-2.0±0.9（t=8.84,P<0.01）;内转受限从术前-0.2±0.4矫正至术后-1.0±0.4（t=4.62,P<0.05）。本组患者术后均未出现垂直或旋转复视。结论上直肌转位联合内直肌后徙术,可以同期进行。单独上直肌转位不会带来新的垂直斜视和旋转斜视。上直肌转位术联合调整缝线下的内直肌后徙术是治疗外展神经全麻痹的有效方法之一。     

Traumatic dislocation of the globe into the maxillary sinus associated with extraocular muscle injury

Background The mechanism of complete dislocation of an intact globe into the maxillary sinus after an extensive blowout fracture has not been clearly documented. Methods A 68-year-old man sustained orbital wall fractures of the right orbit, resulting in dislocation of the globe into the maxillary sinus, associated with the transection of the medial and inferior rectus (MR and IR). We repaired the orbital wall fractures using Medpor barrier sheets, and repositioned the dislocated globe. And then, the distal section of the IR was sutured at its proximal end and the severed distal section of the MR was sutured at the fascial sheath and Tenon’s capsule. Results After repositioning, the eyeball was intact without signs of perforation, but the patient’s visual acuity was impaired, exhibiting a loss of light perception, coupled with a noted pallor of the optic disc. The patient’s eye movement was severely restricted, but supraduction and abduction proved possible. Conclusions This case demonstrates that the globe can be dislocated into the maxillary sinus following orbital wall fracture associated with extraocular muscle injury, and provides a clue into the mechanism underlying dislocation of the globe into the maxillary sinus.     

Muscle belly union associated with simultaneous medial rectus recession for treatment of myopic myopathy: results in 33 eyes

Purpose

To describe the results achieved using muscle belly union associated with the recession of the ipsilateral medial rectus muscle to treat myopic myopathy and restore the normal anatomical relationship of superior and lateral rectus (LR).

Methods

A retrospective, nonrandomized study performed on 33 eyes of 26 patients who underwent muscle belly union between January 2004 and October 2012. We preoperatively and postoperatively recorded: best-corrected visual acuity; refraction; intraocular pressure; complete orthoptic assessment, including the angle of deviation and maximal abduction measured using the Goldmann perimeter. Pictures of the eyes in all gaze directions were taken before and after the surgical treatment. Anatomical relationships between muscle cone and eye globe were preoperatively analyzed using magnetic resonance imaging (MRI). Surgical complications were noted.

Results

The follow-up period was 6 months. Preoperative mean BVCA was 0.97±0.96 logMAR (ranging from 0.1 to 3 logMAR) and no changes were detected during postoperative controls. Preoperative mean hypotropia and esotropia were, respectively, 10.2±3.9 prism diopters (PD) and 46.2±15.5 PD. Postoperative mean hypotropia was 2.48±2.00 PD (P<0.001) and mean esotropia was 7.36±9.09 PD (P<0.001). A statistical incrementation of mean maximal abduction (P<0.001) was also noticed.

Conclusions

Muscle belly union—coupled with the recession of the ipsilateral medial rectus muscle when considered convenient—is the elective surgical technique in myopic myopathy, when a downward displacement of LR muscle is shown on MRI with coronal sections.     

Treatment of a complication after surgical removal of an aneurysmal cyst of the ethmoid

INTRODUCTION: An aneurysmal cyst (AC) is a rare benign bony tumor with a possible aggressive extension. We present a complication following the surgical ablation of an ethmoidal AC. CLINICAL HISTORY AND FINDINGS: A 40-year-old man with a left ethmoidal AC extending to the orbital roof underwent 2 surgeries. After the second one involving a neuro-surgical approach, a bilateral palsy of the superior oblique muscles (SO) appeared. The diplopia did not improve following a bilateral asymmetrical recession of the inferior recti muscles done elsewhere. There was an excyclotorsion up to 20 degrees in down gaze and a vertical deviation of 10 degrees in primary position. THERAPY AND OUTCOME: We performed a bilateral tucking of the anterior SO fibres with, on the left, an advancement of the inferior rectus and a resection of the medial rectus muscles. Two weeks after surgery the absence of cyclotorsional deviation allowed a binocular vision. CONCLUSION: The double vision due to the excyclotorsion, which was the main complaint, could be alleviated by an anterior strengthening of the SO. A precise measurement of the cyclotorsion is required for the surgical procedure.     

内直肌超常量后徙和继发性外斜视的关系

目的 研究内直肌超常量后徙与继发性外斜视的关系.方法 对2003～2009年住院的43例内斜术后继发外斜的病人进行回顾性分析,分别观察常规量内直肌后徙(内直肌附着点距角膜缘的距离≤11.5mm)和超常量内直肌后徙(内直肌附着点距角膜缘的距离＞11.5mm)与眼球运动和继发性外斜视的关系.结果 13例眼球内转受限,其中发现内直肌常规量后徙33例中只有3例眼球内转受限,超常量内直肌后徙的10例患者均有眼球运动受限,经x2检验,P＜0.05;对10例内直肌超常量后徙的患者6例行内直肌前徙,术后眼球运动无受限,眼位正位;而经同等手术量内直肌缩短的4例患者中只有1例术后眼球内转轻度受限,但术后眼位正位.另外3例患者术后眼球运动仍明显受限,残留外斜视.39例术中内直肌附着点距角膜缘的距离≤11.5mm,35例(89.7%)术后正位,4例内直肌附着点距角膜缘的距离＞11.5mm,术后只有1例(25%)正位.结论 (1)内直肌超常量后徙可造成术后眼球运动受限,从而导致继发性外斜视.(2)单纯内直肌缩短术后斜视度不稳定,外直肌后徙联合后徙的内直肌前徙是治疗继发性外斜视的有效方式.     

硅胶带部分直肌肌腹联结术治疗重度高度近视眼固定性内下斜视的疗效

目的：观察硅胶带部分直肌肌腹联结术同时联合内直肌后退术治疗重度高度近视眼固定性内下斜视 （MSF）的安全性和有效性。方法：回顾性系列病例研究。收集2017年3月至2021年4月在空军军医 大学西京医院眼科行单眼或双眼硅胶带联结上直肌颞侧1/2 和外直肌上1/2 部分肌腹且同时联合内 直肌后退术的重度MSF患者8例（12眼）。年龄30~80（53.8±15.6）岁；等效球镜度为-26.00~-13.50 （-20.41±4.12）D；B超测量眼轴长度26.34~35.30（30.16±2.51）mm。术后随访时间6个月~3年。对 比分析患者手术前后内斜视、下斜视、眼球外转和上转受限程度改变，以及眼球脱位角度(AGD)的 改变。采用配对样本t检验以及Wilcoxon符号秩和检验进行数据处理。结果：8例（12眼）患者内斜度 由术前（+101±13）PD减为术后的（+3±5）PD，下斜视度由术前30（25，34）PD减为术后的0（0，0） PD，外转受限由术前的-5（-5，-5）降为术后的-2（-3，-1），上转受限由术前-5（-5，-5）降 为术后的-2（-2，-2），差异均有统计学意义（均P<0.01）。手术前后影像学资料完整的5例（8眼）， AGD由术前的（185±28）°减为术后（121±19）°，差异有统计学意义（t=8.96，P<0.001）。术前有代 偿头位患者3例，术后头位均明显改善或消失。术后有3例患者术眼有异物感，3周后消失。结论： 硅胶带上直肌和外直肌部分肌腹联结术联合内直肌后退术治疗重度MSF安全有效，可以显著矫正重 度内下斜视和改善眼球运动。     

Botulinum toxin as adjunct for refractory compressive optic neuropathy in Graves' disease

An euthyroid patient was referred for compressive optic neuropathy in Graves' disease. Under prednisone therapy the right and left visual acuities were 1.0 and 0.4, with a profound decrease in color vision on the left. Bilateral anterior orbital decompressions were performed. When prednisone was withdrawn postoperatively, the visual acuity of the right eye dropped to 0.32 with bilateral complete failure on the Ishihara color test. A biopsy of the inferior oblique muscle of the left eye confirmed Graves' disease and additional transantral decompression of the right orbital apex was performed. Under intravenous methylprednisolone therapy, the visual acuity dropped postoperatively to 0.2 and 0.4, respectively. 15 U botulinum toxin were given by retrobulbar injection between the inferior and lateral rectus muscles. Four days later the patient called and said that the visual acuity in the right eye had improved tremendously. Two weeks after the injection the visual acuity was 0.7 in both eyes, although prednisone had been reduced to 20 mg by that time. The convergent strabismus had increased but the already severely restricted motility of the right eye had been little affected by the retrobulbar injection, and adduction not at all. Orbital CT-scan showed thinning of the inferior and lateral rectus muscles, but not of the medial rectus.     

Recovery of a Disinserted Medial Rectus Muscle after Pterygium Surgery

Purpose: To report a case of recovery of a medial rectus which was accidentally disinserted after surgical treatment of a recurrent pterygium.

Method: Report of a case of inadvertent medial rectus disinsertion after pterygium excision at a secondary care hospital which was referred to a tertiary care hospital in Northern Thailand.

Result: A 40-year-old healthy woman was referred by a general ophthalmologist at a secondary care center to our hospital. She had undergone recurrent pterygium excision with amniotic membrane transplantation on the nasal side of her right eye. Immediately after the last operation, she complained of horizontal binocular diplopia. On the first postoperative day, the patient could not adduct the eye beyond the primary position. Her measurements in primary position were 45 prism diopters of right exotropia on distant and near. The diagnosis of iatrogenic medial rectus disinsertion was made. Three weeks after pterygium excision, revision surgery was performed; the medial rectus was found and reattached to its normal insertion site. On the first postoperative day, the patient referred a small vertical diplopia in the primary position. Orthoptic examination five months post-operatively demonstrated orthotropia and absence of diplopia in primary position, but minimal horizontal diplopia in right gaze.

Conclusions: Accidental rectus muscle disinsertion after pterygium excision surgery is a serious but rare postoperative complication of pterygium surgery. Great care should be taken intraoperatively to avoid this complication. Reattachment of the disinserted medial rectus will produce a satisfactory resolution of the problem.     

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

PURPOSE: To report retrieval of a medial rectus muscle completely detached from the globe and lost in the orbital tissue in four eyes. METHOD: A lost medial rectus muscle was retrieved in four eyes of four patients with either a transcutaneous medial orbitotomy approach or a transnasal endoscopic ethmoid sinus approach. RESULTS: The lost medial rectus muscle was successfully retrieved in all four patients. One patient lost the medial rectus muscle secondary to trauma, and the other three cases resulted from complications of strabismus surgery. The mean preoperative angle of exotropia was 44 prism diopters. The endoscopic approach was attempted in three patients, and the medial rectus muscle was successfully found in two of these patients. In one case in which the endoscopic approach was used, an image guidance system was used to aid in finding the lost medial rectus muscle. The endoscopic approach was abandoned in one case in which the medial rectus muscle could not be identified after extensive searching, but the muscle was subsequently found by means of the transcutaneous medial orbitotomy approach. A transcutaneous medial orbitotomy alone was used to find the lost medial rectus muscle in one of the cases. The postoperative ocular deviation for primary position at distance fixation was a mean of 24 prism diopters of exotropia. With one additional operation in two patients, the mean ocular deviation was less than 12 prism diopters. CONCLUSION: We successfully retrieved a lost medial rectus muscle in four patients with the use of nontraditional strabismus surgical techniques. We effectively combined techniques taken from both ophthalmology and otorhinolaryngology to help solve this difficult problem.     

Vertical rectus muscles transposition in large exotropia with medial rectus muscle transection following endoscopic sinus surgery

PURPOSE: To evaluate the effect of transposition procedures on the vertical rectus muscle (VRM) in the patients who underwent a medial rectus muscle (MR) transection after endoscopic sinus surgery (ESS). METHODS: In 4 patients with exotropia (XT) and a lack of adduction after ESS, orbital CT or MRI revealed a complete transection of the midportion of the MR. Full-tendon VRM transposition was performed within 3 months after injury (early surgery) in 2 patients with 40 delta XT. Two patients with 70 delta and 85 delta XT underwent an X-type augmented Hümmelsheim procedure, which involved pulling each half-tendon and crossing it through the undersurface of the severed MR to the other end of the MR insertion, concurrently with an ipsilateral lateral rectus (LR) recession 11 months and 36 months after ESS, respectively. The adduction deficits were divided into -1 through to -8. The patients were followed up for more than than 1.5 years. RESULTS: Postoperatively, 3 patients showed orthophoria and no diplopia in the primary position. The adduction deficits improved to -3.5 or -4. One patient who underwent an X-type augmented Hümmelsheim procedure showed a residual XT of 25 delta. CONCLUSIONS: VRM transposition is effective in correcting a large XT secondary to a MR transection after ESS. When a longstanding large-angle XT with severe contracture of the ipsilateral LR and massive scarring of the adjacent tissues is present, the X-type augmented Hümmelsheim procedure coupled with an ipsilateral LR recession had an augmenting effect.