Inferior rectus rupture following blowout fracture

Background: Extra-ocular muscle rupture is uncommon, usually seen after penetrating trauma or surgery. It is a very rare cause of diplopia following blunt orbital trauma.
Methods: A patient who presented with no inferior rectus function after blunt orbital trauma is described.
Results: Computed tomography (CT) scans demonstrated a large orbital floor fracture and suggested that the inferior rectus muscle was ruptured. This was confirmed at operation. Despite anatomical repair, there was no postoperative improvement in ocular motility.
Conclusions: Traumatic rupture of the inferior rectus is rare. Forced duction and force generation testing and CT are important in diagnosing ocular motility defects following orbital trauma.     

Orbital imaging demonstrates occult blow out fracture in complex strabismus.

BACKGROUND: While strabismologists are familiar with diagnostic evaluation of suspected blow out fractures, unsuspected blow out fractures may further complicate difficult cases of strabismus not clinically supposed to be related to orbital trauma. METHODS: According to a prospective protocol, we studied five adults presenting with diplopia, and one with convergence-related asthenopia. No patient recalled or had any clinical suspicion of orbital fracture at initial evaluation. Surface coil magnetic resonance imaging of the orbits was performed at 312 microm resolution, slice thickness 2 mm. Quasicoronal images in central gaze were supplemented with eccentric gaze positions, and sagittal and axial images as indicated. RESULTS: Five patients had incomitant hypertropia, and one had abducens paralysis. Magnetic resonance imaging disclosed previously unsuspected blow out fractures in all six patients. Three patients had medial wall fracture, one bilaterally. Two patients had inferior wall fractures, and one inferomedial. Although only one patient had an extraocular muscle displaced into a sinus, all had evidence of orbital connective tissue distortion in the region of the rectus extraocular muscle pulleys influencing muscle paths. These effects altered the presentations of more familiar pathologies such as superior oblique palsy. After learning of the MRI findings, most patients then recalled orbital trauma from as early as childhood. CONCLUSION: Unsuspected blow out fractures occur and may confound the usual findings in complex strabismus. High-resolution orbital imaging can detect blow out fractures and clarify the pathophysiology, enabling appropriate surgical management.     

Complete inferior rectus muscle transection secondary to orbital blowout fracture

Complete extraocular muscle transection is uncommon in the setting of blunt trauma. We report a case of a 53-year-old male that developed diplopia after hitting his face directly on a concrete slab after a fall. On examination, he had a right hypertropia with a complete infraduction deficit. A CT scan of the face showed an orbital floor blowout fracture with complete inferior rectus transection. On surgical exploration, the distal and proximal ends of the muscle were identified and sutured together, and the floor fracture was repaired. At his post-operative visits, the patient had a persistent infraduction deficit, but subjectively had improved diplopia.     

爆裂性眼眶骨折病例分析及诊断治疗体会

本文报告６例爆裂性眼眶骨折。病人均有眼前部钝挫伤史、眼球内陷、眼球运动障碍和复视。在Ｘ线和ＣＴ检查方法中，以眼眶Ｘ线断层摄片和ＣＴ冠状扫描的诊断率较高。对３例病人进行了手术治疗，术中应用医用钛合金板封闭眶下壁骨折孔收到了令人满意的效果。     

The Management of Traumatic Isolated Inferior Rectus Rupture

Traumatic inferior rectus rupture is a rare cause of diplopia following blunt trauma in the absence of blowout fracture. We report the case of a heavy goods vehicle driver, aged 42 years, with isolated rupture of the inferior rectus following blunt ocular trauma. The technique of repair, using a Hummelsheim-type procedure, is described. Good alignment was achieved at 1 month following surgery, with an excellent field of binocular vision. Other than vertical diplopia on extreme upgaze, the patient was asymptomatic and remained so 15 months following surgery. He was able to continue his job without any significant visual concerns. The surgical outcome was better than that described in previous reports of inferior rectus rupture. We feel that a Hummelsheim-type procedure is a useful option in the management of inferior rectus rupture.     

Medial rectus muscle incarceration in pediatric medial orbital wall trapdoor fractures

PURPOSE: We describe two cases of orbital trapdoor fractures with medial rectus muscle incarceration. METHODS: Small interventional case series. RESULTS: This is a retrospective university based report of two healthy males (11 and 14 years old) who developed diplopia following blunt orbital trauma. Both patients had decreased horizontal ocular motility of the involved eye with minimal additional evidence of trauma. Computed tomography (CT) demonstrated no significant bony displacement; however, the left medial rectus muscle was located within the ethmoid sinus in the first and had an abnormal size and shape in the second case. In both cases, during urgent surgical repair, the incarcerated medial rectus muscle was gently released from linear non-displaced medial wall fractures and ocular motility normalized postoperatively. CONCLUSIONS: In pediatric patients sustaining blunt orbital trauma, medial rectus incarceration should be considered and managed accordingly.     

The management of traumatic isolated inferior rectus rupture

Traumatic inferior rectus rupture is a rare cause of diplopia following blunt trauma in the absence of blowout fracture. We report the case of a heavy goods vehicle driver, aged 42 years, with isolated rupture of the inferior rectus following blunt ocular trauma. The technique of repair, using a Hummelsheim-type procedure, is described. Good alignment was achieved at 1 month following surgery, with an excellent field of binocular vision. Other than vertical diplopia on extreme upgaze, the patient was asymptomatic and remained so 15 months following surgery. He was able to continue his job without any significant visual concerns. The surgical outcome was better than that described in previous reports of inferior rectus rupture. We feel that a Hummelsheim-type procedure is a useful option in the management of inferior rectus rupture.     

眼眶爆裂性骨折应用Medpor外科种植体联合医用耳脑胶治疗的研究

目的探讨Medpor外科种植体联合医用耳脑胶治疗眼眶爆裂性骨折的临床应用意义。方法手术治疗眼眶骨折26例（26眼）。术前常规CT检查,并检查眼球内陷、复视及眼球运动情况,评价术后治疗效果。结果术后25例眼球内陷得到明显改善,术后6个月,21例复视完全治愈,3例复视症状好转,所有病例无Medpor植入术后不良反应。结论眼眶爆裂性骨折应早期即做出准确诊断,如伴明显复视与眼球内陷,应该早期手术治疗,术中应用Medpor联合医用耳脑胶植入骨折缺损处,术后早期行眼球运动训练,可取得良好疗效。     

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.     

Pupillary capture of implantable contact lens after blunt trauma

A 33-year-old woman visited our clinic with blurry vision and periorbital swelling after experiencing blunt trauma to left eye. Ten months earlier, she had implantable contact lens (ICL) implantation in the left eye. Biomicroscopic examination showed that that 1 footplate of the ICL was entrapped in the pupillary aperture at the 7 o'clock position and the ICL was placed vertically. The patient had limited ocular movement in lateral gaze, and the computed tomography showed a medial orbital wall fracture. Pupillary capture of the ICL was surgically corrected with an iris manipulator under topical anesthesia. After the ICL was repositioned, the patient's uncorrected visual acuity was restored to 20/32, as before the injury. Pupillary capture of the ICL may occur after blunt ocular trauma.     

Superior oblique tendon expansion in the management of superior oblique dysfunction.

Traditional superior oblique weakening procedures may be unpredictable and lead to superior oblique underaction. The use of 240 retinal band as a spacer to lengthen the superior oblique tendon has been proposed as a more controlled approach than superior oblique tenotomy and related procedures. The use of this technique is reported in a patient with diplopia following an orbital floor blow out fracture, and in a child with Brown's superior oblique tendon sheath syndrome.     

眼眶爆裂性骨折患者的手术疗效分析

目的 探讨眼眶爆裂性骨折患者的手术治疗效果。方法 回顾性总结1994－1999年经不同入路开眶术治疗56例眼眶爆裂性骨折患者的手术疗效。结果 结膜或下睑睫毛下皮肤入路开眶术52例,眉弓皮肤入路2例,结膜－口腔联合入路开眶术2例,术前平均眼球内陷3.4mm,术后平均内陷1.2mm,术后复视症状完全消失18例,部分消失25例,无变化9例。术后出现眶下神经麻痹4例,置入硅胶移位1例。结论 手术是治疗眼眶爆裂性骨折的较好方法,手术疗效与手术时机及填充物体积相关,经结或下睑睫毛下皮肤入路开眶术具有操作简单,暴露充分,术后无可见瘢;术中充分松解嵌顿的眼外肌防止再粘连是消除复视的关键。     

眼眶壁爆裂性骨折56例的修复治疗

目的 探讨眼眶壁爆裂性骨折手术治疗的方法和效果。方法 眼眶壁爆裂性骨折56例,采用眼眶骨膜下垫压填充术修复治疗,并总结分析其疗效。结果 47例有眼球运动障碍的患者中,42例恢复正常,5例仍有不同程度的复视。19例并发眼球内陷者中,14例得到充分矫正,5例较术前有明显改善。随访中未发现垫入物排斥现象。结论 对于伴有复视、眼球运动障碍的眼眶壁爆裂性骨折应尽早手术治疗。当双眼突出度相差大于3mm,即应手术矫正,且当眶脂肪萎缩时应增加垫压物,手术关键应在骨膜下进行,以避免并发症。骨水泥和Medpor使用起来安全,效果肯定。     

Post-traumatic orbital emphysema: a case report

Orbital emphysema is often associated with orbital fracture or communication with paranasal sinuses. It is usually moderate but could be the cause of optic neuropathy or central retinal artery occlusion. We report a case of massive orbital emphysema with ocular hypertony and prethrombosis of the central retinal artery. Emergency surgical decompression performed by an ophthalmologist and an otorhinolaryngologist provided complete and prompt relief. The authors emphasize the importance of preventing nose blowing after orbital trauma or surgery.     

眶壁骨折修复术后斜视和复视的手术治疗

目的 观察眶壁修复术后斜视和复视眼外肌手术矫正效果.方法 对14例眼眶爆裂性骨折修复手术6月后仍有斜视和复视的患者,采取二期眼外肌手术治疗.结果 4例为限制性斜视,二期手术探查,松解肌肉、解除限制因素,后徙受累肌或/和缩短拮抗肌后,前方及前下方视野内复视消除;10例为非限制性眼肌功能不足所致斜视,二期手术缩短受累肌/和后徙拮抗肌后,9例复视明显好转,前方及前下方视野内垂直及水平斜视度分别小于10△和15△.1例仍有眼位偏斜,需佩戴三棱镜矫正复视.结论 正确分析爆裂性眼眶骨折修复术后斜视和复视的原因,采取相应的术式,可获得较好的治疗效果.     

Bone from an orbital floor fracture causing an intraocular foreign body

PURPOSE: To describe the ophthalmoscopic and radiologic findings of a patient who sustained blunt orbital trauma. A piece of bone from the fractured orbital wall caused an intraocular foreign body. DESIGN: Case report. METHODS: An 18-year-old man underwent full ophthalmoscopic examination 1 week after sustaining blunt ocular trauma to the right eye while playing basketball. B-scan ultrasonography and computed tomography of the orbits were also performed. RESULTS: Visual acuity, intraocular pressure, and anterior segment examination were normal. Funduscopic examination revealed a fragment of bone that had penetrated the sclera, choroid, and retina. A hole in the sclera was visible. No treatment was performed. Three months later, the patient had no ocular complaints or complications as a result of this injury. CONCLUSION: Bone from a patient's orbit may cause an intraocular foreign body that may be followed conservatively in certain circumstances.     

Surgical treatment of diplopia caused by fractures of the orbital floor

Oculomotor disturbance resulting from orbital floor fractures have different etiologic factors, sometimes damage of one of the ocular motor nerves, caused by direct injury to the orbit; this damage occurs also to one or more of the extrinsic ocular muscles, especially the obliques; frequently, the diplopia is caused by prolapsed orbital tissues with or without muscle entrapment or by a muscle fibrosis; when the diplopia appears after orbital floor reconstruction there is often a palsy of the inferior rectus muscle in front of silicone implant or bone graft on the orbital floor. In oculomotor disturbance after orbital floor fracture, the first stage will be to recognize the mechanism of the diplopia by a clinical examination, motility in the nine positions, Hess Charts, binocular vision and field, forced duction, radiography and sometimes coronal computed tomography which also allow visualization of soft tissues densities, including all extraocular muscles. If there is an indication of orbital surgery, it will be done always in first; oculomotor surgery will be done if necessary at the second stage, if there is a permanent diplopia without evolution during six months. The purpose of the treatment is to obtain orthophoria in primary position and in down gaze. A series of cases of fracture of the orbital floor with resulting diplopia are described. The method, the time, and the indications of orbital or oculomotor surgery are discussed according the variety of cases.     

Comparative findings in childhood‐onset versus adult‐onset optic disc pit maculopathy

Purpose: To compare the clinical characteristics of eyes with childhood‐onset to those with adult‐onset optic disc pit maculopathy. Methods: Twenty‐seven eyes of 25 patients with optic disc pit maculopathy were reviewed. The clinical characteristics, clinical history including a history of blunt trauma, ophthalmoscopic evaluations and intraoperative findings in the childhood‐onset (age <15 years, four eyes of four patients) cases were compared with those in the adult‐onset (≥15 years, 23 eyes of 21 patients) cases of optic disc pit maculopathy. The strength of the vitreous adhesions was graded by what was required to create a posterior vitreous detachment (PVD); grade 1 = with vitreous cutter, grade 2 = by microhook or forceps and grade 3 = by forceps with removal of remnants of Cloquet’s canal. Results: The incidence of visual impairments following blunt trauma was significantly higher in childhood‐onset (three of four eyes) than that of adult‐onset (0 of 23 eyes, p = 0.0014). Vitreous surgery with creation of a PVD was performed in the four childhood‐onset eyes and 18 adult‐onset eyes after an absence of a spontaneous resolution. The grade of the vitreous adhesions was significantly higher in childhood‐onset than in adult‐onset eyes (p = 0.0096). Conclusions: An ocular trauma may provide an opportunity to detect optic disc pits. However, childhood‐onset optic disc pit maculopathy was noted most commonly following blunt ocular trauma in eyes with a strong vitreous adhesion to the optic disc margin.     

A Case of Acquired Brown Syndrome after Surgical Repair of a Medial Orbital Wall Fracture

A case of acquired Brown syndrome caused by surgical repair of medial orbital wall fracture is reported in the present paper. A 23-year-old man presented at the hospital with right periorbital trauma. Although the patient did not complain of any diplopia, the imaging study revealed a blow-out fracture of the medial orbital wall. Surgical repair with a calvarial bone autograft was performed at the department of plastic surgery. The patient was referred to the ophthalmologic department due to diplopia that newly developed after surgery. The prism cover test at distant fixation showed hypotropia of the right eye, which was 4 prism diopters (PD) in primary gaze, 20 PD in left gaze, while orthophoric in right gaze. Eye movement of the right eye was markedly limited on elevation in adduction with normal elevation in abduction with intorsion in the right eye present. Forced duction test of the right eye showed restricted elevation in adduction. Computerized tomography scan of the orbits showed the right superior oblique muscle was entrapped between the autografted bone fragment and posterior margin of the fracture. When repairing medial orbital wall fracture that causes Brown syndrome, surgeons should always be careful of entrapment of the superior oblique muscle if the implant is inserted without identifying the superior and posterior margin of the orbital fracture site.     

眶底爆裂性骨折致眼球运动障碍的上颌窦手术进路治疗

目的 观察上颌窦进路手术治疗眶下壁爆裂性骨折所致眼球运动障碍的临床效果.方法 对12例12只眼眶下壁爆裂性骨折伴复视及眼球运动障碍者,眼眶CT显示:眼外肌眶内软组织嵌顿于眶下壁骨折区,伤后观察2周,复视及眼球运动障碍无明显改善,采用上颌窦进路行眶下壁骨折复位术.术后随诊3～6个月.结果 12例患者术中开放上颌窦后可清晰观察到眶下壁骨折区各个边界及眶内软组织嵌顿情况,术中均将嵌顿在眶底骨折处的眶内组织推送回眶内,眶底骨折复位.术后12例患者中10例各方向眼球运动不受限,无复视,2例正前方及下方无复视,向上方运动轻度受限.术后1例并发上颌窦炎,经上颌窦冲洗治愈.结论 上颌窦进路早期治疗单纯眶下壁爆裂性骨折所致眼球运动障碍是有效的.