Clinico-Radiologic Findings of Entrapped Inferior Oblique Muscle in a Fracture of the Orbital Floor

A 51-year old man presented with vertical and torsional diplopia after reduction of a blowout fracture at another hospital one year ago. He had no anormalies of head position and 14 prism diopters (PD) right hypertropia (RHT) in the primary position. In upgaze no vertical deviation was found, and hyperdeviation on downgaze was 35PD. Bielschowsky head tilt test showed a negative response. Distinct superior oblique (SO) and inferior rectus (IR) underaction of the right eye was noted but IO overaction was mild on the ocular version test. Double Maddox rod test (DMRT) revealed 10-degree extorsion, but fundus extorsion was minimal in the right eye.Thin-section coronal CT scan showed that there was no fracture line on the anterior orbital floor, but a fracture remained on the posterior orbital floor. Also, the anterior part of the right inferior oblique muscle was vertically reoriented and the medial portion of the inferior oblique muscle was not traced on the coronal CT scan. The patient underwent 14 mm right IO recession and 3 mm right IR resection. One month after the surgery, his vertical and torsional diplopia were eliminated in the primary position.     

Acquired simulated brown syndrome following surgical repair of medial orbital wall fracture

Simulated Brown syndrome is a term applied to a myriad of disorders that cause a Brown syndrome-like motility. We encountered a case of acquired simulated Brown syndrome in a 41-year-old man following surgical repair of fractures of both medial orbital walls. He suffered from diplopia in primary gaze, associated with hypotropia of the affected eye. We performed an ipsilateral recession of the left inferior rectus muscle as a single-stage intraoperative adjustment procedure under topical anesthesia, rather than the direct approach to the superior oblique tendon. Postoperatively, the patient was asymptomatic in all diagnostic gaze positions.     

A Case of Pseudo-Duane's Retraction Syndrome With Old Medial Orbital Wall Fracture

We report a case of pseudo-Duane''s retraction syndrome with entrapment of the medial rectus muscle in an old medial orbital wall fracture presenting identical clinical symptoms as Duane''s retraction syndrome. A 15-year-old boy presented with persistent limited right eye movement since a young age. Examination showed marked limited abduction, mildly limited adduction, and globe retraction accompanied by narrowing of the palpebral fissure during attempted adduction in the right eye. He showed a right esotropia of 16 prism diopters and his head turned slightly to the right. A slight enophthalmos was noted in his right eye. A computed tomography scan demonstrated entrapment of the medial rectus muscle and surrounding tissues in an old medial orbital wall fracture. A forced duction test revealed a marked restriction of abduction in the right eye. A 5 mm recession of the right medial rectus muscle was performed. Postoperatively, the patient''s head turn and esotropia in the primary position were successfully corrected, but there was still some limitations to his ocular movement. The importance of several tests such as the forced duction test and an imaging study should be emphasized in making a diagnosis for limitation of eye movement.     

Extraocular muscle dynamics in diplopia from enophthalmos

The mechanism of diplopia from enophthalmos is not well understood. We describe a 55-year-old man who underwent a left transorbital craniotomy for clipping of a basilar aneurysm. The lateral orbital wall was not reconstructed properly, resulting in 8?mm of left enophthalmos. Months after surgery the patient developed diplopia with ocular excursions, although he remained orthotropic in primary gaze. The left eye was limited in elevation, adduction, and abduction. These findings were confirmed by eye movement recordings, which showed ocular separation increasing with gaze eccentricity. A CT scan demonstrated a defect in the sphenoid and frontal bones, profound enophthalmos, and shortening of the rectus muscles. Slack in the extraocular muscles reduced the force generated by each muscle, causing diplopia with ocular rotation. This case underscores the value of careful orbital wall reconstruction after orbitotomy and suggests a mechanism for diplopia produced by postoperative enophthalmos.     

Spontaneous consecutive Brown syndrome following superior oblique palsy

A 28-year-old female presented with a left trochlear nerve palsy, after indirect head trauma, with no fracture or orbital lesion. She had diplopia, a hypertropia and excyclotropia on right downgaze. Three months later the trochlear palsy had been replaced by Brown's syndrome: a deficit of elevation in adduction, with diplopia, incyclotropia and hypertropia in up-gaze. The Brown syndrome remained the same over a period of 18 months. A 31-year-old male suffered from severe brain contusion with intracerebral haemorrhage and bilateral trochlear nerve palsy. Three years later, he had a bilateral trochlear palsy with bilateral severe Brown's syndrome, with a right hypertropia and 10° to 25° incyclotropia in upgaze and 5° to 10° excyclotropia in downgaze. The field of binocular vision was shifted to left gaze. Orbital CT scan was normal. At surgery, the forced duction test was positive for Brown's syndrome on both sides and the tendon of the superior oblique muscle of the right eye was thickened. The field of binocular vision was centralized after surgery but torsional diplopia in upgaze and downgaze was present as before. Secondary Brown's syndrome after (persisting or vanishing) trochlear nerve palsy without any direct trauma to the superior oblique muscles or the orbit could be caused by a fibrotic reaction of the superior oblique tendon or adjacent structures. This could be due to inactivity or to indirect trauma.     

Longitudinal tear of the inferior rectus muscle in orbital floor fracture

We report a case of longitudinal avulsion of the inferior rectus muscle following orbital floor fracture and describe its clinical presentation, computed tomography (CT) features and management. A 53-year-old man felt vertical diplopia in all gaze immediately after the trauma. Orthoptic assessment showed left over right hypertropia of 20 prism diopters and left exotropia of 10 prism diopters in primary position. The left orbital floor fracture and the prolapse of orbital contents into the maxillary sinus were presented by CT. Exploration of the orbit was performed under general anesthesia. The displaced bone fragment was elevated and repositioned below the slastic implant. Diplopia continued in all directions of gaze, although the impairment of depression was reduced postoperatively. A residual left hypertropia of 10 prism diopters and exotropia of 10 prism diopters was present in primary position 1 month after surgery, though there were no enopthalmos or worsening of hypesthesia. Repeated CT revealed the muscle avulsion of inferior rectus at the lateral portion of the belly. The avulsion of a small segment of the inferior rectus and its herniation into maxillary sinus in more posterior views was detected by review of the preoperative images. Muscle avulsion should be considered in the management of orbital fracture if orbital tissue entrapment and nerve paresis are excluded as causes of reduction in ocular motility. A thorough review of the imaging studies for possible muscle injury is required before surgery in all cases of orbital fracture.     

Management of diplopia in patients with blowout fractures

Purpose:

To report the management outcomes of diplopia in patients with blowout fracture.

Materials and Methods:

Data for 39 patients with diplopia due to orbital blowout fracture were analyzed retrospectively. The inferior wall alone was involved in 22 (56.4%) patients, medial wall alone was involved in 14 (35.8%) patients, and the medial and inferior walls were involved in three (7.6%) patients. Each fracture was reconstructed with a Medpore^® implant. Strabismus surgery or prism correction was performed in required patients for the management of persistent diplopia. Mean postoperative follow up was 6.5 months.

Results:

Twenty-three (58.9%) patients with diplopia underwent surgical repair of blowout fracture. Diplopia was eliminated in 17 (73.9%) patients following orbital wall surgery. Of the 23 patients, three (7.6%) patients required prism glasses and another three (7.6%) patients required strabismus surgery for persistent diplopia. In four (10.2%) patients, strabismus surgery was performed without fracture repair. Twelve patients (30.7%) with negative forced duction test results were followed up without surgery.

Conclusions:

In our study, diplopia resolved in 30.7% of patients without surgery and 69.2% of patients with diplopia required surgical intervention. Primary gaze diplopia was eliminated in 73.9% of patients through orbital wall repair. The most frequently employed secondary surgery was adjustable inferior rectus recession and <17.8% of patients required additional strabismus surgery.     

Superior oblique posterior tenectomy in patients with Brown syndrome with small deviations in the primary position.

INTRODUCTION: Procedures used to weaken the superior oblique muscle (SO) tendon in the treatment of patients with Brown syndrome, may result in severe complications, including complete SO palsy, overcorrections, foreign body extrusion, and scarring with limitation to ocular rotations. SO posterior tenectomy moderately weakens abduction and depression while preserving most of the torsional action of the SO muscle. PURPOSE: We sought to evaluate motor and sensorial results after SO posterior tenectomy in patients with Brown syndrome who had a small vertical deviation (less than 7 prism diopters [PD]) in primary position but severe limitation to elevation in adduction. METHODOLOGY: We retrospectively analyzed 12 consecutive patients with unilateral Brown syndrome who underwent a 15 mm tenectomy of the posterior four-fifths fibers of the ipsilateral SO tendon. Intraoperative forced duction showed restriction to elevation in adduction in all subjects. No patient had concomitant surgery on any other extraocular muscle. RESULTS: The mean patient age at diagnosis was 6.9 +/- 1.7 years. Preoperative vertical deviation measured 4 +/- 1 PD in the primary position and 12 +/- 2 PD in elevation in adduction. Postoperative follow-up was 24.7 +/- 9.2 months. Postoperatively, all patients had less than 2 PD of orthotropia in the primary position, and the deviation in elevation in adduction was significantly improved at 3 +/- 2 PD (P < 0.05). Elevation in adduction improved from -4.0 preoperatively to -1.9 +/- 1 postoperatively (P = 0.0000003) and no patient experienced underaction of the SO. Postoperatively, all patients had stereopsis in primary position. CONCLUSION: The use of SO posterior tenectomy improves alignment and ocular rotations in patients with Brown syndrome, resulting in fusion, small vertical deviation in primary position, and minimal-to-no anomalous head posture, in whom the most important finding is a disfiguring downshoot on attempted adduction. Other advantages include minimal-to-no postoperative SO muscle underaction and no risk of foreign body extrusion, fibrosis, and scarring.     

Isolated lesion of the medial orbital wall following endonasal surgery. Isolated fractures of the medial orbital wall

Background: Isolated fractures of the medial orbital wall are infrequent. The diagnostic triad includes: adduction block, exotropia with diplopia in all directions of gaze, positive passive duction in abduction. Sometimes a slight enophthalmos is present. Computed tomography shows the extension and the seat of the fracture. Case report: The authors illustrate the case of a 60 year old male who presented with a breach of the medial orbital wall following endonasal surgery. Results: The patient was successfully operated using an iliac bone graft inserted via an eyebrow-nasal cutaneous approach, after a previous attempt with a transconjunctival approach performed in another hospital had failed. A good functional and aesthetic result was observed within the first year after surgery. After almost 11 years a full adduction is still present and diplopia is absent. Conclusion: The authors underline the importance of an early diagnosis and prompt surgical treatment. The fat-muscle entrapment should be removed and the bone defect closed. A close cooperation between ophthalmologist and plastic surgeon is suggested. This revised version was published online in August 2006 with corrections to the Cover Date.     

Inflammatory Brown syndrome: case report

Brown syndrome fits the group of restrictive strabismus and is caused by a movement limitation of the superior oblique tendon through the trochlea. It is characterized by parallelism in the primary gaze position, limitation or absence of elevation in adduction, frequent depression of the eye in adduction with anisotropy in V-pattern and positive passive duction in the elevation in adduction. It is called inflammatory Brown syndrome, a secondary disorder, which main causes are local inflammation in the orbit and inflammatory diseases such as rheumatoid arthritis and tenosynovitis. A case of a 44 year-old patient, male, complaining of binocular vertical diplopia due to recurring dextroversion is reported. It was diagnosed as inflammatory Brown syndrome of uncertain etiology, confirmed by magnetic nuclear resonance, and with spontaneous resolution.     

Acquired retraction of the eye as the first sign of myositis

The authors report a patient who was diagnosed with idiopathic orbital myositis based on the findings of diplopia, worse on right gaze, globe retraction on adduction and injection at the lateral muscle tendon insertion of the left eye. Although orbital myositis as a cause of acquired retraction of the eye is rare, they wish to emphasize the importance of globe retraction with injection over the recti as an important clue for the diagnosis of orbital myositis.     

A case of congenital oblique retraction syndrome with upshoot in adduction

We treated a 27-year-old man who suffered from a congenital eye movement abnormality. The patient could not adduct the left eye, and showed exotropia, hypertropia and excyclotropia of the left eye. The range of abduction was also limited. The left eye showed marked upshoot on right gaze and eye globe retraction on right down gaze under conditions of right-eye viewing. The superior rectus muscle of the left eye was recessed and transposed nasally. The insertion of the superior oblique muscle was found to be defective. The upshoot and face turn improved after surgery. The globe retraction on right down gaze was no longer evident. We believe that the superior rectus muscle was innervated by an anomalous branch of the oculomotor nerve, which was originally destined to innervate the medial rectus, and that simultaneous contraction of the superior and inferior rectus muscles caused the globe retraction on right down gaze. This case also suggests the possibility that some part of the upshoot in adduction in Duane's syndrome is due to the co-contraction of the superior and medial rectus muscles due to this innervation anomaly.     

An Unexpected Outcome of Blunt Ocular Trauma: Rupture of Three Muscles

Introduction: Traumatic strabismus due to isolated extraocular muscle rupture is uncommon. Treatment usually depends on the severity of both the subjective and objective findings. Methods: We report a male patient with restricted abduction and supraduction in the right eye follow ing a blunt ocular trauma. The exploration revealed the rupture of superior rectus, superior oblique, and lateral rectus muscles. Only lateral rectus muscle could be sutured to the proximal segment. Superior rectus and superior oblique muscles were severed brutally, so that repairing was not possible.

Results: On the day after exploration and primary suturation, there was 25 prism diopters (PD) hypotropia and 15 PD esotropia in his right eye with severe limited supraduction and abduction. His major complaint was a large vertical diplopia which resolved partially with the prismatic glasses prescribed. After 6 months follow-up, medial rectus and inferior rectus recession was performed in the right eye. The patient had a limited but improved abduction after the operation. He was orthotropic and had a single binocular vision in the primary position.

Discussion: In suspected extraocular muscle ruptures, orbital imaging methods and surgical exploration should be considered promptly. MRI may be mandatory to demonstrate the severed muscles in cases with persistent diplopia and normal CT. Prognosis is usually better in patients having partial extraocular muscle damage and treatment options should be evaluated on patient basis.     

Brown Syndrome Following Upper Eyelid Ptosis Repair

Brown syndrome is characterised by impaired supraduction worse in adduction due to a restricted superior oblique tendon passing through the trochlea. A few reports have previously described Brown syndrome after upper eyelid surgery, including blepharoplasty and ptosis repair. The authors describe two additional cases of Brown syndrome following ptosis repair. The first case is a 65-year-old woman with new-onset vertical binocular diplopia following bilateral levator advancement surgery. Ocular motility examination demonstrated moderate impairment of elevation in adduction. The second case is a 35-year-old woman who presented with new-onset intermittent binocular diplopia following right upper lid ptosis repair. Examination revealed large vertical fusional amplitudes and a large left intermittent hyperphoria in an alignment pattern consistent with Brown syndrome. Despite presenting after surgery, these cases differ in mechanism. The first case likely occurred due to intraoperative impairment of the superior oblique tendon sheath or trochlea, whereas the second case represented an unmasking of a long-standing, previous vertical strabismus that was consistent with a Brown syndrome pattern.     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

眼眶骨折不同位点的修复对眼球内陷治疗的影响

目的：通过对眼眶内壁联合下壁骨折患者手术后眼球内陷治疗情况的临床观察,探讨不同手术位点的修复对手术预后的意义。

方法：回顾性分析眼眶内壁与下壁骨折伴眼球内陷23例23眼患者的临床资料。术后观察3mo,眼球内陷均小于2mm。通过术后CT检查,分析后隅角、内壁上缘、下壁外缘三个手术位点的修复情况。

结果：术后患者预后良好,三个手术位点的修复情况是不同的,其中后隅角的修复率最高(100%),内壁上缘的修复率次之(83%),下壁外缘修复率最低(43%)。

结论：不同手术位点的修复对于手术效果的影响是不同的,其中后隅角的修复对手术效果作用最大; 手术中对重要位点的关注可以指导手术操作,减小手术风险。     

眼眶骨折伴斜视患者的临床诊治分析

目的 分析眼眶骨折伴斜视患者的斜视性质、眼眶骨折修复的手术时机和术后斜视的变化等.方法 回顾分析2001年1月到2008年12月在中山大学中山眼科中心诊治的眼眶骨折患者.常规作眼眶CT检查、被动转动试验、眼位和眼球运动检查、复像试验,观察眼眶骨折修复前后眼位和眼球运动情况等.结果 共87例90只眼,男性66例,女性21例;年龄3～68岁(平均30.6岁);右眶27例,左眶57例,双眶3例.36%的患者有视力受损.32%为眼眶爆裂性骨折,68%为复合性骨折;以内壁和下壁骨折多见.术前47%的患者有斜视,其中麻痹性41.5%,限制性58.5%;眼眶骨折修复后:35例术前有斜视者(平均随访1年),28.6%斜视消失;17.1%正前方和下方功能位置无斜视,37.1%斜视部分好转或不变;17.1%斜视加莺;1例术前无斜视,术后出现医源性斜视.结论 眼眶骨折伤后患眼斜视的性质包括麻痹性和限制性,骨折修复手术时机存在争论,以下情形需要尽快手术:(1)影像学检查显示有眼外肌断裂;(2)CT扣描和被动转动试验均示有明确的眼外肌嵌顿,保守治疗二周无好转;(3)外壁和上壁的Blow-in骨折.眼眶骨折修复术后其斜视既可消失也可不变或加重;医源性斜视要尽量避免.     

The Binocular Visual System in Amblyopia

We treated a 27-year-old man who suffered from a congenital eye movement abnormality. The patient could not adduct the left eye, and showed exotropia, hypertropia and excyclotropia of the left eye. The range of abduction was also limited. The left eye showed marked upshoot on right gaze and eye globe retraction on right down gaze under conditions of right-eye viewing.The superior rectus muscle of the left eye was recessed and transposed nasally.The insertion of the superior oblique muscle was found to be defective. The upshoot and face turn improved after surgery. The globe retraction on right down gaze was no longer evident.We believe that the superior rectus muscle was innervated by an anomalous branch of the oculomotor nerve, which was originally destined to innervate the medial rectus, and that simultaneous contraction of the superior and inferior rectus muscles caused the globe retraction on right down gaze.This case also suggests the possibility that some part of the upshoot in adduction in Duane's syndrome is due to the co-contraction of the superior and medial rectus muscles due to this innervation anomaly.     

Endoscopic and trans-fornix removal of a giant orbital-ethmoidal osteoma

A 39-year old female was referred with a 2 year history of slowly progressive headache, exophthalmos, diplopia and restricted eye movements with exotropia of the right eye. Orthoptic examination revealed restricted elevation and mildly restricted adduction of the right eye. CT and MRI demonstrated a large (35 x 20 x 23 mm) calcified infraorbital lesion extending into the ethmoidal sinus. Because the visual field defects were progressive and the acuity OD dropped to 20/80 surgical intervention was necessary. The osteoma was successfully removed using an inferior and medial orbitotomy with swinging eyelid combined with an endoscopic approach. In a second procedure the orbital floor was reconstructed with a porous polyethylene (Medpor) implant. A final procedure consisted of a 3 mm recession of the left superior rectus muscle and infundibulotomy by the sinus surgeon to open the blocked maxillary sinus. After 6 months visual acuity OD had returned to 20/20. Orthoptic examination showed normal binocular function.     

Repair of medial orbital wall fracture: transcaruncular approach

The aim of this paper is to demonstrate the safety and the use of the transcaruncular approach as a surgical technique for managing a medial wall fracture. This approach was used in 40 patients with a isolated medial or a combined medial and inferior orbital wall fracture between September 1998 and September 2002. A computed tomographic scan was taken before and after surgery. The ocular motility and enophthalmos were checked before and after surgery. The transcaruncular approach provided the appropriate surgical exposure in all cases. Patients were followed up for a mean of 9.4 months (range, 524 months) after repairing the orbital wall fracture. Hertel exophthalmometry showed that among the 40 patients; 24 patients showed no enophthalmos. The enophthalmos ranged from 0.51 mm in 14 patients and 1.5 mm enphthalmos was noted in 2 patients. A clinically significant enophthalmos =2 mm was not found postoperatively. Preoperatively, 12 patients (30%) had a diplopia in the primary position of the gaze and 26 patients (65%) had a diplopia within 30 degrees of the gaze. Postoperatively, all patients had an orthotropia in the primary position but 4 patients (10%) had a residual diplopia either on the lateral gaze (2 patients) or the upgaze (2 patients). There were 2 cases of an implant misplacement. The transcaruncular approach provides a safe, rapid, and cosmetically pleasing surgical approach for managing a isolated medial wall fracture. When combined with the inferior transconjunctival approach, a combined medial and inferior orbital wall fracture can be successfully repaired.