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Periorbital globe fixation after severe extraocular muscle injury
Periorbital globe fixation after severe extraocular muscle injury Chang Yeom Kim, MD,a Kyou Ho Lee, MD,a Cheng-Zhe Wu, MD,b and Sang Yeul Lee, MD, PhDa
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.
Case Report
A
62-year-old woman was referred to the Department of Ophthalmology, Yonsei University College of Medicine, Seoul, for extraocular motion deficit of the right eye after bilateral transnasal endoscopic ethmoidectomy for chronic sinusitis. On initial examination immediately after endoscopic sinus surgery (ESS), the patient’s visual acuity and intraocular pressure were within the normal ranges, but the right eye had 40D exotropia and limitation of adduction (Figure 1A). The patient experienced binocular diplopia in all gaze positions. Postoperative orbital magnetic resonance imaging after ESS showed right medial rectus muscle transection (Figure 2). The patient declined further surgery in the immediate postoperative period; orbital exploration was only possible 5 months after ESS. The surgery was performed under general anesthesia using a transconjunctival transcaruncular approach. The transcaruncular incision and dissection were performed as we previously reported.1 The subperiosteal space was explored in the direction of the orbital apex, and a bony defect of the posterior medial wall that resulted from the ethmoidectomy was noted. A periorbital incision around the defect was performed but the transected right medial rectus muscle could not be found. We thus attempted to tether the globe at the posteromedial periorbita to restore alignment. Two double-armed 5-0 nonabsorbable braided polyester sutures were passed through the periorbita, posterior to the previously made incision around the bony defect (Figure 3A). A limbal incision created an anterior conjunctival window to expose Author affiliations: aInstitute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea; bDepartment of Ophthalmology, Affiliated Hospital, Yanbian University Medical College, Jilin, China Submitted January 23, 2013. Revision accepted April 25, 2013. Correspondence: Sang Yeul Lee, MD, PhD, Department of Ophthalmology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea (email: [email protected]). J AAPOS 2013;17:530-532. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2013.04.011
530
the insertion of the right medial rectus muscle. Curved mosquito forceps were passed through the anterior window toward the posterior medial wall and grasped the sutures (Figure 3B). The sutures were pulled out anteriorly (Figure 3C) and anchored to the sclera immediately superior and inferior of the right medial rectus muscle insertion point. Suture tension was adjusted to align the eyes (Figure 3D). The bony defect of the posterior medial wall was repaired with a porous polyethylene implant (Medpor barrier implant 8305; Porex Surgical Inc, Newnan, GA). Postoperatively, the patient had satisfactory alignment in the primary position (Figure 1B) without diplopia and was able to manage daily activities, including climbing stairs, without difficulty. Although she has suffered from mild dizziness, she remained orthotropic in primary gaze at last follow-up, 1 year after surgery.
Discussion Endonasal ethmoidectomy often injures the lamina papyracea and induces orbital complications, including periorbital ecchymosis, proptosis, retrobulbar hemorrhage, nasolacrimal duct injury, medial rectus muscle damage, and optic nerve injury.2,3 With paranasal sinus surgery, surgeons should suspect orbital injury when proptosis, conjunctival hemorrhage, extraocular motion deficit, and diplopia develop. Immediate assessment of the orbit, including tonometry, fundus examination to ensure perfusion of the optic nerve and retina, and imaging studies are warranted.2 Extraocular muscle injury, resulting in permanent diplopia, is one of the most devastating and surgically challenging ophthalmic complications of paranasal sinus surgery. Several approaches exist for restoring ocular alignment after extraocular muscle injury. Orbital exploration with direct reanastomosis is advocated when the posterior 20 mm of muscle remains and is contractile4; however, primary reanastomosis is often precluded by muscle loss. A transnasal endoscope and a peripheral stimulator can be helpful in recovering the lost muscle.5,6 In cases of severe injury, muscle transposition surgery may be advised. Muscle-to-muscle anastomosis using interposition grafting or hang-back adjustable sutures and globe tethering operations using alloplastic materials or vascularized periosteal flap have also been reported.2,7 Botulinum toxin injection into the ipsilateral antagonist muscle prevents secondary muscle contracture and may enable single vision. Three 5-unit injections of botulinum toxin-A within 3 to 4 weeks of muscle injury are recommended.2 None of these
Journal of AAPOS
Volume 17 Number 5 / October 2013
Kim et al
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FIG 1. Nine diagnostic positions of gaze in a 62-year-old woman with transected right medial rectus muscle after transnasal endoscopic ethmoidectomy. A, Before surgery, showing right exotropia and marked limitation of adduction of the right eye. B, One month after periorbital fixation surgery, showing orthotropia in primary gaze.
fixation is relatively safe compared with attempted retrieval of a transected muscle, which can cause additional orbital structure injury. It is also easier to perform than the periosteal flap.7 Typically early surgical intervention is necessary in cases of severely damaged extraocular muscles to prevent permanent scar contracture and fibrosis,2,3 but our patient had a good postoperative outcome despite delayed surgery.
References
FIG 2. Preoperative orbital magnetic resonance imaging showing a transected right medial rectus muscle. The patient underwent surgery using the periorbital fixation technique.
procedures has yielded long-lasting satisfactory outcomes, and the prognosis remains relatively poor.2,3,5 Periorbital globe fixation was introduced for the management of oculomotor nerve palsy in 2004 and modified thereafter.8-10 We used this method in a patient with medial rectus muscle transection, and the outcome was anatomically and functionally superior to outcomes reported for cases that used conventional methods.3 Working within a narrow surgical space requires the surgeon’s close attention to avoid injuring the optic nerve, vessels, and other critical structures. When adjusting eye alignment, the two anchoring scleral sutures (on the superior and inferior aspects of the injured muscle) should be balanced to prevent vertical strabismus. Approximately 5D-10D overcorrection is necessary to account for the possibility of the contralateral orbital muscle contracting after the anesthesia wears off.7 In the present case, periorbital globe fixation effectively treated severe extraocular muscle injury. Periorbital globe
Journal of AAPOS
1. Lee CS, Yoon JS, Lee SY. Combined transconjunctival and transcaruncular approach for repair of large medial orbital wall fractures. Arch Ophthalmol 2009;127:291-6. 2. Bleier BS, Schlosser RJ. Prevention and management of medial rectus injury. Otolaryngol Clin North Am 2010;43:801-7. 3. Thacker NM, Velez FG, Demer JL, Rosenbaum AL. Strabismic complications following endoscopic sinus surgery: diagnosis and surgical management. J AAPOS 2004;8:488-94. 4. Thacker NM, Velez FG, Demer JL, Wang MB, Rosenbaum AL. Extraocular muscle damage associated with endoscopic sinus surgery: an ophthalmology perspective. Am J Rhinol 2005;19:400-405. 5. Hong JE, Goldberg AN, Cockerham KP. Botulinum toxin A therapy for medial rectus injury during endoscopic sinus surgery. Am J Rhinol 2008;22:95-7. 6. McKeown CA, Metson RB, Dunya IM, Shore JW, Joseph MP. Transnasal endoscopic approach to the medial rectus to recover lost muscles. In: Lennerstrand G, ed. Update on Strabismus and Pediatric Ophthalmology: Proceedings of the June 1994 Joint ISA and AAPOS Meeting. Vancouver, Canada. Boca Raton, FL: CRC Press; 1995: 423-6. 7. Goldberg RA, Rosenbaum AL, Tong JT. Use of apically based periosteal flaps as globe tethers in severe paretic strabismus. Arch Ophthalmol 2000;118:431-7. 8. Srivastava KK, Sundaresh K, Vijayalakshmi P. A new surgical technique for ocular fixation in congenital third nerve palsy. J AAPOS 2004;8:371-7. 9. Sharma P, Gogoi M, Kedar S, Bhola R. Periosteal fixation in thirdnerve palsy. J AAPOS 2006;10:324-7. 10. Saxena R, Sinha A, Sharma P, Phuljhele S, Menon V. Precaruncular approach for medial orbital wall perioseal anchoring of the globe in oculomotor nerve palsy. J AAPOS 2009;13:578-82.
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Volume 17 Number 5 / October 2013
FIG 3. Schematic drawing of the periorbital fixation technique. A, Two double-armed 5-0 nonabsorbable braided polyester sutures are passed through the periorbita, posterior to the previously made incision around the bony defect. B, A limbal incision creates an anterior conjunctival window to expose the insertion of the right medial rectus muscle, and curved mosquito forceps are passed through the anterior window toward the posterior medial wall to grasp the sutures. C, Sutures are pulled out anteriorly and anchored to the sclera immediately superior and inferior of the right medial rectus muscle insertion point. D, Suture tension is adjusted to align the eyes.
Journal of AAPOS
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.
Case Report
A
62-year-old woman was referred to the Department of Ophthalmology, Yonsei University College of Medicine, Seoul, for extraocular motion deficit of the right eye after bilateral transnasal endoscopic ethmoidectomy for chronic sinusitis. On initial examination immediately after endoscopic sinus surgery (ESS), the patient’s visual acuity and intraocular pressure were within the normal ranges, but the right eye had 40D exotropia and limitation of adduction (Figure 1A). The patient experienced binocular diplopia in all gaze positions. Postoperative orbital magnetic resonance imaging after ESS showed right medial rectus muscle transection (Figure 2). The patient declined further surgery in the immediate postoperative period; orbital exploration was only possible 5 months after ESS. The surgery was performed under general anesthesia using a transconjunctival transcaruncular approach. The transcaruncular incision and dissection were performed as we previously reported.1 The subperiosteal space was explored in the direction of the orbital apex, and a bony defect of the posterior medial wall that resulted from the ethmoidectomy was noted. A periorbital incision around the defect was performed but the transected right medial rectus muscle could not be found. We thus attempted to tether the globe at the posteromedial periorbita to restore alignment. Two double-armed 5-0 nonabsorbable braided polyester sutures were passed through the periorbita, posterior to the previously made incision around the bony defect (Figure 3A). A limbal incision created an anterior conjunctival window to expose Author affiliations: aInstitute of Vision Research, Department of Ophthalmology, Yonsei University College of Medicine, Seoul, Korea; bDepartment of Ophthalmology, Affiliated Hospital, Yanbian University Medical College, Jilin, China Submitted January 23, 2013. Revision accepted April 25, 2013. Correspondence: Sang Yeul Lee, MD, PhD, Department of Ophthalmology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Korea (email: [email protected]). J AAPOS 2013;17:530-532. Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2013.04.011
530
the insertion of the right medial rectus muscle. Curved mosquito forceps were passed through the anterior window toward the posterior medial wall and grasped the sutures (Figure 3B). The sutures were pulled out anteriorly (Figure 3C) and anchored to the sclera immediately superior and inferior of the right medial rectus muscle insertion point. Suture tension was adjusted to align the eyes (Figure 3D). The bony defect of the posterior medial wall was repaired with a porous polyethylene implant (Medpor barrier implant 8305; Porex Surgical Inc, Newnan, GA). Postoperatively, the patient had satisfactory alignment in the primary position (Figure 1B) without diplopia and was able to manage daily activities, including climbing stairs, without difficulty. Although she has suffered from mild dizziness, she remained orthotropic in primary gaze at last follow-up, 1 year after surgery.
Discussion Endonasal ethmoidectomy often injures the lamina papyracea and induces orbital complications, including periorbital ecchymosis, proptosis, retrobulbar hemorrhage, nasolacrimal duct injury, medial rectus muscle damage, and optic nerve injury.2,3 With paranasal sinus surgery, surgeons should suspect orbital injury when proptosis, conjunctival hemorrhage, extraocular motion deficit, and diplopia develop. Immediate assessment of the orbit, including tonometry, fundus examination to ensure perfusion of the optic nerve and retina, and imaging studies are warranted.2 Extraocular muscle injury, resulting in permanent diplopia, is one of the most devastating and surgically challenging ophthalmic complications of paranasal sinus surgery. Several approaches exist for restoring ocular alignment after extraocular muscle injury. Orbital exploration with direct reanastomosis is advocated when the posterior 20 mm of muscle remains and is contractile4; however, primary reanastomosis is often precluded by muscle loss. A transnasal endoscope and a peripheral stimulator can be helpful in recovering the lost muscle.5,6 In cases of severe injury, muscle transposition surgery may be advised. Muscle-to-muscle anastomosis using interposition grafting or hang-back adjustable sutures and globe tethering operations using alloplastic materials or vascularized periosteal flap have also been reported.2,7 Botulinum toxin injection into the ipsilateral antagonist muscle prevents secondary muscle contracture and may enable single vision. Three 5-unit injections of botulinum toxin-A within 3 to 4 weeks of muscle injury are recommended.2 None of these
Journal of AAPOS
Volume 17 Number 5 / October 2013
Kim et al
531
FIG 1. Nine diagnostic positions of gaze in a 62-year-old woman with transected right medial rectus muscle after transnasal endoscopic ethmoidectomy. A, Before surgery, showing right exotropia and marked limitation of adduction of the right eye. B, One month after periorbital fixation surgery, showing orthotropia in primary gaze.
fixation is relatively safe compared with attempted retrieval of a transected muscle, which can cause additional orbital structure injury. It is also easier to perform than the periosteal flap.7 Typically early surgical intervention is necessary in cases of severely damaged extraocular muscles to prevent permanent scar contracture and fibrosis,2,3 but our patient had a good postoperative outcome despite delayed surgery.
References
FIG 2. Preoperative orbital magnetic resonance imaging showing a transected right medial rectus muscle. The patient underwent surgery using the periorbital fixation technique.
procedures has yielded long-lasting satisfactory outcomes, and the prognosis remains relatively poor.2,3,5 Periorbital globe fixation was introduced for the management of oculomotor nerve palsy in 2004 and modified thereafter.8-10 We used this method in a patient with medial rectus muscle transection, and the outcome was anatomically and functionally superior to outcomes reported for cases that used conventional methods.3 Working within a narrow surgical space requires the surgeon’s close attention to avoid injuring the optic nerve, vessels, and other critical structures. When adjusting eye alignment, the two anchoring scleral sutures (on the superior and inferior aspects of the injured muscle) should be balanced to prevent vertical strabismus. Approximately 5D-10D overcorrection is necessary to account for the possibility of the contralateral orbital muscle contracting after the anesthesia wears off.7 In the present case, periorbital globe fixation effectively treated severe extraocular muscle injury. Periorbital globe
Journal of AAPOS
1. Lee CS, Yoon JS, Lee SY. Combined transconjunctival and transcaruncular approach for repair of large medial orbital wall fractures. Arch Ophthalmol 2009;127:291-6. 2. Bleier BS, Schlosser RJ. Prevention and management of medial rectus injury. Otolaryngol Clin North Am 2010;43:801-7. 3. Thacker NM, Velez FG, Demer JL, Rosenbaum AL. Strabismic complications following endoscopic sinus surgery: diagnosis and surgical management. J AAPOS 2004;8:488-94. 4. Thacker NM, Velez FG, Demer JL, Wang MB, Rosenbaum AL. Extraocular muscle damage associated with endoscopic sinus surgery: an ophthalmology perspective. Am J Rhinol 2005;19:400-405. 5. Hong JE, Goldberg AN, Cockerham KP. Botulinum toxin A therapy for medial rectus injury during endoscopic sinus surgery. Am J Rhinol 2008;22:95-7. 6. McKeown CA, Metson RB, Dunya IM, Shore JW, Joseph MP. Transnasal endoscopic approach to the medial rectus to recover lost muscles. In: Lennerstrand G, ed. Update on Strabismus and Pediatric Ophthalmology: Proceedings of the June 1994 Joint ISA and AAPOS Meeting. Vancouver, Canada. Boca Raton, FL: CRC Press; 1995: 423-6. 7. Goldberg RA, Rosenbaum AL, Tong JT. Use of apically based periosteal flaps as globe tethers in severe paretic strabismus. Arch Ophthalmol 2000;118:431-7. 8. Srivastava KK, Sundaresh K, Vijayalakshmi P. A new surgical technique for ocular fixation in congenital third nerve palsy. J AAPOS 2004;8:371-7. 9. Sharma P, Gogoi M, Kedar S, Bhola R. Periosteal fixation in thirdnerve palsy. J AAPOS 2006;10:324-7. 10. Saxena R, Sinha A, Sharma P, Phuljhele S, Menon V. Precaruncular approach for medial orbital wall perioseal anchoring of the globe in oculomotor nerve palsy. J AAPOS 2009;13:578-82.
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Kim et al
Volume 17 Number 5 / October 2013
FIG 3. Schematic drawing of the periorbital fixation technique. A, Two double-armed 5-0 nonabsorbable braided polyester sutures are passed through the periorbita, posterior to the previously made incision around the bony defect. B, A limbal incision creates an anterior conjunctival window to expose the insertion of the right medial rectus muscle, and curved mosquito forceps are passed through the anterior window toward the posterior medial wall to grasp the sutures. C, Sutures are pulled out anteriorly and anchored to the sclera immediately superior and inferior of the right medial rectus muscle insertion point. D, Suture tension is adjusted to align the eyes.
Journal of AAPOS