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Superior oblique palsy: A complication of endoscopic sinus surgery
Short Reports Superior oblique palsy: A complication of endoscopic sinus surgery Jessica S. Lin, MD,a Ting T. Liu, MD,a R. Peter Manes, MD,b and Jennifer A. Galvin, MDa A 34-year-old woman with chronic sinusitis and nasal polyps was treated with bilateral pansinusotomy. Postoperatively, she had a unilateral superior oblique paresis. We suspect that superior oblique damage occurred without involvement of the medial rectus because of inadvertent entry of the endoscopic probe through the superior lamina into the left orbit.
Case Report
A
34-year-old woman presented 1 day after nasal endoscopic surgery with acute diplopia to an outside general ophthalmology office. Four days later she was referred to Yale Eye Center for further evaluation of her postoperative diplopia. Of note, her procedure was a stereotactic computer-assisted navigation with bilateral frontal sinusotomy, sphenoidotomy, total ethmoidectomy, and maxillary antrostomy with tissue removal. Medications included acetaminophen with codeine, fluticasone propionate nasal spray, and prednisone (20 mg daily). There was no prior history of trauma, strabismus, or diplopia before this surgery. On ophthalmological examination, corrected visual acuity was 20/20 in both eyes, ocular motility was 1 deficit in the field of action of the left superior oblique, and both pupils were round and reactive. She was found to have a left hypertropia of 6D in primary gaze and 9D in right gaze. Right head tilt was orthotropic, but there was a left hypertropia of 10D on left head tilt. Stereoacuity was reduced to 400 seconds of arc. Double Maddox rod testing demonstrated 5 of extorsion in the left eye. On prism adaptation test, her diplopia resolved with a 6 base-up prism over the right eye. Slit-lamp examination demonstrated ecchymosis over her left medial canthus. Otherwise, the anterior segment examination was within normal limits. At postoperative day 1, MRI of the orbits,
Author affiliations: aDepartment of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut; bSection of Otolaryngology, Department of Surgery, Yale School of Medicine Submitted May 29, 2014. Revision accepted October 12, 2014. Correspondence: Dr. Jennifer A. Galvin, MD, Yale School of Medicine, Department of Ophthalmology and Visual Science, 40 Temple Street, 3rd Floor, New Haven, CT 06510 (email: [email protected]). J AAPOS 2015;-:1-2. Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2014.10.031
Journal of AAPOS
FIG 1. Magnetic resonance imaging of the orbits with post-contrast enhancement noted on the 1 mm thin–cut coronal view. The arrow indicates enlargement of the proximal aspect of the left superior oblique muscle, with questionable discontinuity of left superior oblique muscle.
with post-contrast enhancement noted on the 1 mm thincut coronal view, showed intramuscular edema, inflammation, and enlargement of the proximal aspect of the left superior oblique muscle with questionable discontinuity of left superior oblique muscle (Figure 1). The remaining extraocular muscles appeared intact. The clinical examination and imaging was consistent with an iatrogenic left superior oblique palsy. At 1 month follow-up her left hypertropia in primary gaze decreased to 1D, and double Maddox rod testing showed no extorsion. Her symptoms became minimal, with the only noticeable diplopia in reading position, as her left hypertropia was measured at 14D in downgaze. She was orthotropic on right head tilt and had a left hypertropia of 6D on left head tilt. At 3 months’ follow-up, she had a small right head tilt of \5 and remained orthotropic in primary gaze with no extorsion on double Maddox rod testing. In downgaze, her left hypertropia was noted to be increased, measuring at 18D. She was orthotropic on right head tilt and had left hypertropia of 6D on left head tilt. At both 1 and 3 month follow-up, the ocular versions showed a persistence of a 1 deficit in the field of action of the left superior oblique.
Discussion Superior oblique palsy after endoscopic surgery has been known to occur in conjunction with damage to the medial or inferior rectus muscle, with the medial rectus being the most commonly affected muscle because it lies closest to the lamina papyracea.1-4 A retrospective review of 15 cases demonstrated superior oblique palsy in 4 cases from nerve damage, damage to or destruction of the muscle itself, or due to mild contusion of the muscle.1 To our knowledge, this is the first reported case of isolated superior oblique palsy following nasal endoscopic surgery. Surgical techniques involving external frontal approaches that do not involve endoscopic means have been reported to cause isolated unilateral superior oblique palsy in the literature in 4 cases.3,4 We suspect that the left unilateral
1
2
Lin et al
superior oblique damage occurred without involvement of the medial rectus or inferior rectus due to inadvertent entering of the superior lamina with the endoscopic probe. It is unlikely that the trochlea was directly damaged because magnetic resonance imaging revealed an injury posterior to the globe and well posterior to the anatomic location of the trochlea. Our patient’s clinical examination indicated edematous and inflammatory damage to the superior oblique, not a near complete/ partial transection of the muscle. The improvement of edema and inflammation surrounding the left superior oblique over a 3-month period was clinically evident. While her left hypertropia resolved in primary gaze, her left hypertropia increased in downgaze from 10D to 18D. For surgical intervention of diplopia relief in downgaze, we suggest right inferior rectus recession with a Faden
Volume - Number - / - 2015 fixation suture. We would suggest avoiding surgery on the left superior oblique because both her torsion and her hypertropia in primary gaze is resolved.
References 1. Thacker NM, Velez FG, Demer JL, Rosenbaum AL. Strabismus complications following endoscopic sinus surgery: diagnosis and surgical management. J AAPOS 2004;8:488-94. 2. Huang CM, Meyer DR, Patrinely JR, et al. Medial rectus muscle injuries associated with functional endoscopic sinus surgery: characterization and management. Ophthal Plast Reconstr Surg 2003;19:25-37. 3. Rosenbaum AL, Astle WF. Superior oblique and inferior rectus muscle injury following frontal and intranasal sinus surgery. J Pediatr Ophthalmol Strabismus 1985;22:194-202. 4. Bartley J, Eagleton N, Rosser P, Al-Ali S. Superior oblique muscle palsy after frontal sinus mini-trephine. Am J Otol 2012;33:181-3.
Journal of AAPOS
Case Report
A
34-year-old woman presented 1 day after nasal endoscopic surgery with acute diplopia to an outside general ophthalmology office. Four days later she was referred to Yale Eye Center for further evaluation of her postoperative diplopia. Of note, her procedure was a stereotactic computer-assisted navigation with bilateral frontal sinusotomy, sphenoidotomy, total ethmoidectomy, and maxillary antrostomy with tissue removal. Medications included acetaminophen with codeine, fluticasone propionate nasal spray, and prednisone (20 mg daily). There was no prior history of trauma, strabismus, or diplopia before this surgery. On ophthalmological examination, corrected visual acuity was 20/20 in both eyes, ocular motility was 1 deficit in the field of action of the left superior oblique, and both pupils were round and reactive. She was found to have a left hypertropia of 6D in primary gaze and 9D in right gaze. Right head tilt was orthotropic, but there was a left hypertropia of 10D on left head tilt. Stereoacuity was reduced to 400 seconds of arc. Double Maddox rod testing demonstrated 5 of extorsion in the left eye. On prism adaptation test, her diplopia resolved with a 6 base-up prism over the right eye. Slit-lamp examination demonstrated ecchymosis over her left medial canthus. Otherwise, the anterior segment examination was within normal limits. At postoperative day 1, MRI of the orbits,
Author affiliations: aDepartment of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut; bSection of Otolaryngology, Department of Surgery, Yale School of Medicine Submitted May 29, 2014. Revision accepted October 12, 2014. Correspondence: Dr. Jennifer A. Galvin, MD, Yale School of Medicine, Department of Ophthalmology and Visual Science, 40 Temple Street, 3rd Floor, New Haven, CT 06510 (email: [email protected]). J AAPOS 2015;-:1-2. Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2014.10.031
Journal of AAPOS
FIG 1. Magnetic resonance imaging of the orbits with post-contrast enhancement noted on the 1 mm thin–cut coronal view. The arrow indicates enlargement of the proximal aspect of the left superior oblique muscle, with questionable discontinuity of left superior oblique muscle.
with post-contrast enhancement noted on the 1 mm thincut coronal view, showed intramuscular edema, inflammation, and enlargement of the proximal aspect of the left superior oblique muscle with questionable discontinuity of left superior oblique muscle (Figure 1). The remaining extraocular muscles appeared intact. The clinical examination and imaging was consistent with an iatrogenic left superior oblique palsy. At 1 month follow-up her left hypertropia in primary gaze decreased to 1D, and double Maddox rod testing showed no extorsion. Her symptoms became minimal, with the only noticeable diplopia in reading position, as her left hypertropia was measured at 14D in downgaze. She was orthotropic on right head tilt and had a left hypertropia of 6D on left head tilt. At 3 months’ follow-up, she had a small right head tilt of \5 and remained orthotropic in primary gaze with no extorsion on double Maddox rod testing. In downgaze, her left hypertropia was noted to be increased, measuring at 18D. She was orthotropic on right head tilt and had left hypertropia of 6D on left head tilt. At both 1 and 3 month follow-up, the ocular versions showed a persistence of a 1 deficit in the field of action of the left superior oblique.
Discussion Superior oblique palsy after endoscopic surgery has been known to occur in conjunction with damage to the medial or inferior rectus muscle, with the medial rectus being the most commonly affected muscle because it lies closest to the lamina papyracea.1-4 A retrospective review of 15 cases demonstrated superior oblique palsy in 4 cases from nerve damage, damage to or destruction of the muscle itself, or due to mild contusion of the muscle.1 To our knowledge, this is the first reported case of isolated superior oblique palsy following nasal endoscopic surgery. Surgical techniques involving external frontal approaches that do not involve endoscopic means have been reported to cause isolated unilateral superior oblique palsy in the literature in 4 cases.3,4 We suspect that the left unilateral
1
2
Lin et al
superior oblique damage occurred without involvement of the medial rectus or inferior rectus due to inadvertent entering of the superior lamina with the endoscopic probe. It is unlikely that the trochlea was directly damaged because magnetic resonance imaging revealed an injury posterior to the globe and well posterior to the anatomic location of the trochlea. Our patient’s clinical examination indicated edematous and inflammatory damage to the superior oblique, not a near complete/ partial transection of the muscle. The improvement of edema and inflammation surrounding the left superior oblique over a 3-month period was clinically evident. While her left hypertropia resolved in primary gaze, her left hypertropia increased in downgaze from 10D to 18D. For surgical intervention of diplopia relief in downgaze, we suggest right inferior rectus recession with a Faden
Volume - Number - / - 2015 fixation suture. We would suggest avoiding surgery on the left superior oblique because both her torsion and her hypertropia in primary gaze is resolved.
References 1. Thacker NM, Velez FG, Demer JL, Rosenbaum AL. Strabismus complications following endoscopic sinus surgery: diagnosis and surgical management. J AAPOS 2004;8:488-94. 2. Huang CM, Meyer DR, Patrinely JR, et al. Medial rectus muscle injuries associated with functional endoscopic sinus surgery: characterization and management. Ophthal Plast Reconstr Surg 2003;19:25-37. 3. Rosenbaum AL, Astle WF. Superior oblique and inferior rectus muscle injury following frontal and intranasal sinus surgery. J Pediatr Ophthalmol Strabismus 1985;22:194-202. 4. Bartley J, Eagleton N, Rosser P, Al-Ali S. Superior oblique muscle palsy after frontal sinus mini-trephine. Am J Otol 2012;33:181-3.
Journal of AAPOS