Cauterization-mediated restriction from penetrating orbital trauma.

A healthy 32-year-old woman presented with binocular diplopia immediately after sustaining a penetrating injury to the left periocular adnexa with a hot metal skewer. Examination revealed an incomitant esotropia, with complete limitation of abduction of the left eye with downshoot in left gaze and normal afferent visual function. Computed tomography and magnetic resonance imaging demonstrated no fracture, but there was mild thickening of the medial rectus muscle and associated fat stranding. Lack of orbitomuscular tethering or hematoma led to the presumptive diagnosis of thermal cauterization injury causing left medial rectus restriction. Given the lack of literature on this mechanism of injury, the patient was monitored closely. She exhibited remarkable spontaneous improvement in motility over 6 months, with near orthophoria in primary gaze. However, bothersome residual esotropic diplopia in left gaze prompted a left medial rectus recession, with a good outcome. This case demonstrates that isolated extraocular muscle thermal injuries and consequential strabismus can recover spontaneously; longitudinal observation before surgical intervention may be appropriate in such cases.

Diplopía binocular por paresia o parálisis oculomotoras: resultados de las opciones de tratamiento / Binocular Diplopia due to Oculomotor Paresis or Palsies: Outcomes of Treatment Options

Objetivo: Determinar resultados de las opciones de tratamiento para la diplopía binocular en pacientes con paresia o parálisis oculomotoras. Método: Se realizó un estudio descriptivo, longitudinal y prospectivo de una serie de casos que acudieron a la consulta del Servicio de Oftalmología Pediátrica del Instituto Cubano de Oftalmología Ramón Pando Ferrer. Se evaluaron las variables: edad, sexo, etiología, opciones de tratamiento, limitación de los movimientos oculares, eliminación de diplopía, fusión y estereopsis. Resultados: La etiología más frecuente fue la microvascular. El 66,7 por ciento de la muestra estudiada se resolvió solo con tratamiento médico, de ellos el 100,0 por ciento con diagnóstico de paresias o parálisis del tercer nervio craneal, seguido por el sexto y cuarto con 63,6 por ciento y 33,3 por ciento, respectivamente. Necesitaron tratamiento médico, quirúrgico y aplicación de toxina botulínica seis pacientes, el 33,3 por ciento del cuarto y el 22,7 por ciento del sexto nervio craneal. El resto de las opciones de tratamiento solo con un paciente. No se halló asociación significativa entre opciones de tratamiento y nervio craneal afectado. El 86,6 por ciento finalizó sin limitación de los movimientos oculares. El 86,7 por ciento de los casos eliminaron la diplopía en todas las posiciones diagnósticas de la mirada. El 76,7 por ciento logró fusión y el 56,7 por ciento estereopsis. Conclusiones: El tratamiento médico y el combinado de médico más inyección de toxina botulínica y cirugía de músculos extraoculares fueron las opciones más utilizadas y permitieron alineamiento ocular y eliminación de la diplopía binocular(AU)

Objective: To determine outcomes of treatment options for binocular diplopia in patients with oculomotor paresis or paralysis. Method: A descriptive, longitudinal and prospective study was carried out of a series of cases that were assisted at the consultation of the Pediatric Ophthalmology Service at Ramón Pando Ferrer Cuban Institute of Ophthalmology. The variables evaluated were age, sex, etiology, treatment options, limitation of ocular movements, elimination of diplopia, fusion and stereopsis. Results: The microvascular etiology was the most frequent. 66.7 percent of the studied sample was resolved only with medical treatment, 100.0 percent of them had a diagnosis of paresis or paralysis of the third cranial nerve, followed by the sixth and fourth with 63.6 percent and 33.3 percent, respectively. Six patients required medical and surgical treatment and application of botulinum toxin, 33.3 percent of the fourth and 22.7 percent of the sixth cranial nerve. The rest of the treatment options with only one patient. No significant association was found between treatment options and affected cranial nerve. 86.6 percent finished without limitation of eye movements. 86.7 percent of cases eliminated diplopia in all diagnostic gaze positions. 76.7 percent achieved fusion and 56.7 percent stereopsis. Conclusions: Medical treatment and combined medical treatment plus botulinum toxin injection and extraocular muscle surgery were the most used options and allowed ocular alignment and elimination of binocular diplopia(AU)

Entrapment of the inferior oblique and inferior rectus muscles in orbital trapdoor fracture.

A 10-year-old male presented to our institution 6 days after sustaining trauma to his right eye from a fall. A thorough physical examination could not be done due to severe eye pain and inability to open the eyelids; however, computed tomographic imaging done at this time showed a trapdoor fracture with incarceration of the inferior oblique and inferior rectus muscles. The fracture was reduced through a transconjunctival incision and secured with a polytetrafluoroethylene implant. Three months after the surgery, extraocular motility is almost full and equal.

Medial Rectus Anastomosis Under Endoscopic Endonasal Orbital Approach With Image-Guided Navigation: A New Way of Repairing a Ruptured Medial Rectus.

BACKGROUND: With the extensive development of endoscopic sinus surgery, iatrogenic medial rectus muscle injury should be treated with caution. Traditional methods to repair a ruptured medial rectus need an anterior orbitotomy approach, with more injury and difficulty in finding the posterior end of the ruptured medial rectus. OBJECTIVE: To explore a new method to repair a ruptured medial rectus. METHODS: Eight cases of iatrogenic medial rectus rupture after endoscopic sinus surgery were reviewed from July 2015 to January 2019. Assisted by image-guided navigation, the ruptured medial rectus was sutured under an endoscopic endonasal orbital approach. Two methods were designed to suture the ruptured medial rectus. Optic nerve and orbital decompression were performed in 5 cases with visual impairment. The extent of exotropia and diplopia were followed up for 5 to 33 months after surgery. RESULTS: With the help of image guidance, the posterior and anterior ends of the ruptured medial rectus of all patients were pinpointed, and operations using medial rectus anastomosis were successfully completed in 7 patients. The exotropia of these patients was corrected, and they have recovered. The vision of 2 patients recovered. There were no minor or major complications intraoperatively or postoperatively. CONCLUSION: Assisted by image-guided navigation, medial rectus anastomosis under an endoscopic endonasal orbital approach is a feasible method. The key to preventing orbital complications is strict professional training, including identification of the Onodi air cell and correct application of powered instrumentation.

Lateral Rectus Muscle Injury During Double-Headed Pterygium Surgery: A Rare Complication.

A 43-year-old man developed double vision, esotropia, and abduction limitation after excision of a doubleheaded pterygium. Exploration during strabismus surgery 4 months later revealed a partially severed lateral rectus muscle and extensive conjunctival scarring. Direct injury to the lateral rectus muscle during pterygium surgery is extremely rare. Prevention and management strategies are discussed. [J Pediatr Ophthalmol Strabismus. 2020;57:e96-e99.].

Foreign body extrusion associated with N-butyl-2-cyanoacrylate glue used with rectus muscle hang-back recession.

OBJECTIVE: Standard rectus muscle recessions require suturing muscle to sclera posterior to the insertion, which is dangerous as the sclera is thin. Extraocular muscle hang-back recession can avoid the posterior scleral needle pass but has been reported to be unstable. The purpose of this study is to assess the use of N-butyl-2-cyanoacrylate to aid reattachment of rectus muscle to sclera during hang-back recession. DESIGN: 2 Phase Study: Phase 1 was a wet lab animal study; Phase 2 was a small case series. PARTICIPANTS: Phase 1, 14 frozen bank rabbit heads; Phase 2, 4 human adult patients with myopia and large exotropia. METHODS: Phase 1: Frozen bank rabbit heads were used to simulate human hang-back rectus muscle recession. Fourteen rectus muscles were recessed by hang-back and glued to sclera with either cyanoacrylate glue alone (group 1) or glue over prolene mesh for greater stability (group 2). Primary outcome was muscle detachment force measured at 20, 30, and 40 seconds. Phase 2: Four patients with myopia and large exotropia who underwent bilateral hang-back lateral rectus recessions with cyanoacrylate glue were retrospectively studied. RESULTS: Phase 1: Group 1 mean detachment force measured at 30 seconds was 172.07 g versus 376.5 g in group 2 (p < 0.01). Phase 2: All patients had excellent postoperative alignment within 5 PD of orthophoria and no overcorrections. Two patients had unilateral glue extrusion at 1 month requiring in-office removal under topical anaesthesia. CONCLUSIONS: Cyanoacrylate glue with or without mesh resulted in adequate muscle-to-sclera adhesion with a detachment force at least 2 times the force of a normal rectus muscle contraction. Patients undergoing hang-back lateral rectus recession with cyanoacrylate glue had excellent stable postoperative alignment; however, half had the complication of late extrusion of glue foreign body.

Oculocardiac Reflex in a Pediatric Trauma Patient.

We describe the case of a 6-year-old boy who presented to a tertiary care emergency department after a motor vehicle accident with facial trauma and bradycardia. The patient was found to have an orbital floor fracture and inferior rectus muscle entrapment with resulting bradycardia secondary to the oculocardiac reflex. The oculocardiac reflex is an uncommon cause of bradycardia in the setting of trauma but should be considered because it can necessitate surgical intervention.

Trauma palpebral severo / Severe palpebral trauma

RESUMEN La ubicación anatómica de los párpados los predispone a ser dañados frecuentemente por causas traumáticas. Se informa la evolución de un paciente masculino, de 22 años de edad, remitido a la Consulta de Urgencia del Instituto Cubano de Oftalmología "Ramón Pando Ferrer" por presentar trauma palpebral grave en su ojo izquierdo producido por un alambre. Al examen oftalmológico se constató colgajo extenso del párpado superior, que colgaba fijado de la porción temporal. Se comprobó herida horizontal de la aponeurosis del elevador del párpado superior, de bordes anfractuosos, que se extendía a todo el párpado, así como sección del canalículo superior. Se confirmó el diagnóstico de herida avulsiva grave, con afectación del borde libre palpebral y sección del canalículo superior. Se decidió la conducta quirúrgica: reconstrucción palpebral, que incluyó aponeurosis del músculo elevador del párpado superior, canalículo superior con sonda bicanalicular y borde libre palpebral. Durante el seguimiento se constataron buenos resultados estéticos y funcionales. El conocimiento de la anatomía palpebral y una reconstrucción minuciosa de los tejidos palpebrales permiten resultados posquirúrgicos excelentes en un trauma palpebral grave(AU)

ABSTRACT The anatomical location of the eyelids predisposes them to be frequently damaged by traumatic causes. The evolution of a patient aged 22 years is reported, who was referred at Ramón Pando Ferrer Cuban Institute of Ophthalmology for presenting severe eyelid trauma in his left eye caused by a wire. The ophthalmological examination showed a large flap of the upper eyelid, which hung fixed from the temporal portion. Horizontal wound of the aponeurosis of the upper eyelid elevator, with an abnormal fracture, which extended to the entire eyelid, as well as section of the upper canaliculus, was found. The diagnosis of severe avulsive wound was confirmed, with involvement of the palpebral free edge and section of the upper canaliculus. Surgical behavior was decided: eyelid reconstruction, which included aponeurosis of the upper eyelid lift muscle, upper canaliculus with bicanalicular probe and palpebral free edge. During the follow-up, good aesthetic and functional results were observed. The knowledge of the eyelid anatomy and a thorough reconstruction of the eyelid tissues allow excellent post-surgical results in severe eyelid trauma(AU)

Post traumatic retinal injuries: Does the ocular protective reflex play a crucial role?

Traumatic retinal injuries are commonly encountered in most retinal subspecialty clinics. Retinal dialysis, detachment and other complications consequent to blunt trauma are often thought to be due to equatorial expansion of the globe following an antero-posterior compressive force. However, stretching of the globe along the primary anatomical equator may not hold true for the adjusted globe position as a consequence of the protective Bell's phenomenon which gets activated before impact. The upward and outward rolling of the globe likely creates a new equator, with the compressive forces acting along this new plane, thereby leading to stretching along the ocular coats closer to the retinal periphery. Additionally, the coup and countercoup mechanisms with increased vulnerability of temporal sclera predisposes to retinal complications more commonly along the temporal and the nasal retina. Further, retinal complications involving other quadrants can also be explained through understanding of the Bell's phenomenon.

Persistent visual disturbances after concussion.

BACKGROUND: Ocular dysfunction, including eye movement defects, has been documented in up to 69% of patients with concussion. However, standard sports-related concussion assessment protocols do not typically include any clinical examination of the ocular system. OBJECTIVE: The aim of this article is to inform general practitioners (GPs) about ocular defects associated with concussion, identify test procedures and highlight the important role of GPs within the concussion paradigm. DISCUSSION: Ocular dysfunction that commonly occurs with concussion includes abnormalities of accommodation, convergence, saccades and smooth pursuits. This may cause blurred vision, double vision, ocular pain and difficulty with close work. Symptoms can severely affect daily work, school or play activities. Patients complaining of extended ocular symptoms following concussion should be referred to an ophthalmologist for a complete ocular assessment.

Challenging Surgical Approach to a Lost Inferior Rectus Muscle Following Penetrating Orbital Trauma.

A 37-year-old man suffered a penetrating left orbital injury with rupture of the inferior rectus muscle and avulsion of the optic nerve. The orbit was explored and the inferior rectus muscle stump was identified 25 mm from the limbus. Despite this, the muscle was successfully reattached and the patient achieved satisfactory postoperative alignment. [J Pediatr Ophthalmol Strabismus. 2019;56:e49-e52.].

Complete Inferior Rectus Transection Following Blunt Trauma: A Case Report and Novel Approach to Surgical Repair.

Inferior rectus avulsion following blunt trauma is rare, with even fewer reported cases of complete transection. The authors report a case of orbital floor fracture and inferior rectus muscle transection without herniation following blunt orbital trauma. This case first highlights the difficulty in diagnosing complete inferior rectus muscle transection clinically and with imaging and second that an acceptable functional outcome can be achieved by a novel surgical repair approach utilizing contiguous orbital anatomical relations of the inferior oblique and inferior rectus muscles.

What decides the nature of extraocular muscle injury? The probable mechanism of flap tear and rupture.

The assessment of nature and the extent of extraocular muscle injuries during initial visit in ocular emergencies is of paramount importance to avoid/minimize the subsequent need for strabismus surgery. Based on our experience in managing acute globe and orbital injuries and cases of strabismus, we propose the probable mechanism involved in the occurrence of extraocular muscle flap tear and a complete rupture of the muscle. During high-velocity injuries when the forces are equally transmitted along the orbital bony framework and the globe, then due to differential shearing forces created between the global and the orbital fibres leads to a flap tear. In the second scenario, if the forces are only directed along the bony framework, then the globe continues to be in continuous motion leading to increased tension between the muscles and the globe. Thus the weaker portions between these two structures are at risk of complete separation, that is along the insertion of muscle onto the globe or the musculotendinous portion.

Inadvertent inferior oblique extirpation during orbital decompression.

PURPOSE: To report a case of inadvertent inferior oblique extirpation during orbital decompression, its management, and postoperative result. METHODS: A 38-year-old female with thyroid eye disease underwent cosmetic right orbital decompression during whichinferior oblique extirpation was noticed. RESULT: The muscle was repaired on the same session (illustrated in the article) with no postoperative diplopia at 3-month follow-up. CONCLUSION: Inferior oblique injury should be considered among the uncommon yet important complications of orbital decompression. It can be easily found and repaired in the same session as demonstrated in this case report.

Isolated Superior Rectus Muscle Hematoma Following Blunt Orbital Trauma.

Isolated ocular muscle hematoma due to blunt trauma is very rare. In this study, a 15-year-old patient presented with an isolated superior rectus hematoma due to an orbital hit from a cellular phone. He was treated with oral corticosteroids alone. Marked improvement in symptoms and eye movements was observed.

Zygomatic dental implant induced orbital fracture and inferior oblique trauma.

A 51-year-old female underwent four upper zygomatic dental implants (ZI) and one upper and four lower conventional implants. Immediately postoperatively, the patient had pain and diplopia upon manual elevation of the edematous eyelid. Panoramic x-ray showed a malpositioned right upper ZI, requiring removal of the right upper ZI the following day. The patient had delayed referral to ophthalmology one month later for persistent diplopia. Computed tomography scan and magnetic resonance imaging demonstrated a right inferolateral fracture with fibrosis surrounding the inferior oblique muscle. Clinical exam showed right lower eyelid retraction, right hypotropia, and inability to elevate in adduction, consistent with a right inferior oblique paresis. Surgical exploration revealed incarceration of lid and orbital tissue into the fracture. After repositioning of the prolapsed tissue, a high-density porous polyethylene implant was placed for fracture repair. The inferior fornix was reconstructed with amniotic membrane and 5-fluorouracil was injected into the scar tissue. Six months later, the patient underwent strabismus surgery with resolution of symptoms.

Delayed surgical treatment of orbital trapdoor fracture in paediatric patients.

BACKGROUND: Trapdoor fracture is a special type of orbital blowout fracture. Although early surgery is recommended, there still remain some patients delayed by various reasons. In this study, we analysed the clinical characteristics of delayed paediatric patients, especially those with different levels of ocular motility restriction before surgery. METHODS: Thirty patients (3 to 14 years old) who underwent delayed surgery for trapdoor fractures between January 2008 and September 2016 were enrolled. Their demographics, causes of injury and delay, clinical features, imaging data and follow-up information were collected. RESULTS: Muscular entrapment was found in 17 patients (group A) and soft-tissue entrapment in 13 patients (group B). 12 (7 in group A) presented with severe motility restriction and 18 (10 in group A) with mild restriction before surgery. 41.7% with severe restriction recovered after surgery, compared with 83.3% with mild restriction. Four (23.7%) in group A (all with severe restriction) and six (46.2%) in group B (half with severe restriction) presented with persistent diplopia. CONCLUSIONS: Long recovery time and a high percentage of persistent diplopia are the main problems of delayed trapdoor fracture in children. A prompt surgery within 48 hours is strongly recommended in patients with muscular entrapment even if an urgent treatment is hard to achieve. So are patients with soft-tissue entrapment and significant motility restriction. In the other patients without such indications, even though some recovery might be possible in the long term, a prompt surgery right after diagnosis is still preferable regardless of the entrapped contents.

Autophagy in Zebrafish Extraocular Muscle Regeneration.

Zebrafish extraocular muscles regenerate after severe injury. Injured myocytes dedifferentiate to a mesenchymal progenitor state and reenter the cell cycle to proliferate, migrate, and redifferentiate into functional muscles. A dedifferentiation process that begins with a multinucleated syncytial myofiber filled with sarcomeres and ends with proliferating mononucleated myoblasts must include significant remodeling of the protein machinery and organelle content of the cell. It turns out that autophagy plays a key role early in this process, to degrade the sarcomeres as well as the excess nuclei of the syncytial multinucleated myofibers. Because of the robustness of the zebrafish reprogramming process, and its relative synchrony, it can serve as a useful in vivo model for studying the biology of autophagy. In this chapter, we describe the surgical muscle injury model as well as the experimental protocols for assessing and manipulating autophagy activation.