Extraocular muscle injury during endoscopic sinus surgery: an ophthalmologic perspective

Simplification of the complex: Successful management of large-angle exodeviation after endoscopic sinus surgery

PURPOSE

To report the clinical characteristics and successful management of large-angle exodeviation due to medial rectus muscle (MR) transection incurred during endoscopic sinus surgery (ESS).

METHODS

The medical records of 5 consecutive inpatients with MR complete transection following ESS resulting in large-angle paralytic exodeviation between November 2014 and June 2021 were reviewed. The type of muscle injury, clinical characteristics, surgical procedure and dosage, and long-term outcomes were evaluated.

RESULTS

All 5 patients manifested exodeviations of 72 PD to >133 PD with no adduction capacity (graded -4); all of them had proven orbital trauma and complete MR transection with a ≥20 mm distal (globe attached) stump based on CT scans and/or MRI imaging. They underwent a supra-maximal recession (10-12 mm) of the lateral rectus and resection (10-15 mm) of the medial rectus on the affected eye. At least 1 year (1 to 5 years) following the corrective surgery, the patients still maintained orthophoria or had a small angle of exotropia (≤ 8 PD) in primary gaze with successful fusion, and 3 of them (Case 3, 4, and 5) exhibited a certain degree of stereopsis. In addition, appreciable adduction occurred (graded -1 to -3).

CONCLUSIONS

A supra-maximal recession/resection shows favorable outcomes in patients with proven complete transection MR with a ≥20 mm distal (globe attached) stump. It can help to achieve good ocular alignment and even yield improvements in adduction over time.

Temporalis Fascia for the Management of Medial Rectus Damage Secondary to Endoscopic Sinus Surgery: A Case Report

Purpose:

To report a challenging case of medial rectus (MR) damage secondary to endoscopic sinus surgery (ESS).

Methods:

A 37-year-old woman presented with diplopia, exotropia, and adduction deficit of the right eye due to the right MR injury secondary to the ESS.

Results:

As a stepwise approach, she respectively underwent repairing of the damaged MR plus ipsilateral lateral rectus recession, half-tendon vertical rectus transposition to the MR insertion, and eventually nasal globe fixation with temporalis fascia that ultimately provided a single vision in the primary position with orthophoria.

Conclusions:

Re-establishment of an acceptable field of a single binocular vision in the context of iatrogenic MR injury is challenging and often requires multiple step-wise operations. Temporalis fascia is a safe and strong autogenous material, which can be used for globe fixation in this setting.

Aetiology, clinical features and surgical outcomes of isolated medial rectus palsy

IMPORTANCE

Isolated medial rectus palsy is extremely rare in clinical practice.

BACKGROUND

To report demographics, aetiology, clinical findings, imaging features and surgical outcomes in patients with isolated medial rectus palsy.

DESIGN

Retrospective study.

PARTICIPANTS

All patients treated for isolated medial rectus palsy at Zhongshan Ophthalmic Center, Sun Yat-sen University, between September 2003 and March 2019.

METHODS

Review of patient records.

MAIN OUTCOME MEASURES

Aetiology, clinical findings, imaging features and surgical outcomes.

RESULTS

A total of 32 patients (22 males, 10 females) were included. Mean age was 33.19 ± 19.78 years. The right eye was involved in 17 patients, the left eye was involved in 14 patients, and both eyes were involved in one patient. The most common causes were iatrogenic injury (43.75%), followed by trauma (37.50%) and congenital (18.75%). The most common clinical findings included outward deviation, diplopia and limited adduction. Six patients showed combined small-angle vertical strabismus, and 10 patients experienced a scale of -1 motility defect in other directions. After individualized strabismus surgery, preoperative exotropia of 60 ± 25 prism diopters (PD) was significantly reduced to 12 ± 13 PD (t = 10.938, P < .0001). Ocular motility improved in 21 patients, and five patients achieved normal ocular motility. Successful correction was obtained in 20/32 (62.50%) patients, with under-correction in 12/32 (37.50%) patients. Twenty-eight patients had only one surgery, three patients had two surgeries and one patient had three surgeries.

CONCLUSIONS AND RELEVANCE

The most common cause of isolated medial rectus palsy was local injury. Satisfactory results were obtained after individualized surgical interventions based on personalized preoperative evaluations.

Should Oral Corticosteroids be Used in Medical Therapy for Chronic Rhinosinusitis? A Risk Analysis

OBJECTIVES

Oral corticosteroid (OCS) as a part of appropriate medical therapy (AMT) (formerly maximal medical therapy) in chronic rhinosinusitis remains controversial. While the risks of OCS are well known, the benefit remains unclear due the absence of a standardized prescribing regimen. Consequently, it is difficult to characterize whether the risks of OCS and its ability to avert endoscopic sinus surgery (ESS) are helpful in AMT. When OCS is highly effective at averting surgery, the lesser risks of OCS would be justified because it can avoid the greater risks of ESS. When OCS is poorly effective at averting ESS, the risks of OCS would not be justified because many patients will be exposed to both risks. This study seeks to identify the threshold effectiveness of OCS at averting ESS that would minimize risk exposure to patients.

METHODS

A probabilistic risks-based decision analysis was constructed from literature reported incidences and impacts of adverse events of OCS and ESS. Monte Carlo analysis was performed to identify the minimum effectiveness required to avoid further intervention (MERAFI) for chronic sinusitis without nasal polyp (CRSsNP) and chronic sinusitis with nasal polyp (CRSwNP).

RESULTS

The analysis showed MERAFI results of 20.8% (95% CI 20.7-20.9%) for CRSsNP and 16.8% (95% CI 16.7-16.9%) for CRSwNP.

CONCLUSIONS

Given reported OCS effectiveness in the range of 34-71% in CRSsNP and 46-63% in CRSwNP, this analysis suggests that the inclusion of OCS in AMT may be the lower risk strategy.

LEVEL OF EVIDENCE

N/A Laryngoscope, 131:473-481, 2021.

Medial rectus muscle loss: Is immediate lateral rectus disinsertion a solution? A case report with review of the literature

Purpose

To report a case of medial rectus (MR) muscle loss during the strabismus surgery with a late successful management and review of the literature.

Methods

The left MR was lost during resection in a 14-year-old girl who had undergone strabismus surgery elsewhere. The surgeon disinserted the antagonist lateral rectus (LR) muscle in the same session following unsuccessful attempts to retrieve the lost muscle. She was referred to our clinic two months later with a large angle exotropia and a complete lack of adduction. We performed a half-tendon transposition of vertical rectus muscles to the MR insertion and attached the residual fibers of the LR to the orbital periosteum.

Results

She was orthotropic after the surgery and remained stable until 6 months with a significant improvement of the adduction.

Conclusions

Simultaneous LR disinsertion is not a solution for MR loss. Half-tendon transposition of the vertical recti to the original insertion of the lost MR and periosteal fixation of the LR are good options as a second-stage operation in patients with MR loss during strabismus surgery.

Challenging Management of Double Vision After Functional Endoscopic Sinus Surgery-A Series of 6 Cases

PURPOSE

To present 6 cases of orbital trauma, diplopia and strabismus after functional endoscopic sinus surgery (FESS).

DESIGN

Retrospective observational case series.

METHODS

The medical charts of suitable patients were reviewed for information on medical examination, imaging studies, the type of corrective surgery, and surgical outcomes.

STUDY POPULATION

All patients with diplopia and strabismus after undergoing FESS who were treated or consulted at our institution between 2008 and 2017 were included.

MAIN OUTCOME MEASURES

The presence and extent of strabismus and double vision at the end of follow-up.

RESULTS

Six patients complained of diplopia after FESS; all of them had proven orbital trauma. In Cases 1-5, patients suffered medial rectus (MR) muscle transection and subsequent exotropia. Their prognosis was guarded despite prompt surgical intervention, and ranged from large exotropia when direct recovery of the MR was attempted, to primary gaze orthotropia but with minimal adduction capacity, during which vertical recti transposition was attempted. Patient 6 sustained transient diplopia, although all of his extraocular muscles appeared intact on imaging. His eye position and movement were completely resolved with conservative measures only.

CONCLUSIONS

Our experience was that immediate recovery procedures to reattach the muscle in cases with proven transection of the MR muscle are futile, and that definitive corrective strabismus surgery (ie, vertical muscle transposition) has a better chance to achieve favorable results.