Strabismus, 2013; 21(4): 225–229 ! Informa Healthcare USA, Inc. ISSN: 0927-3972 print / 1744-5132 online DOI: 10.3109/09273972.2013.833955
A conventional strabismus surgical approach for lost medial rectus muscles Halil Ibrahim Altinsoy, MD1, Osman Melih Ceylan, MD1, Fatih Mehmet Mutlu, MD1, and Gokcen Gokce, MD2 Department of Ophthalmology, Gulhane Military Medical Academy & Medical School, Ankara, Turkey and 2 Department of Ophthalmology, Sarikamis Military Hospital, Kars, Turkey
ABSTRACT We present 3 cases of successful conventional strabismus surgery to retrieve lost medial rectus (MR) muscles. In all cases the lost MR muscle was retrieved and re-attached to the intended scleral point. Two patients had residual exotropia, while the third case was orthophoric after surgery. The retrieval of lost MR muscle using conventional strabismus surgery technique can be successfully achieved if the lost MR muscle is recognized early and the re-operation is performed by an experienced surgeon. Keywords: Lost muscle, reoperation, strabismus surgery
INTRODUCTION
Preoperative and postoperative evaluation included the angle of deviation in the prism diopters (PD) as measured by the prism and cover test at near and distance, and duction limitations were graded on a scale of 1 to 4 ( 4, no movement beyond the midline; 3, 25% of movement remained; 2, 50% of movement remained; and 1, 75% of movement remained).5 All of the cases were evaluated with computerized tomography (CT). Two patients underwent reoperation on the first day, and one patient 1 week after the previous strabismus surgery. Two of the patients underwent reoperation under local anesthesia, and one (aged 8 years) had repeat surgery under general anesthesia. Using an operating microscope, the same surgeon (HIA) performed all of the reoperations.
A lost rectus muscle is one that has completely detached from the globe and has retracted through the posterior Tenon’s capsule. Rectus muscles can be lost due to trauma or surgery, including sinus surgery, strabismus surgery, and other ocular surgeries.1-3 Medial rectus (MR) muscles lost during strabismus surgery are rarely found.4 A lost MR muscle is usually expected in the presence of an overcorrection after esotropia (ET) surgery or undercorrection after exotropia (XT) surgery, resulting in limited duction in the field of action of the muscle. We present 3 cases of successful conventional strabismus surgery to retrieve lost MR muscles.
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1
MATERIALS AND METHODS Case Reports Data collection and study performance conformed to the institutional ethics review board-approved protocol and were compliant with the principles of the Declaration of Helsinki. The mean age of the patients was 17.6 8.5 (21, 24, 8) years. All patients had undergone horizontal rectus muscle surgery.
Case 1 A 21-year-old man who had undergone a left lateral rectus (LR) recession of 7 mm and an MR resection of 6 mm to correct 35 PD constant XT was referred to our department. The best corrected visual acuity (BCVA)
Received 7 November 2012; Accepted 15 June 2013; Published online 24 October 2013 Correspondence: Osman Melih Ceylan, Gulhane Military Medical Academy & Medical School, Department of Ophthalmology, Ankara, Turkey. Tel: +903123045872. E-mail: [email protected]
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226 H. I. Altinsoy et al. was 1.0 (Snellen Chart) for both eyes. The patient had diplopia that was worse in the right gaze. In the patient history, while the resected MR muscle was being resutured at the original insertion, the sutures broke, and the MR was lost. Postoperatively, the patient had a 30 PD left XT at near and 45 PD left XT at distance. The limitation of adduction in the left eye was 4. By CT, the MR muscle was located behind the equator and adjacent to the medial wall of the orbit. The patient underwent exploration through the previous limbal conjunctival incision 1 day after the initial surgery. The left MR muscle was retracted behind the posterior Tenon’s capsule. The dehisced muscle tissue was identified and advanced to the original anatomical location using a 6-0 vicryl suture. At the 3-month follow-up, the patient had a residual 12 PD XT and no limitation of adduction. Case 2 A 22-year-old man who had a history of strabismus surgery due to constant XT was referred to our department. The patient’s previous surgical history was unavailable because the referring surgeon did not send a postsurgical report and could not discuss the patient on the phone. The BCVA was 1.0 (Snellen Chart) for both eyes. The patient had diplopia that was worse in the left gaze. The patient may have previously undergone right LR recession and MR resection. Postoperatively, the patient had a 70 PD right XT at near and 80 PD right XT at distance. Adduction of the right eye was limited at 4. The patient underwent exploration 1 day after the previous surgery through a limbal conjunctival incision. The lost MR muscle was identified in the subtenon space at the level of the equator and then re-attached to the original anatomical insertion. The intraoperative forced duction test illustrated a 3 limitation to adduction. After surgical exploration of the right LR muscle, the LR was found in its original insertion with the sutures. However, the LR might have been resected or sutured to the original insertion after the loss of the MR by a surgeon who feared a malpractice lawsuit; we could not determine the exact procedure. We performed an 8-mm LR recession to correct the adduction limitation and XT. At the 1-month followup, the patient was still 30 PD XT at distance and near with a 2 adduction limitation. One month later, the contralateral left LR was recessed 7 mm, and the left MR was resected 5 mm for the residual XT. At the 3-month follow-up, the patient had a residual 15 PD XT and a 1 limitation of adduction in the right eye. Case 3 An 8-year-old girl was referred to our department 1 week after undergoing right LR resection (8.5 mm) and MR recession to correct 50 PD ET. According to the patient’s surgical history, the MR muscle
was lost intraoperatively when the sutures holding it broke. After this surgery, she had a 30 PD right XT at near and 35 PD right XT at distance. The BCVA was 1.0 (Snellen Chart) for both eyes. She had a 4 limitation of adduction of the right eye. The patient underwent an MR exploration through the previous limbal conjunctival incision. The lost MR muscle was identified in the subtenon space, and the muscle was reattached with a 5.5-mm recession to the intended point to provide orthophoria. At the 6-month followup, the patient was orthophoric in the primary position without any limitation of adduction.
DISCUSSION The retrieval of lost MR muscles is more difficult than the retrieval of other lost rectus muscles. The MR muscle has the greatest risk of slippage and loss because it does not have fascial attachments to the oblique muscles, unlike the superior, lateral, and inferior rectus muscles.6 Plager and Parks reported that 10% of lost MR rectus muscles were retrievable, while 67% of other extraocular muscles were retrievable. Reoperation on a patient within 10 days of the original surgery prevents contracture of the lost muscle.3,7 In our case series, cases 1 and 2 underwent reoperation 1 day after the previous surgery. Case 3 underwent reoperation 1 week after the initial surgery. We believe that performance of the exploration surgery within the early time period recommended in the literature was an important factor for either finding and retrieving the lost MR muscle or preventing muscle contracture. Preoperative CT imaging is helpful for the localization of the lost muscle during both early and late periods.2-3 Magnetic resonance imaging can also help locate the lost muscle when CT cannot reveal the position. However, radiologic imaging does not guarantee a successful surgery. A lost MR muscle can retract within the muscle sheath that is connected to the intermuscular membrane both above and below the MR muscle. Particular attention should be paid to identifying the intermuscular membrane and sheath and avoiding cutting them. A lost MR muscle may not always be located behind the posterior Tenon’s capsule. Often, the MR muscle can be found inside the sheath if appropriate retractors (Helveston Barbie Retractor) are used to adequately display the muscle. Furthermore, if it is identified sufficiently early, there might be sutures in the lost muscle that can facilitate its retrieval. However, no sutures were identified in any of our cases. Even if the lost muscle is retrieved and re-attached, in some cases, additional strabismus surgery will be required for the residual deviation.2 In this study, additional strabismus surgery was only required for the second case. Strabismus
Strabismus Downloaded from informahealthcare.com by Universitat de Girona on 11/17/14 For personal use only.
Surgical Approach of Lost Medial Rectus
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FIGURE 1. a) Case 1; preoperative left XT with lost left MR muscle. b) Case 1; third day after the surgical correction of the lost left MR muscle. c) Case 1; orbital tomography-lost MR muscle (arrow).
FIGURE 2. (a) Case 2; preoperative right XT with lost right MR muscle. (b) Case 2; two months after the surgical correction of the lost right MR muscle and one month after the recession and resection surgery of the left eye. (c) Case 2; finding the lost muscle and reattaching it to the original insertion by the previous limbal incision. !
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228 H. I. Altinsoy et al.
FIGURE 3. a) Case 3; primary right ET before recession and resection surgery. b) Case 3; one week after the surgery results with lost MR muscle. c) Case 3; three weeks after the surgical correction of the lost right MR muscle.
Lost muscles are usually not accessible by conventional strabismus surgical approaches.8 Transconjunctival orbitotomy, transcutaneous medial orbitotomy, and the transnasal endoscopic approach have been described to rescue a lost rectus muscle.8,9,10,11 Transcaruncular incision is another technique to used access the medial extraconal orbit for a lost MR.12,13 Generally, the most commonly lost muscle is the MR, and a transcaruncular incision provides optimal access to the medial extraconal orbit.13 In this study, all of the exploration surgeries were performed on the muscle path by gentle dissection through the previous limbal incision. The success of the conventional strabismus approach is related to performing the exploration surgery early and avoiding extensive dissection to prevent fat adhesions and orbital scarring. Lost muscles were retrieved by identifying the muscle fibers using an operating microscope, without using additional techniques of conventional strabismus surgery. A Helveston Barbie Retractor is helpful to adequately expose the muscle during surgery. In the majority of cases, retrieving a lost muscle is comparably superior to a transposition procedure.14 Although Plager and Parks reported that, among different types of muscles, finding a lost MR muscle is the most difficult, lost MR muscles were found without any difficulty by early conventional (limbal approach) strabismus surgery in all of our cases. Successful conventional strabismus surgery for the management of lost muscles seems to depend on the earlier diagnosis and reoperation using an
operation microscope by an experienced strabismologist (Figure 1–3).
ACKNOWLEDGEMENTS This study was conducted in Gulhane Military Medical Academy & Medical School, Department of Ophthalmology, Ankara, Turkey. This study was approved by the Institutional Review Board of Gulhane Military Medical Academy and conformed to the requirements of the United States Health Insurance Portability and Privacy Act. This study was edited by American Journal Experts.
DECLARATION OF INTEREST The authors declare no conflicts of interest.
REFERENCES 1. Hamlet YJ, Goldstein JH, Rosenbaum JD. Dehiscence of the lateral rectus muscle following intrascleral buckling procedure. Ann Ophthalmol 1982;14:694–697. 2. Murray AD. Slipped and lost muscles and other tales of the unexpected. Philip Knapp Lecture. J AAPOS 1998;2: 133–143. 3. Plager DA, Parks MM. Recognition and repair of the ‘‘lost’’ rectus muscle. A report of 25 cases. Ophthalmology 1990;97: 131–137. Strabismus
Surgical Approach of Lost Medial Rectus
Strabismus Downloaded from informahealthcare.com by Universitat de Girona on 11/17/14 For personal use only.
4. MacEwen CJ, Lee JP, Fells P. Aetiology and management of the ‘detached’ rectus muscle. Br J Ophthalmol 1992;76: 131–136. 5. Ansons AM, Davies H. Diagnosis and Management of Ocular Motility Disorders. Oxford: Blackwell Science; 2001. 6. Lenart TD, Lambert SR. Slipped and lost extraocular muscles. Ophthalmol Clin North Am 2001;14:433–442. 7. Moen C, Marsh IB. Inferior oblique syndrome: an underrecognized complication of strabismus surgery. Eye 1998; 12:970–972. 8. Srivastava SK, Reichman OS, Lambert SR. The use of an image guidance system in retrieving lost medial rectus muscles. J AAPOS 2002;6:309–314. 9. Kennedy DW, Goodstein ML, Miller NR, et al. Endoscopic transnasal orbital decompression. Arch Otolaryngol Head Neck Surg 1990;116:275–282.
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10. Lenart TD, Reichman OS, McMahon SJ, Lambert SR. Retrieval of lost medial rectus muscles with a combined ophthalmologic and otolaryngologic surgical approach. Am J Ophthalmol 2000;130:645–652. 11. Underdahl JP, Demer JL, Goldberg RL, Rosenbaum AL. Orbital wall approach with preoperative orbital imaging for identification and retrieval of lost or transected extraocular muscles. J AAPOS 2001;5:230–237. 12. Balch KC, Goldberg RA, Green J, Shorr N. The transcaruncular approach to the medial orbit and ethmoid sinus. Facial Plast Surg Clinics North Am 1998;6:41–58. 13. Shorr N, Baylis HI, Goldberg RA, Perry JD. Transcaruncular approach to the medial orbit and orbital apex. Ophthalmology 2000;107:1459–1463. 14. Goldberg RA. Is there a ‘‘lost’’ rectus muscle in strabismus surgery? Am J Ophthalmol 2001;132:101–103.
A conventional strabismus surgical approach for lost medial rectus muscles Halil Ibrahim Altinsoy, MD1, Osman Melih Ceylan, MD1, Fatih Mehmet Mutlu, MD1, and Gokcen Gokce, MD2 Department of Ophthalmology, Gulhane Military Medical Academy & Medical School, Ankara, Turkey and 2 Department of Ophthalmology, Sarikamis Military Hospital, Kars, Turkey
ABSTRACT We present 3 cases of successful conventional strabismus surgery to retrieve lost medial rectus (MR) muscles. In all cases the lost MR muscle was retrieved and re-attached to the intended scleral point. Two patients had residual exotropia, while the third case was orthophoric after surgery. The retrieval of lost MR muscle using conventional strabismus surgery technique can be successfully achieved if the lost MR muscle is recognized early and the re-operation is performed by an experienced surgeon. Keywords: Lost muscle, reoperation, strabismus surgery
INTRODUCTION
Preoperative and postoperative evaluation included the angle of deviation in the prism diopters (PD) as measured by the prism and cover test at near and distance, and duction limitations were graded on a scale of 1 to 4 ( 4, no movement beyond the midline; 3, 25% of movement remained; 2, 50% of movement remained; and 1, 75% of movement remained).5 All of the cases were evaluated with computerized tomography (CT). Two patients underwent reoperation on the first day, and one patient 1 week after the previous strabismus surgery. Two of the patients underwent reoperation under local anesthesia, and one (aged 8 years) had repeat surgery under general anesthesia. Using an operating microscope, the same surgeon (HIA) performed all of the reoperations.
A lost rectus muscle is one that has completely detached from the globe and has retracted through the posterior Tenon’s capsule. Rectus muscles can be lost due to trauma or surgery, including sinus surgery, strabismus surgery, and other ocular surgeries.1-3 Medial rectus (MR) muscles lost during strabismus surgery are rarely found.4 A lost MR muscle is usually expected in the presence of an overcorrection after esotropia (ET) surgery or undercorrection after exotropia (XT) surgery, resulting in limited duction in the field of action of the muscle. We present 3 cases of successful conventional strabismus surgery to retrieve lost MR muscles.
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1
MATERIALS AND METHODS Case Reports Data collection and study performance conformed to the institutional ethics review board-approved protocol and were compliant with the principles of the Declaration of Helsinki. The mean age of the patients was 17.6 8.5 (21, 24, 8) years. All patients had undergone horizontal rectus muscle surgery.
Case 1 A 21-year-old man who had undergone a left lateral rectus (LR) recession of 7 mm and an MR resection of 6 mm to correct 35 PD constant XT was referred to our department. The best corrected visual acuity (BCVA)
Received 7 November 2012; Accepted 15 June 2013; Published online 24 October 2013 Correspondence: Osman Melih Ceylan, Gulhane Military Medical Academy & Medical School, Department of Ophthalmology, Ankara, Turkey. Tel: +903123045872. E-mail: [email protected]
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226 H. I. Altinsoy et al. was 1.0 (Snellen Chart) for both eyes. The patient had diplopia that was worse in the right gaze. In the patient history, while the resected MR muscle was being resutured at the original insertion, the sutures broke, and the MR was lost. Postoperatively, the patient had a 30 PD left XT at near and 45 PD left XT at distance. The limitation of adduction in the left eye was 4. By CT, the MR muscle was located behind the equator and adjacent to the medial wall of the orbit. The patient underwent exploration through the previous limbal conjunctival incision 1 day after the initial surgery. The left MR muscle was retracted behind the posterior Tenon’s capsule. The dehisced muscle tissue was identified and advanced to the original anatomical location using a 6-0 vicryl suture. At the 3-month follow-up, the patient had a residual 12 PD XT and no limitation of adduction. Case 2 A 22-year-old man who had a history of strabismus surgery due to constant XT was referred to our department. The patient’s previous surgical history was unavailable because the referring surgeon did not send a postsurgical report and could not discuss the patient on the phone. The BCVA was 1.0 (Snellen Chart) for both eyes. The patient had diplopia that was worse in the left gaze. The patient may have previously undergone right LR recession and MR resection. Postoperatively, the patient had a 70 PD right XT at near and 80 PD right XT at distance. Adduction of the right eye was limited at 4. The patient underwent exploration 1 day after the previous surgery through a limbal conjunctival incision. The lost MR muscle was identified in the subtenon space at the level of the equator and then re-attached to the original anatomical insertion. The intraoperative forced duction test illustrated a 3 limitation to adduction. After surgical exploration of the right LR muscle, the LR was found in its original insertion with the sutures. However, the LR might have been resected or sutured to the original insertion after the loss of the MR by a surgeon who feared a malpractice lawsuit; we could not determine the exact procedure. We performed an 8-mm LR recession to correct the adduction limitation and XT. At the 1-month followup, the patient was still 30 PD XT at distance and near with a 2 adduction limitation. One month later, the contralateral left LR was recessed 7 mm, and the left MR was resected 5 mm for the residual XT. At the 3-month follow-up, the patient had a residual 15 PD XT and a 1 limitation of adduction in the right eye. Case 3 An 8-year-old girl was referred to our department 1 week after undergoing right LR resection (8.5 mm) and MR recession to correct 50 PD ET. According to the patient’s surgical history, the MR muscle
was lost intraoperatively when the sutures holding it broke. After this surgery, she had a 30 PD right XT at near and 35 PD right XT at distance. The BCVA was 1.0 (Snellen Chart) for both eyes. She had a 4 limitation of adduction of the right eye. The patient underwent an MR exploration through the previous limbal conjunctival incision. The lost MR muscle was identified in the subtenon space, and the muscle was reattached with a 5.5-mm recession to the intended point to provide orthophoria. At the 6-month followup, the patient was orthophoric in the primary position without any limitation of adduction.
DISCUSSION The retrieval of lost MR muscles is more difficult than the retrieval of other lost rectus muscles. The MR muscle has the greatest risk of slippage and loss because it does not have fascial attachments to the oblique muscles, unlike the superior, lateral, and inferior rectus muscles.6 Plager and Parks reported that 10% of lost MR rectus muscles were retrievable, while 67% of other extraocular muscles were retrievable. Reoperation on a patient within 10 days of the original surgery prevents contracture of the lost muscle.3,7 In our case series, cases 1 and 2 underwent reoperation 1 day after the previous surgery. Case 3 underwent reoperation 1 week after the initial surgery. We believe that performance of the exploration surgery within the early time period recommended in the literature was an important factor for either finding and retrieving the lost MR muscle or preventing muscle contracture. Preoperative CT imaging is helpful for the localization of the lost muscle during both early and late periods.2-3 Magnetic resonance imaging can also help locate the lost muscle when CT cannot reveal the position. However, radiologic imaging does not guarantee a successful surgery. A lost MR muscle can retract within the muscle sheath that is connected to the intermuscular membrane both above and below the MR muscle. Particular attention should be paid to identifying the intermuscular membrane and sheath and avoiding cutting them. A lost MR muscle may not always be located behind the posterior Tenon’s capsule. Often, the MR muscle can be found inside the sheath if appropriate retractors (Helveston Barbie Retractor) are used to adequately display the muscle. Furthermore, if it is identified sufficiently early, there might be sutures in the lost muscle that can facilitate its retrieval. However, no sutures were identified in any of our cases. Even if the lost muscle is retrieved and re-attached, in some cases, additional strabismus surgery will be required for the residual deviation.2 In this study, additional strabismus surgery was only required for the second case. Strabismus
Strabismus Downloaded from informahealthcare.com by Universitat de Girona on 11/17/14 For personal use only.
Surgical Approach of Lost Medial Rectus
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FIGURE 1. a) Case 1; preoperative left XT with lost left MR muscle. b) Case 1; third day after the surgical correction of the lost left MR muscle. c) Case 1; orbital tomography-lost MR muscle (arrow).
FIGURE 2. (a) Case 2; preoperative right XT with lost right MR muscle. (b) Case 2; two months after the surgical correction of the lost right MR muscle and one month after the recession and resection surgery of the left eye. (c) Case 2; finding the lost muscle and reattaching it to the original insertion by the previous limbal incision. !
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228 H. I. Altinsoy et al.
FIGURE 3. a) Case 3; primary right ET before recession and resection surgery. b) Case 3; one week after the surgery results with lost MR muscle. c) Case 3; three weeks after the surgical correction of the lost right MR muscle.
Lost muscles are usually not accessible by conventional strabismus surgical approaches.8 Transconjunctival orbitotomy, transcutaneous medial orbitotomy, and the transnasal endoscopic approach have been described to rescue a lost rectus muscle.8,9,10,11 Transcaruncular incision is another technique to used access the medial extraconal orbit for a lost MR.12,13 Generally, the most commonly lost muscle is the MR, and a transcaruncular incision provides optimal access to the medial extraconal orbit.13 In this study, all of the exploration surgeries were performed on the muscle path by gentle dissection through the previous limbal incision. The success of the conventional strabismus approach is related to performing the exploration surgery early and avoiding extensive dissection to prevent fat adhesions and orbital scarring. Lost muscles were retrieved by identifying the muscle fibers using an operating microscope, without using additional techniques of conventional strabismus surgery. A Helveston Barbie Retractor is helpful to adequately expose the muscle during surgery. In the majority of cases, retrieving a lost muscle is comparably superior to a transposition procedure.14 Although Plager and Parks reported that, among different types of muscles, finding a lost MR muscle is the most difficult, lost MR muscles were found without any difficulty by early conventional (limbal approach) strabismus surgery in all of our cases. Successful conventional strabismus surgery for the management of lost muscles seems to depend on the earlier diagnosis and reoperation using an
operation microscope by an experienced strabismologist (Figure 1–3).
ACKNOWLEDGEMENTS This study was conducted in Gulhane Military Medical Academy & Medical School, Department of Ophthalmology, Ankara, Turkey. This study was approved by the Institutional Review Board of Gulhane Military Medical Academy and conformed to the requirements of the United States Health Insurance Portability and Privacy Act. This study was edited by American Journal Experts.
DECLARATION OF INTEREST The authors declare no conflicts of interest.
REFERENCES 1. Hamlet YJ, Goldstein JH, Rosenbaum JD. Dehiscence of the lateral rectus muscle following intrascleral buckling procedure. Ann Ophthalmol 1982;14:694–697. 2. Murray AD. Slipped and lost muscles and other tales of the unexpected. Philip Knapp Lecture. J AAPOS 1998;2: 133–143. 3. Plager DA, Parks MM. Recognition and repair of the ‘‘lost’’ rectus muscle. A report of 25 cases. Ophthalmology 1990;97: 131–137. Strabismus
Surgical Approach of Lost Medial Rectus
Strabismus Downloaded from informahealthcare.com by Universitat de Girona on 11/17/14 For personal use only.
4. MacEwen CJ, Lee JP, Fells P. Aetiology and management of the ‘detached’ rectus muscle. Br J Ophthalmol 1992;76: 131–136. 5. Ansons AM, Davies H. Diagnosis and Management of Ocular Motility Disorders. Oxford: Blackwell Science; 2001. 6. Lenart TD, Lambert SR. Slipped and lost extraocular muscles. Ophthalmol Clin North Am 2001;14:433–442. 7. Moen C, Marsh IB. Inferior oblique syndrome: an underrecognized complication of strabismus surgery. Eye 1998; 12:970–972. 8. Srivastava SK, Reichman OS, Lambert SR. The use of an image guidance system in retrieving lost medial rectus muscles. J AAPOS 2002;6:309–314. 9. Kennedy DW, Goodstein ML, Miller NR, et al. Endoscopic transnasal orbital decompression. Arch Otolaryngol Head Neck Surg 1990;116:275–282.
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10. Lenart TD, Reichman OS, McMahon SJ, Lambert SR. Retrieval of lost medial rectus muscles with a combined ophthalmologic and otolaryngologic surgical approach. Am J Ophthalmol 2000;130:645–652. 11. Underdahl JP, Demer JL, Goldberg RL, Rosenbaum AL. Orbital wall approach with preoperative orbital imaging for identification and retrieval of lost or transected extraocular muscles. J AAPOS 2001;5:230–237. 12. Balch KC, Goldberg RA, Green J, Shorr N. The transcaruncular approach to the medial orbit and ethmoid sinus. Facial Plast Surg Clinics North Am 1998;6:41–58. 13. Shorr N, Baylis HI, Goldberg RA, Perry JD. Transcaruncular approach to the medial orbit and orbital apex. Ophthalmology 2000;107:1459–1463. 14. Goldberg RA. Is there a ‘‘lost’’ rectus muscle in strabismus surgery? Am J Ophthalmol 2001;132:101–103.
