LATERAL RECTUS MUSCLE PARALYSIS ASSOCIATED W I T H CLOSED-HEAD TRAUMA EARL R. CROUCH, JR., M.D.,
AND MARTIN J. URIST,
M.D.
Chicago, Illinois T h e site of impaired innervation causing lateral rectus muscle paralysis after closedhead trauma is often difficult to determine. It may be supranuclear, involving the nucleus of the sixth cranial nerve, or involving the sixth nerve anywhere in its course. H o w ever, many patients with lateral rectus muscle paralysis after closed-head trauma have characteristic clinical findings that may in dicate the location of disturbed innervation.
findings were noted. Three cases were repre sentative of the group. C A S E REPORTS
Case 1—A 7-year-old girl complained of crossed eyes for one year after an automobile crash ; she had been unconscious for two months secondary to brain concussion. Initial examination revealed 45° of esotropia with the right eye fixing and 45° of right esotropia with the left eye fixing (Fig. 1). Lateral version reflexes indicated underaction of both lateral rectus muscles and bilateral laterally directed gaze palsy. Neither eye moved beyond the midline on attempted abduction. The palpebrai fissure widened in abduction and narrowed in adduction (pseudo-Duane's phenome non). At obliquely directed downgaze, the move ment of the eyes on outgaze was greater. Measure ment of Bell's phenomenon showed 5° of esotropia on upgaze. Five months after the initial injury, both medial rectus muscles were recessed 10 mm and both lateral rectus muscles were resected 10 mm. Postoperatively, the eyes were straight in the primary position (Fig. 2) ; there was no diplopia. On upgaze, she had 60° of exotropia, and in down gaze, 8 of esotropia. In obliquely directed poses (Fig. 3), versions showed normal action of the lateral rectus muscles at obliquely directed up- and outgaze with marked limitation of the medial rectus muscles at up- and ingaze. Obliquely directed down gaze showed marked limitation of the lateral rectus
M A T E R I A L AND METHODS
W e studied 21 patients with unilateral or bilaterial lateral rectus muscle paralysis after closed-head trauma. T h e patients were ob served for six months or more after correc tive strabismus surgery. W e measured devia tions in the primary position (Hirschberg method) and on extreme laterally and verti cally directed gaze ( T a b l e ) . M a x i m u m ex cursions on laterally directed gaze were re corded by Urist's 1 · 2 lateral version reflex method to provide a permanent photographic record of these extreme positions of gaze. I n patients with diplopia, we charted Lan caster diplopia fields and the graded W i r t figures to test fusion. Preoperative evaluation included data such as time of injury, period of unconsciousness, existence of evident diplopia, corrected visual acuity, and side of paralyzed muscle ( T a b l e ) . Deviation in de grees in the primary position, extreme up gaze a n d extreme downgaze, and diagnosis of gaze palsy were recorded. Bell's phenome non, fissure narrowing on adduction, fissure widening on abduction, oblique muscle move ments of the eyes, and positive neurologic From the Department of Ophthalmology, Uni versity of Illinois Eye and Ear Infirmary, Chicago, Illinois. Reprint requests to Earl Crouch, Jr., M.D., Uni versity of Illinois Eye and Ear Infirmary, 18SS W. Taylor St., Chicago, IL 60612.
Fig. 1 (Crouch and Urist). Case 1. Preoperative bilateral lateral rectus muscle paralysis with gaze palsy and pseudo-Duane's phenomenon. Top, With the left eye fixing, she has 4S° of right esotropia. Middle left, Lateral version reflex, right gaze: R.E., 8°; L.E., 45°. Middle right, Lateral version reflex, left gaze : R.E., 45° ; L.E., 0. Bottom left, 20° of esotropia on upgaze. Bottom right, 50° of esotropia on downgaze.
990
—
+ +
10 yr 13 yr
14 yr
2yr
Yes 11 days
3 days
45 min
Unknown Yes
3, 19 4.31
5.21
6.10
7,50 8.16
lyr 2yr
7yr 3yr
4 mo 16 yr 6 mo
5yr
8 days
28 days
4 days
Yes 2 days
30 min Yes
Unknown Unknown 2 days
3 wks
11,40
12,21
13,27
14,42 15, 32
16,8} 17,67
18,66 19, 16 20, 12
21.27
Bilateral LE Bilateral RE Bilateral Bilateral Bilateral Bilateral RE Bilateral LE Bilateral Bilateral RE Bilateral RE Bilateral Bilateral Bilateral Bilateral
20/20
20/25 20/20
20/20
20/20
20/20 20/20
20/25
20/20
20/20
20/40
20/20
20/30 20/20
20/20 20/25
20/20 20/20 20/20
20/25
20/30
20/20 20/20
20/15
20/25 20/25 20/20
20/20 20/20
20/30 20/30
20/20
20/20
20/20
20/20
20/30
20/20 20/20
20/20
20/20
Bilateral
20/20
20/20
Paralyzed Side LET 35° RET 25° LET 50° RET 50° ET 10° LET 25° RET 10° RET 20° LET 35° RET 25° LET 25° Orthophoric LET 15° RET 10° RET 45° LET 20° RET 12° LET 20° RET 50° LET 55° LET 20° RET 35° RET 20° LET 35° RET 50° RET 10° LET 15° RET 10° RET 20° LET 25° RET 25° RET 10° 0 with head turn ET 5° RET 25° LET 60°
Deviation!
10 mm 0
ET 15° VET ET 45°
XT 5° XT 5°
35° 15° 20° 5° 0 10 mm 0 35° 0 35° 20° ET 15° 25° 20°
0 ET 5° NVP ET 35° NVP ET 25° NVP ET 50° ET 35° VET ET 20° NVP ET 50° VET ET 15° NVP ET 10° NVP ET 25° VET ET 45° ET 5° VET ET 10° NVP ET 35° VET
XT 20° X T 5° ET 5° XT 10° ET 35° ET 20° XT 10° ET 35° XT 10° XT 5° ET 15° ET 25° XT 1° XT 10° ET 10°
5 mm
0
ET 35°
ET 5°
0
0
ET 60° NVP
XT to ET 20°
No picture
0
RE
0
25° 8 mm 8 mm
2 mm 10 mm
25° 10 mm
5 mm
20° ET
10°
10 mm
O
25° 5 mm
0
10 mm
0 45°
0
0
LE
Abduction
ET 45° VET
Down LE
5°
5° 15°
25°
35° 20° 20°
25° 45°
Bilateral
To right
Bilateral
Bilateral Bilateral
Bilateral
35°
45°
25° 25° 20°
20° 25°
Bilateral
Bilateral Bilateral Bilateral
Bilateral To right
To right To right
To right
5 mm To left
6 mm 35° 1 mm 30°
2 mm
45°
5 mm 35"
2 mm 25°
0
25° 15°
20°
To right
20° 45° 25°
To left Bilateral
Bilateral
Bilaterali
35° 20°
50°
45°
Gaze Palsy
25° 25°
50°
35°
RE
Adduction
Lateral Version Reflexes
ET 20°
Up
Deviation on Gazet
* ET signifies esotropia; LET, left esotropia; RET, right esotropia; VET, V esotropia; XT, exotropia; and NVP, neutralizing V pattern, t Hirschberg, in primary position. t Eye in ET position moves less than 35° in adduction and less than 10 mm from corneoscleral limbus on the sclera in abduction.
—
+ + +
2yr
+ + — + +
~-
—
+ + + + +
2yr
6 mo
lwk
Yes
9,15
10, 15
lyr
8 mo
1 yr 9 mo
—
lyr
2 mo
2.7
+
6hr
1,46
5 wks
Unconscious
Time Corrected visual Between Acuity Trauma and Dip lopia ■ Examina· LE RE tion
Case, Age (yr)
SUMMARY OF PATIENT DATA
TABLE*
S
C/3 C/3
r
>
>
5=d
M
π
C/i
d
C/5
H
Π
So M
M 50 > f
f
>
p Ov
oF
AND MARTIN J. URIST,
M.D.
Chicago, Illinois T h e site of impaired innervation causing lateral rectus muscle paralysis after closedhead trauma is often difficult to determine. It may be supranuclear, involving the nucleus of the sixth cranial nerve, or involving the sixth nerve anywhere in its course. H o w ever, many patients with lateral rectus muscle paralysis after closed-head trauma have characteristic clinical findings that may in dicate the location of disturbed innervation.
findings were noted. Three cases were repre sentative of the group. C A S E REPORTS
Case 1—A 7-year-old girl complained of crossed eyes for one year after an automobile crash ; she had been unconscious for two months secondary to brain concussion. Initial examination revealed 45° of esotropia with the right eye fixing and 45° of right esotropia with the left eye fixing (Fig. 1). Lateral version reflexes indicated underaction of both lateral rectus muscles and bilateral laterally directed gaze palsy. Neither eye moved beyond the midline on attempted abduction. The palpebrai fissure widened in abduction and narrowed in adduction (pseudo-Duane's phenome non). At obliquely directed downgaze, the move ment of the eyes on outgaze was greater. Measure ment of Bell's phenomenon showed 5° of esotropia on upgaze. Five months after the initial injury, both medial rectus muscles were recessed 10 mm and both lateral rectus muscles were resected 10 mm. Postoperatively, the eyes were straight in the primary position (Fig. 2) ; there was no diplopia. On upgaze, she had 60° of exotropia, and in down gaze, 8 of esotropia. In obliquely directed poses (Fig. 3), versions showed normal action of the lateral rectus muscles at obliquely directed up- and outgaze with marked limitation of the medial rectus muscles at up- and ingaze. Obliquely directed down gaze showed marked limitation of the lateral rectus
M A T E R I A L AND METHODS
W e studied 21 patients with unilateral or bilaterial lateral rectus muscle paralysis after closed-head trauma. T h e patients were ob served for six months or more after correc tive strabismus surgery. W e measured devia tions in the primary position (Hirschberg method) and on extreme laterally and verti cally directed gaze ( T a b l e ) . M a x i m u m ex cursions on laterally directed gaze were re corded by Urist's 1 · 2 lateral version reflex method to provide a permanent photographic record of these extreme positions of gaze. I n patients with diplopia, we charted Lan caster diplopia fields and the graded W i r t figures to test fusion. Preoperative evaluation included data such as time of injury, period of unconsciousness, existence of evident diplopia, corrected visual acuity, and side of paralyzed muscle ( T a b l e ) . Deviation in de grees in the primary position, extreme up gaze a n d extreme downgaze, and diagnosis of gaze palsy were recorded. Bell's phenome non, fissure narrowing on adduction, fissure widening on abduction, oblique muscle move ments of the eyes, and positive neurologic From the Department of Ophthalmology, Uni versity of Illinois Eye and Ear Infirmary, Chicago, Illinois. Reprint requests to Earl Crouch, Jr., M.D., Uni versity of Illinois Eye and Ear Infirmary, 18SS W. Taylor St., Chicago, IL 60612.
Fig. 1 (Crouch and Urist). Case 1. Preoperative bilateral lateral rectus muscle paralysis with gaze palsy and pseudo-Duane's phenomenon. Top, With the left eye fixing, she has 4S° of right esotropia. Middle left, Lateral version reflex, right gaze: R.E., 8°; L.E., 45°. Middle right, Lateral version reflex, left gaze : R.E., 45° ; L.E., 0. Bottom left, 20° of esotropia on upgaze. Bottom right, 50° of esotropia on downgaze.
990
—
+ +
10 yr 13 yr
14 yr
2yr
Yes 11 days
3 days
45 min
Unknown Yes
3, 19 4.31
5.21
6.10
7,50 8.16
lyr 2yr
7yr 3yr
4 mo 16 yr 6 mo
5yr
8 days
28 days
4 days
Yes 2 days
30 min Yes
Unknown Unknown 2 days
3 wks
11,40
12,21
13,27
14,42 15, 32
16,8} 17,67
18,66 19, 16 20, 12
21.27
Bilateral LE Bilateral RE Bilateral Bilateral Bilateral Bilateral RE Bilateral LE Bilateral Bilateral RE Bilateral RE Bilateral Bilateral Bilateral Bilateral
20/20
20/25 20/20
20/20
20/20
20/20 20/20
20/25
20/20
20/20
20/40
20/20
20/30 20/20
20/20 20/25
20/20 20/20 20/20
20/25
20/30
20/20 20/20
20/15
20/25 20/25 20/20
20/20 20/20
20/30 20/30
20/20
20/20
20/20
20/20
20/30
20/20 20/20
20/20
20/20
Bilateral
20/20
20/20
Paralyzed Side LET 35° RET 25° LET 50° RET 50° ET 10° LET 25° RET 10° RET 20° LET 35° RET 25° LET 25° Orthophoric LET 15° RET 10° RET 45° LET 20° RET 12° LET 20° RET 50° LET 55° LET 20° RET 35° RET 20° LET 35° RET 50° RET 10° LET 15° RET 10° RET 20° LET 25° RET 25° RET 10° 0 with head turn ET 5° RET 25° LET 60°
Deviation!
10 mm 0
ET 15° VET ET 45°
XT 5° XT 5°
35° 15° 20° 5° 0 10 mm 0 35° 0 35° 20° ET 15° 25° 20°
0 ET 5° NVP ET 35° NVP ET 25° NVP ET 50° ET 35° VET ET 20° NVP ET 50° VET ET 15° NVP ET 10° NVP ET 25° VET ET 45° ET 5° VET ET 10° NVP ET 35° VET
XT 20° X T 5° ET 5° XT 10° ET 35° ET 20° XT 10° ET 35° XT 10° XT 5° ET 15° ET 25° XT 1° XT 10° ET 10°
5 mm
0
ET 35°
ET 5°
0
0
ET 60° NVP
XT to ET 20°
No picture
0
RE
0
25° 8 mm 8 mm
2 mm 10 mm
25° 10 mm
5 mm
20° ET
10°
10 mm
O
25° 5 mm
0
10 mm
0 45°
0
0
LE
Abduction
ET 45° VET
Down LE
5°
5° 15°
25°
35° 20° 20°
25° 45°
Bilateral
To right
Bilateral
Bilateral Bilateral
Bilateral
35°
45°
25° 25° 20°
20° 25°
Bilateral
Bilateral Bilateral Bilateral
Bilateral To right
To right To right
To right
5 mm To left
6 mm 35° 1 mm 30°
2 mm
45°
5 mm 35"
2 mm 25°
0
25° 15°
20°
To right
20° 45° 25°
To left Bilateral
Bilateral
Bilaterali
35° 20°
50°
45°
Gaze Palsy
25° 25°
50°
35°
RE
Adduction
Lateral Version Reflexes
ET 20°
Up
Deviation on Gazet
* ET signifies esotropia; LET, left esotropia; RET, right esotropia; VET, V esotropia; XT, exotropia; and NVP, neutralizing V pattern, t Hirschberg, in primary position. t Eye in ET position moves less than 35° in adduction and less than 10 mm from corneoscleral limbus on the sclera in abduction.
—
+ + +
2yr
+ + — + +
~-
—
+ + + + +
2yr
6 mo
lwk
Yes
9,15
10, 15
lyr
8 mo
1 yr 9 mo
—
lyr
2 mo
2.7
+
6hr
1,46
5 wks
Unconscious
Time Corrected visual Between Acuity Trauma and Dip lopia ■ Examina· LE RE tion
Case, Age (yr)
SUMMARY OF PATIENT DATA
TABLE*
S
C/3 C/3
r
>
>
5=d
M
π
C/i
d
C/5
H
Π
So M
M 50 > f
f
>
p Ov
oF
