Medial Rectus
Injury
From Intranasal
Surgery
Louis E. Mark, MD, John S. Kennerdell, MD
• Severe medial rectus injury occurred in two cases following intranasal sinus surgery. In the first case a scarred medial rectus muscle was found at the time of corrective surgery. Reexamination of the surgical specimen in the second case confirmed our finding of medial rectus transection. Both patients had good cos¬ metic and functional improvement by means of vertical recti transposition to correct their large angle, fixed exotropias. A review of the literature indicates that this is, to our knowledge, a previously unreported complication of intranasal si¬ nus surgery.
(Arc/7 Ophthalmol 97:459-461, 1979)
"C^xtraocular muscle dysfunction is
a
complication
of nasal and paranasal sinus surgery for inflam¬ matory disease and, when it occurs, is usually transient. Reports of perma¬ nent muscle damage with fixed, inca¬ rare
pacitating heterotropias following
such surgery are rare. Guibor' de¬ scribed the case of a 19-year-old woman in whom a severe exotropia and immobility of her only functional eye developed secondary to adhesions of the medial rectus after a standard medial canthal transcutaneous resec¬ tion for a frontoethmoid mucocele; four reconstructive muscle procedures ensued. Griffiths and Smith2 pre¬ sented two identical cases of optic atrophy, enophthalmos, ptosis of the globe, and complete restriction of extraocular muscle function that oc¬ curred after Caldwell-Luc procedures and maxillary antrum packing for chronic sinusitis. Extraocular muscle function remained markedly re¬ stricted in both cases following orbital floor repair. We report here two cases of medial rectus trauma following two other accepted surgical procedures for in¬ flammatory sinus disease, intranasal ethmoidectomy and intranasal poly¬ pectomy. To the best of our knowl¬ edge, this complication has not pre¬ viously been reported with these
REPORT OF CASES
Case l.-A 37-year-old woman with obstructive polyposis involving the nasal vault and ethmoid sinus, as well as nasal septal deformity, underwent a left transnasal ethmoidectomy and septal re¬ construction in April 1973. At the time of surgery a dehiscence approximately 1 cm in diameter was noted in the medial wall of the left orbit and "confirmed" by means of a fine wire (sinus) probe. Orbital fat was visualized in the defect. Postoperatively, ecchymoses and edema of the left orbit, in addition to moderate temperature eleva¬ tion, were considered to be due to either hemorrhage or infection. An intranasal packing was removed the morning after surgery. Paralysis of the left medial rectus muscle was noted after several days concomitant with resolution of the swelling. The patient complained of diplopia that persisted during the next three months. Examina¬ tion in July 1973 showed a corrected visual acuity of 20/30 in each eye. A constant exotropia of the left eye measuring 46 prism diopters (PD) in the primary posi¬ tion was due to a severe paralysis of the left medial rectus muscle, without any other extraocular muscle involvement. The left eye was capable of limited adduction but could not reach the midline (Fig 1). Findings from the remainder of the ocular examination were completely within nor¬ mal limits. Rhinological examination disclosed a supratip saddling of the nose secondary to severe
the submucous resection of the septum, as well as absence of the middle turbinâtes on each side. There were no nasal polyps and the interior of the left sphenoid sinus was visualized through an opening in its anteri¬ or wall. The patient reported improvement in her diplopia, which prompted a conserva¬ tive therapeutic approach. Occlusion of the left eye to avoid diplopia and gaze exer¬ cises for the right eye were recom¬ mended. The patient was seen by us for the first time in February 1974 when her exotropia was noted to be worse owing to contracture of the lateral rectus muscle and failure of the function of the medial rectus to return. Adduction saccades of the left eye were absent. The next month, one year after the original nasal surgery, extraocular muscle surgery was performed. A 7-mm left later¬ al rectus recession was followed by isola¬ tion of the left medial rectus. This muscle was found to have the consistency of scar
tissue; however,
a
posterior exploration
to
determine the cause of the muscle atrophy was not undertaken. Instead, the superior and inferior rectus muscles were trans¬ posed to positions adjacent to the medial rectus insertion. Postoperatively the pa¬ tient was orthophoric in the primary posi¬ tion but had very little horizontal move¬ ment of the left eye. She was last seen 11 months later and continued to be binocular in the primary position (Fig 2). Case 2.—A 47-year-old woman with aller¬ gic rhinitis was admitted to a hospital in January 1976 because of bilateral nasal polyposis and chronic left maxillary sinusi-
procedures. Accepted
publication March 10, 1978. Departments of Ophthalmology and Neurology (Dr Kennerdell), University of Pitts¬ burgh. Reprint requests to Eye and Ear Hospital, 230 Lothrop St, Pittsburgh, PA 15213 (Dr Kenner¬ dell). for
From the
Fig 1.—Patient 1 three months after transnasal tion and inability to adduct left eye.
ethmoidectomy showing large
Downloaded From: http://archopht.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/04/2015
exodevia-
Fig 4.—Biopsy specimen of case 2 demon¬ strating bone and juxtaposed extraocular (medial rectus) muscle tissue (hematoxy¬ lin-eosin, original magnification 70).
Fig
2.—Patient 1 is
orthophoric
in
primary position
11 months after corrective surgery.
2 three months after nasal polypectomy and Caldwell-Luc procedure. Forced duction test suggested mechanical restriction causing large exodeviation of left eye.
Fig 3.—Patient
tis. She was asthmatic and hypothyroid, for which she took hydroxyzine hydrochloride (Marax) and thyroid extract. Several nasal polypectomies had been performed pre¬
viously.
With the patient under general anesthe¬ sia, a left nasal polypectomy and CaldwellLuc procedure were performed with drain¬ age of mucopurulent fluid and excision of diseased epithelium from the antrum. An intranasal antrostomy was made and the nasal cavity, but not the antrum, was
packed. Postoperatively swelling of the left cheek and eye developed. She was seen in consultation by an ophthalmologist who found 4+ lid edema and ecchymosis,
subconjunctival hemorrhage, conjunctival
chemosis, and exotropia, which were all on the left side. Findings from the ophthal¬ moscopic examination were normal and the patient complained of diplopia. The con¬ sultant's impression was "massive medial rectus bleeding with loss of function of the muscle." Oral prednisone therapy was started along with topical steroids and the
patient was discharged on the ninth post¬ operative day. In March 1976 the patient was found to
have normal corrected vision in each eye and an exotropia of the left eye of about 50 PD. The left eye did not adduct and forced duction testing suggested evidence of mechanical restriction of medial rotation (Fig 3). The fundi were normal. Corrective
surgery was recommended but declined by the patient. When no change in her condi¬ tion ensued during the next several months, however, she underwent muscle surgery on July 14, 1976. An 8-mm left lateral rectus recession was followed by an exploration of the medial rectus muscle. The distal medial rectus was found to be emanating from a cicatricial scar posterior to the globe. When the muscle was dissected free from the cicatrix, it became evident that it had previously been severed. The distal 10 mm of the muscle was excised and the scar tissue coming from the medial orbit was brought up and attached to the stump of the medial rectus. Following the operation, however, the patient still exhibited between 25 and 30 PD of exotropia of the left eye and could not adduct her left eye. She was readmit¬ ted in September 1976 and underwent a transposition of the superior and inferior rectus muscles to the medial rectus inser¬ tion. The conjunctiva was recessed lateral¬ ly. Striated extraocular muscle, which was found later on a histological slide obtained from the hospital where nasal surgery had been performed (Fig 4), substantiated the clinical impression that the medial rectus had been lacerated. The course after this second operation was uneventful except for a mild pupillary irregularity that was first noted about four weeks later. The patient had an exotropia of the left eye of about 15 PD in the primary position that persisted until the time she was last seen one year later (Fig 5). At that time there was little movement of the left eye in any direction. Single binocular vision was obtained by a minimal right head turn, right head tilt, and slight chin depression. The left pupil was 1 mm larger than the right and slightly peaked toward three small midperipheral transil¬ lumination defects of the iris, suggesting that a mild degree of anterior segment ischemia had resulted from the surgery. No further corrective surgery is contem¬
plated.
COMMENT
The
description of intranasal ethmoidectomy as a surgical procedure is generally credited to Mosher,' who
later advocated its abandonment be¬ of serious complications in favor of the external or medial orbital
cause
Downloaded From: http://archopht.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/04/2015
bony defects that present preoperatively.
dial wall may reveal were
not
as in our two cases, the in referring such patients or their reluctance to undergo another
However,
delay
operative procedure ly intervention.
Fig 5—Patient 2 one year after second corrective muscle small angle exotropia in primary position.
approach.
In the last
by
Davison,4
eight
years,
Harrison,5
reports Eichel," and Kidder and associates7
have reaffirmed the role of this tech¬ nique in the treatment of inflammato¬ ry ethmoid disease, although the external approach is still more popu¬ lar. One reason given for its continued lack of popularity is the difficulty in learning a technique in which expo¬ sure is suboptimal. The procedure is
most commonly performed to remove allergic polyps arising from within the
sinus or to ablate the sinus in cases of chronic infection. A less radical, but more temporary (recurrence being considered inevita¬ ble), approach for obstructive disease is the intranasal polypectomy. Intranasal antrostomy at the level of either the inferior or middle meatus permits drainage of the antrum.8 According to Myers and Myers,9 most surgeons who carry out nasal polypectomies unwit¬ tingly perform some form of minor intranasal ethmoidectomy. With sur¬ gery of both these types, intracranial and optic nerve complications are possible.51"'1 Smith1- has reported acute blindness from orbital hemor¬ rhage following a transnasal opera¬ tion for recurrent polyps. Medial rectus muscle injury during intranasal surgery may occur directly when an instrument, such as a sinus probe, is accidentally passed through a defect in the medial orbital wall, which has been weakened by the chronically diseased sinus epithelium. If the muscle itself is not lacerated, its blood or nerve supply may be inter-
procedure showing residual
rupted or a cicatricial adhesion of the muscle to the globe or bone may form, restricting the eye's movement. If orbital fat herniating into the sinus is mistaken for hyperplastic, polypoid sinus epithelium, the chances are
great that traction will be exerted
on
it, thereby tenting up either the medial rectus or superior oblique
muscle. Accidental muscle transection then occur within the sinus itself.
can
Similarly, fibro-fatty proliferation leading to tissue scarring and restrict¬
ed eye movements can occur whenever the combination of blood and extruded fat exists in the orbit.13 Ocular motili¬ ty may become severely restricted if muscle or fat becomes inadvertently impaled in a bony defect at the time of surgery.
Although Eichel" refers to a case in which orbital hemorrhage following intranasal surgery led to transient diplopia, no cases of severe, lasting extraocular muscle dysfunction simi¬ lar to ours were found in the litera¬ ture. We agree with Helveston and Grossman14 that the diagnosis and treatment of patients with suspected extraocular muscle laceration should be prompt before secondary antago¬ nist contractures develop. When there is little or no orbital edema or hemor¬ rhage, the demonstration of normal forced ductions in an exotropic eye with diminished saccades and severe limitation of adduction suggests an avulsed medial rectus muscle follow¬ ing this type of surgery. Orbital emphysema may be present and hypocycloidal polytomography of the me-
can
preclude ear¬
Medial rectus trauma resulting in fixed heterotropia from intranasal sinus surgery is a distinct clinical enti¬ ty, albeit rare. A high index of suspi¬ cion, coupled with the necessary clini¬ cal means of prompt diagnosis, can minimize the effects of this complica¬ tion. Repair consists essentially of exploration and reattachment of the lacerated ends of the muscle or tendon. Whenever viable muscle can¬ not be found for reattachment, or when secondary contracture prevents realignment by simple recession of the lateral rectus combined with resection or resection with advance¬ ment of the medial rectus, then one of the various muscle transfer proce¬ dures is indicated. But when combined with horizontal muscle surgery, even the Jensen procedure is not without risk to the anterior segment15; such muscle transfer surgery should there¬ fore be performed cautiously. The goal here is single binocular vision in at least the primary position. References 1. Guibor : Surgical reconstruction of compli¬ cations associated with fronto-ethmoid mucocele surgery. Trans Am Acad Ophthalmol Otolaryn¬
gol 80:454-457, 1975. 2. Griffiths JP, Smith B: Optic atrophy follow¬ ing Caldwell-Luc procedure. Arch Ophthalmol 86:15-18, 1971.
3. Mosher HP: The applied anatomy and the intranasal surgery of the ethmoid labyrinth. Trans Am Laryngol Soc 34:25-45, 1912. 4. Davison FW: Intranasal surgery. Laryngo¬ scope 79:502-511, 1969. 5. Harrison DFN: Surgery in allergic sinusitis. Otolaryngol Clin North Am 4:79-95, 1971. 6. Eichel GS: The intranasal ethmoidectomy procedure: Historical, technical and clinical considerations. Laryngoscope 82:1806-1821, 1972. 7. Kidder TM, Toohill RJ, Unger JD, et al: Ethmoid sinus surgery. Laryngoscope 84:1525-
1534, 1974.
8. Lavelle RJ, Harrison MS: Infection of the sinus: The case for middle meatal antrostomy. Laryngoscope 81:90-106, 1971. 9. Myers D, Myers E: The medical and surgical treatment of nasal polyps. Laryngoscope 84:833847, 1974. 10. Chandler JR: Iatrogenic cerebrospinal rhinorrhea. Trans Am Acad Ophthalmol Otolaryn¬ gol 74:576-584, 1970. 11. Sachdev V, Drapkin A, Hollín S, et al: Subarachnoid hemorrhage following intranasal procedures. Surg Neurol 8:122-125, 1977. 12. Smith JL (ed): Neuro-ophthalmology Up¬ date. New York, Masson, 1977, 3. 13. Parks MM: Ocular Motility and Strabis¬ mus. New York, Harper & Row Publishers, Ine, 1975, 2. 14. Helveston EM, Grossman RD: Extraocular muscle lacerations. Am J Ophthalmol 81:754-760, 1976. 15. Van Noorden GK: Anterior segment ischemia following the Jensen procedure. Arch Ophthalmol 94:845-847, 1976.
maxillary
Downloaded From: http://archopht.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/04/2015
Injury
From Intranasal
Surgery
Louis E. Mark, MD, John S. Kennerdell, MD
• Severe medial rectus injury occurred in two cases following intranasal sinus surgery. In the first case a scarred medial rectus muscle was found at the time of corrective surgery. Reexamination of the surgical specimen in the second case confirmed our finding of medial rectus transection. Both patients had good cos¬ metic and functional improvement by means of vertical recti transposition to correct their large angle, fixed exotropias. A review of the literature indicates that this is, to our knowledge, a previously unreported complication of intranasal si¬ nus surgery.
(Arc/7 Ophthalmol 97:459-461, 1979)
"C^xtraocular muscle dysfunction is
a
complication
of nasal and paranasal sinus surgery for inflam¬ matory disease and, when it occurs, is usually transient. Reports of perma¬ nent muscle damage with fixed, inca¬ rare
pacitating heterotropias following
such surgery are rare. Guibor' de¬ scribed the case of a 19-year-old woman in whom a severe exotropia and immobility of her only functional eye developed secondary to adhesions of the medial rectus after a standard medial canthal transcutaneous resec¬ tion for a frontoethmoid mucocele; four reconstructive muscle procedures ensued. Griffiths and Smith2 pre¬ sented two identical cases of optic atrophy, enophthalmos, ptosis of the globe, and complete restriction of extraocular muscle function that oc¬ curred after Caldwell-Luc procedures and maxillary antrum packing for chronic sinusitis. Extraocular muscle function remained markedly re¬ stricted in both cases following orbital floor repair. We report here two cases of medial rectus trauma following two other accepted surgical procedures for in¬ flammatory sinus disease, intranasal ethmoidectomy and intranasal poly¬ pectomy. To the best of our knowl¬ edge, this complication has not pre¬ viously been reported with these
REPORT OF CASES
Case l.-A 37-year-old woman with obstructive polyposis involving the nasal vault and ethmoid sinus, as well as nasal septal deformity, underwent a left transnasal ethmoidectomy and septal re¬ construction in April 1973. At the time of surgery a dehiscence approximately 1 cm in diameter was noted in the medial wall of the left orbit and "confirmed" by means of a fine wire (sinus) probe. Orbital fat was visualized in the defect. Postoperatively, ecchymoses and edema of the left orbit, in addition to moderate temperature eleva¬ tion, were considered to be due to either hemorrhage or infection. An intranasal packing was removed the morning after surgery. Paralysis of the left medial rectus muscle was noted after several days concomitant with resolution of the swelling. The patient complained of diplopia that persisted during the next three months. Examina¬ tion in July 1973 showed a corrected visual acuity of 20/30 in each eye. A constant exotropia of the left eye measuring 46 prism diopters (PD) in the primary posi¬ tion was due to a severe paralysis of the left medial rectus muscle, without any other extraocular muscle involvement. The left eye was capable of limited adduction but could not reach the midline (Fig 1). Findings from the remainder of the ocular examination were completely within nor¬ mal limits. Rhinological examination disclosed a supratip saddling of the nose secondary to severe
the submucous resection of the septum, as well as absence of the middle turbinâtes on each side. There were no nasal polyps and the interior of the left sphenoid sinus was visualized through an opening in its anteri¬ or wall. The patient reported improvement in her diplopia, which prompted a conserva¬ tive therapeutic approach. Occlusion of the left eye to avoid diplopia and gaze exer¬ cises for the right eye were recom¬ mended. The patient was seen by us for the first time in February 1974 when her exotropia was noted to be worse owing to contracture of the lateral rectus muscle and failure of the function of the medial rectus to return. Adduction saccades of the left eye were absent. The next month, one year after the original nasal surgery, extraocular muscle surgery was performed. A 7-mm left later¬ al rectus recession was followed by isola¬ tion of the left medial rectus. This muscle was found to have the consistency of scar
tissue; however,
a
posterior exploration
to
determine the cause of the muscle atrophy was not undertaken. Instead, the superior and inferior rectus muscles were trans¬ posed to positions adjacent to the medial rectus insertion. Postoperatively the pa¬ tient was orthophoric in the primary posi¬ tion but had very little horizontal move¬ ment of the left eye. She was last seen 11 months later and continued to be binocular in the primary position (Fig 2). Case 2.—A 47-year-old woman with aller¬ gic rhinitis was admitted to a hospital in January 1976 because of bilateral nasal polyposis and chronic left maxillary sinusi-
procedures. Accepted
publication March 10, 1978. Departments of Ophthalmology and Neurology (Dr Kennerdell), University of Pitts¬ burgh. Reprint requests to Eye and Ear Hospital, 230 Lothrop St, Pittsburgh, PA 15213 (Dr Kenner¬ dell). for
From the
Fig 1.—Patient 1 three months after transnasal tion and inability to adduct left eye.
ethmoidectomy showing large
Downloaded From: http://archopht.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/04/2015
exodevia-
Fig 4.—Biopsy specimen of case 2 demon¬ strating bone and juxtaposed extraocular (medial rectus) muscle tissue (hematoxy¬ lin-eosin, original magnification 70).
Fig
2.—Patient 1 is
orthophoric
in
primary position
11 months after corrective surgery.
2 three months after nasal polypectomy and Caldwell-Luc procedure. Forced duction test suggested mechanical restriction causing large exodeviation of left eye.
Fig 3.—Patient
tis. She was asthmatic and hypothyroid, for which she took hydroxyzine hydrochloride (Marax) and thyroid extract. Several nasal polypectomies had been performed pre¬
viously.
With the patient under general anesthe¬ sia, a left nasal polypectomy and CaldwellLuc procedure were performed with drain¬ age of mucopurulent fluid and excision of diseased epithelium from the antrum. An intranasal antrostomy was made and the nasal cavity, but not the antrum, was
packed. Postoperatively swelling of the left cheek and eye developed. She was seen in consultation by an ophthalmologist who found 4+ lid edema and ecchymosis,
subconjunctival hemorrhage, conjunctival
chemosis, and exotropia, which were all on the left side. Findings from the ophthal¬ moscopic examination were normal and the patient complained of diplopia. The con¬ sultant's impression was "massive medial rectus bleeding with loss of function of the muscle." Oral prednisone therapy was started along with topical steroids and the
patient was discharged on the ninth post¬ operative day. In March 1976 the patient was found to
have normal corrected vision in each eye and an exotropia of the left eye of about 50 PD. The left eye did not adduct and forced duction testing suggested evidence of mechanical restriction of medial rotation (Fig 3). The fundi were normal. Corrective
surgery was recommended but declined by the patient. When no change in her condi¬ tion ensued during the next several months, however, she underwent muscle surgery on July 14, 1976. An 8-mm left lateral rectus recession was followed by an exploration of the medial rectus muscle. The distal medial rectus was found to be emanating from a cicatricial scar posterior to the globe. When the muscle was dissected free from the cicatrix, it became evident that it had previously been severed. The distal 10 mm of the muscle was excised and the scar tissue coming from the medial orbit was brought up and attached to the stump of the medial rectus. Following the operation, however, the patient still exhibited between 25 and 30 PD of exotropia of the left eye and could not adduct her left eye. She was readmit¬ ted in September 1976 and underwent a transposition of the superior and inferior rectus muscles to the medial rectus inser¬ tion. The conjunctiva was recessed lateral¬ ly. Striated extraocular muscle, which was found later on a histological slide obtained from the hospital where nasal surgery had been performed (Fig 4), substantiated the clinical impression that the medial rectus had been lacerated. The course after this second operation was uneventful except for a mild pupillary irregularity that was first noted about four weeks later. The patient had an exotropia of the left eye of about 15 PD in the primary position that persisted until the time she was last seen one year later (Fig 5). At that time there was little movement of the left eye in any direction. Single binocular vision was obtained by a minimal right head turn, right head tilt, and slight chin depression. The left pupil was 1 mm larger than the right and slightly peaked toward three small midperipheral transil¬ lumination defects of the iris, suggesting that a mild degree of anterior segment ischemia had resulted from the surgery. No further corrective surgery is contem¬
plated.
COMMENT
The
description of intranasal ethmoidectomy as a surgical procedure is generally credited to Mosher,' who
later advocated its abandonment be¬ of serious complications in favor of the external or medial orbital
cause
Downloaded From: http://archopht.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/04/2015
bony defects that present preoperatively.
dial wall may reveal were
not
as in our two cases, the in referring such patients or their reluctance to undergo another
However,
delay
operative procedure ly intervention.
Fig 5—Patient 2 one year after second corrective muscle small angle exotropia in primary position.
approach.
In the last
by
Davison,4
eight
years,
Harrison,5
reports Eichel," and Kidder and associates7
have reaffirmed the role of this tech¬ nique in the treatment of inflammato¬ ry ethmoid disease, although the external approach is still more popu¬ lar. One reason given for its continued lack of popularity is the difficulty in learning a technique in which expo¬ sure is suboptimal. The procedure is
most commonly performed to remove allergic polyps arising from within the
sinus or to ablate the sinus in cases of chronic infection. A less radical, but more temporary (recurrence being considered inevita¬ ble), approach for obstructive disease is the intranasal polypectomy. Intranasal antrostomy at the level of either the inferior or middle meatus permits drainage of the antrum.8 According to Myers and Myers,9 most surgeons who carry out nasal polypectomies unwit¬ tingly perform some form of minor intranasal ethmoidectomy. With sur¬ gery of both these types, intracranial and optic nerve complications are possible.51"'1 Smith1- has reported acute blindness from orbital hemor¬ rhage following a transnasal opera¬ tion for recurrent polyps. Medial rectus muscle injury during intranasal surgery may occur directly when an instrument, such as a sinus probe, is accidentally passed through a defect in the medial orbital wall, which has been weakened by the chronically diseased sinus epithelium. If the muscle itself is not lacerated, its blood or nerve supply may be inter-
procedure showing residual
rupted or a cicatricial adhesion of the muscle to the globe or bone may form, restricting the eye's movement. If orbital fat herniating into the sinus is mistaken for hyperplastic, polypoid sinus epithelium, the chances are
great that traction will be exerted
on
it, thereby tenting up either the medial rectus or superior oblique
muscle. Accidental muscle transection then occur within the sinus itself.
can
Similarly, fibro-fatty proliferation leading to tissue scarring and restrict¬
ed eye movements can occur whenever the combination of blood and extruded fat exists in the orbit.13 Ocular motili¬ ty may become severely restricted if muscle or fat becomes inadvertently impaled in a bony defect at the time of surgery.
Although Eichel" refers to a case in which orbital hemorrhage following intranasal surgery led to transient diplopia, no cases of severe, lasting extraocular muscle dysfunction simi¬ lar to ours were found in the litera¬ ture. We agree with Helveston and Grossman14 that the diagnosis and treatment of patients with suspected extraocular muscle laceration should be prompt before secondary antago¬ nist contractures develop. When there is little or no orbital edema or hemor¬ rhage, the demonstration of normal forced ductions in an exotropic eye with diminished saccades and severe limitation of adduction suggests an avulsed medial rectus muscle follow¬ ing this type of surgery. Orbital emphysema may be present and hypocycloidal polytomography of the me-
can
preclude ear¬
Medial rectus trauma resulting in fixed heterotropia from intranasal sinus surgery is a distinct clinical enti¬ ty, albeit rare. A high index of suspi¬ cion, coupled with the necessary clini¬ cal means of prompt diagnosis, can minimize the effects of this complica¬ tion. Repair consists essentially of exploration and reattachment of the lacerated ends of the muscle or tendon. Whenever viable muscle can¬ not be found for reattachment, or when secondary contracture prevents realignment by simple recession of the lateral rectus combined with resection or resection with advance¬ ment of the medial rectus, then one of the various muscle transfer proce¬ dures is indicated. But when combined with horizontal muscle surgery, even the Jensen procedure is not without risk to the anterior segment15; such muscle transfer surgery should there¬ fore be performed cautiously. The goal here is single binocular vision in at least the primary position. References 1. Guibor : Surgical reconstruction of compli¬ cations associated with fronto-ethmoid mucocele surgery. Trans Am Acad Ophthalmol Otolaryn¬
gol 80:454-457, 1975. 2. Griffiths JP, Smith B: Optic atrophy follow¬ ing Caldwell-Luc procedure. Arch Ophthalmol 86:15-18, 1971.
3. Mosher HP: The applied anatomy and the intranasal surgery of the ethmoid labyrinth. Trans Am Laryngol Soc 34:25-45, 1912. 4. Davison FW: Intranasal surgery. Laryngo¬ scope 79:502-511, 1969. 5. Harrison DFN: Surgery in allergic sinusitis. Otolaryngol Clin North Am 4:79-95, 1971. 6. Eichel GS: The intranasal ethmoidectomy procedure: Historical, technical and clinical considerations. Laryngoscope 82:1806-1821, 1972. 7. Kidder TM, Toohill RJ, Unger JD, et al: Ethmoid sinus surgery. Laryngoscope 84:1525-
1534, 1974.
8. Lavelle RJ, Harrison MS: Infection of the sinus: The case for middle meatal antrostomy. Laryngoscope 81:90-106, 1971. 9. Myers D, Myers E: The medical and surgical treatment of nasal polyps. Laryngoscope 84:833847, 1974. 10. Chandler JR: Iatrogenic cerebrospinal rhinorrhea. Trans Am Acad Ophthalmol Otolaryn¬ gol 74:576-584, 1970. 11. Sachdev V, Drapkin A, Hollín S, et al: Subarachnoid hemorrhage following intranasal procedures. Surg Neurol 8:122-125, 1977. 12. Smith JL (ed): Neuro-ophthalmology Up¬ date. New York, Masson, 1977, 3. 13. Parks MM: Ocular Motility and Strabis¬ mus. New York, Harper & Row Publishers, Ine, 1975, 2. 14. Helveston EM, Grossman RD: Extraocular muscle lacerations. Am J Ophthalmol 81:754-760, 1976. 15. Van Noorden GK: Anterior segment ischemia following the Jensen procedure. Arch Ophthalmol 94:845-847, 1976.
maxillary
Downloaded From: http://archopht.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/04/2015
