Ocular
Motility Complications Following Intranasal Surgery
John T. Flynn, MD; Kenneth . Mitchell, MD; Dwain G. Fuller, MD; Howard . London, MD; Harold . Cohen, MD
• The ocular motility problem of two patients following intranasal surgery is examined. The patients were studied by eye movement records and ultrasonogra¬ phy. Surgery in both cases revealed a
defect of the medial orbital wall with tissue incarcerated in the defect.
scar
(Arch Ophthalmol 97:453-458, 1979)
Tntranasal procedures for chronic sinus disease were commonly per¬ formed by rhinologists in the earlier part of this century.''4 A renewed interest in this mode of therapy is evident.' Thorough descriptions of the regional anatomy8 suggest possi¬ ble ocular or neurological complica¬ tions that may result from injury to the optic nerve, carotid canal, cribri¬ 7
polypectomy 15 years previously for simi¬ lar symptoms. On Jan 10, 1977, a bilateral nasal polypectomy and anterior ethmoidectomy were performed. On return to his hospital room, the lids of the right eye were ecchymotic and swollen, but the globe was noted to be white. On the following day he was seen by an ophthalmologic consultant who found a large exotropia, an apparent paresis of the right medial rectus, and possible paresis of the right superior rectus, inferior oblique muscle, and su¬ perior oblique muscle. He believed this might be due to a retrobulbar hemorrhage. A regimen of sodium borate (Collyrium) and oral enzymes was begun. As the eyelid swelling improved, the patient noted hori¬ zontal diplopia, which he overcame by clos-
ing his right eye. improve with time.
The
diplopia
did not
Examination on Jan 25 at the Bascom Palmer Eye Institute disclosed visual acui¬ ties of 20/20 in both eyes. The right eye was deviated markedly to the right (Fig 1). With the right eye fixing at 6 m, his measurements were 50 prism diopters (PD) of exotropia in the primary position, 20 PD in gaze right, and 100+ PD in gaze left. On attempted levoversion, the right eye dem¬ onstrated a small, slow movement toward, but not attaining, the primary position. Vertical gazes appeared intact, as did oblique gazes in the abducted position. Optokinetic nystagmus showed no evi¬ dence of a fast phase in the right eye with targets moving toward the patient's right.
form
plate, lamina papyracea, fovea ethmoidalis, and cavernous sinus. Not mentioned, however, is direct injury
to the extraocular muscles or their nerves. We describe two patients with such injuries to the extraocular mus¬
cles
as a complication of intranasal polypectomy and anterior ethmoidec-
tomy.
REPORT OF CASES Case 1.-Clinical
Summary.—A 69-year-
old man had symptoms of chronic nasal obstruction. He had undergone a nasal
Accepted
for publication May 22, 1978. From the Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine. Reprint requests to Bascom Palmer Eye Insti¬ tute, PO Box 520009 Biscayne Annex, Miami, FL 33152 (Dr Flynn).
Fig
1.—Nine
positions
of gaze of
patient 1.
Note
severe
limitation of adduction of
eye.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/06/2015
right
Fig 2.—Left, -scan echography of right orbit scanning from temporal side of globe. Right,
made with probe Various acoustic
echoes.
Fig 3.—Left, Nasal biopsy specimen containing striated muscle and fat (hematoxylin-eosin, original magnification 120). Right, High-power view of nerve entering striated muscle (hematoxylin-eosin, original magnification 300).
Fig 4.—Exposed medial rectus muscle in extending into mass of scar tissue in medial
situ on globe and orbital wall.
Fig 5.—Frayed muscle after repeated attempts to free muscle from scar
tissue.
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Fig
6.—Field of binocular
single vision
Fig 7.—Nine positions of gaze of patient depression in adduction of right eye.
of
patient within normal field
of
single binocular vision (dotted outline).
2. Note limited adduction, elevation, and
25 XT
45 XT 5RHT
65 XT 2 LHT
20 XT 7RHT
40 XT 12 RHT
50 XT
18 XT 7 RHT
25 XT 16 RHT
30 XT 20 RHT
measurements of patient 2 XT indicates exotropia; RHT, right hypertropia; and LHT, left hypertropia. Values are expressed as prism diopters.
Fig 8.—Motility at 6
m.
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Fig 9.—Left, -scan echography organized scar tissue present echoes.
of medial orbital wall with abnormal within wall. Right, Various acoustic
Fig 10.—Left, Section of biopsy specimen showing striated muscle and orbital fat (hematoxylin-eosin, original magnification 120). Right, High-power view of striated muscle present in nasal biopsy specimen (hematoxylin-eosin, original magnification 300).
Fig 11 .—Operative exposure of right medial rectus muscle at its insertion extending backward nasally into scar in medial orbital wall.
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Fig
12.—Field of binocular
single
vision of
patient
2
as
compared with
field of normal
performed. through the
A traction suture woven insertion of the right medial rectus muscle was brought out through the medial canthal ligament and the globe was anchored in adduction for three weeks. After removal of this traction suture, the patient's eye fused in the primary position but had double vision looking to either side. His field of binocular single vision" then slowly increased to its present level (Fig 6), but he still had severe limitation of medial, lateral, and oblique gazes.
The traction test showed slight limitation to extreme adduction of the right globe.
Active forced generation" was absent on attempted adduction. Findings from the remainder of the ocular examination were normal. Laboratory Studies.— -scan echography of the right orbit showed abnormal access to the ethmoid sinus area nasally (Fig 2, left and right), with evidence of a sizeable defect in the medial orbital wall. Addition¬ ally, a mass lesion of low acoustic density inside the medial orbital wall was identi¬ fied. This lesion had the echographic char¬ acteristics of an organized hematoma or cicatricial tissue. The left orbit was echographically normal.
Eye
movement
recordings
on
April
Case 2.—Clinical
Fig 13.—Artist's conception of defect in medial orbital wall with incarceration of scar tissue, orbital fat, and muscle. Nerve in this illustration is spared. a mass of scar tissue (Fig 4). Repeated attempts to free it from this mass succeeded only in producing bleeding and dangerous fraying of the remaining fibers (Fig 5). An ear, nose, and throat surgeon attempted to reduce the mass
itself in
from the nasal side, but this too was unsuc¬ cessful. It was therefore elected to leave the muscle in situ. A 10-mm recession of the right lateral rectus muscle was
Summary.—A 53-year-
had a long history of nasal allergies with polyps, for which multiple polypectomies had been performed in the past with no known sequelae. On Oct 8, 1976 she had a bilateral nasal polypectomy and an anterior ethmoidectomy. The surgeon encountered brisk bleeding in the right ethmoidal labyrinth and multiple packings had to be applied to obtain hemostasis. After removal of the diseased tissue from the ethmoidal labyrinth, the surgeon believed that the lamina papyracea was absent and therefore discontinued further curettage. Brisk bleeding was again encountered from the right ethmoi¬ dal labyrinth requiring repacking while the left ethmoidal labyrinth was being oper¬ ated on. The patient was seen in consulta¬ tion by an ophthalmologist the day after surgery. He noted ptosis of the right upper lid, palpebrai and orbital ecchymosis, old
4
showed hypometric saccades'" of the right eye to the right with the left eye covered and demonstrated diminished optokinetic responses in the right eye. The biopsy report showed that, in addi¬ tion to the typical tissue specimen of nasal polyps and inflammatory tissue, fat, striated muscle, and nerve were present (Fig 3, left and right). Course.—On May 5,1977, a surgical explo¬ ration of the right medial rectus muscle and the medial orbital wall was performed. The medial rectus was found to be attached to the globe at its insertion. It extended from this point posterior and medial for a distance of about 20 mm, where it buried
subject (dotted line).
woman
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/06/2015
chemosis of the conjunctiva, and limitation of movement of the muscles innervated by the third cranial nerve paresis on the right, which was associated with an orbital hema¬ toma. When the ptosis cleared, the patient experienced horizontal and vertical diplo¬ pia. One month after surgery the patient was able to move the right eye to the midline from its abducted position. During the ensuing months, a slight increase in adduction occurred without spontaneous fusion. Examination at the Bascom Palmer Eye Institute on March 4, 1977 showed visual acuities of 20/20 in both eyes. The lid fissures were equal and levator function was normal in both eyes. Hypesthesia was present over the distribution of the distal right infratrochlear nerve and on the medial aspect of the right cornea. Motility examination showed an alternating exotro¬ pia with a right hypertropia and prefer¬ ence for right eye fixation (Fig 7). Her measurements at 6 m were as outlined in
Fig 8.
The right hypertropia increased on right head tilt. A right excyclotropia of 7° was measured. Ocular rotations demonstrated limitation of action of the right medial rectus and the right inferior and superior oblique muscles. The traction test revealed mild limitation of extreme adduction and limitation of elevation in adduction. Exophthalmometry disclosed 2 mm of right enophthalmos. Findings from the remain¬ der of the ocular examination were normal. Laboratory Studies.-On March 17 orbital -scan echography of the right orbital wall showed a considerable orbital wall defect in the region of the ethmoid sinuses (Fig 9, left and right). Abnormal low-reflective tissue was identified inside the medial orbital wall. This finding suggested orga¬ nized hematoma or scar tissue. The left orbit was echographically normal. Eye movement recordings on April 15 showed the presence of saccades with the right eye but diminished optokinetic nys¬ tagmus responses. A review of the biopsy specimens disclosed the presence of fat and striated muscle (Fig 10, left and right) in addition to the typical diseased mucosa and bone. Course.—On July 11 the patient under¬ went exploration of the right medial rectus and orbital wall (Fig 11). Exactly the same findings were encountered as in the previous case. No attempt was made to reduce the scarred mass by the orbital or nasal approach. Instead, a 10-mm resection of the right medial rectus muscle was
combined with an 8-mm reces¬ sion of the left lateral rectus muscle. On July 21 the patient had a distance deviation of 7 PD of right hypertropia in the primary position and 16 PD of right hypertropia in down gaze. Ocular rotations of the right eye and lateral rotation of the left eye were limited. She was given 16 PD base down over the lower segment of the right bifocal lens for reading. During the months since surgery, the patient's field of binocular single vision has slowly increased
performed,
(Fig 12).
COMMENT
The lateral boundaries of the eth¬ moid sinuses may be distorted in extensive mucoperiosteal disease. The lamina papyracea may become so attenuated as to be practically nonex¬ istent. This is apparently what was found in case 2. Vigorous curettage and snaring in this region might pierce the orbital periosteum, with prolapse of orbital fat. Bleeding may obscure the field and further surgery might result in the complication seen in the two cases in this report. The diagnosis of this complication of anterior ethmoidectomy is made by history and by motility examination. Echography is of use in identifying surgical violation of the orbit. A-scan examination documents a bony defect in the medial orbital wall, as well as abnormal tissue (hematoma and/or cicatrix) within the orbit. The most important point in the prevention of this complication seems to be the recognition of the possibility that it might occur especially in the presence of brisk bleeding in an area of reduced surgical visualization. It seems obvious that the surgeon should desist from further attempts to remove more tissue in such in¬ stances.
Our conception of the consequences of the injury is sketched (Fig 13). In effect, a "blowout" of the medial or¬ bital wall is created with fat, muscle, and nerves entrapped in the resultant scar tissue. The scarred mass acts as the functional origin of the involved rectus muscle. When innervation is uninterrupted, adduction may be pos¬ sible, albeit restricted (case 2). If the
nerves are
involved
or
if restriction is
marked, adduction is absent (case 1). Involvement of the superomore
nasal medial orbital wall in
case
2 is
suggested by the infratrochlear hypesthesia and the right superior oblique involvement.
It seems to us that attempts to reduce the scar are futile and will not result in functional restoration of the muscle. The reason is obvious from the biopsy specimens, which demon¬ strated substantial sections of extir¬ pated extraocular muscle. The prognosis in these patients seems reasonably good for binocular single vision in the primary position and a few degrees to either side. Beyond that, single vision becomes problematic because of the severe limitation of the movements, which sets a limit on useful binocular single vision. This investigation was supported in part Research to Prevent Blindness, New York.
by
References 1. Skillern RH: The Catarrhal and Suppura¬ tive Diseases of the Accessory Sinuses of the Nose. Philadelphia, JB Lippincott Co, 1913. 2. Hajek M: Pathology and Treatment of the Inflammatory Diseases of the Nasal Accessory Sinuses, Heitgen J, Hansel F (trans). St Louis, CV Mosby Co, 1926. 3. Mosher HP: The surgery of the ethmoidal labyrinth. Trans Sec Laryn Otol Rhinol, 1914, pp 232-251. 4. Eichel BS: The intranasal ethmoidectomy procedure: Historical, technical and clinical considerations. Laryngoscope 82:1806-1821, 1972. 5. Friedman WH: Surgery for chronic hyper¬ plastic rhinosinusitis. Laryngoscope 85:1999-
2011, 1975.
6. Divson FW: Hyperplastic sinusitis: A fiveyear study. Ann Otol Rhinol Laryngol 72:462-474, 1963. 7. Kidder TM, Toohill RJ, Unger JD, et al: Ethmoid sinus surgery. Laryngoscope 84:15251534, 1974. 8. Mosher HP: The surgical anatomy of the ethmoid labyrinth. Ann Otol Rhinol Laryngol 38:869-901, 1929. 9. Scott AB, Collins CC, O'Meara DM: A forceps to measure strabismus forces. Arch Ophthalmol 88:330-333, 1972. 10. Weber RB, Daroff RB: The metrics of horizontal saccadic eye movements in normal humans. Vision Res 11:921-928, 1971. 11. Feibel RM, Roper-Hall G: Evaluation of the field of binocular single vision in incomitant strabismus. Am J Ophthalmol 78:800-805, 1974.
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Motility Complications Following Intranasal Surgery
John T. Flynn, MD; Kenneth . Mitchell, MD; Dwain G. Fuller, MD; Howard . London, MD; Harold . Cohen, MD
• The ocular motility problem of two patients following intranasal surgery is examined. The patients were studied by eye movement records and ultrasonogra¬ phy. Surgery in both cases revealed a
defect of the medial orbital wall with tissue incarcerated in the defect.
scar
(Arch Ophthalmol 97:453-458, 1979)
Tntranasal procedures for chronic sinus disease were commonly per¬ formed by rhinologists in the earlier part of this century.''4 A renewed interest in this mode of therapy is evident.' Thorough descriptions of the regional anatomy8 suggest possi¬ ble ocular or neurological complica¬ tions that may result from injury to the optic nerve, carotid canal, cribri¬ 7
polypectomy 15 years previously for simi¬ lar symptoms. On Jan 10, 1977, a bilateral nasal polypectomy and anterior ethmoidectomy were performed. On return to his hospital room, the lids of the right eye were ecchymotic and swollen, but the globe was noted to be white. On the following day he was seen by an ophthalmologic consultant who found a large exotropia, an apparent paresis of the right medial rectus, and possible paresis of the right superior rectus, inferior oblique muscle, and su¬ perior oblique muscle. He believed this might be due to a retrobulbar hemorrhage. A regimen of sodium borate (Collyrium) and oral enzymes was begun. As the eyelid swelling improved, the patient noted hori¬ zontal diplopia, which he overcame by clos-
ing his right eye. improve with time.
The
diplopia
did not
Examination on Jan 25 at the Bascom Palmer Eye Institute disclosed visual acui¬ ties of 20/20 in both eyes. The right eye was deviated markedly to the right (Fig 1). With the right eye fixing at 6 m, his measurements were 50 prism diopters (PD) of exotropia in the primary position, 20 PD in gaze right, and 100+ PD in gaze left. On attempted levoversion, the right eye dem¬ onstrated a small, slow movement toward, but not attaining, the primary position. Vertical gazes appeared intact, as did oblique gazes in the abducted position. Optokinetic nystagmus showed no evi¬ dence of a fast phase in the right eye with targets moving toward the patient's right.
form
plate, lamina papyracea, fovea ethmoidalis, and cavernous sinus. Not mentioned, however, is direct injury
to the extraocular muscles or their nerves. We describe two patients with such injuries to the extraocular mus¬
cles
as a complication of intranasal polypectomy and anterior ethmoidec-
tomy.
REPORT OF CASES Case 1.-Clinical
Summary.—A 69-year-
old man had symptoms of chronic nasal obstruction. He had undergone a nasal
Accepted
for publication May 22, 1978. From the Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami School of Medicine. Reprint requests to Bascom Palmer Eye Insti¬ tute, PO Box 520009 Biscayne Annex, Miami, FL 33152 (Dr Flynn).
Fig
1.—Nine
positions
of gaze of
patient 1.
Note
severe
limitation of adduction of
eye.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/06/2015
right
Fig 2.—Left, -scan echography of right orbit scanning from temporal side of globe. Right,
made with probe Various acoustic
echoes.
Fig 3.—Left, Nasal biopsy specimen containing striated muscle and fat (hematoxylin-eosin, original magnification 120). Right, High-power view of nerve entering striated muscle (hematoxylin-eosin, original magnification 300).
Fig 4.—Exposed medial rectus muscle in extending into mass of scar tissue in medial
situ on globe and orbital wall.
Fig 5.—Frayed muscle after repeated attempts to free muscle from scar
tissue.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/06/2015
Fig
6.—Field of binocular
single vision
Fig 7.—Nine positions of gaze of patient depression in adduction of right eye.
of
patient within normal field
of
single binocular vision (dotted outline).
2. Note limited adduction, elevation, and
25 XT
45 XT 5RHT
65 XT 2 LHT
20 XT 7RHT
40 XT 12 RHT
50 XT
18 XT 7 RHT
25 XT 16 RHT
30 XT 20 RHT
measurements of patient 2 XT indicates exotropia; RHT, right hypertropia; and LHT, left hypertropia. Values are expressed as prism diopters.
Fig 8.—Motility at 6
m.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/06/2015
Fig 9.—Left, -scan echography organized scar tissue present echoes.
of medial orbital wall with abnormal within wall. Right, Various acoustic
Fig 10.—Left, Section of biopsy specimen showing striated muscle and orbital fat (hematoxylin-eosin, original magnification 120). Right, High-power view of striated muscle present in nasal biopsy specimen (hematoxylin-eosin, original magnification 300).
Fig 11 .—Operative exposure of right medial rectus muscle at its insertion extending backward nasally into scar in medial orbital wall.
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/06/2015
Fig
12.—Field of binocular
single
vision of
patient
2
as
compared with
field of normal
performed. through the
A traction suture woven insertion of the right medial rectus muscle was brought out through the medial canthal ligament and the globe was anchored in adduction for three weeks. After removal of this traction suture, the patient's eye fused in the primary position but had double vision looking to either side. His field of binocular single vision" then slowly increased to its present level (Fig 6), but he still had severe limitation of medial, lateral, and oblique gazes.
The traction test showed slight limitation to extreme adduction of the right globe.
Active forced generation" was absent on attempted adduction. Findings from the remainder of the ocular examination were normal. Laboratory Studies.— -scan echography of the right orbit showed abnormal access to the ethmoid sinus area nasally (Fig 2, left and right), with evidence of a sizeable defect in the medial orbital wall. Addition¬ ally, a mass lesion of low acoustic density inside the medial orbital wall was identi¬ fied. This lesion had the echographic char¬ acteristics of an organized hematoma or cicatricial tissue. The left orbit was echographically normal.
Eye
movement
recordings
on
April
Case 2.—Clinical
Fig 13.—Artist's conception of defect in medial orbital wall with incarceration of scar tissue, orbital fat, and muscle. Nerve in this illustration is spared. a mass of scar tissue (Fig 4). Repeated attempts to free it from this mass succeeded only in producing bleeding and dangerous fraying of the remaining fibers (Fig 5). An ear, nose, and throat surgeon attempted to reduce the mass
itself in
from the nasal side, but this too was unsuc¬ cessful. It was therefore elected to leave the muscle in situ. A 10-mm recession of the right lateral rectus muscle was
Summary.—A 53-year-
had a long history of nasal allergies with polyps, for which multiple polypectomies had been performed in the past with no known sequelae. On Oct 8, 1976 she had a bilateral nasal polypectomy and an anterior ethmoidectomy. The surgeon encountered brisk bleeding in the right ethmoidal labyrinth and multiple packings had to be applied to obtain hemostasis. After removal of the diseased tissue from the ethmoidal labyrinth, the surgeon believed that the lamina papyracea was absent and therefore discontinued further curettage. Brisk bleeding was again encountered from the right ethmoi¬ dal labyrinth requiring repacking while the left ethmoidal labyrinth was being oper¬ ated on. The patient was seen in consulta¬ tion by an ophthalmologist the day after surgery. He noted ptosis of the right upper lid, palpebrai and orbital ecchymosis, old
4
showed hypometric saccades'" of the right eye to the right with the left eye covered and demonstrated diminished optokinetic responses in the right eye. The biopsy report showed that, in addi¬ tion to the typical tissue specimen of nasal polyps and inflammatory tissue, fat, striated muscle, and nerve were present (Fig 3, left and right). Course.—On May 5,1977, a surgical explo¬ ration of the right medial rectus muscle and the medial orbital wall was performed. The medial rectus was found to be attached to the globe at its insertion. It extended from this point posterior and medial for a distance of about 20 mm, where it buried
subject (dotted line).
woman
Downloaded From: http://archopht.jamanetwork.com/ by a University of California - San Diego User on 06/06/2015
chemosis of the conjunctiva, and limitation of movement of the muscles innervated by the third cranial nerve paresis on the right, which was associated with an orbital hema¬ toma. When the ptosis cleared, the patient experienced horizontal and vertical diplo¬ pia. One month after surgery the patient was able to move the right eye to the midline from its abducted position. During the ensuing months, a slight increase in adduction occurred without spontaneous fusion. Examination at the Bascom Palmer Eye Institute on March 4, 1977 showed visual acuities of 20/20 in both eyes. The lid fissures were equal and levator function was normal in both eyes. Hypesthesia was present over the distribution of the distal right infratrochlear nerve and on the medial aspect of the right cornea. Motility examination showed an alternating exotro¬ pia with a right hypertropia and prefer¬ ence for right eye fixation (Fig 7). Her measurements at 6 m were as outlined in
Fig 8.
The right hypertropia increased on right head tilt. A right excyclotropia of 7° was measured. Ocular rotations demonstrated limitation of action of the right medial rectus and the right inferior and superior oblique muscles. The traction test revealed mild limitation of extreme adduction and limitation of elevation in adduction. Exophthalmometry disclosed 2 mm of right enophthalmos. Findings from the remain¬ der of the ocular examination were normal. Laboratory Studies.-On March 17 orbital -scan echography of the right orbital wall showed a considerable orbital wall defect in the region of the ethmoid sinuses (Fig 9, left and right). Abnormal low-reflective tissue was identified inside the medial orbital wall. This finding suggested orga¬ nized hematoma or scar tissue. The left orbit was echographically normal. Eye movement recordings on April 15 showed the presence of saccades with the right eye but diminished optokinetic nys¬ tagmus responses. A review of the biopsy specimens disclosed the presence of fat and striated muscle (Fig 10, left and right) in addition to the typical diseased mucosa and bone. Course.—On July 11 the patient under¬ went exploration of the right medial rectus and orbital wall (Fig 11). Exactly the same findings were encountered as in the previous case. No attempt was made to reduce the scarred mass by the orbital or nasal approach. Instead, a 10-mm resection of the right medial rectus muscle was
combined with an 8-mm reces¬ sion of the left lateral rectus muscle. On July 21 the patient had a distance deviation of 7 PD of right hypertropia in the primary position and 16 PD of right hypertropia in down gaze. Ocular rotations of the right eye and lateral rotation of the left eye were limited. She was given 16 PD base down over the lower segment of the right bifocal lens for reading. During the months since surgery, the patient's field of binocular single vision has slowly increased
performed,
(Fig 12).
COMMENT
The lateral boundaries of the eth¬ moid sinuses may be distorted in extensive mucoperiosteal disease. The lamina papyracea may become so attenuated as to be practically nonex¬ istent. This is apparently what was found in case 2. Vigorous curettage and snaring in this region might pierce the orbital periosteum, with prolapse of orbital fat. Bleeding may obscure the field and further surgery might result in the complication seen in the two cases in this report. The diagnosis of this complication of anterior ethmoidectomy is made by history and by motility examination. Echography is of use in identifying surgical violation of the orbit. A-scan examination documents a bony defect in the medial orbital wall, as well as abnormal tissue (hematoma and/or cicatrix) within the orbit. The most important point in the prevention of this complication seems to be the recognition of the possibility that it might occur especially in the presence of brisk bleeding in an area of reduced surgical visualization. It seems obvious that the surgeon should desist from further attempts to remove more tissue in such in¬ stances.
Our conception of the consequences of the injury is sketched (Fig 13). In effect, a "blowout" of the medial or¬ bital wall is created with fat, muscle, and nerves entrapped in the resultant scar tissue. The scarred mass acts as the functional origin of the involved rectus muscle. When innervation is uninterrupted, adduction may be pos¬ sible, albeit restricted (case 2). If the
nerves are
involved
or
if restriction is
marked, adduction is absent (case 1). Involvement of the superomore
nasal medial orbital wall in
case
2 is
suggested by the infratrochlear hypesthesia and the right superior oblique involvement.
It seems to us that attempts to reduce the scar are futile and will not result in functional restoration of the muscle. The reason is obvious from the biopsy specimens, which demon¬ strated substantial sections of extir¬ pated extraocular muscle. The prognosis in these patients seems reasonably good for binocular single vision in the primary position and a few degrees to either side. Beyond that, single vision becomes problematic because of the severe limitation of the movements, which sets a limit on useful binocular single vision. This investigation was supported in part Research to Prevent Blindness, New York.
by
References 1. Skillern RH: The Catarrhal and Suppura¬ tive Diseases of the Accessory Sinuses of the Nose. Philadelphia, JB Lippincott Co, 1913. 2. Hajek M: Pathology and Treatment of the Inflammatory Diseases of the Nasal Accessory Sinuses, Heitgen J, Hansel F (trans). St Louis, CV Mosby Co, 1926. 3. Mosher HP: The surgery of the ethmoidal labyrinth. Trans Sec Laryn Otol Rhinol, 1914, pp 232-251. 4. Eichel BS: The intranasal ethmoidectomy procedure: Historical, technical and clinical considerations. Laryngoscope 82:1806-1821, 1972. 5. Friedman WH: Surgery for chronic hyper¬ plastic rhinosinusitis. Laryngoscope 85:1999-
2011, 1975.
6. Divson FW: Hyperplastic sinusitis: A fiveyear study. Ann Otol Rhinol Laryngol 72:462-474, 1963. 7. Kidder TM, Toohill RJ, Unger JD, et al: Ethmoid sinus surgery. Laryngoscope 84:15251534, 1974. 8. Mosher HP: The surgical anatomy of the ethmoid labyrinth. Ann Otol Rhinol Laryngol 38:869-901, 1929. 9. Scott AB, Collins CC, O'Meara DM: A forceps to measure strabismus forces. Arch Ophthalmol 88:330-333, 1972. 10. Weber RB, Daroff RB: The metrics of horizontal saccadic eye movements in normal humans. Vision Res 11:921-928, 1971. 11. Feibel RM, Roper-Hall G: Evaluation of the field of binocular single vision in incomitant strabismus. Am J Ophthalmol 78:800-805, 1974.
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