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BRIEF COMMUNICATION
Year : 2020  |  Volume : 8  |  Issue : 3  |  Page : 111-114

Successful repair of severed medial rectus following trauma


Department of Ophthalmology, King Georges' Medical University, Lucknow, Uttar Pradesh, India

Date of Submission08-Nov-2019
Date of Decision02-Mar-2020
Date of Acceptance27-Jul-2020
Date of Web Publication4-Dec-2020

Correspondence Address:
Siddharth Agrawal
Department of Ophthalmology, King Georges' Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_90_19

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  Abstract 


Direct injury to the extraocular muscles following penetrating orbital trauma is often challenging for the clinicians. The decision whether to attempt primary repair or to have a staged approach is difficult to make, with each having its merits and demerits. We report here a case of direct injury to the medial rectus resulting in its complete transection. The patient was successfully managed by imaging followed by exploration and reattachment of the transected muscle in a single surgery.

Keywords: Exotropia, ptosis, severed medial rectus, trauma


How to cite this article:
Singh V, Sharma A, Chaubey A, Kumar P, Agrawal S, Kaur A. Successful repair of severed medial rectus following trauma. J Clin Ophthalmol Res 2020;8:111-4

How to cite this URL:
Singh V, Sharma A, Chaubey A, Kumar P, Agrawal S, Kaur A. Successful repair of severed medial rectus following trauma. J Clin Ophthalmol Res [serial online] 2020 [cited 2021 Jan 25];8:111-4. Available from: https://www.jcor.in/text.asp?2020/8/3/111/302204




  Introduction Top


Strabismus following trauma may result in incomitant type of strabismus, which is often difficult to manage. The mechanism may involve direct injury to the muscle, nerves, entrapment of soft tissue, or a combination of these.

Direct injury to extraocular muscle has been reported rarely. Usually, this is associated with penetrating orbital trauma. The most frequently affected muscle is the medial rectus.[1],[2],[3],[4] The various etiology of strabismus due to orbital trauma requires an individualized approach. Appropriate diagnosis of the type and severity of injury and differentiation of mechanical and neurological involvement is critical in planning the approach for management. Imaging is required to determine the extent of extraocular muscle or bony damage.

The authors report a case of direct injury to the medial rectus muscle and its management.


  Case Report Top


A 9-year-old male student came to an emergency with complaints of an inability to move the right eye (RE) inward and partial drooping of the right upper lid, following injury by brake handle of bicycle 12 h back. On examination, his Snellen best-corrected visual acuity (BCVA) was RE 6/18, left eye (LE) 6/6. 4 mm ptosis of the right upper lid, conjunctival congestion, right exotropia of 45° and inability to adduct RE were noted. The conjunctiva and Tenon’s capsule were lacerated [Figure 1] and [Figure 2]. RE cornea had a superficial corneal abrasion. The posterior segment examination of RE and LE examination was normal. Computerized tomography (CT scan) of the right orbit showed transected right medial rectus (RMR) muscle along with orbital emphysema and fracture in the floor of orbit with no herniation of orbital contents. There was no retained foreign body, and the globe was intact [Figure 3] and [Figure 4]. The diagnosis of traumatic dehiscence of RMR was made.
Figure 1: Preoperative photographs. Right exotropia (about 45°) with laceration and prolapse of Tenon’s capsule and conjunctiva

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Figure 2: Marked limitation (−4) of adduction righty eye

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Figure 3: Computerized tomography scan of orbit. Right orbital emphysema and transected rear end of right medial rectus muscle

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Figure 4: Fracture in right orbital floor

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Right orbital exploration and medial rectus repair under general anesthesia were planned on the same day.

On exploration, RMR was completely transected about 15 mm posterior to insertion. The rear end was lost in orbit and was recovered by careful dissection. It was pulled up and united with the anterior part using vicryl 6-0 suture. Tenon’s capsule and conjunctiva were sutured in separate layers with vicryl 8-0 suture [Figure 5], [Figure 6], [Figure 7]. No management was done for the fracture of the orbital floor. The patient was assessed on the postoperative days 1, 7, and after 1 month. The patient was orthotropic in primary position with-1 limitation of adduction at 1 month. Diplopia in extreme levoversion was not troublesome. One scale measurement revealed an asymmetry of 1 mm (RE enophthalmos). Ptosis improved after the resolution of edema, 2 mm ptosis persisted [Figure 8],[Figure 9], [Figure 10], [Figure 11]. RE BCVA was 6/6; the patient and parents were satisfied with the outcome.
Figure 5: Intraoperative photographs. Distal end of the right medial rectus muscle (15 mm)

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Figure 6: Proximal end of the right medial rectus

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Figure 7: After closure of Tenon’s capsule and conjunctiva

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Figure 8: Postoperative photographs day 7. Right exotropia (about 10°)

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Figure 9: Attempt of adduction

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Figure 10: After 1 month. Almost full adduction (−1)

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Figure 11: Orthotropia with mild ptosis

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  Discussion Top


Ocular injuries often involve extraocular muscles. In such injuries, the muscle-tendon or the muscle may be torn across completely or partially. Complete disinsertion of a muscle leads to its retraction, making it difficult to retrieve the muscle. The medial rectus, unlike other recti, has no attachment to the oblique muscles.[5] Moreover, its straighter course makes it more prone to be lost in the orbit in case it is severed.

In the present case, the RMR was completely transected and had retracted. It was identified by retroplacing and displacing the globe laterally with exploration along the medial orbital wall. It should be remembered that rotating the globe and exploring toward the posterior pole will only push the muscle more posterior and through the Tenon’s capsule.[5],[6] The muscle was successfully sutured with a good outcome. The enophthalmos of RE was possibly due to fat prolapse and its loss. The enopthalmos was probably responsible for ptosis. Accurate diagnosis and prompt intervention resulted in good surgical outcome.

The advantages of early intervention are greater chances of functional recovery and lesser morbidity. The disadvantage being dealing with edema due to trauma. Imaging to identify the site and severity of the injury is essential before exploration. Although magnetic resonance imaging is ideal for soft-tissue imaging, essential information is also available with CT scan using 2 mm slices. Optimal intervention generally involves targeted exploration with recovery and repair of the damaged, transected, or lost extra-ocular muscle.[7],[8],[9] Even after satisfactory surgery, minimal limitation in motility may persist.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Burke MJ, Del Monte M, DeRespinis P. Medial rectus muscle laceration. J Pediatr Ophthalmol Strabismus 2001;38:98-102.  Back to cited text no. 1
    
2.
Helveston EM, Grossman RD. Extraocular muscle lacerations. Am J Ophthalmol 1976;81:754-60.  Back to cited text no. 2
    
3.
Ludwig IH, Brown MS. Flap tear of rectus muscles: An underlying cause of strabismus after orbital trauma. Ophthalmic Plast Reconstr Surg 2002;18:443-9.  Back to cited text no. 3
    
4.
von Noorden GK, Hansell R. Clinical characteristics and treatment of isolated inferior rectus paralysis. Ophthalmology 1991;98:253-7.  Back to cited text no. 4
    
5.
Rosenbaum AL, Santiago AP. Slipped, disinserted or severed, and lost muscles. In: Clinical Strabismus Management Principles and Surgical Techniques. Philadelphia, PA: WB Saunders Company; 2001. p. 534-35.  Back to cited text no. 5
    
6.
Von Noorden GK, Campos EC. Principles of surgical treatment. In: Binocular Vision and Ocular Motility: Theory and Management of Strabismus. 6th ed. St. Louis, MO: CV Mosby; 2001. p. 618-9.  Back to cited text no. 6
    
7.
Lemade PT, Karandikar SC, Vaijwade SP, Ahuja S. Traumatic disinsertion of medial rectus muscle. Indian J Ophthalmol 1981;29:115-6.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Murray AD. An Approach to Some Aspects of Strabismus from Ocular and Orbital Trauma. Middle East Afr J Ophthalmol 2015;22:312-9.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Choudhury D, Sharma PK. A case report of traumatic dislocation of eyeball. Niger J Ophthalmol 2016;24:89-91.  Back to cited text no. 9
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]



 

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