Korean J Ophthalmol.  2008 Jun;22(2):104-110. 10.3341/kjo.2008.22.2.104.

Vertical Rectus Muscles Transposition in Large Exotropia with Medial Rectus Muscle Transection Following Endoscopic Sinus Surgery

• Cho YA
• Rah SH
• Kim MM
• Lee JY

• KMID: 1099004
• DOI: http://doi.org/10.3341/kjo.2008.22.2.104

Abstract

PURPOSE: To evaluate the effect of transposition procedures on the vertical rectus muscle (VRM) in the patients who underwent a medial rectus muscle (MR) transection after endoscopic sinus surgery (ESS). METHODS: In 4 patients with exotropia (XT) and a lack of adduction after ESS, orbital CT or MRI revealed a complete transection of the midportion of the MR. Full-tendon VRM transposition was performed within 3 months after injury (early surgery) in 2 patients with 40delta XT. Two patients with 70delta and 85delta XT underwent an X-type augmented Hummelsheim procedure, which involved pulling each half-tendon and crossing it through the undersurface of the severed MR to the other end of the MR insertion, concurrently with an ipsilateral lateral rectus (LR) recession 11 months and 36 months after ESS, respectively. The adduction deficits were divided into -1 through to -8. The patients were followed up for more than than 1.5 years. RESULTS: Postoperatively, 3 patients showed orthophoria and no diplopia in the primary position. The adduction deficits improved to -3.5 or -4. One patient who underwent an X-type augmented Hummelsheim procedure showed a residual XT of 25delta. CONCLUSIONS: VRM transposition is effective in correcting a large XT secondary to a MR transection after ESS. When a longstanding large-angle XT with severe contracture of the ipsilateral LR and massive scarring of the adjacent tissues is present, the X-type augmented Hummelsheim procedure coupled with an ipsilateral LR recession had an augmenting effect.

Keyword

Endoscopic sinus surgery; Exotropia; Medial rectus muscle transection; Vertical rectus muscles transposition

MeSH Terms

Adult
Aged
Endoscopy/*adverse effects
Exotropia/diagnosis/etiology/*surgery
Eye Movements
Female
Humans
*Iatrogenic Disease
Magnetic Resonance Imaging
Male
Middle Aged
Oculomotor Muscles/injuries/pathology/*surgery
Paranasal Sinus Diseases/*surgery
Tendon Transfer/*methods
Tomography, X-Ray Computed
Vision, Binocular

Figure

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  Fig. 1 The method of surgery used in this study. (A) Diagram of the full thickness vertical muscle transposition toward medial rectus muscle in patients 1 and 2. (B) Diagram of the X-type augmented Hummelsheim operation in patients 3 and 4.

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  Fig. 2 Patient 1. (A) Preoperatively, he showed marked exotropia and a -4 adduction deficiency. The right eye could not pass the midline. (B) Postoperatively, orthophoria in the primary position and better adduction of the right eye were shown.

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  Fig. 3 Patient 1. Orbital computerized tomography after endoscopic sinus surgery. (A) Axial view (B) Coronal view. Note the defect in the medial wall of the right orbit and the transaction of the right medial rectus muscle.

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  Fig. 4 Patient 3. (A) Preoperatively, fixed large-angle exotropia of 85Δand absent adduction (-7 limitation) of his right eye. (B) Postoperatively, he obtained orthophoria in the primary position and improved adduction to the midline eye.

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  Fig. 5 Patient 3. The findings on orbital magnetic resonance imaging after endoscopic sinus surgery. (A) Coronal view (B) Axial view. Note the defect in the medial wall of the right orbit and the severed medial rectus muscle in the right eye (white arrow).

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