Korean J Ophthalmol.  2013 Aug;27(4):304-307. 10.3341/kjo.2013.27.4.304.

Bupivacaine Injection to Lateral Rectus in Abducens Nerve Palsy

• Kyung S
• Jeon J

• KMID: 1705430
• DOI: http://doi.org/10.3341/kjo.2013.27.4.304

Abstract

A 49-year-old female presented with bilateral abducens nerve palsies. She had 75 prism diopter esotropia. The extraocular movement of the lateral rectus was -1 limitation for the right eye and -4 limitations for the left. After performing orbital magnetic resonance imaging (MRI), 2 mL of bupivacain (5 mg/mL) was injected into the left lateral rectus (LR). One month after injection, a further orbital MRI was performed. Subsequently, recession of both medial rectus (6 mm) and resection of the left LR (9 mm) were performed. After one month, bupivacaine had no hypertrophic effects. There was little change in angle of deviation. The orbital MRI scan showed a 1.91% increase in volume compared to the muscle prior to the injection. Histological findings showed no muscle fibers of the left LR muscle, only the fiber nucleus and the collagen that replaced the fibers. We report on the changes in stiffness and muscle volume and on the histology of the muscle one month after injecting bupivacaine into the paralyzed left LR muscle combined with standard surgical treatment.

Keyword

Abducens nerve diseases; Bupivacaine; Magnetic resonance imaging

MeSH Terms

Abducens Nerve/*pathology
Abducens Nerve Diseases/*drug therapy/pathology
Anesthetics, Local/*administration & dosage/adverse effects
Bupivacaine/*administration & dosage/adverse effects
Female
Humans
Magnetic Resonance Imaging
Middle Aged
Anesthetics, Local
Bupivacaine

Figure

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  Fig. 1 Patient presents with bilateral abducens nerve palsy, (A) at one month after bupivacaine injection to the left lateral rectus (B). There was no change in deviation. Magnetic resonance imaging T1-weighted coronal and axial scans of the orbits showing images taken before bupivacaine injection (C) and one month after injection (D). The arrows indicate the atrophic left lateral rectus muscle, and the volume of the left lateral rectus muscle showed a 1.91% increase (ITK-SNAP software).

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  Fig. 2 Photomicrographs of left resected lateral rectus after bupivacaine injection (×10, ×20). The nuclei of the muscle fibers and the collagen that replaced the fibers were observed (A), control (intermittent exotopia, 43-year-old woman, ×10, ×20) (B), Masson's trichrome staining. Patient six months (C) and 18 months (D) after standard treatment (recession of both medial rectus muscles and resection of the left lateral rectus). Orthotropia is maintained, and adduction of the left eye is limited compared to that at six months due to stiffness of the injected left lateral rectus at 18 months.

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