We described the clinical, surgical details and results (motor and sensory) of the retrieving procedure of traumatically avulsed muscles in three patients with no previous history of strabismus or diplopia seen in the Department of Ophthalmology, State University of Campinas, Brazil. The slipped muscle portion was reinserted at the original insertion and under the remaining stump, which was sutured over the reinserted muscle. For all three cases there was recovery of single binocular vision and stereopsis.Foram descritos os quadros clínicos, detalhes cirúrgicos e resultados (motores e sensoriais) da reinserção de músculos traumaticamente avulsionados, em três pacientes sem estória prévia de estrabismo ou diplopia, atendidos no Departamento de Oftalmologia da Universidade Estadual de Campinas. A porção muscular deslizada foi reinserida na linha da inserção original e sob o coto remanescente, o qual foi acomodado e suturado sobre o músculo reinserido. Para os três casos houve recuperação da visão binocular única e da estereopsia.12412

Carvalho, Keila Monteiro de

Ikeda, Karin Suzete

Minguini, Nilza

Arquivos Brasileiros de Oftalmologia

English

Repositorio da Producao Cientifica e Intelectual da Unicamp

124 Arq Bras Oftalmol. 2013;76(2):124-5
Relatos de Casos | Case RepoRts
INTRODUCTION
Extraocular muscle avulsion of traumatic etiology is not fre­
quent(1,2). The medial and inferior recti are the most frequently inju ­
red muscles. This has been explained by reflex reaction of up and 
out movement of the eye (Bells’ phenomenon) when eye injury is 
threa tening.
Chances of retrieving a transected muscle are higher in cases of 
trauma comparing to inadverted transaction during muscle surgery, 
as their attachments to other extraocular muscles and nearby tissues 
are often preserved(2).
Excluding the medial rectus that lacks attachment to another 
muscle, an intact muscle disinserted by trauma will typically be loca­
ted in a sufficiently anterior position for a standard transconjunctival 
approach with no need of orbitotomy(3).  
Preoperative high resolution CT scans with proper techniques 
and magnetic resonance imaging can identify the damaged muscle 
in detail. The oculocardiac reflex is also an effective aid in identifying 
the tissue as muscle, during repairing surgery(4).
In this series, we describe the clinical and surgical findings, repai­
ring technique and the surgical results from three patients that were 
admitted to University of Campinas Clinical Hospital, Brasil, victims of 
ocular trauma and consequent muscle disinsertion. 
CASE REPORT
Case 1 
A 17­year­old female was victim of a dog bite in her left me ­
dial orbital region. Approximately two hours later, she came to the 
emergency room complaining of double vision and limitation of 
mo vement of her left eye. She had no previous history of strabismus 
or ambliopia. Examination on presentation revealed visual acuities 
of 20/20 in her right eye and 20/50 in her left eye. The patient had a 
large angle left exotropia and loss of left adduction. A tendon stump 
of approximately 2.5 mm could be observed through a medial bul­
bar conjunctival laceration. A retinal hemorrhage and a laceration of 
inferior lacrimal canaliculus were also noted. On surgical exploration 
rupture of the globe was not found. The lost medial rectus muscle 
could be located when oculocardiac reflex was observed with trac­
tion of the suspected tissue located at the equator. The tissue was 
then sutured at its original insertion point under the preserved tendon 
stump which was then blended and sutured over the reinserted 
muscle. The conjunctiva and lacrimal lacerations were also repaired. 
One week later alignment was straight in all positions of gaze with no 
limitation on ductions or versions. No double vision was present and 
a stereoacuity of 40 seconds of arc was measured. Retinal treatment 
was not necessary and visual acuity had normalized. (Figure 1).
Case 2 
A 50­year­old, presented with exodeviation of the left eye, which 
suddenly developed after her face was struck with a suspended hook 
three hours previously. Visual acuity of this eye was reduced to 20/50 
and adduction was severely limited. A 10 mm long, crescent­shaped, 
wound was seen in the medial conjunctiva and it was apparent that 
the medial rectus had been avulsed. At surgery it was possible to lo ­
calize and relocate the snapped muscle with the aid of oculocardiac 
reflex and using the same technique as in case 2. Motility and senso­
Traumatic avulsion of extraocular muscles: case reports
Avulsão traumática de músculos extraoculares: relatos de casos
Nilza MiNguiNi¹, KariN Suzete iKeda², Keila MoNteiro de Carvalho³
 Submitted for publication: March 18, 2013
 Accepted for publication: May 23, 2013
 Study carried out at Universidade Estadual de Campinas - Unicamp - Campinas (SP), Brazil.
1 Assistant Physician, Department of Ophthalmology and Otorhinolaryngology, Faculty of Medical 
Sciences, Universidade Estadual de Campinas - Unicamp - Campinas (SP), Brazil.
2 Ophthalmologist and postgraduate student, Department of Ophthalmology and Otorhinolaryngo -
logy, Faculty of Medical Sciences, Universidade Estadual de Campinas - Unicamp - Campinas 
(SP), Brazil.
3 Professor, Department of Ophthalmology and Otorhinolaryngology, Faculty of Medical Sciences, 
Universidade Estadual de Campinas - Unicamp - Campinas (SP), Brazil.
 Funding: No specific financial support was available for this study
 Disclosure of potential conflicts of interest: N.Minguini, None; K.S.Ikeda, None; K.M.Carvalho; None
 Correspondence address: Nilza Minguini. Departamento de Oftalmo/ORL - Hospital de Clínicas 
Unicamp. Rua Vital Brasil, 251 - Campinas (SP) - 13083-888 - Brazil
 E-mail: minguini@uol.com.br
 Research Ethical Commmittee, Universidade Estadual de Campinas - Unicamp, Campinas (SP), 
Brazil. Pratocol: no 013/2012
ABSTRACT
We described the clinical, surgical details and results (motor and sensory) of the 
retrieving procedure of traumatically avulsed muscles in three patients with no 
pre vious history of strabismus or diplopia seen in the Department of Ophthalmolo ­
gy, State University of Campinas, Brazil. The slipped muscle portion was reinserted 
at the original insertion and under the remaining stump, which was sutured over 
the reinserted muscle. For all three cases there was recovery of single binocular 
vision and stereopsis.
Keywords: Eye injuries; Oculomotor muscles/injuries; Strabismus/surgery; Diplopia; 
Depth perception; Case reports
RESUMO
Foram descritos os quadros clínicos, detalhes cirúrgicos e resultados (motores e senso-
riais) da reinserção de músculos traumaticamente avulsionados, em três pacientes sem 
estória prévia de estrabismo ou diplopia, atendidos no Departamento de Oftalmologia 
da Universidade Estadual de Campinas. A porção muscular deslizada foi reinserida 
na linha da inserção original e sob o coto remanescente, o qual foi acomodado e 
suturado sobre o músculo reinserido. Para os três casos houve recuperação da visão 
binocular única e da estereopsia.
Descritores: Traumatismos oculares; Músculos oculomotores/lesões; Estrabismo/
cirurgia; Diplopia; Percepção de profundidade; Relatos de casos 
Minguini N, et al.
125Arq Bras Oftalmol. 2013;76(2):124-5
rial results were satisfactory. Although a moderate limitation of left 
eye adduction had persisted, primary position alignment and normal 
stereoacuity were recovered (Figure 2).
Case 3 
A 58­year­old woman presented to the State University of Cam­
pinas Clinical Hospital complaining of double vision with a history 
of trauma in her right eye caused by a hook of a wire coat­hanger. 
On examination, best­corrected visual acuity was 20/40 in the right 
eye and 20/25 in the left. She had no history of strabismus or double 
vision before this accident. In primary position, the right eye was 
hypertropic and the infraduction of this eye was almost absent. A 
inferior bulbar conjunctival laceration was diagnosed and it became 
apparent that the inferior rectus muscle had been avulsed near its in­
sertion, because there were 3mm of tendon hanging loose from the 
scleral insertion. No retinal lesions or hemorrhages were noted. The 
intraocular pressure was normal and rupture of the globe was con­
sidered unlikely. At surgery, performed 24 hours after the accident, 
the proximal portion of the muscles could not be easily found. No 
ocular­cardiac reflex was presented when traction was done on any 
suspected tissue, except when the inferior oblique was hooked. Then, 
amounts of lacerated and swollen tissues above the inferior oblique 
were brought to the inferior rectus insertion and sutured bellow the 
remaining portion of tendon with 6­0 VicrylTM. The tendon stump was 
blended and sutured over the supposed newly sutured muscle belly. 
At two weeks of follow up, motility examination showed that depres­
sion was normalized, but a slight limitation of elevation was found. 
No double vision was present in primary and down gaze positions. 
Visual acuity was bilaterally normal. Stereoacuity of 40 seconds of arc 
was measured. Further surgery for repairing reduced palpebral fissure 
has been rejected by the patient (Figure 3).
DISCUSSION
A severed nerve to an extraocular muscle, or a crushed muscle 
must always be considered as differential diagnosis of a transected 
muscle in cases of strabismus due to ocular trauma. In this series, 
tendon stumps at the insertion sites were incontestable evidences 
of the right diagnosis rationale. 
Certainly, the surgical technique employed in this series, as it 
had resembled a resection procedure, had induced a change in both 
load and length/tension muscle properties. However, there must 
have been a muscle adaptation which can explain the efficacy of the 
procedures for the three reported cases, all of them ending up with 
maximal grade of stereopsy.
The time limit during which a muscle may be recovered with 
good function is unknown(5,6). Wright had suggested that the pro­
cedure should be done as soon as 7 to 10 days after the traumatic 
event(5). In this series, the surgeries were performed at 1 to and 3 days 
after trauma, fact that should have corroborated the good sensorial 
and motor results.
There were not requested imaging studies for the patients of this 
series. Some authors feel diagnostic imaging do not need to be done 
routinely for cases of slipped or lost muscles(7). In agreement with 
them, we also consider that these tests did not prove to be essential 
for the cases reported, since clinical signs were considered sufficient 
for surgical planning. 
REFERENCES
 1. Plagger DA, Parks MM. Recognition and repair of the “lost” rectus muscle. A report of 
25 cases. Ophthalmology. 1990;97(1):131­6.
 2. MacEwen CJ, Lee JP, Fells P. Aetiology and management of the ‘detached’ rectus 
muscle. Br J Ophthalmol. 1992;76(3):131­6.
 3. Knapp P. Lost muscle. In: Symposium on strabismus: transactions of the New Orleans 
Academy Ophthalmology. St Louis: CV Mosby; 1978. p.301­6.
 4. Apt L, Isenberg SJ. The oculocardiac reflex as a surgical aid in identifying a slipped or 
‘lost’ extraocular muscle. Br J Ophthlamol. 1980;64(5):362­5.
 5. Wright KW. Discussion. Ophthalmology. 1990; 97(1):136­7. [discussion on: Plagger DA, 
Parks MM. Recognition and repair of the “lost” rectus muscle. A report of 25 cases. 
Ophthalmology. 1990;97(1):131­6].
 6. Underdahl JP, Demer JL, Goldberg RL, Rosembaum AL. Orbital wall Approach with 
preoperative orbital imaging for identification and retrieval of lost or transected 
extraocular muscles. J AAPOS. 2001;5(4):230­7.
 7. Greenwald MJ, Ticho BH, Engle JM. Extraocular muscle surgery. In Krupin T: Atlas of 
Complications of Ophthalmic Surgery. London: Wolfe; 1993. p.11­5.
Figure 3. Case 3 - Patient at two weeks of follow-up. Motility examination showing 
nor malized depression and a slight limitation of elevation. The reduced right palpebral 
fissure can be observed.
B
A
Figure 1. Case 1 - Preoperative exotropia in primary position and limitation of adduction 
of the left eye (A). The same patient seven days after surgery (advancing the left medial 
rectus) showing no limitation of left eye adduction (B).
A
B
Figure 2. Case 2 - Preoperative exotropia in primary position and limitation of adduction 
of the left eye (A). The same patient at sixty days after surgery (advancing the left medial 
rectus) showing a residual limitation of left eye adduction (B).


Avulsão traumática de músculos extraoculares: relatos de casos

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