Forced Duction Test Research Articles

Successful alignment following multiple surgeries in a child with severe esotropia and a congenital cranial dysinnervation disorder

Aim: To report the alignment, visual outcome and surgical strategy for severe bilateral congenital esotropia caused by a congenital cranial dysinnervation disorder (CCDD). This was successfully treated with a combination of interventions that included alternate occlusion, botulinum toxin, and conventional and augmented transposition procedures. Methods: A girl presented at 2 months of age with a marked esotropia and severe bilateral impairment of abduction of both eyes, and an inability to fix with either eye in the primary position. Her investigation and treatment are described. Results: The patient initially underwent alternate daily occlusion to prevent the development of amblyopia, followed by simultaneous bilateral medial rectus (MR) botulinum toxin and large bilateral MR recessions based on pre-operative forced duction testing (FDT). This operation was performed at 1 year of age with the aim of releasing the tight MR and reducing the esotropia. After initial improvement, the impairment of abduction gradually increased over the next month. She subsequently underwent sequential inferior oblique myectomy and augmented transposition procedures, which enabled her to fix in the primary position with either eye and with a small-angle esotropia. Conclusion: Substantial improvement in the alignment of the eyes in a child with a complex congenital esotropia secondary to a CCDD is achievable.

Superior oblique tucking for treatment of superior oblique palsy.

To investigate the efficacy and safety of isolated superior oblique tucking in the treatment of congenital superior oblique palsy. Twenty-one patients with unilateral congenital superior oblique palsy and lax superior oblique tendon underwent isolated superior oblique tucking and retrospective analysis of the amount of tucking procedure, preoperative and postoperative vertical deviation in the primary position and reading position, abnormal head posture, ocular motility, and corrected objective torsion. Patients were evaluated before and 6 to 12 months after surgery. The average vertical deviation in the primary position was 10.9 ± 3.3 prism diopters (PD) before surgery and 1.5 ± 2.6 PD after surgery (n = 21, P < .05). The average vertical deviation in the reading position was 15.6 ± 3.6 PD before surgery and 2.6 ± 3.1 PD after surgery (P < .05). The average corrected vertical deviation was 9.9 ± 3.2 PD in the primary position and 13.0 ± 3.4 PD in the reading position (P < .05). The amount of tucking ranged from 5 to 12 mm (mean: 8.3 ± 2.3 mm), which was not related to the corrected vertical deviation in the primary and reading positions, the preoperative vertical deviation in the reading position, or the corrected objective torsion. After surgery, all patients had head posture that was normal or less than 5°. Unremarkable superior oblique underaction and negative head tilt test were found in all patients after surgery. All patients had mild Brown syndrome after surgery, but none were symptomatic. Isolated superior oblique tucking is an efficient and safe procedure for treatment of superior oblique palsy with hyperdeviation less than 15 PD in the primary position and remarkable superior oblique underaction. The superior oblique forced duction test was the most important criterion for planning surgery.

Trochlea surgery for acquired Brown syndrome

To describe surgical treatment of acquired Brown syndrome by trochlea reconstruction and trochlea adhesiotomy. The medical records of patients with acquired Brown syndrome who underwent intraoperative forced duction testing under direct view of the trochlea from 2010 to 2012 were retrospectively reviewed. In all cases, the site of restricted movement was identified, after which either the trochlea was reconstructed or the trochlear adhesion was removed. Surgical results were assessed by means of the pre- and postoperative Hess chart scores and binocular single vision test scores. Six eyes of 6 patients were included. In 4 patients the trochlea was reconstructed; in 2, the adhesion was removed. A significant improvement in the Hess chart scores was observed postoperatively in 5 of the 6 patients (P = 0.047). Binocular single vision test scores also significantly improved in 4 of 5 patients (P = 0.019). No iatrogenic superior oblique muscle paresis was observed in any of the patients. Our technique of isolating the source of limitation of elevation and treating with trochlea reconstruction or adhesion removal successfully treated acquired Brown syndrome in these patients.

Ethmoidal Sinus Mucocele as a Cause of Acquired Brown Syndrome

Dear Editor, A mucocele is composed of a respiratory epithelial lined mucus-containing lesion with accumulation of mucoid secretion. Sometimes, it produces remodeling of the bony structure and influences the adjacent tissues [1]. In this case, extension of the ethmoid sinus mucocele and remodeling of the orbital structure were major causes of acquired Brown syndrome. Although various causes of acquired Brown syndrome have been described, this is the first reported case of acquired Brown syndrome due to ethmoidal sinus mucocele in Korea. A 69-year-old male presented to our institution with a newly-developed diplopia. There was no history of trauma or any medical illness. At initial examination, visual acuity was 20 / 30 in both eyes. The intraocular pressure was 17 mmHg in the right and 20 mmHg in the left eye. There was no relative afferent pupillary defect and color vision was normal. A soft compressible tender mass measuring 2 × 2 mm on the superonasal aspect of the left upper lid extending from the trochlea to the medial canthal tendon was noted. A motility examination showed an underelevation in adduction of the left eye mimicking Brown syndrome (Fig. 1A). A left hypotropia of 2 prism diopters (PD) to 4 PD in primary gaze, which increased to 6 PD in right and upgaze, was present. Forced duction testing indicated a restriction of elevation in adduction of the left eye. Computed tomography (Fig. 1B) revealed an expansile nonenhancing 30 × 25 mm mass of the left ethmoidal sinus having an intraorbital extension consistent with a mucocele. The mass appeared to be pressing on the globe causing effacement of the left medial rectus and superior oblique tendon with anterolateral displacement of the trochlea. The patient underwent endoscopic ethmoidectomy and evacuation of the mucocele by an otolaryngologist. Postoperatively at two months, there was complete resolution of the diplopia and the patient was asymptomatic. A forced duction test revealed no restrictions. Fig. 1 (A) Preoperative versions of subject in nine diagnostic positions of gaze, demonstrating underelevation in adduction of the left eye. (B) Orbital computed tomography scan showing the nonenhancing 30 × 25 mm mass (arrow) of the left ethmoidal sinus ... Brown syndrome is characterized by limited elevation in adduction with positive forced duction testing [2]. The mechanism of acquired Brown syndrome in this case was thought to be the ethmoidal sinus mass preventing anterior tendon movement through the trochlea or the spread of inflammation from an adjacent sinus disease [3]. Complete resolution of symptoms after surgery suggests that mechanical effects were the main cause in this case. Although acquired Brown syndrome is rare, ethmoidal sinus mucocele should be considered in differential diagnosis of acquired Brown syndrome.

Traumatic 6 th Nerve Palsy Managed with Medial Rectus Recession with Hangback Sutures and Hummelsheim Procedure

Traumatic paralytic esotropia due to 6 th nerve palsy is not uncommon but difficult to manage. We reported a case of 38-year-old male who sustained head injury in road traffic accident 15 years ago and inward deviation of his left eye. His vision in right eye was 20/20 and counting fingers at one foot in the left eye. He had >70 prism diopters esotropia in the left eye with restriction of movements in all directions of gaze except adduction. His forced duction test was positive. Examinations of the anterior and posterior segments of both eyes were within normal limits. Magnetic resonance imaging suggested old traumatic insult in the left eye. Diagnosis of left eye traumatic 6 th nerve palsy with medial rectus contracture was made. Left medial rectus recession with hangback sutures and Hummelsheim procedure were performed. Postoperatively, the patient's vision in the left eye had improved to 20/80 the esotropia had reduced to 15 prism diopters (delta).

Presumed Acute Adenoviral Dacryoadenitis Associated with Epidemic Keratoconjunctivitis: A Case Report

Traumatic paralytic esotropia due to 6th nerve palsy is not uncommon but difficult to manage. We reported a case of 38‑year‑old male who sustained head injury in road traffic accident 15 years ago and inward deviation of his left eye. His vision in right eye was 20/20 and counting fingers at one foot in the left eye. He had >70 prism diopters esotropia in the left eye with restriction of movements in all directions of gaze except adduction. His forced duction test was positive. Examinations of the anterior and posterior segments of both eyes were within normal limits. Magnetic resonance imaging suggested old traumatic insult in the left eye. Diagnosis of left eye traumatic 6th nerve palsy with medial rectus contracture was made. Left medial rectus recession with hangback sutures and Hummelsheim procedure were performed. Postoperatively, the patient's vision in the left eye had improved to 20/80 the esotropia had reduced to 15 prism diopters (delta).

Surgery for Complete Vertical Rectus Paralysis Combined with Horizontal Strabismus

Aims. To report outcomes of the simultaneous surgical correction of vertical rectus paralysis combined with moderate-to-large angle horizontal strabismus. Methods. If a preoperative forced duction test was positive, antagonist muscle weakening surgery was performed, and then augmented partial rectus muscle transposition (APRMT) + partial horizontal rectus recession-resection was performed 2 months later. If a preoperative forced duction test was negative, APRMT + partial horizontal rectus recession-resection was performed. Antagonistic muscle weakening surgery and/or conventional recession-resection of the horizontal and/or vertical muscles of the contralateral eye was performed 2 months later, as needed. Results. Ten patients with a mean age of 22.3 ± 13.0 years were included and mean follow-up was 7.1 months. The mean vertical deviation that APRMT corrected was 21.4 ± 3.7 PD (prism diopter). The absolute deviation in horizontal significantly decreased from a preoperative value of 48.5 ± 27.4 PD to a value of 3.0 ± 2.3 PD 6 months postoperatively. The movement score decreased from a value of −5 ± 0 preoperatively to a value of −2.7 ± 0.8 at 6 months postoperatively. Conclusion. For patients with complete vertical rectus paralysis combined with a moderate- to-large angle of horizontal strabismus, combined APRMT and partial horizontal rectus recession-resection is safe and effective for correcting vertical and horizontal strabismus.

Different Onset Pattern of Oculocardiac Reflex in Pediatric Medial Wall Blowout Fractures

We report the 2 pediatric patients who had radiographic confirmation of a rare case of medial orbital wall "trapdoor" fracture with extraordinary symptoms of oculocardiac reflex (OCR). This was a small interventional case series. This is the retrospective report of 2 boys (13 and 10 years old) who developed diplopia, pain, nausea/vomiting, and general malaise following blunt trauma. However, the onset pattern of OCR was absolutely different: delayed onset of OCR just following therapeutic forced duction test to treat the orbital content herniation in the first case and a sudden onset after injury in the second case. In both cases, urgent surgery led to complete normalization of ocular motility. Prompt diagnosis and proper treatment are critical to maximize clinical outcome for this rare and critical trauma.

No ocular motility complications after subtenon topotecan with fibrin sealant for retinoblastoma

ObjectiveTo report our long-term experience with the local toxicity profile and ocular motility changes after treatment of intraocular retinoblastoma with subtenon topotecan chemotherapy. DesignCross-sectional study. ParticipantsTen eyes in 8 patients with retinoblastoma treated with subtenon topotecan. MethodsWe assessed potential complications in ocular motility in eyes with retinoblastoma treated with subtenon topotecan using forced duction testing under general anaesthesia. Eyes subsequently enucleated because of treatment failure were examined histologically. ResultsTen eyes in 8 patients with retinoblastoma treated with 1 to 4 injections of subtenon topotecan were examined repeatedly, with a mean follow-up period of 37 months. Ocular motility remained normal in all eyes by forced duction, with no observed persistent conjunctival congestion, abnormal ocular motility, or enophthalmos in retained eyes 3 years after last injection. Histopathologic examination of the 2 enucleated eyes did not reveal signs of orbital tissue necrosis or fibrosis. ConclusionsUnlike subtenon carboplatin, subtenon topotecan therapy is not associated with long-term toxicity affecting ocular muscles or orbital soft tissue. No effect on ocular motility was observed.

Risk factors influencing the outcome of strabismus surgery following retinal detachment surgery with scleral buckle

To determine factors associated with surgical success in patients undergoing strabismus surgery after retinal detachment repair with scleral buckle. The medical records of consecutive patients who underwent strabismus surgery after repair of retinal detachment with scleral buckle were retrospectively reviewed. A successful "motor" outcome was defined as horizontal deviation <10(Δ) and vertical deviation <4(Δ) in the primary position; successful "sensory" outcome was no diplopia in the primary position. Various factors such as removing the scleral buckle at the time of strabismus surgery, the macula structural status, size of the preoperative deviation, presence of restriction to passive movement, and whether the eye with the scleral buckle was the operated eye were compared among groups based on motor success. A total of 25 patients were included. The overall motor success rate was 72% after 1.8 ± 0.9 operations, with 62% of patients diplopia free in the primary position. Horizontal deviation <10(Δ) (P = 0.005) and minimal restriction on forced duction test were associated with motor success after the first surgery (P = 0.05). Partial or entire scleral buckle removal (n = 15) and fellow-eye surgery were not significantly correlated with motor success in our cohort. There were no retinal redetachments after scleral buckle removal. A small preoperative horizontal deviation, and minimally restricted ocular rotations wereassociated with better results. Removing the scleral buckle did not improve results.

Traumatic Lysis of the Inferior Rectus Muscle

The study aims to report a rare case of traumatic lysis of inferior rectus muscle after a traffic accident. This is a case report wherein the clinical features, computed tomographic findings, and surgical treatment were presented. A 42-year-old woman complained of double vision and upward deviation of the left eye for 13 months after being involved in a traffic accident. The alternate prism and cover test both at distance and near testing showed an exotropia of 18 prism diopters (PD) and hypertropia of 50 PD of the left eye. The left eye had complete restriction of downward movement, and the forced duction test was negative. Computed tomography disclosed that the middle portion of the left inferior rectus muscle was absent. Diagnosis was traumatic lysis of left inferior rectus muscle. The deviation of the left eye was corrected by left superior rectus muscle recession and partial transposition of the medial and lateral rectus muscles. Six months after surgery, no deviation at the primary position both at distance and near testing was present; however, the left eye remained at a -3 restriction of downward movement. Paralysis of the inferior rectus muscle may have resulted from the traumatic lysis, a rare clinical feature that can be confirmed by computed tomography.

Isolated Horizontal Gaze Palsy With Congenital Pontine Hypoplasia

We read with great interest the article by Connors et al. (1) published in the Journal on the “16 syndrome.” The authors described an interesting eye movement pattern characterized by bilateral limitation of horizontal eye movements and bilateral facial nerve palsies that was caused by an acquired disorder of the pontine tegmentum. We evaluated a patient with bilateral horizontal gaze palsies due to a congenital abnormality of the central nervous system. An 11-year-old boy was referred to our clinic for evaluation of eye movements. Visual acuity was 20/20 in each eye. There was no abnormal head posture and the eyes were orthophoric in primary position. Ocular movements showed a bilateral horizontal gaze palsy with normal vertical eye movements. Horizontal movements could not be elicited with the Doll's head maneuver and horizontal saccades and pursuit movements were absent. Convergence to a near target was normal (see Supplemental Digital Content, Video, https://links.lww.com/WNO/A76). Forced duction testing was negative and the remainder of the ocular examination was unremarkable. Brain magnetic resonance imaging (MRI) revealed hypoplasia of the dorsal pons with a midsagittal cleft extending ventrally from the floor of the fourth ventricle (Fig. 1). The facial colliculi were absent and there was mild atrophy of the midbrain and medulla.FIG. 1: A. T2 axial magnetic resonance imaging (MRI) demonstrates a midsagittal cleft (arrow) producing “split pons sign.” B. T1 sagittal MRI shows pontine hypoplasia with abnormal appearance of the floor of the fourth ventricle.A variety of congenital disorders of the pons have been reported with horizontal gaze palsy. These include Moebius syndrome (2), associated with synergetic convergence (3) and with scoliosis (4,5). The clinical findings of scoliosis appear to require atrophy of the medulla ("butterfly" configuration on MRI), which was not present in our case.

Computer-assisted diagnosis of monocular elevation deficiency

Our aim is to demonstrate the benefits of using a computer model to support the clinical diagnosis of complex eye motility disorders. For diagnosis and differential diagnosis we compared the clinical data of a patient with suspected monocular elevation deficiency (MED) and the corresponding computer simulation with the simulations of rectus superior palsy, vertical Duane miswiring syndrome and two simulations of asymmetric gaze palsy. We used our biomechanical eye model SEE-KID for the computer simulations, which is partly based on ideas and concepts of the software system Orbit™ by Joel Miller. A young patient with the clinical characteristics of congenital MED, unilateral limitation of up-gaze above midline, with accompanying ptosis on the affected right side, mild head posture, chin-up position, partial binocular functions and Bell's phenomenon was examined. Pupillary situation, cover test, version and duction movements, saccadic test, Parks-Bielschowsky phenomenon and head tilt test, stereopsis test, Bagolini striated lens test and forced duction test were assessed. Up to the age of 5 years we used the prism cover test in the nine main gaze positions; later we switched to the Hess-Lancaster test for analyzing deviations. We also used our computer model for evaluating the diagnosis and for differential diagnosis of our patient. The simulation results from the SEE-KID model support the diagnosis of supranuclear MED, which can be achieved in the model by varying central innervations, contrary to the modification of muscle forces in the simulation of a rectus superior palsy. It is necessary to distinguish between supranuclear, nuclear, interstitial or peripheral lesions with regard to monocular elevation deficit. Simulations of patients with similar pathologies in a way that the simulations correspond to the patient-measured values support (beside the clinical signs) the diagnosis of supranuclear or infranuclear lesions.

Video demonstrations of classical or rare signs in pediatric ophthalmology and strabismus

To demonstrate using high quality video, rare or classical clinical or surgical signs in pediatric ophthalmology and strabismus. Pediatric ophthalmologists, orthoptists, and training ophthalmologists. Many rare or classical signs are often described in textbooks but not always recorded in busy clinics. Equally some surgical signs are so rare that very few people get to see them. This workshop allows the audience to see videos of such signs with an explanation from the ophthalmologist who had recorded them. Many of the conditions shown in the video demonstartions are usually seen in tertiary and quarternary settings but may well present in the primary or secondary setting. Ideally all physicians would have access to such videos for contued medical education but these are not currently available at any one site. This workshop should make the audience more confident in making diagnoses based on the signs shown. It should allow them to better formulate treatment plans based on the clinical signs. The surgical videos will allow the audience to see unusual procedures or signs so they are more familiar with them. Six experienced authors will have 12 minutes each to present videos of surgical, and clinical signs of classical, or rare conditions. Each presenter will be quizzed by other panel members about differential diagnoses for clinical signs or alternative techniques for surgical videos. Some of these will be videos of oculo-palatal myoclonus, signs in pediatric myasthenia gravis, endoscopic evaluation of a failed Ahmed Tube, forced duction test of a lax superior oblique tendon, floppy iris syndrome in a child,eyemovents in a child diagnosed with neurological tics which were due to dry eye syndrome, goniotomy in aniridia, nystagmus of benign paroxysmal hemiplegia of childhood, paradoxical pupils, forced duction test to cure Brown syndrome and rupture of an inferior rectus muscle during strabismus surgery. Demonstration of classical or rare clincial signs and surgical techniques using high quality video and inter-panel debate.

New strabismus surgical techniques

Five new strabismus surgical procedures were developed by the authors and were presented as a workshop at the AAPOS annual meeting of the American Association for Pediatric Ophthalmology and Strabismus. They are summarized here to introduce these methods to the reader and provide surgeons with more options in approaching difficult strabismus problems. Diagnosis and correction of consecutive strabismus attributable to stretched scar is discussed. The pulley posterior fixation procedure is a unique approach to correct high accommodative convergence or to augment a maximal medial rectus recession. Diagnosis and repair of the partial avulsion (flap tear) of a rectus muscle allows correction of some restrictive strabismus following blunt trauma. The nasal myectomy of the inferior oblique muscle corrects persistent inferior oblique overaction without sacrificing the tether effect gained by a previous anterior transposition of the inferior oblique. The full advancement of the superior oblique tendon offers another option to strengthen a weak superior oblique muscle.

Vertical synergistic divergence: To be or not to be, that is the quintessential question

Dear Editor, We do not concur and reiterate that clinical picture cascades down consummately to a hallmark bilateral Brown Syndrome (BBS) presentation.[1–3] Documentation of forced duction test results, ductions, measurements of deviation in prism diopters in nine cardinal gazes with either eye fixing, fundus photographs for torsion, in tandem with findings on neuroimaging/surgical exploration and surgical outcomes would be seminal in sifting the maze, but reports skirt all of that.[1,3] Full bilateral elevation in abduction with gross bilateral limitation of elevation in adduction with down-shoot of adducted eye consistently in side, up and down gazes, with globes nailed in down position and negative head tilt test results, unequivocally cohere to a diagnosis of BBS. An alternative diagnosis can only be entertained in the presence of negative exaggerated forced duction tests, which were not done.[1,3] The report is cryptic as to whether one or both eyes are having 3rd nerve palsy, the extent of involvement, recovery and aberrant innervation, if any present.[1,3] Either eye is dipping in adduction, and the left eye will also dip if the right eye is allowed to fixate and elevate in slight abduction.[3] No light is shed on the plausible location/pathway/mechanism/causation of the expounded synergistic vertical divergence involving only the right eye, in view of the facts that up gaze fibers freely cross in the posterior commissure, whereas down gaze fibers are uncrossed, and the superior rectus (SR) receives crossed innervation through the opposite subnucleus. It follows that proposed synergistic divergence/convergence cannot be conflated via up gaze fibers at the supranuclear level. Neither can it be conflated at the nuclear/infranuclear level. Superior oblique (SO) overactions (not known whether it is primary or secondary) as propounded[1,3] do not produce globes nailed-in down gaze in adduction. In 3rd nerve palsy, as the depressor action of SO is compromised, they instead cause intorsion. Thus, bilateral overdepression in adduction sans intorsion cannot be ascribed to bilaterally overacting SOs due to (right) 3rd nerve palsy as surmised.[1,3] There is nothing proximate to “no significant ocular torsion,” as torsional position of the globe is a state and, therefore, it may only be normal or abnormal.[3] Further, the downshoot is only in adduction, not in abduction, and therefore cannot be explained by aberrant innervation of SR as SRs act in abduction.[1,3] The SR has to be paretic to undergo aberrant innervation; the report does not state so[3] and resultant cocontraction of vertical recti on up gaze will engender convergence retraction instead. Overaction of SOs, downshoot and widening of palpebral fissure in adduction is known in Brown Syndromes, and is the likely cause of asymmetrical underdepression of both eyes in abduction, the hallmark finding militating against BBS as per the report.[1] No perfidy will be committed anyway if congenital 3rd nerve palsy and BBS coexist. In the absence of irrefutable documentary evidence on forced duction tests against BBS and nine gaze deviations fixing with either eye, no meaningful conclusions can be drawn about muscle overactions/underactions and any abstruse synergistic vertical divergence/convergence. Thus, the proposed esoteric expositions about misinnervation and synergistic divergence are bereft of any neuroanatomical substrate at supranuclear/nuclear/infranuclear levels, and are overtly speculative, emanating from a skewed interpretation of a hallmark congenital BBS presentation.[1,3]

Surgical management of hypotropia in congenital fibrosis of extraocular muscles (CFEOM) presented by pseudoptosis

PurposeTo describe the demographics, characteristics, management pitfalls, and outcomes of pseudoptosis associated with congenital fibrosis of the extraocular muscles (CFEOM).MethodsA retrospective review was performed of eight patients presenting with ptosis and hypotropia to oculoplastic service. All patients underwent full ocular evaluation and magnetic resonance imaging of brain and orbit. Five of these patients underwent stepwise correction of hypotropia by single-stage adjustable strabismus surgery (SSASS), followed by a frontalis sling if needed.ResultsEight patients had congenital strabismus with severe ptosis and a positive forced duction test. There was a highly significant improvement from preoperative mean hypotropia angle of 30 prism diopters (PD) to 9 PD mean postoperative angle (P = 0.006). Surgery for ptosis was not needed in 80% of eyes.ConclusionCFEOM involving both ptosis and hypotropia could be properly managed with the correct sequence of surgical steps. Proper vertical alignment by correction of hypotropia utilizing SSASS may alleviate the need for ptosis surgery.

Visual Diagnosis: A 6-year-old Girl With Restricted Upward Gaze of Her Right Eye

Brown syndrome is an incomitant strabismus syndrome characterized by inability of the eye to elevate during adduction. • Primary Brown syndrome is thought to occur due to the inability of the superior oblique tendon to stretch.However, there are many secondary causes of this condition that must be ruled out. • Despite significant misalignment of the eyes during upgaze, patients with Brown syndrome usually do not have decreased vision or diplopia with primary gaze. • Unlike paralytic strabismus, forced duction tests demonstrate restriction and a Parks’ three-step test does not demonstrate a paralytic muscle. Spontaneous resolution is frequent, and surgical management typically is not indicated because of the high incidence of postoperative symptomatic superior oblique palsy.

Prise en charge des troubles oculomoteurs après effraction iatrogène de l’orbite au cours d’interventions sinusiennes endoscopiques

Orbital wall fracture may occur during endoscopic sinus surgery, resulting in oculomotor disorders. We report the management of four cases presenting with this surgical complication. A non-comparative observational retrospective study was carried out on four patients presenting with diplopia after endoscopic ethmoidal sinus surgery. All patients underwent full ophthalmologic and orthoptic examination as well as orbital imaging. All four patients presented with diplopia secondary to a medial rectus lesion confirmed by orbital imaging. A large horizontal deviation as well as limitation of adduction was present in all cases. Surgical management consisted of conventional recession-resection procedures in three cases and muscle transposition in one patient. A useful field of binocular single vision was restored in two of the four patients. Orbital injury may occur during endoscopic sinus surgery and cause diplopia, usually secondary to medial rectus involvement due to the proximity of this muscle to the lamina papyracea of the ethmoid bone. Surgical management is based on orbital imaging, duration of the lesion, evaluation of anterior segment vasculature, results of forced duction testing and intraoperative findings. In most cases, treatment is aimed at the symptoms rather than the cause, and the functional prognosis remains guarded.

Unilateral inferior rectus hypoplasia in a child with Axenfeld-Rieger syndrome

A 6-year-old boy with Axenfeld-Rieger syndrome presented with exotropia and a right hypertropia with limited depression. Computed tomography revealed hypoplasia of the right inferior rectus muscle. Forced duction testing was notable for a tight right superior rectus muscle. A superior rectus muscle recession reduced the primary position hypertropia but did not improve the patient's downgaze. To our knowledge, unilateral inferior rectus muscle hypoplasia has not been described previously in a patient with Axenfeld-Rieger syndrome.