Childhood burns in south eastern Nigeria

A case has been presented in this article of congenital absence of bilateral inferior rectus muscles combined with restriction of the lateral rectus muscle and malinsertion of the inferior oblique muscle to the lateral rectus muscle. The surgical procedures for correction of the absence of the inferior rectus muscle and embryogenesis of extraocular muscles were also reviewed.     

Combined paresis and restriction of the extraocular muscles after orbital fracture: a study of 16 patients

Sixteen patients with combined paresis and restriction of extraocular muscle(s) orbital fracture repair were studied before and after in order to determine the clinical features and management of such patients. All 16 patients showed limited ductions of the involved eye in the field of action of the entrapped, paretic muscle and of the antagonist muscle after orbital fracture. Single extraocular muscles (13 patients) and two extraocular muscles (three patients) were demonstrated adjacent to the fracture site on orbital computed tomography (CT). In three patients prior to orbital surgery, a deviation in primary position was present. After fracture repair with release of the entrapped muscle in all patients, evidence of paresis of the muscle was demonstrated by underaction in its field of action and overaction in the field of its antagonist. There was a resultant manifest tropia or phoria in the primary position. In seven patients, the paresis gradually improved with no tropia and little diplopia in the functional fields of gaze. Three patients had minimal deviations and required no further treatment. Six patients with significant deviations required prisms (three patients) or strabismus surgery (three patients). The latter three patients had two muscles involved. Results of this study demonstrate that the ophthalmologist must appropriately diagnose patients with paresis and restriction of an extraocular muscle and counsel them that "new" diplopia may occur after orbital fracture repair and that this diplopia may require additional therapy.     

Diagnosis and surgical management of strabismus associated with thyroid-related orbitopathy

BACKGROUND: In the healing phase of thyroid-related orbitopathy, fibrosis and contracture of the extraocular muscles may result in restrictive ocular motility. Ocular misalignment may occur in both eyes and along three different axes of rotation. Successful surgical treatment depends on precise identification of the muscles that are restricting motility and producing the misalignment. METHODS: Between 1980 and 1994, 22 patients were surgically treated for restrictive strabismus caused by thyroid-related orbitopathy. Preoperatively, all patients underwent complete neuroophthalmic, oculoplastic, and orthoptic examinations. Analysis of ductions, measurement of torsion, and the use of monocular neutralization techniques were essential additions to the usual motility exam. Patients were placed into diagnostic categories based on the clinical pattern of extraocular muscle restriction. Adjustable recessions were done for all initial surgeries. RESULTS: Patients with unilateral inferior rectus involvement or with ipsilateral inferior rectus-contralateral superior rectus involvement had large vertical deviations (equal to or > 20 prism diopters [delta]). Patients with bilateral inferior rectus involvement had small vertical deviations (< 20 delta). Excyclotorsion correlated strongly with the presence of tight inferior recti. Vertical comitance (upgaze versus downgaze measurement of equal to or < 15 delta) correlated with the ipsilateral inferior rectus-contralateral superior rectus pattern of involvement. Vertical incomitance (upgaze versus downgaze measurement of > 15 delta) correlated with unilateral inferior rectus involvement. Eighteen of 22 patients had excellent postoperative alignment and elimination of diplopia in functional positions of gaze. Those with less favorable results developed reversal of the hypertropia and exotropia in downgaze. Sixteen out of 19 patients who underwent inferior rectus recession had induced inferior eyelid retraction. CONCLUSION: Different combinations of extraocular muscle restriction in this series of patients produced characteristic patterns of misalignment. Appropriate, adjustable, strabismus surgery was successful in restoring binocular vision in 21 out of 22 patients with a minimum of complications.     

Parvovirus B19 in the Czech Republic. Seroepidemiologic study

Two rare cases of strabismus resulting from contracture of the extraocular rectus muscles after retrobulbar anesthesia for cataract surgery are described. Clinical signs in both cases suggested that the development of the impaired function of the lateral and superior rectus muscles followed the same pattern: initial stimulation followed by paretic and restrictive stages. Abnormal enlargement of the muscles was identified by computed tomography (CT) and magnetic resonance imaging (MRI). The data indicate that the strabismus was the result of direct injection of anesthetics into the rectus muscle.     

Long-term observation of ablatio-prophylaxis with kryopexy (author''s transl)

Five cases of laceration of an extraocular muscle without involvement of the globe or significant involvement of the adnexa occurred after injury with a pencil, mower blade, screen door, and building nail, and at surgery when the surgeon operated on the wrong muscle. The inferior rectus muscle was involved in three cases, the lateral rectus muscle in one, and the medial rectus muscle in one, Traumatic muscle laceration involves the inferior or medial rectus muscles more often than the other muscles. This may occur for two reasons: these muscles are closer to the corneoscleral limbus, and they are more visible during the protective blink with associated upward and usually outward movement of the globe (Bell's phenomenon). When the lacerated muscle could be found, it was repaired either by reinsertion to the sclera or reunion of the severed muscle segments. When the muscle could not be found, a muscle transfer procedure was carried out. Patients with fusion before injury regained fusion in part of the visual field after muscle repair.     

Computed tomography in Graves' ophthalmopathy

The CT scan with the 160 x 160 matrix demonstrated both the normal orbital anatomy and the abnormal orbital anatomy of Graves' ophthalmopathy in great detail. In Graves' ophthalmopathy, the cardinal pathologic feature of extraocular muscle enlargement was accurately reflected on the CT scan and was a distinctive, diagnostically reliable finding. Enlargement of the medial and lateral rectus muscles and of the apex of the muscle cone were the most consistent findings. The severity of the CT scan abnormalities correlated well with clinical severity. Because muscle cone abnormality was observed characteristically in those patients with sight loss, we suggest that pressure by the extraocular muscles on the optic nerve may contribute to visual acuity loss in this disease.     

Structure-function correlations in the human medial rectus extraocular muscle pulleys

PURPOSE: Fibroelastic pulleys function like the trochlea to fix the position and pulling direction of the recti extraocular muscles within the orbit. This study characterized the fine structure of the human medial rectus muscle pulley. METHODS: Human medial rectus muscle pulley tissue was dissected at autopsy, immersed in aldehyde fixative solution, and processed for and examined with light and electron microscopy. RESULTS: Pulley structure were located within posterior Tenon's fascia, closely surrounding the medial rectus muscle. Pulleys were comprised of a dense collagen matrix with alternating bands of collagen fibers precisely arranged at right angles to one another. This three-dimensional organization most likely confers high tensile strength to the pulley. Elastin fibrils were interspersed in the collagen matrix. Fibroblasts and mast cells were scattered throughout the relatively acellular and avascular collagen latticework. Connective tissue and smooth muscle bundles suspended the pulley from the periorbita. Smooth muscle was distributed in small, discrete bundles attached deeply into the dense pulley tissue. CONCLUSIONS: Fine structural observations confirm the existence and substantial structure of a pulley system in association with the medial rectus extraocular muscle. The presence of pulleys must be considered in models of the oculomotor plant. The cytoarchitecture and placement of pulleys suggest that they are internally rigid structures and are consistent with the idea that they determine functional origins for the extraocular muscles. However, the nature of the connective tissue-smooth muscle struts suspending the pulley system to the orbit supports the notion that the pulley position, and thus the vector force of the eye muscles, may be adjustable.     

Selective ablation of immature blood vessels in established human tumors follows vascular endothelial growth factor withdrawal

In the guinea pig, lateral deviation of the head is a cardinal symptom of the vestibular syndrome caused by unilateral labyrinthectomy. In the course of recovery from this syndrome (vestibular compensation), lateral deviation of the head disappears completely in 2-3 days. Because this symptom is known to be due to the lesion of the horizontal semicircular canal system, and since obliquus capitis inferior (OCI) muscle is activated predominantly by yaw rotation (horizontal vestibulocollic reflex), we hypothesized that changes in the activity of this muscle could be at least in part responsible for the lateral head deviation caused by unilateral labyrinthectomy. In order to test this hypothesis, electromyographic (EMG) activities of the right and left OCI muscles, as well as eye movements, were recorded in 12 head-fixed alert guinea pigs at various times after left surgical labyrinthectomy (performed with the animals under halothane anesthesia). After the operation, a decrease in tonic EMG activity was observed in the right (contralateral to the lesion) OCI muscle while an increase in tonic EMG activity was detected in the left (ipsilateral) OCI muscle. In addition, phasic changes in EMG activity associated with ocular nystagmic beats occurred in the OCI muscles. These phasic changes were in the opposite direction to those of the tonic changes. There were bursts of activity in the right OCI and pauses in the left OCI. From measurements of rectified averaged EMG activities which took into account both parts (tonic and phasic) of the phenomenon, it was concluded that the labyrinthectomy-induced asymmetry between the activities of the left and right OCI muscles was high enough and lasted long enough to be an important mechanism in the lateral deviation of the head caused by unilateral labyrinthectomy.     

Lactate dehydrogenase isoenzyme pattern in the eye muscles. Deviation in myopia

The lactate dehydrogenase isoenzyme patterns in 46 extraocular eye muscle samples removed at surgery for squint were determined by acrylamide-gel electrophoresis and reduction of NAD coupled with formazan reaction. Muscle type subunits predominated in the isoenzymes of the medial and lateral rectus muscles of emmetropic and hypermetropic eyes, whereas heart type subunits predominated in those of myopic eyes.     

Surgical treatment for primary cardiac malignant lymphoma

A 60-year-old woman who complained of palpitation was diagnosed as ventricular tachycardia on electrocardiography and admitted to our hospital. The ultrasonic cardiography showed cardiac tumor in right ventricle and right atrium. Due to the obstruction of the right ventricle inflow by the tumor, we immediately performed resection of cardiac tumor and repair of right ventricle wall under cardiopulmonary bypass. The tumor was diagnosed as malignant lymphoma by pathological examination for surgical specimen of tumor. After operation her general condition was good, but residual cardiac lymphoma developed large size. We performed radiation therapy for cardiac lymphoma. Therefore the lymphoma was reduced to minimum size. Six months after operation metastatic malignant lymphoma appeared at whole body. So we performed chemotherapy for reduction of systemic malignant lymphoma. At first the chemotherapy was very effective. But metastasis spread rapidly and effectiveness of chemotherapy reduced. Thirteen months after operation she died for respiratory distress, probably due to metastatic brain tumor.     

Outcome of Perthes'' disease in unselected patients after femoral varus osteotomy and splintage

PURPOSE: To study the incidence, cause, recovery time, and prevention of diplopia following subcutaneous injection of botulinum A toxin for the treatment of facial spasms. METHODS: Patients who experienced diplopia after botulinum A toxin injections had their deviations examined in detail. When the muscle that caused diplopia was identifiable, the injection closest to that muscle was omitted in the next treatment in an attempt to prevent diplopia. RESULTS: Of 250 patients receiving about 1500 sets of injections, 25 (1.7%) incidents of diplopia occurred in 10 patients. Excluding two patients who declined further treatment after having diplopia on their first botulinum A toxin treatment, seven of the remaining eight patients had multiple incidents of diplopia. The most common pattern of diplopia was "uncertain diagnosis." The most common identifiable cause of diplopia was paresis of the inferior oblique muscle. Omission of the injection into the central portion of the lower eyelids in the next treatment prevented recurrence of diplopia in only one of the four patients. No significant correlation between botulinum A toxin doses injected and times to recovery was noted. CONCLUSIONS: Diplopia following botulinum A toxin treatment is uncommon. Seven patients (3% of patients studied) had 22 episodes of diplopia (88% of episodes). When diplopia occurs, it tends to recur on reinjection, sometimes with a prolonged recovery time. This response may not be dose dependent. The extraocular muscles of some patients may be more susceptible to chemodenervation than others, or botulinum A toxin may diffuse to extraocular muscles more easily in some patients than in others.     

Functioning muscle transplantation after wide excision of sarcomas in the extremity

Free functioning muscle transplantation was performed after resection of 23 sarcomas in the extremity. There were 21 soft tissue sarcomas and two malignant bone tumors. The tumor resection was performed with a wide margin in all except two patients who had a marginal margin in a limited area. The consequent extensive soft tissue defect received free musculocutaneous flaps, the motor nerve of which was repaired in the recipient site. The most frequent procedure was latissimus dorsi transplantation to replace thigh muscles in 17 cases. The other donors included gracilis, tensor fascia lata, and rectus femoris, which were selected according to the site of defects. Patients were followed up for a mean of 60 months (range, 13-119 months). The grafted muscles showed reinnervation at a mean of 6 months postoperatively in all patients except for a 75-year-old patient. Obtained contraction of the muscles was powerful in 18 patients and fair in four patients. Performance of the salvaged limb significantly improved after recovery of the muscles. Although there were five distant recurrences, local recurrence was seen in one patient with systemic metastases. Because muscle loss could be compensated functionally for by the innervated free muscle transfer, the method encouraged surgeons to perform more radical tumor excisions and this may have contributed to the excellent local tumor control that was achieved. Thus, functioning muscle transplantation was extremely useful in limb salvage surgery from the functional and oncologic viewpoints.     

Orbital myopathy in metastatic malignant paraganglioma: a paraneoplastic syndrome?

BACKGROUND: Several disease entities of the orbit are known which display an autoimmunological pathogenesis. Among these disease entities the thyroid-related immune orbitopathy and the idiopathic orbital inflammatory syndrome (orbital pseudotumor). The pathogenesis of these diseases is not well understood; however, an autoimmune inflammatory reaction histologically characterized by a chronic inflammatory cell infiltrate has been suggested. One care of orbital pseudotumor presumably of paraneoplastic origin occurring in a patient with a non-Hodgkin's lymphoma has been reported. We report a patient with a metastatic paraganglioma and a proptosis secondary to enlargement of all extraocular muscles. CASE REPORT: A 52-year-old woman presented with a recent decline in visual clarity of her left eye and diplopia. Two years ago, the diagnosis of a hormonally inactive paraganglioma has been made. Ophthalmologic examination displayed a lagophthalmos caused by a right-sided facial paralysis secondary to a cerebral metastasis and a bilateral enlargement of all extraocular muscles. Curative therapy for the paraganglioma was not available. Palliative therapy as well as a high-dose corticosteroid therapy for the orbitopathy was refused by the patient. The patient died 18 months later. DISCUSSION: Our patient developed orbital changes similar to thyroid-related immune orbitopathy; however, there was no dysfunction of the thyroid. We believe that the orbital changes were a paraneoplastic immune reaction caused by the metastatic paraganglioma. We recommend that in patients who do not conform to the prototypical profile of well-known orbital disease entities should undergo further testing to exclude a remote neoplasm.     

Lateral rectus whole muscle and motor unit contractile measures with the extraocular muscles intact

Both extracellular and intracellular stimulation of single motoneurons were shown to be similarly effective and consistent in eliciting contractile responses in single lateral rectus muscle motor units. The whole muscle was activated by stimulating the sixth nerve in the brain stem. Both whole muscle and motor unit contractile characteristics, under isometric conditions, were found to remain consistent regardless of whether this extraocular muscle was detached or left attached to the globe. In addition, whole muscle twitch and maximum tetanic tension evoked by sixth nerve stimulation was significantly less than would be predicted by the linear summation of individual motor unit twitch and maximum tetanic tensions.     

Extraocular muscle involvement in sarcoidosis

BACKGROUND: Sarcoidosis is a granulomatous inflammatory disease that may have a variety of ocular and orbital manifestations. The most common ocular manifestation is uveitis, and the most common orbital manifestation is dacryoadenitis. Extraocular muscle involvement in sarcoidosis has rarely been reported. The authors report a case of sarcoidosis involving the extraocular muscles of a 15-year-old boy with bilateral, painful, external ophthalmoplegia and enlargement of all extraocular muscles on computed tomography (CT) scan. RESULTS: Lateral rectus muscle biopsy and transbronchial lung biopsy showed noncaseating granulomas characteristic of sarcoidosis. Cultures and serologic studies excluded fungal and mycobacterial diseases. Treatment with oral corticosteroids improved symptoms and signs. CONCLUSIONS: The authors report the first case of sarcoidosis in a patient with symptomatic extraocular muscle involvement, and only the third case in which extraocular muscle involvement has been shown histologically.     

Malignant glomus tumor: a case report and review of the literature

This report concerns a malignant glomus tumor, a rare soft tissue tumor that was examined immunohistochemically and ultrastructurally. It occurred in a 44-year-old male patient who had suffered from dull pain and stiffness in the right thigh for 10 months. Radiographic examination revealed a well-defined osteolytic lesion in the diaphysis of the right femur. Hypervascularity of the tumor was observed angiographically. Computed tomographic and magnetic resonance examinations showed an intramuscular mass invading the marrow space of the femur. Wide resection was performed after open biopsy. Histologically, round to polygonal tumor cells revealed a uniform appearance of round to ovoid nuclei with single large nucleoli and slightly eosinophilic cytoplasm, forming solid sheets of cells interrupted by vessels of varying size. A few mitotic figures and vascular invasion were observed. Immunohistochemically, vimentin and alpha-smooth muscle actin were stained intensely, and muscle actin was positive for tumor cells of the perivascular area. Tumor cells were negative for desmin, factor VIII-related antigen, S-100 protein, neurofilament, cytokeratin, and epithelial membrane antigen. Ultrastructurally, tumor cells were characterized by many cytoplasmic processes, pinocytotic vesicles, plasmalemmal dense plaques, and scattered microfilaments in the cytoplasm. Few cell junctions and focal basement membrane-like structures were observed. No recurrence or metastasis was noted 57 months after operation. This case was considered to be a malignant glomus tumor, that is, a glomangiosarcoma arising de novo.     

Massive orbital cyst of the lateral rectus muscle after retinal detachment surgery

A 73-year-old white man presented with painless proptosis of the right eye 18 years after retinal detachment surgery on the same eye. Computed tomography (CT) showed a mass in the area of the lateral rectus muscle and magnetic resonance imaging (MRI) defined the multiloculated cystic mass to be located within the lateral rectus muscle. At the time of surgery, a large, thin-walled cystic lesion was found within the lateral rectus muscle. Histopathologically, the cystic mass was of nonkeratinizing stratified squamous conjunctival epithelium. Massive orbital cysts after retinal detachment surgery are rare. The authors review the literature and comment on the differential diagnosis and presumed pathogenesis of this lesion.     

A case of diabetic muscle infarction in Japan

Diabetic muscle infarction (DMI) is a rare complication of diabetes mellitus. We report the first recorded case in Japan. A 45-year-old Japanese woman presented with severe pain in the left antero-medial thigh. She had a 14-year history of Type 2 diabetes mellitus (DM). She had first noticed pain in her left thigh after a walk 2 weeks prior to presentation. The pain worsened progressively. She noticed a firm mass in her left thigh. T2-weighted magnetic resonance imaging (MRI) demonstrated a high-intensity signal in the muscle bulk of the anterior component of the left thigh. A needle biopsy of the mass showed necrosis. She was treated with bedrest and an antiplatelet agent. The mass disappeared 8 weeks after admission. DMI is a rare complication of poorly controlled diabetes mellitus. Twenty-seven cases with DMI have been reported in the English literature but we believe this is the first Japanese case with DMI.     

Transnasal endoscopic approach to expose the medial rectus from the annulus of Zinn to the penetration of Tenon''s capsule

Conventional strabismus surgery employs a conjunctival incision to gain access to Tenon's space where a wide variety of procedures are routinely performed on the tendon and anterior aspect of the extraocular muscles. Recently, transnasal endoscopic surgical techniques have gained acceptance as effective means of decompressing the medial wall and floor of the orbit in patients with thyroid-related orbitopathy. The orbital surface of the medial rectus and inferior rectus are exposed from the annulus of Zinn to a position close to where the muscles penetrate Tenon's capsule. In theory, this technique also provides the exposure necessary to locate and retrieve a "lost" medial rectus when the usual sub-Tenon's approach fails to recover the muscle. Cadaver studies demonstrate the feasibility of exposure and suture placement in the stump of a lost medial rectus with passage of the suture through Tenon's capsule to transmit the force of the muscle to the globe, provided that the lost muscle is retrieved before severe contracture develops.     

Primary CNS lymphoma. Infratentorial localization and prolonged survival

A case of a 35-year-old woman presenting infratentorial CNS lymphoma is reported. In 1990 she complained of diplopia, blurred vision and left horizontal nistagmus. An MRI disclosed a lesion in the medulla, pons, and cerebellar vermis and peduncles. Although no treatment was administered, a later RMI showed less extension of the tumor. One year after clinical diagnosis, she received corticosteroids; during the second year a stereotaxic biopsy of the cerebellar lesion was done showing a diffuse B cell non-Hodgkin's lymphoma. A whole brain irradiation was given (50 Gy). She did well for five years, and remains alive (79 months).