Topic outline

  • Grand Rounds

    An adult patient was transferred to BPEI ER after suffering right eye trauma while using a pressure washer machine. Patient reported his right eye had been bleeding and swollen since the accident. Past medical, surgical, and social history were noncontributory. On ophthalmic examination, the best corrected visual acuity was 20/400 in the right eye and 20/20 in left eye, intra-ocular pressure 26 mm Hg in the right eye and 18 mmHg in the left eye. Extraocular movement examination revealed -4 limitation in all positions of gaze on the right eye and full ductions on the left eye. A laceration on the right superior cheek extending to medial canthus, with tissue missing medial to inferior punctum was noted. Anterior segment examination on the right eye revealed 2+ injection and subconjunctival hemorrhage, an inferior area of conjunctival laceration, clear cornea and no hyphema. Dilated fundus exam showed elevation of the retina inferiorly with surrounding heme on the right eye and was unremarkable on left eye. On CT scan of the orbits without contrast, a transection of the right inferior rectus muscle was suspected. Upon initial surgical exploration, a transection of the inferior rectus muscle was confirmed and the posterior stump was not found. A retinal detachment developed and was treated surgically with a scleral buckle. Patient subsequently presented to strabismus clinic for evaluation of bilateral vertical diplopia, constant at distance and near. On sensorimotor examination, patient had significant right hypertropia with limitation to infraduction of the right eye. Surgery was recommended to improve ocular alignment. On repeat exploration, the right inferior rectus muscle was not found. A transposition of the lateral rectus and medial rectus muscles to the inferior rectus muscle insertion was performed. At postoperative week 5 week, the patient had marked improvement of their hypertropia. A Fresnel prism was prescribed to alleviate residual diplopia and a follow-up visit was scheduled.

    Presentation Date: 05/30/2024
    Issue Date: 06/21/2024