muscles and the pupillary sphincter were protected.
Urgent surgical repair is mandatory in patients presenting with unresolved oculocardiac reflexes (OCRs), commonly seen in pediatric patients with limited vertical eye movement due to the entrapped inferior rectus
muscle or periorbital tissues evidently on imaging, a condition known as the "white-eyed" fracture .
Based on the insidious onset, absence of ocular pain, predominance of inferior rectus
muscle swelling, and apparent muscular swelling with minimally swollen tendons [1-3], we diagnosed this case as TRAb-negative euthyroid Graves' ophthalmopathy.
A CT scan revealed a 5 mm defect in the posterior medial orbital floor with inferior displacement of the inferior rectus
muscle into the defect (Figure 2).
ROC curve analysis was conducted to determine the sensitivity and specificity of the inferior rectus
thickness/orbital fat thickness ratio combined with exophthalmos value for predicting the curative effect.
Distribution of muscle involvements Involved muscles LOOM SEOM LOOM+SEOM Single muscle 2/3 (66.6%) 1/2 (50%) 3/5 (60%) Multiple muscles 1/3 (33.3%) 1/2 (50%) 2/5 (40%) Bilateral 1/3 (33.3%) - 1/5 (20%) Medial rectus 2/3 (66.6%) 1/2 (50%) 3/5 (60%) Inferior rectus
- 1/2 (50%) 1/5 (20%) Lateral rectus 1/3 (33.3%) 2/2 (100%) 3/5 (60%) Superior rectus - 1/2 (50%) 1/5 (20%) LOOM: limited oligosymptomatic ocular myositis; SEOM: severe exophthalmic ocular myositis
Table 1: Extraocular examination of left eye Extraocular muscle Function Movement of left eye Medial rectus Adduction Absent Superior rectus Elevator in abduction Absent Inferior rectus
Depressor in abduction Absent Inferior oblique Elevator in adduction Absent Superior oblique Depressor in adduction Present but not full Lateral rectus Abduction Absent
Magnetic resonance imaging (MRI) of the orbit showed thickening of all left-sided extra-ocular muscles, predominantly left lateral rectus and inferior rectus
muscles with mild retro- orbital inflammatory changes and mild proptosis, consistent with orbital inflammatory pseudotumour (Figure-1).
Selective management of double elevator palsy by either inferior rectus
recession and/or knapp type transposition surgery.
* Medial rectus, inferior rectus
and inferior oblique subnuclei
Mechanical entrapment of the orbital content most commonly the inferior rectus
muscle followed by the inferior oblique muscle causes diplopia in up gaze and down gaze and the forced duction test in this case is positive.
No evidence of any entrapment of the inferior rectus
muscle was seen.
Undercorrection with hypotropia, in one eye of another patient, required inferior rectus
Fortunately, in our patient there was no residual entrapment of the inferior rectus
muscle and this was confirmed by forced-duction test.
Medial rectus is loosened if the eye is deviated inwards and inferior rectus
if it is deviated downwards.