Inverse globe retraction syndrome complicating recurrent pterygium
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《英国眼科学杂志》
Correspondence to:
A O Khan
King Khaled Eye Specialist Hospital, PO Box 7191 Riyadh, Saudi Arabia; arif.khan@mssm.edu
Accepted for publication 2 September 2004
Keywords: globe retraction; pterygium
Often larger and more aggressive than the original lesion, recurrent pterygia can cause visual symptoms that are most often secondary to their mechanical effects on the cornea.1 We report a case of inverse globe retraction syndrome (that is, retraction during abduction) due to the restrictive effect of a recurrent pterygium and the management of this complication.
Case report
A 28 year old man without a medical history or ocular symptoms underwent pterygium excision in his left eye with a superotemporal conjunctival autograft and intraoperative mitomyocin C. Three weeks postoperatively, he noted a feeling of pressure in the left eye and diplopia during left gaze. Two months postoperatively he presented to us and his ophthalmic examination was significant for the following—left eye: 2 mm enophthalmos relative to right eye, recurrence of the pterygium, globe retraction during left gaze secondary to a leash effect from the recurrent pterygium, and minimal abduction deficiency (fig 1). One month later, his examination was stable and surgery was scheduled. Intraoperatively forced ductions showed –1 (on a scale of 1 to 4) limitation of abduction in the left eye. The left eye was positioned in abduction and a 6 mm vertical incision was made in the nasal conjunctival 3 mm posterior to the limbus. A 5x6 mm graft of amniotic membrane (locally procured and kept frozen before use) was sutured in the resultant gap in the conjunctiva using 9–0 Vicryl suture after the conjunctival edges were undermined. Two months following this procedure, the patient’s feeling of pressure was relieved and there is neither diplopia nor globe retraction during left gaze (fig 2).
Figure 1 The patient’s appearance at presentation in (A) primary gaze, (B) right gaze, (C) left gaze. There is relative enophthalmos in the left eye that increases during left gaze. During right gaze, adduction in the left eye occurs with less effort than abduction in the right eye.
Figure 2 The patient’s appearance 6 weeks after amniotic membrane placement in (A) primary gaze, (B) right gaze, (C) left gaze. There is no longer globe retraction left eye during left gaze. During right gaze, adduction in the left eye occurs with effort similar to that needed for abduction in the right eye.
Comment
Inverse globe retraction syndrome is rare.2–5 It has been reported as being caused by medial rectus abnormality,2 innervational misdirection,3 and secondary to restriction from traumatic tissue capture in the medial orbital wall.4,5 The current case demonstrates another cause for the syndrome, globe restriction as a result of a leash effect from aggressive pterygium recurrence. The risk of pterygium recurrence after initial pterygium removal is minimised by the technique of conjunctival autograft with adjunctive mitomyocin C6; however, because aggressive recurrence is still possible initial pterygium surgery should only be performed for patients with significant cosmetic and/or functional concerns. For the management of inverse globe retraction syndrome complicating recurrent pterygium in this case, the use of amniotic membrane as a tissue spacer permitted excellent functional improvement.
References
Hirst LW. The treatment of pterygium. Surv Ophthalmol 2003;48:145–80.
Lew H, Lee JB, Kim HS, et al. A case of congenital inverse Duane’s retraction syndrome. Yonsei Med J 2000;41:155–8.
Chatterjee PK, Bhunia J, Bhattacharyya I. Bilateral inverse Duane’s retraction syndrome—a case report. Indian J Ophthalmol 1991;39:183–5.
Davidson TM, Olesen RM, Nahum AM. Medial orbital wall fracture with rectus entrapment. Arch Otolaryngol 1975;101:33–5.
Gittinger JW Jr, Hughes JP, Suran EL. Medial orbital wall blow-out fracture producing an acquired retraction syndrome. J Clin Neuroophthalmol 1986;6:153–6.
Sanchez-Thorin JC, Rocha G, Yelin JB. Meta-analysis on the recurrence rates after bare sclera resection with and without mitomycin C use and conjunctival autograft placement in surgery for primary pterygium. Br J Ophthalmol 1998;82:661–5.(A O Khan)
A O Khan
King Khaled Eye Specialist Hospital, PO Box 7191 Riyadh, Saudi Arabia; arif.khan@mssm.edu
Accepted for publication 2 September 2004
Keywords: globe retraction; pterygium
Often larger and more aggressive than the original lesion, recurrent pterygia can cause visual symptoms that are most often secondary to their mechanical effects on the cornea.1 We report a case of inverse globe retraction syndrome (that is, retraction during abduction) due to the restrictive effect of a recurrent pterygium and the management of this complication.
Case report
A 28 year old man without a medical history or ocular symptoms underwent pterygium excision in his left eye with a superotemporal conjunctival autograft and intraoperative mitomyocin C. Three weeks postoperatively, he noted a feeling of pressure in the left eye and diplopia during left gaze. Two months postoperatively he presented to us and his ophthalmic examination was significant for the following—left eye: 2 mm enophthalmos relative to right eye, recurrence of the pterygium, globe retraction during left gaze secondary to a leash effect from the recurrent pterygium, and minimal abduction deficiency (fig 1). One month later, his examination was stable and surgery was scheduled. Intraoperatively forced ductions showed –1 (on a scale of 1 to 4) limitation of abduction in the left eye. The left eye was positioned in abduction and a 6 mm vertical incision was made in the nasal conjunctival 3 mm posterior to the limbus. A 5x6 mm graft of amniotic membrane (locally procured and kept frozen before use) was sutured in the resultant gap in the conjunctiva using 9–0 Vicryl suture after the conjunctival edges were undermined. Two months following this procedure, the patient’s feeling of pressure was relieved and there is neither diplopia nor globe retraction during left gaze (fig 2).
Figure 1 The patient’s appearance at presentation in (A) primary gaze, (B) right gaze, (C) left gaze. There is relative enophthalmos in the left eye that increases during left gaze. During right gaze, adduction in the left eye occurs with less effort than abduction in the right eye.
Figure 2 The patient’s appearance 6 weeks after amniotic membrane placement in (A) primary gaze, (B) right gaze, (C) left gaze. There is no longer globe retraction left eye during left gaze. During right gaze, adduction in the left eye occurs with effort similar to that needed for abduction in the right eye.
Comment
Inverse globe retraction syndrome is rare.2–5 It has been reported as being caused by medial rectus abnormality,2 innervational misdirection,3 and secondary to restriction from traumatic tissue capture in the medial orbital wall.4,5 The current case demonstrates another cause for the syndrome, globe restriction as a result of a leash effect from aggressive pterygium recurrence. The risk of pterygium recurrence after initial pterygium removal is minimised by the technique of conjunctival autograft with adjunctive mitomyocin C6; however, because aggressive recurrence is still possible initial pterygium surgery should only be performed for patients with significant cosmetic and/or functional concerns. For the management of inverse globe retraction syndrome complicating recurrent pterygium in this case, the use of amniotic membrane as a tissue spacer permitted excellent functional improvement.
References
Hirst LW. The treatment of pterygium. Surv Ophthalmol 2003;48:145–80.
Lew H, Lee JB, Kim HS, et al. A case of congenital inverse Duane’s retraction syndrome. Yonsei Med J 2000;41:155–8.
Chatterjee PK, Bhunia J, Bhattacharyya I. Bilateral inverse Duane’s retraction syndrome—a case report. Indian J Ophthalmol 1991;39:183–5.
Davidson TM, Olesen RM, Nahum AM. Medial orbital wall fracture with rectus entrapment. Arch Otolaryngol 1975;101:33–5.
Gittinger JW Jr, Hughes JP, Suran EL. Medial orbital wall blow-out fracture producing an acquired retraction syndrome. J Clin Neuroophthalmol 1986;6:153–6.
Sanchez-Thorin JC, Rocha G, Yelin JB. Meta-analysis on the recurrence rates after bare sclera resection with and without mitomycin C use and conjunctival autograft placement in surgery for primary pterygium. Br J Ophthalmol 1998;82:661–5.(A O Khan)