03 Ludwig Final 11/9/01 9:06 AM Page 53

STRABISMUS DUE TO FLAP TEAR OF A RECTUS MUSCLE*

BY Irene H. Ludwig, MD AND Mark S. Brown, MD (BY INVITATION)

ABSTRACT

Purpose: To present a previously unreported avulsion-type injury of the rectus muscle, usually the inferior rectus, and
detail its diagnosis and operative repair.

Methods: Thirty-five patients underwent repair of flap tears of 42 rectus muscles. The muscle abnormality was often sub-
tle, with narrowing or thinning of the remaining attached global layer of muscle. The detached flap of external (orbital)
muscle was found embedded in surrounding orbital fat and connective tissue. Retrieval and repair were performed in
each case.

Results: Fourteen patients had orbital fractures, 7 had blunt trauma with no fracture, and 9 had suspected trauma but
did not undergo computed tomographic scan. Five patients experienced this phenomenon following retinal detachment
repair. Diagnostically, the predominant motility defect in 25 muscles was limitation toward the field of action of the mus-
cle, presumably as a result of a tether created by the torn flap. These tethers simulated muscle palsy. Seventeen muscles
were restricted away from their field of action, simulating entrapment. The direction taken by the flap during healing
determined the resultant strabismus pattern. All patients presenting with gaze limitation toward an orbital fracture had
flap tears. The worst results following flap tear repair were seen in patients who had undergone orbital fracture repair
before presentation, patients who had undergone previous attempts at strabismus repair, and patients who experienced
the longest intervals between the precipitating event and the repair. The best results were obtained in patients who
underwent simultaneous fracture and strabismus repair or early strabismus repair alone.

Conclusions: Avulsion-type flap tears of the extraocular muscles are a common cause of strabismus after trauma, and after
repair for retinal detachment. Early repair produces the best results, but improvement is possible despite long delay.

Tr Am Ophth Soc 2001;99:53-63

INTRODUCTION with recently reported anatomic and functional studies of

the extraocular muscles.
Diplopia following head or facial trauma is usually attrib-
uted to palsy of a cranial nerve or its branch or to incar- METHODS
ceration of an extraocular muscle in an orbital fracture
site. Restriction of eye movement by adhesions to scar tis- SURGICAL APPEARANCE
sue is also reported to contribute to strabismus.1-4
Generally, a lengthy delay (months) is advocated before Thirty-five patients underwent repair of avulsion-type injuries
strabismus surgery is undertaken.1-3,5-8 Repair may consist of one or more rectus muscles. The involved rectus muscle
of ipsilateral muscle surgery and/or a procedure to limit was approached through a standard fornix incision and placed
excursion in the nontraumatized contralateral eye9 to bal- on a muscle hook at its insertion into sclera. The presence of
ance the deficit in the injured one. a flap tear was suggested by 3 different appearances:
In a number of post-traumatic strabismus cases, a 1. A segment of muscle and tendon was missing,
specific type of avulsion injury to the rectus muscle(s) has which narrowed the remaining portion of attached
been identified and repaired. We propose a mechanism muscle (Fig 1).
for the development of the flap tear, which is consistent 2. The outer or orbital layer of muscle was missing,
beginning at the musculotendinous junction and
*From the Department of Ophthalmology, LSU Eye Center, Louisiana extending proximally (Fig 2). These muscles
State University Health Sciences Center, New Orleans (Dr Ludwig) and appeared thinned and lacked intact muscle cap-
the Department of Ophthalmology, The University of South Alabama,
Mobile (Dr Brown). Supported in part by an unrestricted departmental sule. The thinned area involved the entire width of
grant to the LSU Eye Center from Research to Prevent Blindness, Inc, the muscle in some and a smaller portion of
New York, New York. muscle in others.

Tr. Am. Ophth. Soc. Vol. 99, 2001 53

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Ludwig et al
3. The muscle was encased in adherent orbital fat, followed by the right inferior rectus muscle (12), the
requiring careful dissection before disclosure of medial rectus (6), and the superior rectus (2) (Table I).
the avulsion injury, which could appear as either of The predominance of affected left inferior rectus muscles
the two previously described abnormalities. is presumed to be related to the right-handedness of
assailants delivering the trauma in some cases.
In each of the 3 presentations, the torn “flap” of tissue was
found external to the muscle, scarred into surrounding PRECIPITATING EVENT
orbital connective tissue and fat (Fig 3). Sometimes sev-
eral smaller flaps of muscle were found. Fourteen patients had orbital fractures, and 6 had blunt
Forced duction testing was performed before and trauma with documentation of the absence of fracture by
during muscle repair in all cases. Restrictions both toward computed tomographic (CT) scan. In 9 cases, the finding
and away from the direction of the involved muscle’s of flap tear was unexpected and orbital imaging was not
action were often present. In some cases the forced duc- undertaken. In most cases, a long time had elapsed
tion abnormality was subtle, and it only became evident between injury and repair. In 1 child, CT scan was
when the procedure was performed gently, with simulta- obtained following development of downgaze deficiency 1
neous comparison to the uninjured contralateral eye. week after seemingly minor blunt trauma to the inferior
orbital rim. There had been no external signs of the injury
SURGICAL REPAIR TECHNIQUE at the time. He had posterior orbital floor fracture and
inferior rectus flap tear (Fig 7).
The flap was placed on a small muscle hook and dissected Two patients had no specific history of orbital trauma.
free from its orbital attachments at the distal end. A braid- One patient had a normal CT scan and questionable,
ed polyester suture was placed through the distal end of remote history of trauma. Five patients developed flap
the flap, with standard strabismus locking bites (Fig 4). tears after retinal detachment repair (Table II).
The flap was then attached to sclera at the original inser-
tion, or back to the musculotendinous junction, as neces- DIAGNOSIS
sary to restore anatomy (Fig 5). The rent in overlying
Tenon’s capsule, which was always present, was sutured Motility Defects
with 6-0 polyglactin after the protruding orbital fat was In 20 patients, the motility defect was toward the direc-
reposited through the rent. tion of action of the involved muscle, presumably as a
If the capsule of the repaired muscle appeared com- result of a tether created by the flap. Twelve of these pre-
plete, it was repaired directly with buried 6-0 or 7-0 sented as downgaze deficiencies following documented
polyglactin suture. In some cases, the capsule seemed orbital floor fracture. In 10 patients the presenting deficit
partly damaged. In these cases, a free graft of Tenon’s cap- was gaze restriction away from the field of action of the
sule was sutured over the traumatized surface of the mus- muscle, simulating persistent entrapment or muscle fibro-
cle with running 7-0 polyglactin (Fig 6). The Tenon’s graft sis. One had paradoxical esodeviation on attempted
was harvested from an uninvolved quadrant of the same upgaze, along with limitation of elevation and depression
eye, usually superotemporally. after orbital floor fracture repair. One patient had 2
Postoperatively no steroids were used. Patients were involved muscles in 1 eye. The torn medial rectus caused
asked to exercise the muscle frequently by looking in and exotropia with adduction limitation owing to the tether
out of the field of muscle action to prevent adhesions from effect, and the superior rectus tear led to hyperdeviation
re-forming between the flap and surrounding orbital con- owing to a restrictive effect. Two patients had tears of both
nective tissue. inferior rectus muscles and 1 medial rectus muscle each.
The inferior rectus muscles caused asymmetric downgaze
RESULTS reduction owing to the tether effects, and the medial rec-
tus muscle tears led to esotropia owing to restrictive
PATIENT CHARACTERISTICS effects. Another patient, with idiopathic etiology, had
bilateral inferior rectus flap tears, with mild upgaze
The mean age of the 35 patients at time of flap tear repair restriction in 1 eye, and downgaze restriction in the other.
was 40 years (range, 6 to 82 years). The mean delay There was no difference in the appearance of the flap tear
between the date of injury and repair was 67 months or the difficulty of repair in terms of the various types of
(range, 2 weeks to 46 years). Mean postoperative follow- motility patterns. Our impression was that an anterior
up was 9 months (range, 1 to 68 months). The left inferi- attachment site of the flap led to a tether effect and a pos-
or rectus muscle was most commonly involved (22 cases) terior flap position led to pseudo-entrapment.

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Strabismus Due To Flap Tear Of A Rectus Muscle

FIGURE 1 FIGURE 2
Flap tear of inferior rectus, narrowed type (same as in Fig 7A). Arrow Flap tear of medial rectus, thinned type, 2 months after retinal detach-
indicates missing portion of muscle; hook is pulling on insertion of ment repair. Open arrow indicates thinned remaining portion of muscle,
remaining attached portion of muscle. lacking capsule. Solid arrow points to flap, which is pulled outward by
retractor.

FIGURE 3 FIGURE 4A
Flap tear of inferior rectus, 20 years after motorcycle accident. Attached Inferior rectus flap (same patient as in Figs 1, 6, and 7), dissected free,
portion of muscle is held by large hook (open arrow). Flap, held in small and placed on 6-0 braided polyester suture. Lock bites indicated by
hook, is adherent to surrounding orbital tissue (solid arrow). arrows.

FIGURE 4B FIGURE 5
Inferior rectus flap, thinned type. Flap is held on braided polyester Medial rectus from Fig 2, after flap reattachment. Arrow indicates cen-
suture (solid arrows). Hook (open arrow) holds attached, inner portion tral knot in suture.
of muscle.

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Ludwig et al

TABLE II: PRECIPITATING EVENT

CAUSE OF STRABISMUS NO. OF CASES

Orbital fracture 14
Blunt trauma, no fracture 5
Trauma, possible fracture 10
Retinal detachment 5
Idiopathic 1

the inferior rectus based on measurements alone.

Preoperative force generation testing was useful to rule
out nerve palsy. Although restricted in excursion of move-
ment, the involved muscles showed normal strength.
FIGURE 6 Forced duction testing was usually performed immediately
Repaired inferior rectus (same as in Figs 1 and 4a), with overlying Tenon’s before surgery, with the patient under paralytic anesthesia.
graft. Tenon’s fibers are oriented 90° from muscle and tendon fibers.
Since the first case was identified in 1994, every
patient presenting to this practice with a preoperative
TABLE I: INVOLVED MUSCLES diagnosis of orbital fracture together with limitation of
motility toward the direction of the fracture was found to
NO. OF
have a flap tear.
MUSCLES NO. OF
INVOLVED PATIENTS MUSCLE
SURGERY
LEFT RIGHT MEDIAL SUPERIOR
INFERIOR INFERIOR RECTUS RECTUS Sixteen patients underwent direct repair of the flap alone,
RECTUS RECTUS
with no other muscle surgery (Table III). Two of these
1 30 19 8 2 1
required re-repair of the flap: 1 for a small residual flap
2 3 1 2 2 1 segment that had been missed at the initial procedure,
3 2 2 2 2 0
TABLE III: PRIMARY SURGERY

REPAIR OF REPAIR OF FLAP SURGERY ON

Preoperative Diagnosis
FLAP ONLY PLUS RECESSION ADDITIONAL
Five patients were misdiagnosed preoperatively as having OR RESECTION MUSCLES
fourth cranial nerve palsy, 2 as having Brown’s syndrome, OF SAME MUSCLE
and 1 as having sixth cranial nerve palsy. In the first
Total cases 16 4 15
patient treated (MC), a lost inferior rectus was suspected
No. requiring 2 1 5
because of the absence of downgaze. Many of these second procedure
patients would have qualified as having isolated palsy of

FIGURE 7B
FIGURE 7A Preoperative (left) and postoperative (right) motility of 6-year-old boy
CT scan showing posterior orbital fracture with inferior rectus entrap- who underwent simultaneous repair of orbital floor fracture and inferi-
ment (arrow). (Patient’s inferior rectus is seen in Figs 1, 4a, and 6.) or rectus (Figs 1, 4a, and 6) flap tear 2 months after minor blunt trauma.

56
 TABLE IV: CLINICAL DATA OF ALL PATIENTS UNDERGOING REPAIR OF AVULSION-TYPE FLAP TEARS

PATIENT AGE DELAY (MO) MUSCLE ?TETHER CAUSE ?ADD’L ?2ND ALIGN VERSIONS ALIGN VERSIONS FOLLOW-UP
MUSCLE SURGERY PREOP PREOP POSTOP POSTOP

KB 12 1 LIR no football no no RHT8 1-depr, ortho nl depr 10

2-elev
EB 59 3 RIR no struck orbit recess no LHT25 3-elev OD ortho 1-depr, 19
in motorboat RIR6, 3-elev
RLR4
DB 38 13 LIR no RD repair LIR no RHT25 2-elev OS ortho 1-elev, 3
03 Ludwig Final 11/9/01 9:06 AM Page 57

recessed 4 depr OS
RB 42 252 LIR, yes motorcycle no planned LHT14/ 2-depr OS, LH(T)2/ 2-elev, 1
RIR, LMR accident ET20 1-elev OD ET20 2-depr OS
2-abd OS
MC 24 13 LIR yes struck with LSR rec no LHT4 3-depr OS ortho 3-depr OS 68
fist 2/16/94
BC 39 4.5 LIR, yes MVA recLMR6 resect RHT10, 4-abd OS, ortho 1-elevOU, 5
RIR, LMR LLR8, RMR5.5 ET55 1-depr OD, 1-ad, abdOU
LIR3 2-elev OD
PD 29 8 LIR no orbit bumped LLR, LMR yes ortho 4-elev OS ortho 3-elev, 1.5
by childs head inf transp large RHT deprOS
in upgaze
BD 12 0.5 RIR yes bicycle no no RHT14 4-depr OD ortho 1-depr OD 2
handle
TE 82 6 RIR no fell on RSO no LHT10 2-elev, RHT5 ? 1
pavement depr OD
BE 8 8 LIR yes bicycle no yes LHT6 1-depr OS LH2 nl depr 5.5
handle
SE 39 204 LIR no RD repair LLR5 adv LIR to RHT20 2-elev OS RH2 2-elev OS 1
orig insertion
RG 79 10 LSR yes branch struck eye LIRrec6 adv LIR, RHT20 4-elev OS E12 3-elev OU 48
LSO
AG 20 228 RIR no unknown RIR rec3 no ortho. 4-elev OD ortho 3-elev OD 3
Strabismus Due To Flap Tear Of A Rectus Muscle

large LHT
in upgaze
SH 29 24 LSR, LMR yes struck with LSR rec4 no XT10/ 1-elev, X2 1-elev OS 1
fist LHT10 deprOS
1-add OS
CH 42 8 RIR yes MVA no planned RHT9 4-depr OD ortho 3-depr OD 3
WH 82 8 LIR no RD repair LMR4 no RHT5 3-elev OS RHT10 4-elev OS 4
PJ 53 ? LIR yes struck with fist no no ? ? ortho 3-depr OD 18
CJ 32 3 LIR yes struck with LLR8 no LHT35 3-depr OS LH(T)4 3-depr OS 1
fist
JK 68 24 RIR, LIR yes ?blast concussion no no ortho 1-depr OS, ortho normal 1
Korean War LHT6 in 1-elev OD all gaze
downgaze
SL 15 1.5 LIR yes football no no 2-elev 2-depr OS, ortho 2-elev OS 8
ET on elev

57
58
TABLE IV (CONTINUED): CLINICAL DATA OF ALL PATIENTS UNDERGOING REPAIR OF AVULSION-TYPE FLAP TEARS

PATIENT AGE DELAY (MO) MUSCLE ?TETHER CAUSE ?ADD’L ?2ND ALIGN VERSIONS ALIGN VERSIONS FOLLOW-UP
MUSCLE SURGERY PREOP PREOP POSTOP POSTOP

TL 24 87 LIR yes struck with s/p LIR rec no LHT10 3-depr OS ortho 2-depr OS 3.5
elbow
JM 38 360 LIR no possible fist LLR yes RHT30 1-elev OS ortho normal 5
KM 16 6 LIR yes struck with no yes LHT16 2-depr OS ortho 2-depr OS 36
fist
SO 28 24 RIR no air bag recSOOU no ET6/ 3+LSO RHT4 0.1
RHT10
RR 71 7 LIR yes MVA SOOU adv, yes LHT5 2-depr OS ortho 1-depr OS 6
Resect LIR
03 Ludwig Final 11/9/01 9:06 AM Page 58

MS 51 552 LIR yes fell in no planned LHT18/ 4-depr OS LHT14/ 4-depr OS 2

playground ET18 ET14
TS 8 2 RIR yes MVA no no RHT6 2-depr, ortho 1-elev OD 7
2-elev OD
NS 33 264 RMR no struck by no no ET18 1-ad, abd OD, ET6 tr-abd OD 1
elbow 2-elev
in playground
FS 56 3 LMR yes struck with LLR rec10 no XT25 4-add OS ortho 3-add OS 4
tree branch
HV 49 12 LIR yes RD repair recLMR4, res LIR3.5, LHT25 3-depr, X4 3-elev, 8
adv LSO4 res LMR3 1-abd OS, depr OS
3-LSO
BW 65 84 LIR yes fell off myot LMR no LHT10 2-depr OS LH(T)3 2-depr, 1
Ludwig et al

ladder 1-add OS
BW 71 2R MR,RIR no RD repair no no RET25 2-abd, RHT6 2-abd, 0.2
3-elev OD 3-depr OD
HW 6 2 RIR yes struck orbit no no RHT16 4-elev, ortho 1-depr OS 1.5
on bathtub depr OS 3-elev
edge
BW 36 3 LIR yes fell on no no E4(LHT18 2-depr OS ortho normal 25
pavement down)
AW 29 3 LIR yes baseball rec LSR5, no LHT25 4-depr OS ortho 3-depr OS 2
bat LLR6
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Strabismus Due To Flap Tear Of A Rectus Muscle

and the other for a complete flap redetachment. The (CH) had undergone 2 orbital surgeries because of the
redetachment was thought to have occurred as a result of persistent downgaze deficiency. He had severe motility
the child’s failure to move the eye postoperatively, as well restriction noted during subsequent flap tear repair, and
as damage to the muscle capsule and, possibly, loss of although the primary position alignment was restored,
strength of the absorbable suture used to reattach the motility remained poor.
muscle. At reoperation, the flap was reattached with non- Long delay from injury to repair seemed to worsen
absorbable suture and a Tenon’s graft was placed. The sec- the prognosis for some patients, but others did well
ond repair was successful. Nonabsorbable suture has been despite the lapse of many years. Those with smaller flaps
used for flap reattachment in all subsequent cases. and smaller preoperative deviation of alignment had
Forced duction and spring-back testing10 were used to improved chance of resolution with flap-tear repair alone.
determine whether flap tear repair alone relieved the gaze Greater delay to treatment increased the likelihood of fur-
restriction and centered the eye. If not, additional surgery ther surgery on additional muscles. No patient was wors-
was undertaken. ened by flap tear repair (Table IV).

Additional Strabismus Surgery CASE REPORTS

Fifteen patients underwent simultaneous surgery on
other extraocular muscles, and 7 of these required a sec- Case 1
ond strabismus procedure. Four patients exhibited resid- A 12-year-old boy developed diplopia after striking his
ual restriction of motility away from the direction of action right inferior orbital rim on the handle of a bicycle. In the
of the muscle with the flap repair, and they underwent primary position he had a right hyperdeviation of 14 prism
simultaneous recession of that muscle alone during the diopters (D), which increased to 20D on downgaze.
initial surgical procedure. Surgery on additional muscles Elevation and depression of the right eye were markedly
was needed more often when a longer time had elapsed reduced (Fig 8, left). CT scan showed a narrow orbital
between injury and repair. Secondary deviations were floor fracture in the medial portion of the orbital floor,
considered and corrected; the most common was ipsilat- with entrapped orbital tissue and muscle. Orbital fracture
eral lateral rectus recession for exotropia. and strabismus repairs were undertaken at the same time,
3 weeks after injury, by the authors.
Orbital Fracture Repair Forced duction testing showed restriction to eleva-
Six patients had undergone orbital fracture repair prior to tion and depression in the right eye. The fracture site was
flap tear repair, and 3 underwent repair of muscle and approached via standard transconjunctival incision.
orbit on the same day by a strabismus surgeon (I.H.L.) Significant herniated orbital fat and connective tissue
and an ophthalmic plastic surgeon (M.S.B.). These 3 cases were present, and entrapped inferior rectus tissue was
confirmed the impression that the flap tear is remote from identified in the posterior aspect of the fracture (Fig 9).
the fracture site and is not the result of bony impingement After the tissues were lifted out of the fracture, repair was
on the muscle. Five patients with documented fractures made with porous high-density polyethylene barrier
did not undergo fracture repair. sheet, and the wound was closed. The inferior rectus was
then exposed through a standard inferotemporal fornix
POSTOPERATIVE ALIGNMENT

Preoperative and postoperative alignment data were not

analyzed statistically for the group owing the heteroge-
neous population of involved muscles and variety of addi-
tional muscle surgeries performed (Table IV). Of the 16
patients who underwent flap tear repair alone, all were
improved, most achieved resolution of diplopia during
regular activities, and 9 had normal alignment in all gaze
positions.
The best results were achieved in those who under-
went simultaneous repair of flap tear and orbital fracture
and those who did not undergo fracture repair. The worst
results occurred in those who had undergone previous
orbital fracture repair (MC, CH, SL, TL, KM, AW) and/or FIGURE 8
strabismus surgery (RB, MC, TL, MS, FS). One patient Case 1. Preoperative (left) and postoperative (right) motility.

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Ludwig et al
after surgery, the patient was orthotropic in all directions
of gaze. Two years later he remains orthotropic in all
directions.

DISCUSSION

Orbital trauma has been associated with a range of sever-

ity of ocular injuries.11-13 Posttraumatic strabismus has tra-
ditionally been attributed to direct muscle contusion by an
orbital fracture site, orbital hematoma, or nerve damage.1-
8
Spontaneous improvement in diplopia has been report-
ed,1,5,6,8,14 and patients are usually asked to wait for some
time before strabismus repair is considered.1-8 Orbital sur-
gery to relieve entrapment is usually undertaken if diplop-
FIGURE 9 ia persists after 2 to 3 weeks.6,8 Strabismus repair is then
Case 1. Orbital fracture (arrow).
not considered before 4 to 6 months.1-8 Strabismus proce-
incision. The flap tear was identified by the narrowed dures that have been advocated include ipsilateral rectus
appearance of the muscle (Fig 10) and repaired as already resection and recession,3 contralateral superior oblique
described (Fig 11), including free Tenon’s graft. The torn recession,3 rectus muscle transposition procedures,8 and
segment of muscle was markedly anterior to the entrapped the Faden operation to the contralateral eye.9
portion and was clearly distinct and separate from the Since we observed the presence of flap tears without
fracture site. Postoperatively, downgaze gradually orbital fracture, as well as the findings in 3 cases in which
improved, and 6 weeks later motility was normal, with orbital and muscle repairs were concurrent, we believe
orthotropia in all directions of gaze (Fig 8, right). that the avulsion was a related, but separate, finding due
to the original trauma.
Case 2 Recent anatomic studies of the extraocular muscles
A 36-year-old policeman was hit on the back of the head have shown 2 distinct layers: (1) the global layer, adjacent
and fell forward, striking his face on the pavement. He to the globe, and (2) the orbital layer, which lies external-
suffered a brief loss of consciousness. When he became ly. The orbital layer has also been shown to be surround-
aware of his surroundings in the hospital on the next day, ed by dense connective tissue and penetrated by elastin,
he noticed vertical diplopia. An imaging study of the head which effectively inserts the orbital layer of the rectus
was reported to be normal. Twelve days later he present- muscle into the orbital connective tissue.15
ed for strabismus evaluation. Alignment was esophoria of We hypothesize that the sudden downward force expe-
4 in the primary position, and left hypertropia of 16 rienced by the orbital contents at the time of blunt trauma
with esotropia 4 in downgaze. The hyperdeviation was may exert traction on the connective tissue insertion into
absent on right head tilt, and 6 on left head tilt. Left the orbital layer of the muscle, tearing the outer layer away
fourth cranial nerve palsy was diagnosed by a strabismus from the inner, global layer (Fig 12). This mechanism
surgeon (I.H.L.) as well as by a neuro-ophthalmologist. could result in the thinned-type appearance of the flap-tear
There was no improvement by 2 months after injury, and muscle. Other flap tears presented with a narrowed
no torsion was found with subjective testing or fundus appearance of the muscle, with a full or partial thickness
examination. defect of the remaining attached portion of muscle. These
The patient recalled that the left lower lid was ecchy- may have experienced asymmetric avulsion force, leading
motic after the injury. High-resolution magnetic reso- to asymmetric flaps. The force might possibly be transmit-
nance imaging of the orbits and brain, with particular ted to the muscle from the side by the intermuscular sep-
attention to the left inferior rectus, was obtained, but no tum, which would also produce flap asymmetry.
abnormality could be detected. Nine weeks after injury, Perhaps the 2 muscle portions may reunite during
he underwent exploration of the left inferior rectus via an healing; this would explain the cases of spontaneous
inferotemporal fornix incision. A flap tear was found, with improvement that have been reported.1-8 Motility findings
thinning of the muscle proximal to the musculotendinous vary according to the healing pattern of the flap tear. If the
junction and absence of capsule. The repair included clo- flap heals anteriorly, creating a tether, the predominant
sure of the overlying rent in Tenon’s capsule. One week defect would be a loss of function of the involved muscle
after surgery, alignment was orthotropia in primary posi- (Fig 13). Tether-type motility defects are reported to
tion with left hypertropia of 10 in downgaze. Five weeks occur in about one third of orbital floor fractures with

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Strabismus Due To Flap Tear Of A Rectus Muscle

FIGURE 10 FIGURE 11
Case 1. Inferior rectus showing narrowed type of flap tear. Missing por- Case 1. Repaired inferior rectus, with Tenon’s graft.
tion indicated by open arrows. Flap is held on small hook (solid arrow).

FIGURE 12 FIGURE 13
Drawing indicating hypothesized traction on inferior rectus outer layer Drawing indicating anterior flap position after injury, which would cre-
due to orbital fracture, causing avulsion. ate a tether.

vertical diplopia14 and have also been reported with medi- floor fracture has been attributed to palsy of the inferior
al wall fractures.16 A small tether effect of an inferior rec- branch of the third cranial nerve,1-3 but in our series all
tus flap tear could mimic ipsilateral fourth cranial nerve cases with downgaze deficiency after ipsilateral orbital
palsy. This was seen in 5 of our patients, and a similar floor trauma had flap tears. The unexpected finding of
motility pattern after floor fracture has been reported.1,17 identical tears in patients with long-standing strabismus,
A posteriorly healed flap would lead to restriction of gaze some of whom remembered the trauma only after careful
away from the site of injury, which was also common. questioning, is of interest. The trauma was sometimes
Restrictive strabismus was reported in two thirds of floor uneventful and not immediately apparent. After one
fracture patients with vertical diplopia.14 An intermediate learns to recognize the abnormally narrowed or thinned
flap location could allow unimpeded motility. This is rectus muscle with missing capsule, the defect becomes
another possible explanation for spontaneous improve- readily apparent in many cases. A completely restored
ment of diplopia in some orbital fracture patients. muscle capsule confirms that repair is complete. This was
Horizontal abnormalities resolved in several patients after even possible in cases repaired many years after injury.
flap tear alone, suggesting that horizontally directed adhe- Five patients had flap tears after retinal detachment
sions might have contributed to the strabismus. repair. Perhaps the retinal surgeon’s practice of bluntly
On the basis of our experience with this series of stripping connective tissue off the extraocular muscle may
patients, we believe that a tether-type of motility defect is pull away a flap of muscle tissue and lead to postoperative
diagnostic of flap tear. Downgaze deficiency after orbital strabismus.

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Ludwig et al
Immediate and regular eye exercise postoperatively is 14. Cole HG, Smith B. Eye muscle imbalance complicating orbital
important to prevent adhesions from re-forming between floor fractures. Am J Ophthalmol 1963;55:930-935.
15. Demer JL, Oh SY, Poukens V. Evidence for active control of rectus
the muscle and orbital connective tissue. The free Tenon’s extraocular muscle pulleys. Invest Ophthalmol Vis Sci
graft and repair of the overlying rent in Tenon’s capsule 2000;41:1280-1290.
also may help to reduce adhesions. Nonabsorbable suture 16. Rumelt MB, Ernest JT. Isolated blowout fracture of the medial
is always used to reattach or anchor the flap to sclera. orbital wall with medial rectus muscle entrapment. Am J
Ophthalmol 1972;73:451-453.
On the basis of the findings in these patients, it is rec- 17. Ruttum MS, Harris GJ. Orbital blowout fracture with ipsilateral
ommended that all orbital fracture patients with diplopia fourth nerve palsy. Am J Ophthalmol 1985;100(2):343-344.
who are to receive fracture repair undergo simultaneous
exploration of the adjacent rectus muscle(s) through sep- DISCUSSION
arate fornix incision(s), with minimal dissection. If an
unrecognized flap is allowed to attach itself to or near the DR DAVID L. GUYTON. Dr Ludwig’s description of “flap”
implant material, the motility defect becomes more diffi- tears of the extraocular muscles is both fascinating and
cult to treat later. If diplopia is due to flap tear, fracture convincing. Since the recent emphasis by Demer and col-
repair may not be necessary, but if entrapment and flap leagues1 on the attachments between the orbital portions
tear coexist, as in 3 cases of this series, combined repair of the extraocular muscles and the surrounding connec-
produces the best outcome. tive tissue, strabismologists have been looking for practi-
cal applications of this knowledge. Drs Ludwig and
ACKNOWLEDGEMENTS Brown’s flap tear mechanism appears to be consistent
with this new view of connective tissue attachments.
The authors thank David S. Goldberg, MD; John Even before the connective tissue “pulley” concept,
Avallone, MD; David R. Stager Sr, MD; Robbin B. though, the so-called check ligaments, encountered at the
Sinatra, MD; Paula Gebhardt; Leonard Baham, COMT; time of surgery on the rectus muscles, have been well
and Maxine Haslauer for their assistance with this project. known to strabismus surgeons. Especially prominent are
the dense attachments to the inferior rectus muscle, rep-
resenting the origin of the retractors of the lower lid.2,3
REFERENCES These particular attachments, also known as the capsu-
lopalpebral head of the inferior rectus muscle, are very
1. Wojno TH. The incidence of extraocular muscle and cranial nerve strong indeed. It is therefore not surprising that orbital
palsy in orbital floor blow-out fractures. Ophthalmology
trauma from an assailant, or from the cotton-tipped appli-
1987;94:682-687.
2. Metz HS, Scott WE, Madson E, et al. Saccadic velocity and active cator of a retinal detachment surgeon, could tear portions
force studies in blow-out fractures of the orbit. Am J Ophthalmol of the inferior rectus muscle via these attachments, pro-
1974;78:665-670. ducing Dr Ludwig’s “flap” tear. Indeed 87% of the
3. von Noorden GK, Hansell R. Clinical characteristics and treatment
involved muscles in her series were inferior rectus mus-
of isolated inferior rectus paralysis. Ophthalmology 1991;98:253-
257. cles.
4. Duke-Elder S, MacFaul PA. System of Ophthalmology. Vol 14. St How were the several medial rectus and superior rec-
Louis: CV Mosby; 1972;298-306. tus muscles involved? Their check ligaments are not very
5. Helveston EM. The relationship of extraocular muscle problems
strong. Perhaps these cases were the result of locally
to orbital floor fractures: Early and late management. Trans Am
Acad Ophthalmol Otolaryngol 1977;83:660-662. directed trauma, actually shearing off or avulsing a portion
6. Emery JM, von Noorden GK, Schlernitzauer DA. Orbital floor of the muscle. Such injuries have been documented peri-
fractures: Long-term follow-up of cases with and without surgical odically in the literature. In a case of mine several months
repair. Trans Am Acad Ophthalmol Otolaryngol 1971;75:802-812.
ago, the superior rectus muscle had been cleanly disin-
7. von Noorden GK. Binocular Vision and Ocular Motility. St Louis:
CV Mosby; 1996;452-455. serted from the globe purely by trauma.
8. Putterman AM. Management of orbital floor blowout fractures. Dr Ludwig’s contribution is more than just recogni-
Adv Ophthalmic Plast Reconstr Surg 1987;6:281-285. tion of this “flap” tear mechanism. She has successfully
9. Kushner BJ. Management of diplopia limited to down gaze. Arch
repaired most of her cases. Because she has used several
Ophthalmol 1995;113:1426-1430.
10. von Noorden GK. Binocular Vision and Ocular Motility. St Louis: repair techniques, though, we still do not know which of
Mosby; 1996;526-583. these are necessary. For example, how important is the
11. Brown MS, Ky W, Lisman RD. Concomitant ocular injuries with closing of rents in Tenon’s capsule? How important is the
orbital fractures. J Cranio-Maxillofac Trauma 1999;5(1):41-46.
free Tenon’s tissue graft that she has used over the surgi-
12. Fradkin A. Orbital floor fractures and ocular complications. Am J
Ophthalmol 1977;699-700. cally repaired area? Should a non-reactive suture be used
13. Holt JE, Hold R, Blodgett JM. Ocular injuries sustained during instead of an absorbable one? How important are range
blunt facial trauma. Ophthalmology 1983;90:14-18. of movement exercises postoperatively, and do the

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Strabismus Due To Flap Tear Of A Rectus Muscle

patients really do them? Dr Guyton’s suggestion of using a non-reactive suture
I am confident that Dr Ludwig will continue to to repair Tenon’s capsule is an excellent idea. Perhaps a
research these questions. I congratulate her and her co- 7-0 polypropylene would serve well for this.
author Mark Brown for an engaging and provocative pres- The patient’s parents and/or spouses were charged
entation. with the importance of beginning the range of movement
exercises immediately upon awakening. Several of those
REFERENCES who admitted to poor compliance did not do well, but I do
not have enough data to analyze this point. It is easy
1. Demer JL, Oh SY, Poukens V. Evidence for active control of rectus enough to recommend eye movement exercises, and it
extraocular muscle pulleys. Invest Ophthalmol Vis Sci may be important.
2000;41:1280-1290. To answer the question about imaging studies to pre-
2. Hawes MJ, Dortzbach RK. The microscopic anatomy of the lower
eyelid retractors. Arch Ophthalmol 1982;100:1313-1318. operatively demonstrate a flap tear, I obtained no useful
3. Pacheco EM, Guyton DL, Repka MX. Changes in eyelid position information from any of the preoperative CT and MRI
accompanying vertical rectus muscle surgery and prevention of scans I obtained. All were read as normal with respect to
lower lid retraction with adjustable surgery. J Pediatr Ophthalmol the extraocular muscles, excepting several with orbital
Strabismus 1992;29:265-272.
fractures and posterior muscle entrapment. No anterior
[Editor’s notes] DR EDWARD L. RABB asked why it was abnormality could be specifically identified. A few
necessary to advance the torn flap. DR MALCOLM R. ING showed vague scar tissue or edema under the inferior rec-
asked if an abrupt difference in muscle thickness suggest- tus, but these had already undergone orbital fracture
ing a flap tear could be identified on a CT scan prior to repair. One case (case 2 in the manuscript), had several
surgical exploration. repeat high resolution MRI scans performed of the sus-
pect inferior rectus, with no abnormality seen by the radi-
DR IRENE H. LUDWIG. Regarding Dr Guyton’s questions, ologist, despite my insistance that something must be
I am not sure how important all these repairs are. My there. I talked myself into thinking the muscle capsule
instinct is to fix a defect when I see it. I don’t know if clos- was irregular, but there was really no useful information
ing Tenon’s capsule or employing a Tenon’s graft is neces- obtained. His flap was small. The MRI scan would have
sary. I did have 2 cases redetach when I didn’t use the deterred most from exploring the muscle. I now limit
method of repair I described earlier. I had used imaging to orbital CT scans to look for fractures.
absorbable sutures to reattach the flap, and I had not fully To answer the question about why I advance the flap
restored Tenon’s capsule. Both of these cases were in chil- to the insertion, when some flaps originate a few millime-
dren, who also did not exercise their motility postopera- ters posterior to the insertion, I do this when there is a
tively. I then repeated the surgeries the same as the ini- tether limiting the action of the muscle. This tends to
tial repairs, but used non-absorbable sutures for flap reat- strengthen the muscle. In those muscles with restriction
tachment, and free Tenon’s graft over the muscles after of gaze away from the muscle action, I leave the flap a lit-
repair. Their mothers increased the eye movement exer- tle further back.
cises. The second procedures worked.

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