Cauterization-mediated restriction from penetrating orbital trauma

Abstract

A healthy 32-year-old woman presented with binocular diplopia immediately after sustaining a penetrating injury to the left periocular adnexa with a hot metal skewer. Examination revealed an incomitant esotropia, with complete limitation of abduction of the left eye with downshoot in left gaze and normal afferent visual function. Computed tomography and magnetic resonance imaging demonstrated no fracture, but there was mild thickening of the medial rectus muscle and associated fat stranding. Lack of orbitomuscular tethering or hematoma led to the presumptive diagnosis of thermal cauterization injury causing left medial rectus restriction. Given the lack of literature on this mechanism of injury, the patient was monitored closely. She exhibited remarkable spontaneous improvement in motility over 6 months, with near orthophoria in primary gaze. However, bothersome residual esotropic diplopia in left gaze prompted a left medial rectus recession, with a good outcome. This case demonstrates that isolated extraocular muscle thermal injuries and consequential strabismus can recover spontaneously; longitudinal observation before surgical intervention may be appropriate in such cases.

FIG 1.

Ocular alignment and motility, external findings and imaging shortly after penetrating thermal injury to the left nasal orbit. A, Horizontal ocular motility photographs (within 1 day of surgery) with depictions in right gaze (left), primary gaze (middle), and left gaze (right). B, Slit lamp photograph taken in up-and-left gaze, with the lower lid manually lowered showing subconjunctival debris that marks the location of penetrating injury (note, photograph taken 8 months after initial injury). C, Magnetic resonance images: midorbital axial T1-weighted postgadolinium with fat suppression (left), retrobulbar coronal short tau inversion recovery (T2-weighted, fat suppressed) sequence.

FIG 2.

Recovery of ocular alignment and motility. A-D, Horizontal ocular motility photographs with depictions in right gaze (left), primary gaze (middle), and left gaze (right) 10 days (A), 3 months (B), 4 months (C), and 6 months (D) after the initial injury. E, Postoperative photographs taken 15 months after surgery, which was performed 9 months after injury.