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Squint Free Papers
RESULTS
All were males aged 13, 18, 23, 28 and 35 years. Time from injury to presentation
ranged from 6 months to 8 years. Visual acuity was 6/12 or better OU in all of
them.
All complained of cosmetic blemish and 3 complained of vertical diplopa
and 2 had additional horizontal diplopia. Primary position (PP) deviation
ranged from 40 to 70 prism diopters (PD), it was > 70 PD in abduction and
depression in all of them with gross limitation of depression in abduction.
Two had an additional exodeviation of 12 and 18 PD. FDT was mildly to
moderately positive in all of them for depression. Objective intorsion between
8 to 14 degrees was noted in all whereas on double Maddox rods it was 4, 6
and 8 degrees in 3 of them, only in the affected eye. Neuro imaging confirmed
the diagnosis of lost muscle in 3 and on surgical exploration other 2 had
pseudotendon attached at the insertion site but muscle could not be retrieved
as fat started prolapsing. Three patients underwent resection of inferior
oblique 3, 4 and 5 mm along with ATIO and 2 underwent ATIO with out
resection. SR recession of 5mm, 7 mm in 2 each and of 8 mm in one patient was
done simultaneously. Immediately post operatively vertical alignment with in
6 PD of HT was obtained with improvement of depression, intorsion was not
worsened significantly to give rise to any torsional symptoms. However it was
not maintained over subsequent 3 months and HT slowly worsened upto 18
PD in one case. Elevation was limited but patients were asymptomatic.
DISCUSSION
Traumatic dis-insertions and lost IRs apart, even isolated IR palsies are very
rare. In a report of 1000 cases of 3rd, 4rth and 6th cranial nerve palsies IR palsy
was not reported at all. 5
A substantial number of acquired IR palsies are either ischemic or traumatic in
origin and recover spontaneously. 6 Von Noorden reported a series of 21 patients
of isolated IR palsies, 7 of them were traumatic with 5 having a radiologically
confirmed fracture of orbital floor. 4 Forced duction test was negative in most,
abnormal head posture was noted in 13 but was variable and lacked fidelity,
head tilt test was positive in 3 patients only. Ipsilateral recession of SR and
resection of IR was the most commonly performed surgical procedure with
correction of upto 20 PD of HT in PP.
Early intervention is most efficacious while dealing with a lost or slipped IR
as delay may complicate clinical picture due to contracture of SR along with
scarring and fibrosis at the site of injury as happened in our cases. A careful
search for thin avascular muscle capsule/fibrosed tissue should be made and
if found it is likely that muscle has just slipped. In such cases scar tissue should
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