Slipped and lost extraocular muscles

A slipped or lost muscle should be considered in the differential diagnosis of a patient presenting with a marked limitation of duction and inability to rotate the eye beyond the midline. Loss of a rectus muscle can occur after strabismus surgery, trauma, paranasal sinus surgery, orbital surgery, or retinal detachment surgery. The extraocular rectus muscle most frequently slipped or lost is the medial rectus muscle. Forced ductions, active force generation, saccadic velocity studies, differential intraocular pressure measurements, and orbital imaging studies may aid in identifying a slipped or lost muscle. However, no single diagnostic test provides absolute reliability for determining a lost muscle. Slipped muscles develop when the muscular capsule is imbricated without including the muscle or muscle tendon during strabismus surgery. When the capsule is reattached to the sclera, the tendon and muscle are then free to slip posteriorally from the site of attachment. Slipped muscles are retrieved by following the thin avascular muscle capsule posteriorally until the muscle is identified. A lost muscle can be found using a traditional conjunctival approach, by an external orbitotomy, or by an endoscopic transnasal approach. Although many diagnostic maneuvers are useful in identifying a lost rectus muscle, the oculocardiac reflex is the most important. Once the lost muscle is identified, the muscle should be imbricated with a nonabsorbable synthetic suture and securely reattached to the globe.