Novel technique for treating extraocular muscle adherence after fracture repair

To describe a technique for treating extraocular muscle adherence after failed fracture repair(s).

Retrospective review of patients referred with persistent diplopia after prior release of inferior rectus from an orbital fracture. The muscle was freed from all adhesions, intraconal fat mobilised on either side of the affected muscle and the two pedicled fat pads sutured together in the extraconal space.

17 patients had markedly restricted motility after fracture repair, with 13 having had 2-4 prior interventions. After 'fat-wrapping', 10/17 patients showed a major improvement and 3/17 moderate improvement in ocular ductions, binocular single vision (BSV) fields and ocular deviations-together with reduced contralateral overactions. To improve late BSV position, a single strabismus procedure was performed in 3 of these 13 patients (23%). Tissues from seven patients showed muscle infiltrated by gross fibrosis extending from the capsule around the underlying implant. Four patients had poor outcomes due to major parabulbar adhesions, with two out of four being referred with longstanding surgical fistulae in the lower fornix and/or lacrimal sac.

After release from adhesions at the site of prior fracture repair(s), fat-wrapping of the outer surface of the inferior rectus muscle can markedly improve BSV fields, ocular ductions and deviations. Restoration of a viable extraconal fat layer appears to provide a 'fluid' medium between freed muscle and the orbital wall and block further adhesion between the two raw surfaces but the technique has limited results where prior surgery has caused adhesions involving the lower fornix or pre-equatorial tissues.