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Show ORIGINAL CONTRIBUTION Inferior Oblique Paresis, Mydriasis, and Accommodative Palsy as Temporary Complications of Sinus Surgery Hiiseyin Bayramlar, MD, Murat Cem Miman, MD, and Soner Demirel, MD Abstract: A 15- year- old boy had temporary hypertropia, supraduction deficit, ipsilateral mydriasis, and accommodative paresis after bilateral endoscopic ethmoidectomy, bilateral partial inferior turbinectomy, septoplasty, and Cald-well- Luc procedures for chronic sinusitis. Postoperative imaging did not disclose any intra- orbital abnormalities. The patient was treated with oral prednisolone 70 mg/ day on a tapering schedule. Within two months, the ophthalmic abnormalities had resolved. This is the second report to describe such findings, which are attributed to damage of the inferior division of the third cranial nerve secondary to manipulation of adjacent ethmoid tissues. ( JNeuro- Ophthalmol 2004; 24: 225- 227) The surgical drainage and removal of paranasal sinus tissue are common in the management of chronic sinusitis ( 1- 3). The surgical approaches may be external or transna-sal endoscopic, with both having the potential for orbital complications such as extraocular muscle injury or entrapment, enophthalmos, anisocoria, and even blindness ( 1- 6). We report a patient with postoperative temporary mydriasis, accommodation palsy, and inferior oblique paresis after sinus surgery. We believe this to be only the second case of such complications ( 5). CASE REPORT A 15- year- old boy reported chronic purulent rhinor-rhea and nasal obstruction that was diagnosed as chronic sinusitis and nasal polyps. One year earlier, he had undergone bilateral endoscopic ethmoidectomy, bilateral partial inferior turbinectomy, septoplasty, and bilateral Caldwell- Luc procedures. Because of the persistent symptoms, he underwent bilateral medial maxillectomy with revisions of the Cald-well- Luc procedures and excision of the recurrent polyps in Departments of Ophthalmology ( HB, SD) and Otorhinolaryngology ( MCM), Turgut Ozal Medical Center, Inonu University, Malatya, Turkey. Address correspondence to Hiiseyin Bayramlar, MD, Inonu Univers-itesi, Turgut Ozal Tip Merkezi, Goz Hast. A. D., Malatya, Turkey; E- mail: hbayramlar@ yahoo. com the nasal cavities. On the left side, medial maxillectomy was performed successfully through external and transnasal endoscopic approaches. On the right side, it was difficult to find the ostium of the maxilla at the medial wall of the sinus just below the orbit because it was hypoplastic and obscured by intramaxillary fibrosis secondary to the previous surgery. Nevertheless, after removal of the nasal polyps in the right nasal cavity, natural ostium enlargement and inferior meatal antrostomy were performed successfully. On awakening from anesthesia, the patient was noted to have anisocoria, and he reported blurred vision OD and double vision. On ophthalmologic examination, there was no periocular ecchymosis or edema. Uncorrected visual acuity at distance was 20/ 30 OD ( pinhole 10/ 10) and 20/ 20 OS. Visual acuity at near was 20/ 100 OD and 20/ 20 OS. The right pupil measured 7 mm; the left measured 3.5 mm in dim light. The right pupil did not constrict to direct light or a near target; the left constricted normally. The patient had an eight- prism diopter exotropia and a five- prism diopter left hypertropia in primary position and in left gaze. Supraduction OD was moderately reduced in elevation- in-adduction ( Fig. 1). Forced ductions were not performed. Immediate computed tomography of the orbits and paranasal sinuses disclosed no abnormalities in the orbit; the medial and inferior walls were intact ( Fig. 2). Magnetic resonance imaging of the orbit revealed no evidence of fluid accumulation or compression damage to the optic nerve or other intraorbital structures. Postoperative mydriasis, accommodative palsy, and inferior oblique paresis OD caused by traumatic partial palsy of the inferior division of the right third cranial nerve were diagnosed. Oral prednisolone 70 mg daily was started to reduce postoperative edema. On the seventh postoperative day, the diplopia was still present on left superior gaze. Near visual acuity OD had improved to 20/ 40. The right pupil had decreased to 4 mm in dim illumination. The patient was discharged on a tapering schedule of oral prednisolone ( 10 mg per week). At four weeks after surgery, diplopia was present only in far left superior gaze. Near acuity had improved to 20/ 30 OD. The pupils were normal. At eight weeks after surgery, all abnormalities had resolved. J Neuro- Ophthalmol, Vol. 24, No. 3, 2004 225 JNeuro- Ophthalmol, Vol. 24, No. 3, 2004 Bayramlar et al FIG. 1. Our patient's ocular motility on the first postoperative day. Note the right mydriasis, right exotropia, and left hypertropia in primary position, and reduced supraduction- in- adduction OD. DISCUSSION The anatomic proximity of the orbit to the adjacent sinuses exposes the orbital contents to trauma in sinus surgery. Despite this fact, relatively few ophthalmic complications have been reported ( 1- 6). Freedman and Kern ( 7) reported only four minor orbital hemorrhages without visual loss in a series of 1000 consecutive intranasal ethmoidecto-mies. Stankiewicz ( 8) encountered six cases of orbital hemorrhages in a series of 90 endoscopic ethmoidectomies; in only one case did visual loss occur, and it was temporary. Maniglia et al ( 9) reported four cases of blindness after intranasal ethmoid sinus surgery; three cases resulted from severe orbital hemorrhages and one resulted from an orbital abscess. Griffiths and Smith ( 10) described two unilateral blindness cases, one from orbital cellulitis and the other from orbital hemorrhage. Other reported orbital complications are infraorbital nerve hypesthesia, diplopia caused by the injury of an extraocular muscle, enophthalmos, and permanent blindness from orbital hemorrhage, optic nerve transection, or impaction of bone against the optic chiasm during removal of a sphenoid osteoma ( 1- 6,11- 14). Postoperative anisocoria is a rare consequence of endoscopic sinus surgery, which may result from injury to the parasympathetic fibers of the third cranial nerve. In our case, the patient had mydriasis, accommodative paresis, and inferior oblique paresis. To our knowledge, this is only the second case with such complications ( 5). Kosko et al ( 5) reported a patient with unilateral partial third nerve palsy FIG. 2. Coronal computed tomography on the first postoperative day shows intact medial and inferior walls of the right orbit with a relatively hypoplastic right maxillary sinus. The other findings are a left medial maxillectomy, a right inferior meatal antrostomy, and blood and accumulated secretion at the floor of the nasal cavities. 226 © 2004 Lippincott Williams & Wilkins Temporary Inferior Oblique Paresis JNeuro- Ophthalmol, Vol. 24, No. 3, 2004 after bilateral sinus surgery. The authors stated that diplopia and anisocoria resolved two months after the surgery. They suggested that this complication most likely resulted from postoperative edema. The anisocoria in our patient was also probably caused by perineural edema because of the disturbance of the inferior wall of the right maxillary sinus caused by in-tramaxillary manipulation during the revision of the Cald-well- Luc procedure or the surgical manipulation around the lamina papyracea while searching for the natural maxillary ostium. Postoperative imaging did not demonstrate any orbital or intracranial abnormalities. In such circumstances, as in our case, the patient can be reassured that the deficits are transient and that complete recovery may be anticipated within months. Postoperative anisocoria after sinus surgery may also result from spread of the local anesthetic agent, as in the case of Stewart et al ( 4). In that case, however, the anisocoria lasted only three to four hours. REFERENCES 1 • Buus DR, Tse DT, Farris BK. Ophthalmic complications of sinus surgery. Ophthalmology 1990; 97: 612- 9. 2. 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