Department of Ophthalmology, Tenri Hospital, Tenri, Japan.
Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan.
Medicine (Baltimore). 2022 Dec 30;101(52):e31864. doi: 10.1097/MD.0000000000031864.
Pulled-in-two syndrome is one of the significant complications of strabismus surgery. This study aimed to report a case of pulled-in-two syndrome of the contractured medial rectus muscle (MR) that occurred during strabismus surgery for strabismus fixus due to high myopia, and to describe a rescue of this complication.
A woman in her 60s presented to our Ophthalmology Department with the main complaint of unilateral high myopia and severe myopic strabismus fixus. Esotropia exceeded 45° and hypotropia exceeded 15° in her right eye in the Hirschberg test. Right eye duction was markedly limited in every gaze direction. Orbital magnetic resonance images showed rupture of the superior rectus to lateral rectus band ligament and lengthening of the distance between the SR and LR muscles in the right eye.
Due to the patient's ophthalmic examination and imaging results, she was diagnosed with high myopic strabismus fixus.
We performed MR recession and Yokoyama surgery to correct right eye hypoesotropia. In the MR recession procedure, pulled-in-two syndrome (MR muscle tear) occurred. Thus, no additional procedure was performed on the MR. After the surgery, she presented 45 prism diopter exotropia and 18 prism diopter residual right hypotropia in a Krimsky test. We performed a second surgery, combining MR muscle advancement and inferior rectus (IR) muscle recession, 3 months after the first surgery.
One and a half years after the second surgery, she presented exotropia of 14 prism diopters without hypotropia in the Krimsky test and was satisfied with her ocular position and improved motility.
We experienced pulled-in-two syndrome in a case with severe myopic strabismus fixus and achieved a good outcome by performing additional surgery 3 months later, in which the lost MR muscle was advanced. This case underscores that, if the lost muscle cannot be found during surgery, one should maintain composure and perform a reoperation a few months after the initial surgery, if necessary. This case report can aid in making rescue treatment decisions when pulled-in-two syndrome occurs.
拉进-拉出综合征是斜视手术的一种严重并发症。本研究旨在报告一例因高度近视引起的固定性斜视斜视手术后发生的收缩性内直肌（MR）拉进-拉出综合征，并描述该并发症的抢救。
患者为 60 多岁女性，因单侧高度近视和严重近视性固定性斜视就诊于我院眼科。Hirschberg 试验中，右眼内斜视超过 45°，下斜视超过 15°。右眼在各个注视方向的内收均明显受限。眼眶磁共振成像显示右眼上直肌至外直肌带韧带断裂，SR 和 LR 之间的距离延长。
根据患者的眼科检查和影像学结果，诊断为高度近视性固定性斜视。
我们行 MR 后退和 Yokoyama 手术矫正右眼下斜视。在 MR 后退过程中，出现拉进-拉出综合征（MR 肌撕裂）。因此，MR 未进行额外手术。术后，Krimsky 试验中，患者表现为 45 棱镜度外斜视和 18 棱镜度残余右眼下斜视。第一次手术后 3 个月，我们进行了第二次手术，结合 MR 肌肉前徙和下直肌（IR）后退。
第二次手术后 1.5 年，Krimsky 试验中，患者表现为 14 棱镜度外斜视，无下斜视，对眼位和改善的运动功能满意。
我们在一例严重近视性固定性斜视患者中经历了拉进-拉出综合征，通过 3 个月后进行的额外手术获得了良好的结果，在该手术中，丢失的 MR 肌肉得到了前徙。该病例强调，如果在手术中找不到丢失的肌肉，必要时应在初次手术后几个月保持镇静并进行再次手术。本病例报告可为拉进-拉出综合征发生时的抢救治疗决策提供帮助。
