A 67-Year-Old Woman With Diplopia After Sinus Surgery

Sina Rezaei; Rod Foroozan, MD


January 18, 2018


First introduced in 1985, ESS has become the procedure of choice for the surgical management of chronic sinusitis. It is a common procedure, with over 250,000 cases annually in the United States.[1]

As with most surgeries, ESS is not without risks. A study by Krings and colleagues[2] found that major orbital complications occurred at an incidence of 0.23% after the procedure. They also found several predictive factors for complications, including age older than 40 years and having Medicaid. Curiously, procedures with image guidance had twice the rate of major orbital complications and a 60% higher rate of all major complications.[2]

The proximity of the paranasal sinuses to the orbit puts orbital tissue at risk for damage during ESS. The lamina papyracea, which separates the orbit from the ethmoid sinuses, is very thin and particularly susceptible to damage.[3] As a result, several ophthalmic complications can arise from ESS.

These complications can be divided into four groups based on the location of injury: the orbit, optic nerve, lacrimal drainage system, and extraocular muscles. The most common ophthalmic complication overall is orbital hemorrhage. Damage to the optic nerve can lead to visual loss, but damage occurs more often to the lacrimal drainage system, with epiphora occurring after 0.3%-1.7% of cases.[4]

Extraocular muscle damage from ESS can lead to strabismus and diplopia. Owing to its proximity to the lamina papyracea, the medial rectus is the most common extraocular muscle affected, although superior oblique and inferior rectus involvement have also been reported.[4] Partial or complete transection of the medial rectus can lead to moderate- to large-angle exotropia with deficits in adduction. On the other hand, entrapment of the medial rectus can precipitate small-angle esotropia with abduction deficits.[5] Contusion of the muscles, inflammation, fat adherence syndrome, and neurovascular damage can also cause ophthalmoplegia secondary to ESS.[4,5]

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