Isolated superior rectus muscle hematoma with quiet eye after blunt orbital trauma – A case report

Om Shankar Shrivastava; Shimali Patle

doi:10.4103/IJO.IJO_2656_22

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CASE REPORT

Year : 2023 | Volume : 3 | Issue : 2 | Page : 486-487

Isolated superior rectus muscle hematoma with quiet eye after blunt orbital trauma – A case report

Om Shankar Shrivastava¹, Shimali Patle²
¹ Department of Ophthalmology, Govt. Medical College, Ambikpur, Chhattisgarh, India
² Department of Ophthalmology, Sarojini Devi Eye Hospital, Hyderabad, Telangana, India

Date of Submission	11-Oct-2022
Date of Acceptance	02-Jan-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Om Shankar Shrivastava
Department of Ophthalmology, Govt. Medical College, Ambikpur, Chhattisgarh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJO.IJO_2656_22

Abstract

After orbital trauma, medial rectus (MR) and inferior rectus (IR) muscles are the most frequently injured, while the oblique muscles are the least frequently injured. This can be probably because of the anatomical specifications of these muscles within the orbit. It is very unusual to find an isolated muscle injury or hematoma without any other orbital or ocular damage. We report here the case of a 7-year-old boy who presented with an isolated superior rectus muscle (SRM) hematoma after a blunt orbital trauma.

Keywords: Blunt ocular trauma, hematoma, superior rectus muscle

How to cite this article:
Shrivastava OS, Patle S. Isolated superior rectus muscle hematoma with quiet eye after blunt orbital trauma – A case report. Indian J Ophthalmol Case Rep 2023;3:486-7

How to cite this URL:
Shrivastava OS, Patle S. Isolated superior rectus muscle hematoma with quiet eye after blunt orbital trauma – A case report. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 4];3:486-7. Available from: https://www.ijoreports.in/text.asp?2023/3/2/486/374966

Owing to the anatomy of the orbit, which has inflexible walls, even minor injury leads to significant orbital soft tissue damage.^[1] Orbital fractures are common sequelae of blunt trauma.^[2] Traumatic rupture of a rectus muscle is an infrequent injury; even if it occurs, it is usually associated with orbital fracture, hemorrhage, and/globe injury.^[3] The most frequently traumatized extraocular muscle is the medial rectus muscle followed by the inferior rectus muscle.^[1],[4] However, to find an isolated muscle injury or hematoma without any other orbital structure damage is rare in clinics.^[5] We present a case of a 7-year-old boy, who, after sustaining blunt trauma to his right eye, developed isolated superior rectus muscle (SRM) hematoma. To the best of our knowledge, only three cases of posttraumatic isolated SRM hematoma have been published till date in English literature.^[6],[7],[8]

Case Report

A 7-year-old boy was brought to the outpatient department (OPD) with complaints of swelling and mild pain in his right upper eyelid after blunt ocular trauma that occurred following self-fall while playing 1 day back. On clinical examination, visual acuity was 20/20 p in the right eye (RE) and 20/20 in the left eye (LE) with normal pupillary reactions in both eyes. RE had periorbital swelling more marked superiorly with hypotropia, mild exotropia, and proptosis, with no ptosis of the upper eye lid [Figure 1]a. There was limitation of eye movement on upgaze (5 vs. 7 mm in LE) [Figure 1]b; movement restriction was not associated with any pain or discomfort. Force duction test on vertical direction of RE was negative. Visual fields by confrontation method were normal. On measuring with Hertel exophthalmometer, proptosis of RE was around 3–4 mm. On palpation, the orbital margins were intact and no bruit was detected over the proptosed area. Slit-lamp examination of the anterior and posterior segments of RE was unremarkable, except for mildly congested conjunctiva. Anterior and posterior segment examination of LE was normal. Complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), serum electrolytes, and coagulation profile were normal. B-scan of RE showed small extraconal hypoechogenicity measuring 4 ml volume adjacent to SRM, which was most likely hematoma [Figure 2]a. Computed tomography (CT) scan of the brain and orbits showed thick fluid density in the right SRM, suggestive of SR hematoma [Figure 2]b and [Figure 2]c. No other orbital bony fracture or hemorrhage or mass was noted in B-scan and CT scan. Considering the history, clinical picture, and imaging results, diagnosis of isolated right SR hematoma was made. Patient was kept on conservative management and started on a short course of oral corticosteroid (20 mg/kg tapered over 4 weeks). During this period, the swelling and proptosis resolved and the patient regained his ocular motility gradually within another 2–3 weeks. A repeat CT scan done after 2 months showed normal-sized SRM, confirming the complete resolution of hematoma [Figure 1]d.

Figure 1: RE shows (a) periorbital swelling more superiorly with hypotropia, mild exotropia, and proptosis. (b) Upgaze limitation. (c) Bulging out of area posterior to superior tarsal plate (forniceal conjunctiva) due to hematoma. (d) Resolved SR hematoma with complete resolution of proptosis. RE = right eye, SR = superior rectus

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Figure 2: (a) Small extraconal hypoechogenicity measuring 4 ml in volume adjacent to superior rectus, likely a hematoma. Coronal (b) and sagittal (c) sections of CT right orbit show isoechoic fluid density in SR muscle, suggestive of hematoma. CT = computed tomography, SR = superior rectus

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Discussion

Isolated trauma to an extraocular muscle without involvement of adjacent structures is rare. The order of frequency of muscle injury is as follows: medial rectus (MR), inferior rectus (IR), SRM, lateral rectus, and the oblique muscles which are damaged least frequently. This can be explained by the less-protective anatomy of the recti, separating them from the environment. The reason behind this could be forced eyelid closure accompanied by upward and usually outward movement of the eyes (Bell's phenomenon), which brings the IR and the MR muscles more anteriorly. Also, insertions of these two muscles are closer to the limbus, which adds to their vulnerability to get injured.^[9]

Orbital trauma in children with restricted eye movement might cause orbital trap-door fracture because of ample elasticity of bone.^[10] Trap-door fractures result from an acute transient increase in orbital pressure, leading to a flap of bone getting outwardly displaced and then immediately returning to its original position, creating a linear orbital wall fracture.^[10] This was the main differential diagnosis in our patient, but the absence of diplopia, negative force duction test, and the absence of any orbital fracture on CT orbit ruled out the possibility of trap-door fracture. There was no ptosis in our patient, indicating no involvement of Levator Palpabrae Superioris (LPS)–SRM complex, which can be expected as during the embryologic and fetal development, common epimysium is shared by these two muscles, which is rather thick and well demarcated early in development and gradually undergoes selective degeneration and thins out with maturation.^[11] Also, in this case, on retracting the upper eyelid, the area posterior to tarsal plate (forniceal conjunctiva) bulged out mechanically due to hematoma of SRM [Figure 1]c. The mechanism of isolated superior rectus hematoma is most probably bizarre direct injury to SRM, rather than diffuse orbital trauma or blowout fracture.^[8] Fortunately, a confined rectus muscle hematoma is less likely to create compartment syndrome endangering the optic nerve.

The diagnosis of isolated SRM hematoma was made based on relatively quiet eye after blunt trauma and CT orbits suggestive of hematoma in muscle plane without any other soft tissue injury or fracture. Conservative management of such isolated muscle trauma with moderate dose of steroid has been indicated.^[12]

Conclusion

In patients, especially children, with history of ocular trauma having subtle clinical findings, it becomes important to distinguish between isolated muscle hematoma and trap-door fracture with soft tissue or muscle incarceration, as the latter requires surgical intervention, and conservative management alone can lead to muscle ischemia or permanent diplopia.

Declaration of patient consent

Authors certify that they have obtained all appropriate patients consent form. In the form patient's parents (as patient is minor) have given their consent for patient's images and other clinical information to be reported in the journal. They understand that patient's name and initials will not be published and due effort will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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