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| PHOTO ESSAY |
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| Year : 2023 | Volume
: 3
| Issue : 2 | Page : 588-590 |
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Medial rectus muscle laceration with conjunctival pyogenic granuloma
Monalisa Mohapatra1, Anupam Sahu1, Samrat Chatterjee2, Deepshikha Agrawal2
1 Department of Pediatric Ophthalmology and Strabismus Services, MGM Eye Institute, Raipur, Chattisgarh, India
2 Department of Cornea and Anterior Segment Services, MGM Eye Institute, Raipur, Chattisgarh, India
| Date of Submission | 28-Oct-2022 |
| Date of Acceptance | 16-Jan-2023 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Monalisa Mohapatra
Pediatric Ophthalmology and Strabismus Services, MGM Eye Institute, 5th Mile, Vidhan Sabha Road, Saddu, Raipur - 493 111, Chhattisgarh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJO.IJO_2859_22
Keywords: Conjunctival pyogenic granuloma, medial rectus muscle laceration, ocular trauma
How to cite this article:
Mohapatra M, Sahu A, Chatterjee S, Agrawal D. Medial rectus muscle laceration with conjunctival pyogenic granuloma. Indian J Ophthalmol Case Rep 2023;3:588-90 |
How to cite this URL:
Mohapatra M, Sahu A, Chatterjee S, Agrawal D. Medial rectus muscle laceration with conjunctival pyogenic granuloma. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Jun 3];3:588-90. Available from: https://www.ijoreports.in/text.asp?2023/3/2/588/374992 |
A 7-year-old boy presented with complaints of a fleshy mass in the right eye with an outward deviation of the eyeball. The lesion developed 15 days prior to presentation following trauma from a bicycle handle. Imaging findings were compatible with posttraumatic inflammatory changes and emphysema was observed around the medial rectus muscle.
His unaided distance visual acuity was 20/40 and 20/20 in the right and left eyes, respectively, and near vision was N6 in both eyes. In the right eye, an external examination revealed the presence of a fleshy mass in the nasal quadrant, 45° exotropia, and movement restriction on levoversion with a −4 limitation of adduction [Figure 1]. A slit-lamp examination of the right eye revealed the presence of conjunctival pyogenic granuloma 8 × 8 × 3 mm in size in the nasal quadrant, 7 mm away from the limbus, and a corneal epithelial defect of 2.8 × 1.8 mm with infiltrate. Direct microscopy of corneal scrapings with 10% potassium hydroxide wet mount and Gram's stain did not reveal any microorganisms, and cultures were negative for bacteria or fungi. Broad-spectrum antibiotic oral and topical medications with cycloplegic topical drops were advised. Wound exploration and excision of granuloma under general anesthesia were planned after the corneal lesion healed. | Figure 1: A preoperative 9 gaze photograph showing 45° exotropia in the right eye. The Krimsky test showed >50Δ exotropia for near and distance fixation in the primary position and −4 limitation of movement in adduction in the right eye
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After 2 weeks, the patient underwent superficial conjunctival granuloma excision. However, the granuloma was not completely excised as it was suspected to be contiguous with the underlying muscle tendon of the medial rectus. The forced duction test was tight in the right eye. After performing a limbal-based peritomy from 2 to 5 o'clock, it was noticed that the granuloma was emerging from the lacerated medial rectus muscle near its insertion site, i.e., 7 mm away from the limbus. Extensive fibrosis was observed surrounding the proximal part of the muscle, which was the cause of movement restriction in adduction. The proximal part of the muscle along with the granuloma had been disinserted from the insertion site and was cut from the distal part. The distal part of the muscle was reinserted into the insertion site 5.5 mm away from the limbus [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f. After 3 months, a residual squint correction surgery was performed. Postoperatively, the patient became orthotropic and a right ocular motility examination showed improvement in adduction with −1 limitation of movement [Figure 3]a and [Figure 3]b.{Figure 1} | Figure 2: Intraoperative photographs showing (a) granuloma 7 mm away from the limbus [arrows] and (b) extensive fibrosis surrounding the proximal part of the medial rectus muscle[m]. The distal part of the muscle [dm] posterior to the granuloma was secured with 6-0 Vicryl sutures (c) and was cut from the proximal part (d). The proximal part of the muscle [pm] along with the granuloma disinserted from the insertion site (e) and the distal part of the muscle [dm] was reinserted into the insertion site (f)
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 | Figure 3: Postoperative photographs showing (a) orthotropia and the prism cover test showed 3Δ exophoria for distance and near vision in the primary position and (b) right eye −1 limitation of movement in adduction
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| Discussion | |  |
Pyogenic granuloma is a vasoproliferative, inflammatory lesion that is composed of granulation tissue and is essentially a healing response.[1],[2] In our patient, the granuloma formed due to the healing of the lacerated medial rectus muscle and overlying conjunctiva. Although extraocular movement restriction was observed, the presence of the limbal mass confounded the diagnosis. As the insertion of the medial muscle is close to the limbus, it is vulnerable to injuries.[3]
The clinical events in this particular patient highlight not only the conundrums that arise in ocular adnexal trauma but also corrective treatment measures. A strong suspicion of extraocular muscle injury, careful evaluation of the functions of extraocular muscles, and appropriate imaging can prevent misdiagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts 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.
| References | | |
| 1. | Googe JM, Mackman G, Peterson MR, Richey MA, Apple DJ, Brick DC, et al. Pyogenic granulomas of the cornea. Surv Ophthalmol 1984;29:188-92.  |
| 2. | Lee Y, Hyon JY, Jeon HS. Conjunctival pyogenic granuloma: Cases with undetermined etiologies. Korean J Ophthalmol 2019;33:483-4. |
| 3. | Bloom PA, Harrad R. Medial rectus rupture; a rare condition with an unusual presentation. J R Soc Med 1993;86:112-3. |
[Figure 1], [Figure 2], [Figure 3]
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