Original Investigation
Autogenous Fascia Lata Graft Fixation to Treat Exotropia
Resulting From Iatrogenic Medial Rectus Transection
Matthew G. Vicinanzo, M.D*, Chaitanya Allamneni, B.A, Luke W. Deitz, M.D*, and Frederick J. Elsas, M.D*
*Department of Ophthalmology, University of Alabama at Birmingham, Alabama Ophthalmology Associates, and
University of Alabama School of Medicine, Birmingham, Alabama, U.S.A.
Purpose: To describe autogenous fascia lata graft fixation as
a novel method to treat exotropia related to medial rectus (MR)
muscle injury following functional endoscopic sinus surgery.
Methods: Three consecutive patients with MR transection
and exotropia after functional endoscopic sinus surgery
were selected. Preoperative examination was performed; no
MR function was noted for over 3 months after injury. CT
and dynamic functional MRI were performed, where MR
transection and medial wall breach were noted. An autogenous
fascia lata graft was harvested and fixated from the remaining
periosteum of the posterior-most extent of the medial orbital
wall and attached to the globe at the MR insertion. In addition,
an ipsilateral lateral rectus muscle recession was performed.
Results: Alignment of the eyes in primary gaze and downgaze
was achieved and remained so at the 3-month postoperative
examinations, with minimal head turn or prism correction
(<5prism diopters) necessary to control diplopia. Two patients
required recession of the fascial graft for a minor overcorrection
and have remained stable for over 6 months.
Conclusions: Severe exotropia secondary to MR damage
following functional endoscopic sinus surgery is a known
complication historically difficult to treat. Traditional surgical
methods, including vertical muscle transposition, commonly
result in complete recurrence of exotropia and increase risk of
anterior ocular ischemia. Unlike simple nonabsorbable suture
fixation, fascial grafts are completely biointegratable, do not
result in significant inflammation, and are unlikely to rupture.
Fascia lata graft fixation of the MR to the posterior orbital medial
wall is a new and successful method to eliminate exotropia after
MR injury.
(Ophthal Plast Reconstr Surg 2016;XX:0000)
A number of surgical approaches to correct medial rectus (MR)
palsy have been proposed, including maximal horizontal
recession-resection,1 temporal mattress suture,1 muscle transpo-
sition,2,3 periosteal flaps,4 and various alloplastic58 and autoge-
nous1,9 materials as tethers. However, none of these methods has
been shown to adequately restore and maintain ocular alignment,
and a number are technically difficult to perform. Also, large
Accepted for publication April 5, 2016.
Material presented at 2009 Joint Meeting of the American Academy of
Ophthalmology (AAO) and the Pan-Frederick J. American Association of
Ophthalmology (PAAO) on October 2427, 2009 in San Francisco, CA.
The authors have no financial or conflicts of interest to disclose.
Address correspondence and reprint requests to Matthew Vicinanzo,
M.D., 1000, 19th Street South, Birmingham, AL 35205. E-mail: vicinanzo@
yahoo.com
DOI: 10.1097/IOP.0000000000000717
Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016 1
Copyright 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
skin incisions may be needed, and poor cosmesis often results.
Additional risks include orbital hemorrhage, anterior segment
ischemia, inflammation, and implant extrusion or resorption.
Iatrogenic MR palsy, such as that occurring during compli-
cated functional endoscopic sinus surgery (FESS), requires spe-
cial consideration. Functional endoscopic sinus surgery to repair
diseased sinuses is complicated by the finding that the lamina
papyracea separating the orbit from the ethmoid sinus is either
completely damaged or markedly attenuated as a result of sinus
disease. Furthermore, the narrow surgical field, difficult technique,
and newer endoscopic devices designed to reduce hemorrhage
increase the risk of complications.10 Extraocular muscle injury
following FESS is a rare but severe complication, with damage to
the MR, inferior rectus, and superior oblique having been reported
following FESS.11 Injury to the MR, including entrapment, hema-
toma, and transection, is among the most common.12
In cases of iatrogenic MR palsy following FESS, concur-
rent medial orbital wall fracture, medial orbital wall periosteal
compromise, and MR muscle fragmentation preclude the use
of a number of the aforementioned techniques. The purpose of
this study was to examine the outcomes of surgical repair of iat-
rogenic MR palsy using a unique method of autogenous fascia
lata graft fixation.
METHODS
Institutional review board committee approval was obtained
for this prospective case series that adhered to the tenets of the
Declaration of Helsinki. Three consecutive patients with MR transec-
tion and diplopia from exotropia after complicated FESS were selected.
Preoperative examination was performed; no MR function was noted
for over 3months after injury. CT and dynamic functional MRI were
performed, where MR transection and medial wall breach were noted.
A forced duction test as well as a force generation test was performed
to assess adduction deficits. A transcaruncular orbitotomy, as detailed
by Goldberg et al.,13 was chosen for best visualization. An autogenous
fascia lata graft was harvested from the thigh. The graft was fixated
from the remaining periosteum of the posterior-most extent of the me-
dial wall (along and parallel to the residual MR) and attached at the MR
insertion (Fig.1AH). In all cases, the medial wall fracture was repaired
with a SupraFOIL implant. Also, when both ends of the transected MR
were available, their edges were friable, and thus interposing fascia lata
in between these sections was not possible. In addition, an ipsilateral
lateral rectus muscle recession was performed. It should be noted that
this procedure is not intended to restore adduction to the affected eye,
but rather keep it in orthophoria in primary gaze.
RESULTS
Case 1. A 47-year-old male developed diplopia from exotropia after
undergoing FESS. After subsequent medial wall repair, the patient had
left exotropia of 40 prism diopters (PDs) and left hypertropia of 10
 M. G. Allamneni et al. Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016
FIG. 1. Fascia lata graft fixation from the posterior medial wall
to the medial rectus insertion. A, Harvested fascia lata graft.
B, Medial anterior orbitotomy and isolation of medial rectus
muscle. C, Mersilene suture fixation to posterior medial orbital
wall. D, Suture fixation to posterior graft. E, Globe alignment for
anterior suture positioning. F, Anterior graft suture placement.
G, Suture placement at medial rectus muscle insertion. H, Graft
attachment at medial rectus muscle insertion.
FIG. 2. Case 1. A, 40 PD LXT in primary gaze. B, Orthophoria in primary gaze 6 months after fascia lata graft recession. LXT, left exo-
tropia; PD, prism diopter.
2 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
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PD 4 months post FESS (Fig.2A). The forced duction test was free,
indicating MR dysfunction. Left MR force generation was 0. Kinetic
MRI revealed an atrophic LMR with an adduction deficit of 4. Eight
months post FESS, the patient underwent transposition of an autog-
enous fascia lata graft to the left orbit, from posterior to fracture to the
insertion of the left MR muscle. The left lateral rectus muscle was also
recessed 10mm. Three months after graft fixation, the patient devel-
oped esotropia (ET) of 4 PD, and the fascia lata graft had fused with a
slight turn to the left. At 9 and 11 months post graft fixation, the patient
developed left ET of 10 and 25 PD, respectively, with forced duction
testing showing marked limitation to abduction of the left eye. This
necessitated recession of the fascial graft, which had tightly adhered
to the MR muscle, 11mm posterior to the limbus. Two months post
recession, the patient was in orthophoria and has remained stable for
over 6 months (Fig.2B).
Case 2. This male patient had a medial wall fracture with transection of
the LMR after FESS at age 52. This resulted in post operative diplopia,
left exotropia of 50 PD, and an adduction deficit of 4 (Fig.3A). CT re-
vealed a transected left MR. One month after FESS, the forced duction
test indicated a free left MR, on which the severed LMR was repaired
through reanastomosis, and Botox was applied to weaken the antagonist
left lateral rectus. He did well initially, with 2 to 5 PD left exotropia.
However, At 2 months, 4 years, and 9 years after MR repair, the XT
progressively increased from 4 PD to 20 PD to 50 PD, respectively, with
an inability to adduct beyond the midline. Nine years post MR repair,
the 61-year-old patient underwent a fascia lata graft fixation to the left
orbit, from posterior to the medial wall to the insertion of MR. The left
lateral rectus was also recessed 10mm. One month post graft fixation,
the patient had a XT of 5 PD with a slight head turn to the right. Twenty-
seven months post graft fixation, the XT remained 5 PD (Fig.3B).
Case 3. A 44-year-old male suffered a transection of his right MR
(RMR) after FESS. The patient subsequently developed a right XT of
35 PD (Fig.4A). The adduction deficit was 4, and the forced duction
test in adduction was free. Force generation was also absent in adduc-
tion. Five months after fascia lata graft fixation, the patient developed
a right ET of 35 PD (Fig.4B), which necessitated recession of the
fascial graft to 12mm post limbus; also, the right MR was disinserted
and excised. The patient had a XT of 8 PD 5 days post recession but
was in orthophoria 6 months post operatively (Fig.4C).
 Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016 Fascia Lata Graft to Repair Injured Medial Rectus

FIG. 3. Case 2. A, 50 PD LXT in primary gaze. B, Five PD LXT in primary gaze 27 months after fascia lata grafting. LXT, left exotropia.
PD, prism diopter.

FIG. 4. Case 3. A, 35 PD RXT in primary gaze. B, 35 PD RET in primary gaze 4 months after fascia lata graft fixation. C, In orthophoria
6 months after recession of the fascial graft. PD, prism diopter.

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 M. G. Allamneni et al. Ophthal Plast Reconstr Surg, Vol. XX, No. XX, 2016
DISCUSSION
Salazar-Len et al. proposed a method of correcting paralytic
1 sclera. In cases 1 and 3, the fascia and MR had fused into a tight
strabismus using fascia lata graft fixation. Their technique
included a 1.5cm skin incision at the medial canthus. Fascia was
then attached to the periosteum at the insertion of the medial
canthal tendon, and a Wright needle was used to thread the graft
through the MR muscle insertion. A concurrent lateral rectus
muscle recession was also performed. However, in this study,
most patients had significant residual exotropia postoperatively.1
This method offers significant advantages over that of
Salazar-Len et al.1 in which the orbitotomy allows for the
evaluation and treatment of orbit pathology. In addition, fixa-
tion of the fascia lata in the posterior medial orbit versus the
medial canthal tendon insertion allows the graft to more closely
approximate the path of the MR muscle. This orientation, along
with the absence of a skin incision, prevents elevation of the
skin at the medial canthus and allows for better overall postop-
erative cosmesis. Most importantly, the authors found that the
patients were very near orthophoria in primary gaze at least out
to 6 months postoperatively with resolution of their diplopia.
Current techniques to treat exotropia related to MR
injury each have their flaws. Transposition of the superior rec-
tus muscle predisposes to anterior segment ischemia, and tends
to drift resulting in recurrent exotropia. Resection-recession
procedures also often result in recurrence of exotropia. Use
of alloplastic materials to tether the globe results in complica-
tions including extrusion, inflammation, and resorption.4 The
periosteal flap proposed by Goldberg et al.4 is one of the more
intriguing approaches, in that it is autogenous and follows the
natural path of the MR. It also has the added benefit of being
well vascularized, more than fascia lata. However, following
FESS resulting in MR injury, the periosteum is often severed,
allowing little modification, and thus precluding the use of a
periosteal flap. Fascia lata grafting offers numerous advantages
over the aforementioned techniques: it is autogenous, perma-
nent, has great tensile strength, has already been successfully
used in ptosis repair, and does not increase the risk of anterior
segment ischemia. Furthermore, a fascia lata graft allows more
vertical movement than a periosteal flap.
One limitation of fascia lata grafting is that due to its
underdevelopment in young children, enough of it cannot be
harvested for grafting. Also, ET was a complication noted in
2 of 3 patients (cases 1 and 3) following fascia lata transposi-
tion. Cases 1 and 3 both developed marked restriction to abduc-
tion 11 and 5 months following surgery, respectively. In both
patients, the fascia was placed over the injured MR. Of note,
no secondary ET developed in case 2; in this patient, the MR
4 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.
Copyright 2016 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc. Unauthorized reproduction of this article is prohibited.
had been excised, and the fascia was instead placed over the
complex.
In conclusion, using this method, fascia lata graft fixa-
tion, is a successful way of dealing with iatrogenic MR muscle
palsy given the unique anatomical considerations involved. In
addition, this technique should be equally successful in correct-
ing other types of paralytic strabismus involving the MR muscle
including third nerve palsy and ocular fibrosis, a challenging
problem for which no universally accepted surgical approach
has been found.
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