A 36-year-old male who after a traumatic brain injury presented, 8 months later, an incomplete sensory motor medullary syndrome and a left eye pair VI (LE) that produced diplopia in all positions of the gaze.
In the motor exploration limitation of -3, torticollis 10o left side, 45 r endotropy in primary position of gaze with right eye (OD) fixator was observed.
In the sensory examination, the Worth test showed intermittent suppression of OI.
Visual acuity (VA) is OD 1 and OI 1.
The rest of the exploration was normal.
Treatment was performed with two injections of botulinum toxin 5 IU in the middle rectum of the left eye, with a reduction of the endotropy to 30 r without improvement of fertility.
At 6 months, VRT was performed with scleral fixation in the left eye under general anesthesia.
In the immediate postoperative period, we observed a consecutive exotropia of 45 r, reversal of torticollis, limitation of adduction of -1 and accumulation of -1 in the affected eye and diplopia.
After 15 days, 5 U of botulinum toxin was injected into the lateral rectus of the left eye without changing the result. After 2 months, it was decided to remove the scleral fixation, which was technically impossible.
The patient was reoperated by performing a resection of the middle rectum of OI of 7 mm and 5 U of botulinum toxin were injected into the lateral rectus of the OI intraoperatively.
The patient remained with torticollis on the right side of 10o, limitation of voiding -1, exotropia of 10-15 r in primary position of gaze (PPM) without diplopia.
Two years later, the patient presented diplopia, exotropia of 20-30 r in PPM, limitation of the right face of 20 -1, limitation of adduction of -1 and torticollis.
A new resection of the middle rectus of the left eye of 6 mm was performed.
One year after the last surgery, the patient presented: limitation of -1 fixation, torticollis on the right side of 5o, exotropia of 10-15 r in PPM without diplopia.
The patient was satisfied with the result.
