Nasal-inferiore Transposition des M. rectus lateralis bei Okulomotoriusparese

Surgical management of oculomotor nerve palsy - a review of the literature

We aim to review the surgical management techniques available for patients with oculomotor nerve (OMN) palsy, compare and contrast the approaches and subsequent outcomes. A search of the literature was carried out to yield all papers relevant to the topic, and a wide spectrum of surgical techniques were identified. These included: muscle shortening and lengthening procedures, muscle transposition, globe fixation and ptosis surgery. Patients often require a synergistic combination of these techniques. Strabismus surgery for OMN palsy can be approached through a variety of different techniques to improve the quality of life, independence and aesthetics for the patient.

The use of lyophilized bovine pericardium (Tutopatch®) in the management of third nerve palsy following prior conventional strabismus surgery - a case series

To study the secondary management of strabismus due to third nerve palsy using bovine pericardium (Tutopatch®) when previous conventional surgical therapy had failed. Review of our clinic records of selected patients with third nerve palsy, in whom residual deviation had been managed using Tutopatch® after previous surgical correction. The squint angle was measured preoperatively, and at 1 day, 3 months, and if possible 6 months postoperatively. Nine patients were enrolled in this study. One patient had mainly residual vertical deviation and was corrected with tendon elongation of the contralateral superior rectus. Three patients were operated on with tendon elongation of the lateral rectus muscle with or without medial rectus muscle resection and/or advancement (Group 1). Lateral rectus splitting after tendon elongation in addition to the resection and/or advancement of the medial rectus was performed in five patients with complete third nerve palsy (Group 2). In Group 1, the preoperative median squint angle was -20° (range -17° to -25°), which improved postoperatively to -4.5° (range -12° to +3°). In Group 2, the preoperative horizontal and vertical median squint angles were -27° (range -20° to -40°) and 0.5° (range 0° and 20°), respectively. Postoperatively, they had improved to -12.5° (range-2° to -25°), and 1.5° (range 0° to 7°), respectively. Two patients of Group 2 were re-operated due to residual exotropia. No postoperative complications were observed in any patient. In this small series several complex re-do situations of patients with third nerve palsy were evaluated in which Tutopatch® markedly improved outcomes after an initially ineffective surgical management. For better evaluation of its usefulness a study with more patients is recommended.

[Bridle operation for incomplete oculomotor nerve paralysis (superior rectus and lateral rectus nasal inferior transposition)]

PURPOSE

To demonstrate the technique and effectiveness of the bridle operation for oculomotor nerve paralysis with maintained elevation.

METHOD

The bridle operation includes transposition of the lateral rectus muscle (passing behind inferior oblique and rectus muscles) and the superior rectus muscle (behind superior oblique tendon and medial rectus muscle) to the nasal inferior surface of the globe.

RESULTS

In the reported case, this procedure corrected exo-hypertropia of 30-40°/20-30° without inducing cyclotropia.

CONCLUSION

The bridle operation expands the surgical arsenal for paralytic strabismus.

Long term outcomes of strabismus surgery for third nerve palsy

PURPOSE

To report long-term outcomes of strabismus surgery for treatment of third nerve palsy.

METHODS

We performed a 15-year retrospective study of patients who had undergone surgery. We analyzed preoperative mean deviation (at 6 months, 1 year after surgery, and at the end of follow-up), type of surgery, and factors predicting outcomes. A final deviation <10 prism diopters (pd) was considered a good esthetic outcome, and no diplopia in the primary position at the end of follow-up was considered a good functional outcome.

RESULTS

Surgery was performed in 31 cases. Mean age was 36.27 years (women, 51.6%). Total and complete third nerve palsy was recorded in 22.6% and acquired palsy in 80.6%. Mean preoperative horizontal deviation (HD) in primary position was 40.24pd (near) and 44.29 (distance) and 14.33pd in vertical deviation (VD). Mean final HD was 8.94pd (near) and 11.35pd (distance), and mean final VD was 6.13. One surgery was performed in 68.9%. A favorable esthetic outcome was obtained in 64.5% and a successful functional outcome in 72.2%. Statistically significant differences were found between near HD (p=0.019) and distance HD (p=0.035) at 1 year compared with the end of follow-up and between VD at 6 months and 1 year after surgery (p=0.03). Mean follow-up was 6.05 years. No specific factors predicted a successful outcome.

CONCLUSIONS

Esthetic and functional results were similar. No predictors of successful outcome were identified. HD was better 1 year after surgery, and VD improved during follow-up.

Lateral Rectus-Medial Rectus Union: A New Surgical Technique for Treatment of Complete Third Nerve Palsy

PURPOSE

To describe a new surgical technique for the treatment of complete third nerve palsy.

METHODS

This study included patients with chronic complete third nerve palsy. The lateral rectus muscle was split, followed by disinsertion of the superior and inferior halves, which were passed between the sclera and superior and inferior rectus muscles, respectively. Then the medial rectus muscle was sutured as posteriorly as possible from its insertion and cut. Next, the distal stump of the medial rectus muscle was split into two halves and united with the superior and inferior halves of the lateral rectus muscle. Finally, the proximal portion of the medial rectus muscle was sutured back to its original insertion. In cases with hypotropia and a functional superior oblique muscle, superior oblique tenectomy was also performed. Success was defined as postoperative horizontal deviation of 10 prism diopters (PD) or less and vertical deviation of 5 PD or less.

RESULTS

Ten patients with a mean age of 32.4 ± 18.4 years had surgery using this technique; 2 of them had a history of strabismus surgery. Mean exotropia was 84 ± 14.9 PD, which reduced to 6.5 ± 8.2 PD. Mean vertical deviation was 16.5 ± 10 PD, which reduced to 2.5 ± 3.5 PD. Mean follow-up was 13.2 ± 7.9 months, and the success rate was 70% and 90% for horizontal and vertical deviations, respectively.

CONCLUSIONS

The lateral rectus-medial rectus union technique is an effective and long-lasting procedure to overcome large-angle exotropia associated with complete third nerve palsy. This method can also be employed as a reoperation procedure. [J Pediatr Ophthalmol Strabismus. 2019;56(1):10-18.].

Transcaruncular rectus tendon fixation to the orbit and frontalis flap for complete third nerve palsy

PURPOSE

To describe our experience and outcomes managing complete third cranial nerve palsy.

METHODS

This was a retrospective analysis of the clinical records of 7 consecutive patients treated at our centre for unilateral third nerve palsy over the period 2010-2016. We describe our surgical approach using a frontalis muscle flap to correct the eyelid ptosis associated with medial fixation of the rectus muscle tendon to the orbit to correct the horizontal deviation.

RESULTS

The seven patients, four women and three men, were of mean age of 44 ± 19 years [18-75 years]. Follow up was 29 ± 31 months [5-82 months]. In the preoperative exam, exotropia in prism diopters (PD) was -70 ± -28 PD [-30 to -90 PD]. At the end of follow up, this was reduced to -11 ± -14 PD [0 to -30 PD]. Preoperative marginal reflex distance 1 (MRD1) was -4 ± 1 mm [-3 to -5 mm] and palpebral fissure height (PFH) was 0.5 ± 1 mm [0-2 mm]. Surgical undercorrection was the target in all patients due to the absent or poor Bell's phenomenon. At the end of follow up, MRD1 was 2.5 ± 0.5 mm [2-3 mm] and PFH was 7 ± 1 mm [6-8 mm]. Cosmetic and functional results were good in all patients.

CONCLUSIONS

Medial fixation of the rectus muscle tendon to the orbit associated with a frontalis muscle flap is a valid option for the treatment of exotropia and ptosis in patients with third cranial nerve palsy.

A New Surgical Treatment Option for Chronic Total Oculomotor Nerve Palsy: A Modified Technique for Medial Transposition of Split Lateral Rectus Muscle

PURPOSE

To describe a new surgical modified procedure in patients with chronic total oculomotor nerve palsy and to evaluate the results of this procedure.

METHODS

Eight eyes of 6 consecutive patients who underwent strabismus surgery due to chronic total oculomotor nerve palsy were enrolled in the study. The lateral rectus muscle was split into two halves and disinserted from the sclera. The upper half of the muscle was passed under the superior rectus muscle and the inferior half of the muscle was passed under the inferior rectus muscle. The two halves of the muscle were moved to the medial rectus muscle insertion area and were sutured to sclera near the insertion. Additional medial rectus resections were made in the undercorrected patients.

RESULTS

The mean age was 21.8 ± 12.1 years (range: 11 to 42 years). Postoperatively, 4 of 6 patients had stable horizontal deviations; 1 had orthophoria, 2 had 10 prism diopters (PD) of exotropia, and 1 had 10 PD of esotropia. However, 2 cases had 25 and 30 PD of undercorrection. Additional medial rectus resections were made in these undercorrected patients and horizontal deviations reduced to 15 and 20 PD of exotropia, respectively. The mean primary position horizontal deviation, which was 74.1 ± 10.2 PD before the surgeries, reduced to 10.8 ± 6.6 PD after the surgeries (P < .001).

CONCLUSIONS

The authors described a new and relatively simple modified surgical procedure for the treatment of chronic total ocular nerve palsy and reached satisfactory outcomes. Further studies with larger sample sizes are warranted. [J Pediatr Ophthalmol Strabismus. 2016;53(3):150-154.].

Periosteal Fixation Procedures in the Management of Incomitant Strabismus

Managing a case of incomitant strabismus from nerve palsy or extraocular muscle loss is a major challenge. Among possible management options are globe or extraocular muscle fixation to the orbital wall coupled with weakening or strengthening of the relevant antagonist. Extraocular muscle fixation to the orbital wall can also be used in cases of abnormal synkinesis to eliminate the abnormal eye movements of a misfiring extraocular muscle, which thereby allows the use of standard paralytic strabismus surgery techniques. This review article summarizes indications and techniques of periosteal fixation procedures for incomitant strabismus.

Magnetic resonance imaging of bilateral split lateral rectus transposition to the medial globe

PURPOSE

Medial transposition of the split or intact lateral rectus (LR) muscle in oculomotor palsy improves extreme exotropia. We studied rectus pulley positions using high-resolution surface coil MRI before and after LR split with medial transposition surgery in a patient with bilateral oculomotor and trochlear nerve palsies.

METHODS

This is a report of a 14-year-old girl with 90Δ exotropia due to bilateral oculomotor and trochlear nerve palsies following traumatic midbrain infarction at age 6 years. Surgery comprised longitudinal division of each LR into a superior and inferior, threading of both halves between the inferior rectus (IR) and inferior oblique inferiorly, and inferior to the superior oblique and the superior rectus superiorly, with suturing of each 10 mm posterior to the medial rectus (MR) insertion.

RESULTS

Pre-operative MRI of the orbit and extraocular muscles (EOMs) with thin, 2-mm slices revealed bilateral atrophy of all EOMs supplied by the oculomotor and trochlear nerves. Post-operative MRI at 2 months demonstrated no significant changes in rectus EOM pulley positions compared with pre-operative values.

CONCLUSIONS

The LR pulley does not change position even after split LR transposition to the MR insertion, confirming the profound constraint of the connective tissue pulley system on the LR path.