No split, no tenotomy transposition procedure for complete abducens palsy

Outcomes of "a new modification of Jensen technique combined with medial rectus recession" in patients with complete sixth cranial nerve palsy

BACKGROUND

To report the outcomes of "our modified Jensen technique" for treating esotropia in cases with complete sixth cranial nerve (CN VI) palsy.

METHODS

This study is a 30-year case series of isolated complete CN VI palsy who underwent combined medial rectus recession and our modified Jensen operation. We modified the original technique by anchoring the muscle-unifying sutures to the sclera near the equator using a non-absorbable suture. Major outcomes such as postoperative diplopia, face turn, horizontal and vertical eye deviations, and abduction limitation were assessed. Successful surgery was defined as orthotropia or esotropia equal to or less than 8 prism diopters (PD) and the absence of any vertical deviation.

RESULTS

Fifty-three cases with a mean age of 28 years old were included in this study. The male-to-female ratio was 3 to 1. Forty-five cases (85%) presented with unilateral palsy, whereas 8 patients (15%) had bilateral palsy. Trauma was the most common etiology (85%). Diplopia or face turn, presented in 42 patients before the operation, remained in seven cases after the operation. Primary position esotropia, which was the main complaint in all patients, decreased from 49 PD to 4 PD in unilateral palsy and from 101 PD to 10 PD in bilateral palsy. The mean reduction of abduction deficit was 1.78 in unilateral and 1.75 in bilateral palsy. The success rate was 76% in unilateral and 62% in bilateral palsy.

CONCLUSION

Our modified Jensen operation was effective in treating patients with complete CN VI palsy, producing no significant permanent complications.

Surgical management of chronic sixth cranial nerve palsy: case report and literature review

Background

Esotropia resulting from sixth cranial nerve palsy can substantially impact an individual's visual acuity and overall quality of life. If the condition does not resolve in 6-10 months, surgical intervention may be necessary. Various muscle surgeries may be considered, with vertical rectus muscle transposition emerging as the primary option for treatment of complete palsy. However, this technique carries the risk of anterior segment ischemia and post-surgery deviations. Herein, we present a successful treatment of chronic complete sixth nerve palsy using a modified Nishida procedure, without splitting or tenotomy, and an adjunct botulinum toxin A (BTA) injection in the ipsilateral medial rectus muscle.

Case Presentation

A 59-year-old woman with a history of traumatic sixth nerve palsy had previously undergone horizontal muscle strabismus surgeries. Following multiple left medial rectus recessions, lateral rectus resection, and BTA injections, esotropia persisted. The worsening of her condition led to emotional distress and impaired social interaction. Initial examination revealed marked esotropia and limited left eye abduction. Magnetic resonance imaging (SIGNA MR750w, GE Healthcare, Waukesha, WI, USA) of the left eye revealed a contracted medial rectus muscle and substantial atrophy of the left lateral rectus muscle. A modified Nishida procedure was performed with an injection of 3 units of BTA into the ipsilateral medial rectus muscle, resulting in improved ocular alignment and stable findings after nine postoperative months. Furthermore, we supported our successful outcome with a summary of similar reported cases of sixth nerve palsy managed using the modified Nishida procedure with or without adjunctive procedures.

Conclusions

Following the modified Nishida procedure, the patient experienced a reduction in diplopia, improved ocular alignment and stability, and an increased binocular diplopia-free field. This case underscores the importance of an individualized approach to complex strabismus cases and highlights the modified Nishida procedure as a valuable tool in such circumstances. In the future, strabismus management will focus on refining personalized treatment and exploring innovative techniques for complex cases. Our success in using a combination of Nishida procedure and BTA injection should be further investigated in large-scale studies.

Modified Nishida's procedure for esotropia in Duane syndrome associated with Goldenhar syndrome

Modified Nishida's procedure (no split, no tenotomy transposition) has been recently described as an effective surgery for monocular elevation deficiency and for traumatic rupture of the inferior rectus muscle. We report the modified Nishida's procedure combined with medial rectus muscle recession for the treatment of esotropia in unilateral Duane syndrome associated with Goldenhar syndrome. Following the surgery and over a 1-year follow-up period, the patient was orthophoric at distance and near, abduction improved, and the abnormal head position resolved.

No-split, no-tenotomy transposition of only the superior rectus muscle combined with medial rectus recession in patients with complete abducens nerve palsy

PURPOSE

To evaluate the outcomes of no-split, no-tenotomy transposition of only the superior rectus muscle combined with medial rectus recession in patients with complete abducens nerve palsy.

METHODS

In this procedure, the temporal margin of the superior rectus muscle, 10 mm posterior to the insertion, was secured with a nonabsorbable suture and sutured to the sclera at a distance of 12 mm from the limbus in the superotemporal quadrant, halfway between the superior rectus and lateral rectus. Success was defined as distance and near alignment of ≤8^Δ and no diplopia in primary position 6 months after surgery.

RESULTS

A total of 8 patients with abducens nerve palsy underwent the procedure. At the last follow-up, the mean postoperative change in primary position deviation was 42.6^Δ ± 8.1^Δ (range, 34^Δ-57^Δ) for distance and 42.1^Δ ± 7.5^Δ (35^Δ -57^Δ) for near, a significant reduction (P = 0.012). Abduction deficit also improved significantly (P = 0.010). Postoperatively, no vertical deviation or torsional diplopia was induced. At the 6 months' follow-up, compared with the first postoperative visit, an esodrift at near developed in 1 patient. Of the 8 cases, 6 fulfilled the criteria for success.

CONCLUSIONS

In our small study cohort, no-split, no-tenotomy superior rectus transposition and medial rectus recession improved esotropia and abduction limitation without inducing significant vertical deviations or torsional diplopia.

[Nishida Extraocular Muscle Transposition Surgery for Abducens Nerve Palsy]

BACKGROUND

Surgical treatment of abducens nerve palsy depends on the remaining function of the lateral rectus muscle. Vertical rectus transposition surgery is indicated if the attempted maximal abduction effort does not rotate the eye beyond the midline. After the first description more than 100 years ago, a variety of muscle transposition modifications have been suggested. Nishida's minimally-invasive adaptation has attracted a great deal of attention in recent years.

PATIENTS AND METHODS

Retrospective case series of four patients with abducens nerve palsy who were treated with Nishida muscle transposition surgery. Patients' characteristics with special emphasis on comparison between pre- and postoperative angle of deviation and ocular motility are reported.

RESULTS

Four patients (2 females, 2 males) were included in this study. Unilateral transposition surgery was performed in a 7-year-old girl and a 37-year-old woman with a left abducens nerve palsy. In a 56-year-old male with a left sixth nerve palsy and in an 82-year-old male with a right sixth nerve palsy the transposition maneuver was combined with a recession of the medial rectus muscle in the same eye. In all patients, ocular motility was improved and the angle of deviation was reduced.

CONCLUSIONS

Transposition of vertical rectus muscles is well established in the surgical treatment of abducens nerve palsy. Nishida's adaptation is a safe, effective and minimally-invasive treatment option. This vessel-sparing technique also allows for equilateral weakening of the medial rectus muscle.

Outcomes of modified vertical rectus belly transposition versus augmented superior rectus transposition for chronic abducens nerve palsy

PURPOSE

To compare the surgical outcomes of modified vertical rectus belly transposition (mVRBT) and medial rectus recession (MRc) versus augmented superior rectus transposition (aSRT) and MRc in Chinese patients with chronic abducens nerve palsy.

METHODS

The medical records of patients with chronic abducens nerve palsy who underwent mVRBT/MRc or aSRT/MRc were retrospectively reviewed. Pre- and postoperative deviation in primary position, pre- and postoperative abduction limitation, and complications were recorded. Follow-up was at least 6 months.

RESULTS

A total of 26 patients (mean age, 37.9 ± 19.6 years; 16 males [62%]) were included. Fourteen patients underwent mVRBT/MRc (mVRBT group) and 12 underwent aSRT/MRc (aSRT group). Both groups had similar amounts of recession (t = 0.27; P = 0.79). After surgery, statistically significant changes of abduction limitation and esotropia were observed (both P < 0.05). However, the difference in abduction improvement between groups was not statistically significant (mVRBT vs aSRT, 2.3 ± 0.91 vs 2.3 ± 0.97; t = 0.10, P = 0.92). Of the 19 patients who underwent unilateral surgery, preoperative esotropia was similar in both groups (t = 1.3; P = 0.21), but more esotropia was corrected in the mVRBT group than in the aSRT group (mVRBT vs aSRT, 57.8^Δ ± 14.3^Δ vs 44.6^Δ ± 9.8^Δ; t = 2.1; P = 0.047). There was no symptomatic vertical or torsional deviation.

CONCLUSIONS

In our patient cohort, mVRBT/MRc showed a better effect in correcting esotropia and a similar effect in improving abduction limitation compared with aSRT/MRc.