Different techniques have been used with varying success in third nerve palsy. Globe tethering technique is one treatment option. The authors describe a novel surgical technique in which permanent suture is used as a tethering agent associated with lateral rectus myectomy. Three patients underwent this technique. Horizontal alignment was satisfactory postoperatively.
From the Department of Ophthalmology, Farabi Eye Research Center, Tehran University of Medical Sciences, Tehran, Iran.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Masoud Aghsaei Fard, MD, Farabi Eye Research Center, Quazvin Sq., Tehran 1336616351, Iran. E-mail: firstname.lastname@example.org
Received: February 10, 2010
Accepted: May 12, 2010
Posted Online: August 23, 2010
Palsy of the oculomotor or third cranial nerve is a common cause of ophthalmoplegia. Management of oculomotor palsy is challenging because up to five extraocular muscles can be partially or completely involved. The patient suffers from large exotropia with hypotropia, accentuated on adduction.1 Different techniques, including globe tethering, have been used for treatment.2–8 The method presented in this article uses only one muscle and grants stabilization of alignment in primary position.
This study was performed with the agreement of our ethics committee, and methods complied with the Declaration of Helsinki. Informed consent was obtained from all patients or their guardians. Three patients were enrolled for this study.
Surgery was performed under general anesthesia in all patients by a single surgeon (AA).
After preparation and drape, forced duction test was performed. Positive test results showed lateral rectus contracture, which was present in all cases. Subsequently, a fornix-based peritomy was made on the temporal side. The lateral rectus muscle was identified, disinserted, and underwent myectomy up to 10 mm. Scleral reattachment was prevented by putting the cauterized muscle stump in the Tenon space. Then the orifice was cauterized. Conjunctiva was recessed as far as the lateral rectus insertion and closed with 8-0 polyglactin 910 suture. Subsequently, the nasal conjunctiva was given a fornix-based incision larger than usual and then pushed back. Sclera was exposed from medial rectus insertion to limbus. Two double-armed 5-0 polyester (Mersilene; Ethicon, Inc., Somerville, NJ) sutures passed through the more dense tissue under the caruncular tissue.
Meanwhile, the needle was checked to remain inside conjunctiva to prevent suture exposure. Other arms were sutured transiently to the sclera next to the superior and inferior insertion points of the medial rectus muscle and alignment was evaluated (Fig. 1). Intraoperative alignment was assessed with the corneal light reflex test. Because there seemed to be some residual deviation, insertion to sclera was shifted toward the limbus (but not less than 3 mm from the limbus) and tied transiently. The end point for intraoperative alignment was a small overcorrection (approximately 5 to 10 prism diopters) based on the eye position in the orbit.
Figure 1. Schematic Illustration of Globe Tethering Technique to Deep Caruncular Tissue. Two Double-Armed Sutures Passed from Sclera to Caruncular Area (Medial Fornix of the Right Eye).
Eventually, it was sutured permanently at this point, with filaments cut longer than usual and the ends directed under the medial rectus muscle to prevent possible exposure. For better attachment of conjunctiva to sclera, part of the subconjunctival Tenon capsule was removed and conjunctiva was repaired with 8-0 polyglactin 910 sutures following resection of extra conjunctiva. After surgery, the caruncule was inflamed and erythematous, which resolved in time.
A 6-year-old girl presented with right exotropia of 63 prism diopters, right hypertropia of 12 prism diopters, and complete ptosis from birth (Fig. 2A). Preoperative adduction, elevation, and depression were limited. Visual acuity was 20/200 in the right eye and 20/20 in the left eye. The pupils were briskly reactive to light and accommodation. On funduscopy, it appeared intorted. The diagnosis of right third nerve palsy was made and our technique was performed. In addition, superior oblique tendon was disinserted to correct hypotropia. The eye was slightly esotropic after the surgery. However, the long-term result (8 to 10 prism diopters of exotropia) with a follow-up of 24 months was acceptable (Fig. 2B).
Figure 2. (A) Preoperative Exotropia and Hypotropia in Primary Position in Case 1. (B) Postoperative Alignment in Primary Position in Case 1.
A 3-year-old girl was referred with a diagnosis of congenital right third nerve palsy. She had right exotropia of 50 prism diopters and right hypertropia of 8 prism diopters. Preoperative adduction, elevation, and depression were limited. Results of funduscopy were normal. We used the same surgical technique. Postoperative deviation was 4 prism diopters of exophoria. Follow-up was 18 months.
A 7-year-old boy presented with outward deviation of the right eye since birth. He had 45 prism diopters of right exotropia. Preoperative adduction, elevation, and depression were limited. There was a history of lensectomy 2 years previously and lateral rectus recession (5 mm) 1 year previously in the right eye. The left eye had ectopia lentis. Corrected visual acuity was 20/80 in the right eye and 20/25 in the left eye. After conjunctiva was incised, the previously recessed lateral rectus muscle was grasped and put inside the Tenon capsule following a 4-mm myectomy. Then we used globe tethering on the medial side. Postoperative deviation was 6 prism diopters of exophoria. Follow-up was 15 months.
Various methods have been developed for surgical management of third nerve palsy. In Scott’s method, the superior oblique tendon initially undergoes tenotomy at the medial border of the superior rectus muscle and is sutured to sclera 2 to 3 mm anterior to the medial end of the superior rectus insertion.2 Maruo et al. reported excellent results with this technique.3 However, that method might be associated with drawbacks of postoperative hypertropia in adduction or paradoxical ocular movements.4 Daniell et al. advocated a method involving extensive recession-resection with adducting suture.5
Tethering techniques have been used in severe paralytic strabismus. These techniques create a passive fixation of the globe to the periosteum. Fixation can be achieved by attaching the globe directly to an apically based periosteum flap or indirectly with silicon, temporalis fascia, or fascia lata.6–8
In our method, we used the globe tethering technique as a passive fixation of the globe to deep caruncular tissue instead of periosteum with permanent suture. This method was performed on three patients with a 15- to 24-month follow-up period. Horizontal alignment in the primary position was satisfactory during the follow-up. Because surgery only involved one muscle, there was lower risk of anterior segment ischemia and shorter duration of anesthesia was required. Moreover, the procedure was rapid, easy, and safe because it involved minimal eye manipulation.
There are some points worth mentioning. First, the temporal incision of conjunctiva for the lateral rectus muscle procedure must be larger than usual because the cul-de-sac is smaller on the temporal side and the conjunctiva needs to be recessed; otherwise, mechanical effects will hinder correction. Second, in one of our patients, part of the polyester suture was visible under conjunctiva and caused discomfort. Therefore, the suture length was changed to approximately 10 mm in the other patients. The cut suture could be inserted to the underlying tissue without being visible under the conjunctiva. Therefore, we were not concerned about the possible extrusion or exposure of nonabsorbable suture close to the limbus.
Although the early results were successful with this technique, there might be a tendency for eye drift with time. Therefore, long-term follow-up is necessary.
- Malcolm LM. Third cranial nerve palsy: diagnosis and management strategies. In: Rosenbaum AL, Santiago AP, ed. Clinical Strabismus Management: Principles and Surgical Techniques. Philadelphia: W. B. Saunders; 1999:251–258.
- Scott AB. Transposition of superior oblique. Am Orthoptic J. 1977;27:11–14.
- Maruo T, Iwashige H, Kubota N, et al. Results of surgery for paralytic exotropia due to oculomotor palsy. Ophthalmologica. 1996;210:163–167. doi:10.1159/000310699 [CrossRef]
- Saunders RA, Rogers GL. Superior oblique transposition for third nerve palsy. Ophthalmology. 1982;89:310–316.
- Daniell MD, Gregson RM, Lee JP. Management of fixed divergent squint in third nerve palsy using traction sutures. Aust N Z J Ophthalmol. 1996;24:261–265. doi:10.1111/j.1442-9071.1996.tb01590.x [CrossRef]
- Goldberg RA, Rosenbaum AL, Tong JT. Use of apically based periosteal flaps as globe tethers in severe paretic strabismus. Arch Ophthalmol. 2000;118:431–437.
- Awad AH, Shin GS, Rosenbaum AL, Goldberg RL. Autogenous fascia augmentation of a partially extirpated muscle with a subperiosteal medial orbitotomy approach. J AAPOS. 1997;1:138–142. doi:10.1016/S1091-8531(97)90054-9 [CrossRef]
- Salazar-Leon JA, Ramirez-Ortiz MA, Salas-Vargas M. The surgical correction of paralytic strabismus using fascia lata. J Pediatr Ophthalmol Strabismus. 1998;35:27–32.