Journal of Pediatric Ophthalmology and Strabismus

Original Article 

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

Ibrahim Erbagci, MD; Veysi Öner, MD; Erol Coskun, MD; Seydi Okumus, MD

Abstract

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.]

Abstract

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.]

Introduction

The oculomotor nerve provides innervations of the levator palpebrae superior, superior rectus, medial rectus, inferior rectus, and inferior oblique muscles. Total paralysis of the oculomotor nerve causes the acting of lateral rectus and superior oblique muscles with no antagonist. Accordingly, the eye is fixed in an abducted, rather depressed and intorted position with minimal movement. There is an obvious limitation of elevation, depression, and adduction, commonly with contracture of the lateral rectus muscle.1 In addition, ptosis occurs in most patients due to paralysis of the levator palpebra superior muscle.

Surgical treatment of total oculomotor nerve palsy is demanding for strabismus surgeons. The aim of the surgery is to reach a satisfactory alignment in primary position with restricted ocular movements. Conventional recession-resection procedures have little or no effect.2 Therefore, several other methods, such as temporal mattress suture,3 fixation of the eye to the medial orbital wall with a silicon band or a fragment of fascia lata,4,5 disinserting the lateral rectus muscle from the globe and reattaching it to the lateral orbital periosteum,6,7 and excision of a main section of lateral rectus muscle,8 have been reported. However, most of them were complicated and invasive techniques with variable long-term successes. Recently, Gokyigit et al.9 suggested a modification of a surgical procedure that was first developed by Kaufmann10 and found favorable outcomes with this procedure. In Gokyigit et al.'s method,9 the lateral rectus muscle was split into two halves: the superior half was passed under the superior rectus and superior oblique muscles and the inferior half was passed under the inferior rectus and inferior oblique muscles (between the sclera and both the inferior rectus and inferior oblique muscles), and then the ends of the two halves were attached to the medial rectus muscle insertion area.

In the current study, we aimed to evaluate the results of a surgical method that is a modification of Gokyigit et al.'s9 and Kauffman's10 procedures in patients with chronic total oculomotor nerve palsy. In this technique (Gaziantep's modification), the superior and inferior halves of the split lateral rectus muscle were passed under the superior and inferior rectus muscles, respectively, and were then attached near the medial rectus muscle insertion.

Patients and Methods

Eight eyes of 6 consecutive patients who underwent strabismus surgery due to chronic total oculomotor nerve palsy at Gaziantep University Medical School Ophthalmology Department were enrolled in the study. The diagnosis of total oculomotor nerve palsy was made according to dysfunction of the medial rectus, superior rectus, inferior rectus, and inferior oblique muscles, a dilated pupil, and presence of ptosis. Patients with incomplete oculomotor nerve palsy, a previous history of strabismus surgery, and other causes of limited ocular motility were excluded from the study. All patients and parents of pediatric patients were informed about the study procedure and they consented to participate. The study was in accordance with the tenets of the Declaration of Helsinki and was approved by the Gaziantep University Medical School Ethics Committee.

Each patient underwent preoperative and postoperative comprehensive examinations, including measurement of refraction and visual acuity, strabismus examination, ocular motility evaluation, and funduscopy. The assessment of deviation was performed by prism cover or Krimsky test. The presence of diplopia or fusion was evaluated by Worth 4-dot test. Limitation of ocular ductions and forced ductions were scored on a scale from −1 to −5; −4 corresponding to no movement beyond the mid-line and −5 corresponding to failure of moving to midline. Each patient underwent surgery at least 6 months after the initiation of oculomotor nerve palsy. The postoperative follow-up visits were performed at week 1, months 1, 2, 3, and 6, and every 6 months thereafter.

Surgical Procedure

All surgeries were performed by a single experienced strabismus surgeon (IE) under general anesthesia. After making an approximately 300° conjunctival limbal peritomy, the lateral rectus muscle was found. The muscle was split into two halves. After suturing with a 6-0 nonabsorbable polyester suture, the muscle was disinserted from the sclera. Then 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 and were sutured to sclera near the insertion. In 2 patients, additional medial rectus resections were performed after the primary surgery, due to undercorrection.

Statistical Analysis

SPSS for Windows software (version 16.00; SPSS, Inc., Chicago, IL) was used for statistical analyses. Preoperative and final visit strabismus measurements were compared by using paired t tests. A P value of less than .05 was considered statistically significant.

Results

The mean age of the patients was 21.8 ± 12.1 years (range: 11 to 42 years). There were 2 females and 4 males in the study population. All cases had acquired total oculomotor nerve palsy caused by trauma. The follow-up period ranged from 6 to 24 months.

In the second month after the primary surgery, 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 resection procedures were performed in these undercorrected patients and horizontal deviations reduced to 15 and 20 PD of exotropia, respectively. Figures 12 show the preoperative and postoperative photographs of patients.


Preoperative (top) and postoperative (bottom) five gaze ocular motility of a patient who underwent medial transposition of split lateral rectus muscle surgery due to chronic total oculomotor nerve palsy in the left eye.

Figure 1.

Preoperative (top) and postoperative (bottom) five gaze ocular motility of a patient who underwent medial transposition of split lateral rectus muscle surgery due to chronic total oculomotor nerve palsy in the left eye.


Preoperative (left) and postoperative (right) primary position ocular alignment of a patient who underwent medial transposition of split lateral rectus muscle surgery due to bilateral chronic total oculomotor nerve palsy.

Figure 2.

Preoperative (left) and postoperative (right) primary position ocular alignment of a patient who underwent medial transposition of split lateral rectus muscle surgery due to bilateral chronic total oculomotor nerve palsy.

The mean horizontal deviation was 74.1 ± 10.2 PD (range: 60 to 90 PD of exotropia) in primary position before the surgery. After the operations, including only the medial transposition of split lateral rectus muscle (primary surgery) in 4 patients and additional medial rectus resections after the primary surgery in 2 patients, the mean horizontal ocular deviation of primary position significantly decreased to 10.8 ± 6.6 PD (range: 10 PD of esotropia to 20 PD of exotropia) (P < .001). On the other hand, the adduction, depression, and elevation of the affected eyes were still limited and abduction was limited in all study eyes. The demographic and clinical characteristics of the patients are given in Table 1.


Demographic and Clinical Parameters of Patients

Table 1:

Demographic and Clinical Parameters of Patients

We did not observe any intraoperative or postoperative complications related to the primary or secondary surgeries. Four of 6 cases had no diplopia in the primary position or abnormal head posture during the postoperative follow-up period. One case had diplopia in primary position and abnormal head posture in the first postoperative month, but these problems resolved spontaneously in the second month. However, 1 case had persistent diplopia in the primary position after the surgery.

Discussion

The surgical options for the management of large-angle strabismus in patients with total oculomotor nerve palsy are limited due to the fact that all extraocular muscles except for the superior oblique and lateral rectus muscles are paralyzed. Weakening of the lateral rectus muscle by incomplete excision has been ineffective.8 Attaching a silicon elastic band between the medial rectus muscle insertion and the orbital rim has also been suggested.4 This procedure has some disadvantages, including difficulties with the appropriate band choice, the presence of a foreign body inside the orbital cavity, and being inappropriate in pediatric patients whose orbits are continuing to develop. Salazar-León et al.11 suggested fixing the eye globe to the nasal periosteum by using fascia lata. Although this method has satisfactory postoperative outcomes, it is invasive and time-consuming. Additionally, it is inappropriate for small children whose facia lata and orbits are not completely grown. Khaier et al.12 showed that large lateral rectus recession and medial rectus resection combined with muscle traction sutures had favorable results in patients with long-standing exotropia secondary to oculomotor nerve palsy. However, suture-related complications such as conjunctival hypertrophy, infection, and cheese wiring occurred. Tenotomy and medial reinsertion of the superior oblique muscle tendon was also used in the treatment of oculomotor nerve palsy,13–15 although it caused hypertropia in some cases.13,14

Nasal transposition of the lateral rectus muscle by passing the muscle under the superior rectus muscle was first suggested by Taylor.16 It is a simple and relatively short procedure that can be performed on patients of any age. Gräf and Lorenz17 used the nasal transposition of the integral lateral rectus muscle in 3 patients with oculomotor palsy. They found that although the procedure caused a decrease in the exotropia and hypertropia, it resulted in an increase in the incyclotropia. Kauffmann10 modified this technique by splitting the lateral rectus muscle into two halves and moving these halves to the retroequatorial area, near the nasal vortex veins. The upper half was passed under the superior rectus muscle and the lower half was passed under the inferior rectus muscle. After the procedure, there were still 10° to 15° deviation and 10° to 20° head positions in patients. Gokyigit et al.9 reported more successful outcomes by modifying Kauffman's procedure. In Gokyigit et al.'s method,9 the halves of the split lateral rectus muscle were attached to the medial rectus insertion area instead of the vortex veins area. In addition, unlike Kauffman's method, the superior half passed under the superior rectus and superior oblique muscles. Gokyigit et al.'s procedure9 had the advantage of decreasing the risk of hemorrhage related to vortex vein injury and the risk of globe perforation, in addition to more satisfactory outcomes.

In the current study, we used a modified technique of Kauffman's10 and Gokyigit et al.'s9 procedures. Similar to Gokyigit et al.'s procedure,9 we attached the ends of the halves of split lateral rectus muscle near the insertion of medial rectus muscle. On the other hand, similar to Kauffman's method we passed the upper half of the lateral rectus muscle under the superior rectus muscle and passed the lower half of the lateral rectus under the inferior rectus muscle. Our procedure has all of the advantages of Gokyigit et al.'s procedure9 without the disadvantages of the aforementioned studies. Further, it is an easier and shorter method due to the fact that passing the piece of lateral rectus muscle under the superior oblique muscle requires a thorough knowledge of anatomy, extensive experience, and additional time. In addition, it can be speculated that passing the split lateral rectus muscle under the superior oblique muscle, which is not paralytic and acts with no antagonist, may tighten this muscle and increase the small intorsional or vertical components of the deviation. However, this could not be proven without a control group, using Gokyigit et al.'s or Kauffman's procedures for comparison. Small sample size and lack of a control group were the main limitations of the current study.

In the current study, 4 of 6 cases had large angle exotropia without any vertical component. However, 2 cases had additional hypotropia (10 and 15 PD) that resolved completely in 1 case but remained unchanged in the other case (Table 1). Our procedure and Gokyigit et al.'s procedure9 also had favorable effects on vertical deviations in some patients. We believe that this might be achieved by fixing the globe with minimal movements in the primary position.

We have 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 including comparisons of different procedures are warranted.

References

  1. Yonghong J, Kanxing Z, Wei L, Xiao W, Jinghui W, Fanghua Z. Surgical management of large-angle incomitant strabismus in patients with oculomotor nerve palsy. J AAPOS. 2008;12:49–53. doi:10.1016/j.jaapos.2007.07.008 [CrossRef]
  2. Metz HS. 20th Annual Frank Costanbader Lecture: muscle transposition surgery. J Pediatr Ophthalmol Strabismus. 1993;30:346–353.
  3. Callahan A. The arrangement of the conjunctiva in surgery for oculomotor paralysis and strabismus. Arch Ophthalmol. 1961;66:241–246. doi:10.1001/archopht.1961.00960010243016 [CrossRef]
  4. Bicas HE. A surgically implanted elastic band to restore paralyzed ocular rotations. J Pediatr Ophthalmol Strabismus. 1991;28:10–13.
  5. Salazar-León JA, Ramírez-Ortíz MA, Salas-Vargas M. The surgical correction of paralytic strabismus using fascia lata. J Pediatr Ophthalmol Strabismus. 1998;35:27–32.
  6. Velez FG, Thacker N, Britt MT, Alcorn D, Foster RS, Rosenbaum AL. Rectus muscle orbital wall fixation: a reversible profound weakening procedure. J AAPOS. 2004;8:473–480. doi:10.1016/j.jaapos.2004.06.011 [CrossRef]
  7. Morad Y, Kowal L, Scott AB. Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall. Br J Ophthalmol. 2005;89:983–985. doi:10.1136/bjo.2004.051219 [CrossRef]
  8. Sato M, Maeda M, Ohmura T, Miyazaki Y. Myectomy of lateral rectus muscle for third nerve palsy. Jpn J Ophthalmol. 2000;44:555–558. doi:10.1016/S0021-5155(00)00212-4 [CrossRef]
  9. Gokyigit B, Akar S, Satana B, Demirok A, Yilmaz OF. Medial transposition of a split lateral rectus muscle for complete oculomotor nerve palsy. J AAPOS. 2013;17:402–410. doi:10.1016/j.jaapos.2013.05.007 [CrossRef]
  10. Kaufmann H. “Lateralis splitting” in total oculomotor paralysis with trochlear nerve paralysis. Fortschr Ophthalmol. 1991;88:314–316.
  11. Salazar-León JA, Ramírez-Ortíz MA, Salas-Vargas M. The surgical correction of paralytic strabismus using fascia lata. J Pediatr Ophthalmol Strabismus. 1998;35:27–32.
  12. Khaier A, Dawson E, Lee J. Traction sutures in the management of long-standing third nerve palsy. Strabismus. 2008;16:77–83. doi:10.1080/09273970802077474 [CrossRef]
  13. Scott AB. Transposition of the superior oblique. Am Orthopt J. 1977;27:11–14.
  14. Saunders RA, Rogers GL. Superior oblique transposition for third nerve palsy. Ophthalmology. 1982;89:310–316. doi:10.1016/S0161-6420(82)34786-7 [CrossRef]
  15. Yonghong J, Kanxing Z, Wei L, Xiao W, Jinghui W, Fanghua Z. Surgical management of large-angle incomitant strabismus in patients with oculomotor nerve palsy. J AAPOS. 2008;12:49–53. doi:10.1016/j.jaapos.2007.07.008 [CrossRef]
  16. Taylor JN. Surgical management of oculomotor nerve palsy with lateral rectus transplantation to the medial side of the globe. Aust NZ J Ophthalmol. 1989;17:27–31. doi:10.1111/j.1442-9071.1989.tb00486.x [CrossRef]
  17. Gräf M, Lorenz B. Inferior nasal transposition of the lateral rectus muscle for third nerve palsy [article in German]. Klin Monbl Augenheilkd. 2010;227:804–808. doi:10.1055/s-0029-1245737 [CrossRef]

Demographic and Clinical Parameters of Patients

PatientAge (y)/GenderLateralityPreoperative Deviation (PD)Preoperative DuctionsSurgery ProcedureFinal Deviation (PD)Final Ductions




HorizontalHOTHTAbdaAddaHorizontalHOTHTAbdaAdda
127/MBlt90 XT000−5/5MT of split LROrtho00−4/−4−4/−4
213/FBlt80 XT000−5/5MT of split LR + resection of MR20 XT00−4/−4−4/−4
342/MLeft75 XT1500−4MT of split LR10 ET00−4−2
412/FLeft70 XT000−5MT of split LR10 XT00−4−4
511/MLeft60 XT1000−5MT of split LR + resection of MR10 XT100−4−3
626/MRight70 XT000−5MT of split LR10 XT00−4−4
Authors

From Gaziantep University Medical School, Ophthalmology Department, Gaziantep, Turkey (IE, EC, SO); and Recep Tayyip Erdogan University Medical School, Ophthalmology Department, Rize, Turkey (VÖ).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Veysi Öner, MD, Recep Tayyip Erdogan University Medical School, Department of Ophthalmology, Sehitler cad. No: 1, 53200, Rize, Turkey. E-mail: veysioner@gmail.com

Received: April 07, 2015
Accepted: January 21, 2016

10.3928/01913913-20160405-02

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