Transactions 29th European Strabismological Association Meeting – de Faber (ed) © 2005 European Strabismological Association, ISBN 04 1537 211 9

Surgical management of complete oculomotor nerve palsy

N. Sefi Yurdakul, S. Ugurlu & A. Maden

.

Atatürk Education and Research Hospital, Izmir, Turkey

ABSTRACT:

Purpose: To assess the effectiveness of horizontal muscle surgery in association with adducting traction suture in the management of complete oculomotor nerve palsy.

Methods: Large recession of the lateral rectus muscle with hemi-hangback suture, large resection of the medial rectus muscle and adducting traction suture were applied to all patients. For vertical deviation, insertions of the medial and lateral rectus muscles were transposed superiorly. The resultant deviation at primary position was evaluated.

Results: Five patients with a median age of 12 years (6–25 years) were evaluated. The median preoperative horizontal deviation was 65 prism diopters (PD), and vertical deviation was 10 PD. At the last visit, median horizontal deviation was 10 PD, and vertical deviation was 4 PD.

Conclusion: Large recession with loop suture and resection of horizontal muscles combined with adducting traction sutures is a safe and effective procedure in the management of complete oculomotor nerve palsy.

1INTRODUCTION

In complete oculomotor nerve palsy, the eye becomes fixed in a position of abduction, slight depression and intorsion because of unopposed action of the lateral recti and superior oblique muscles. The palsy of the levator palpebrae muscle results in ptosis. The palsy of intrinsic muscles of the eye causes dilatation of the pupil and a palsy of accomodation. The surgical management of this condition presents a formidable challenge and the therapeutic possibilities are limited. The goal of surgery in complete third nerve palsy is to align the paralytic eye in primary gaze (von Noorden & Campos 2002). Various surgical procedures have been described to achieved this goal (Scott 1977, Sato et al. 2000, Kose et al. 2001).

In the current study, the effectiveness of horizontal muscle surgery in association with adducting traction suture in the management of complete oculomotor nerve palsy was assessed.

2MATERIAL AND METHODS

Consecutive patients with complete oculomotor nerve palsy who presented to the division of Strabismus and Neuroophthalmology between April 2001 and June 2003 were included in the study. After a complete ophthalmic examination preoperative ocular motility was evaluated. The degree of ocular deviation was assessed by means of the prism cover test. The functions of the ciliary muscle, spinchter pupilla and levator palpebrae were established.

Surgery was performed under general anesthesia. All of the surgical procedures were done on the muscles of the paralytic eye. Limbal conjunctival incision was used for all patients. The lateral rectus muscles were recessed 10 mm from the original insertion with a 4 mm hemi-hangback loop suture. Large resection of the medial rectus muscle (8 mm) was performed. For vertical deviation correction, insertions of the medial and lateral rectus muscles were transposed superiorly according to

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Figure 1. Preoperative appearance of a patient with congenital oculomotor nerve palsy at primary position (left), immediate postoperative appearance after simultaneous strabismus and ptosis surgery with adducting traction suture in place (middle) and postoperative 6th month appearance (right).

amount of deviation. At the completion of the surgery, traction sutures (5-0 Dacron) were passed through limbal scleral tissue and then passed through the extreme medial canthal area. Sutures were tied over tarsorrhaphy bolsters and left in place for at least four weeks (Figure 1). All patients underwent frontalis suspension surgery either simultaneously or following strabismus surgery. Prospective analysis of the resultant deviation at primary position and patient satisfaction were evaluated at 1st, 3rd, 6th, 12th and 24th months.

3RESULTS

Five patients with a median age of 12 years (range, 6–25 years) were evaluated. Two patients were female, three patients were male. Four patients had unilateral congenital palsy, and one patient had acquired unilateral palsy secondary to an intracranial mass. No patient demonstrated apparent medial rectus muscle function. All five patients had functioning superior oblique and lateral recti muscles, and had ptosis in the involved eyes. The pupils of the patients were dilated and unresponsive to light.

The median preoperative horizontal deviation was 65 prism diopters (PD) (range, 50–85 PD), and vertical deviation was 10 PD (range, 6–18 PD). Median time of limbal traction suture application was 5 week (range, 4–6 weeks). The median follow-up period was 12 months (range, 6–24 months). At the last visit, median horizontal deviation was 10 PD (range, 6–16 PD), and vertical deviation was 4 PD (range, 0–8 PD). Satisfaction with final outcome was rated to be excellent by all patients. None of the patients complained and demanded removal of traction sutures.

4DISCUSSION

Surgical management of complete third nerve palsy is difficult and multiple procedures are often needed to maintain good ocular alignment (Schumacher-Feero et al. 1999). Most authors advocate superior oblique tenotomy and transposition procedures combined with a horizontal recession and resection in the treatment of complete third nerve palsy (Scott 1977, Gottlob et al. 1991, Lee et al. 2001), and report cosmetically satisfactory long term results. Athough superior oblique tendon transposition may be helpful in complete oculomotor nerve palsy with no residual medial rectus function (Gottlob et al. 1991), the procedure is technically difficult and inadequate horizontal alignment, hypertropias or paradoxic ocular movements are possible.

The concept of use of traction sutures in management of oculomotor palsy is not new. Daniell et al. (1996) reported satisfactory results using adducting traction sutures in 24 patients with fixed divergent squint secondary to long-standing oculomotor nerve palsy. They combined a supramaximal horizontal resection/recession procedure, and left the sutures in situ for 6 weeks. They achieved good cosmetic position in all but two patients. Lee et al. (2001) performed horizontal recti resection/recession, supra-placement of the insertions, superior oblique weakening and traction sutures in 7 congenital third nerve palsy patients, and reported reasonable cosmesis. The current study involved a similar

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approach with the above studies with the exception of combined use of the loop suture technique and the traction sutures. The median preoperative horizontal deviation of 65 PD (range, 50–85 PD) was reduced to 10 PD (range, 6–16 PD) at the last follow-up visit. We believe the combined use of traction suture along with loop suture technique might have promoted the effect of supramaximal recession by preventing the re-attachment of lateral rectus anteriorly. Although this concept needs to be validated, Sato et al. (2000) was able to demonstrate the re-attachment of lateral rectus muscle through a fibrous tissue after complete myectomy (without suturing to the globe) in a patient with complete third nerve palsy by magnetic resonance imaging. Hence, it is reasonable to assume that one may achieve a more controlled attachment of lateral rectus muscle by allowing the rectus muscle to hang back in a controlled fashion and applying traction to keep the eye in adduction so as to obtain a new insertion behind the equator.

Correction of vertical deviation secondary to oculomotor palsy may be achieved by the use of superior oblique transposition, inferior rectus recession or transposition of insertions of horizontal recti superiorly. In the current study, surgery of superior oblique muscle was avoided. Insertions of the medial and lateral rectus muscles were transposed superiorly according to amount of deviation, and the median vertical deviation was 4 PD (range, 0–8 PD) at the last visit. With this approach normal function of the superior oblique muscle was preserved and the option of transposition of superior oblique muscle in case of a failed surgical result was kept possible.

Overall satisfaction with final outcome was rated to be excellent by all patients, and no patient was willing to be reoperated for the residual deviation. None of our patients complained of intractable diplopia.

5CONCLUSION

Establishment of ocular alignment in complete oculomotor nerve palsy is a challenging task. Large recession with loop suture and resection of horizontal muscles combined with adducting traction sutures appears to be a safe and effective procedure in reaching this goal.

REFERENCES

Daniell MD, Gregson RM & Lee JP. 1996. Management of fixed divergent squint in third nerve palsy using traction sutures. Aust N Z J Ophthalmol 24: 261–265.

Gottlob I, Catalano RA & Reinecke RD. 1991. Surgical management of oculomotor nerve palsy. Am J Ophthalmol 111: 71–76.

Kose S, Uretmen O & Pamukcu K. 2001. An approach to the surgical management of total oculomotor nerve palsy. Strabismus 9: 1–8.

Lee V, Bentley CR & Lee JP. 2001. Strabismus surgery in congenital third nerve palsy. Strabismus 9: 91–99. Noorden GK von & Campos EC. 2002. Paralytic strabismus. In Binocular vision and ocular motility. Theory

and management of strabismus. 6th ed. St. Louis: Mosby: 414–457.

Scott AB. 1977. Transposition of the superior oblique. Am J Orthop 27: 11–14.

Schumacher-Feero LA, Yoo KW, Solari FM & Biglan AW. 1999. Third cranial nerve palsy in children. Am J Ophthalmol 128: 216–221.

Sato M, Maeda M, Ohmura T & Miyazaki Y. 2000. Myectomy of lateral rectus muscle for third nerve palsy. Jpn J Ophthalmol 44: 555–558.

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