Medial rectus disinsertion for management of chronic complete sixth nerve palsy

Abstract

Purpose

To report the outcomes of the medial rectus (MR) disinsertion procedure for the management of refractory esotropia (ET) with or without Abnormal head posture (AHP) in chronic complete sixth nerve palsy.

Methods

This is a retrospective case series of patients with sixth nerve palsy who suffered from residual ET and diplopia following the conventional strabismus surgeries and underwent MR disinsertion procedure between April 2017 and February 2020. This procedure was offered to the patients who declined to use prism and did not wish to perform surgery on the fellow eye. The demographic and clinical data, including sex, age, visual acuity, pre and postoperative angle of strabismus, duction limitations, results of forced duction and force generation tests, details of prior strabismus surgeries, orbital CT scan findings, and follow up duration were collected from the medical records.

Results

Six patients were enrolled in this study. Mean age was 35.0 ± 14.0 years, and mean follow-up was 15.3 ± 5.9 months. The ET at the Primary position (PP) was 35.0 ± 18.4 prism dioptre (PD) before MR disinsertion, which decreased to 14.2 ± 17.4 PD after MR disinsertion procedure. Four cases needed additional complementary surgeries to improve residual ET in PP. No case developed overcorrection. Abduction deficiency was −5.0 ± 1.3 before MR disinsertion, which improved to − 2.8 ± 0.5 units at last follow-up. The mean of induced adduction deficiency was − 2.9 ± 0.4 at last follow-up.

Conclusions

MR disinsertion can be considered in patients with chronic complete sixth nerve palsy and refractory diplopia when the conventional methods have failed.

Keywords

esotropia muscle disinsertion medial rectus muscle sixth nerve palsy strabismus

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References

Riordan-Eva

Lee

. Management of VIth nerve palsy—avoiding unnecessary surgery. Eye 1992; 6: 386–390.

Akbari

Shomali

Mirmohammadsadeghi

, et al. Augmented superior rectus transposition procedure in duane retraction syndrome compared with sixth nerve palsy. Graefes Arch Clin Exp Ophthalmol 2018; 256: 983–987.

Velez

Chang

Pineles

. Inferior rectus transposition: a novel procedure for abducens palsy. Am J Ophthalmol 2017; 177: 126–130.

Akar

Gokyigit

Pekel

, et al. Vertical muscle transposition augmented with lateral fixation (Foster) suture for duane syndrome and sixth nerve palsy. Eye 2013; 27: 1188–1195.

Bagheri

Veisi

Tavakoli

. Hummelsheim procedure combined with medial rectus recession in complete sixth nerve palsy and esotropic duane retraction syndrome. Eur J Ophthalmol 2020; NOV(23): 1120672120973612.

Wuthisiri

Surukratanaskul

Lekskul

. The surgical outcome of partial vertical rectus muscle transpositions (jensen procedure) combined with ipsilateral medial Rectus recessionin complete sixth nerve palsy at ramathibodi hospital. Ramathibodi Med J 2018; 41: 42–49.

Bagheri

Feizi

Sahebghalam

, et al. Lateral Rectus–medial rectus union: a new surgical technique for treatment of complete third nerve palsy. J Pediatr Ophthalmol Strabismus 2019; 56: 10–18.

Scott

Kraft

. Botulinum toxin injection in the management of lateral rectus paresis. Ophthalmology 1985; 92: 676–683.

Couser

Lenhart

Hutchinson

. Augmented hummelsheim procedure to treat complete abducens nerve palsy. J AAPOS 2012; 16: 331–335.

10.

Hong

Chang

Y-H

Han

S-H

, et al. Effect of full tendon transposition augmented with posterior intermuscular suture for paralytic strabismus. Am J Ophthalmol 2005; 140: 477.e1–477.e9.

11.

Nabie

Andalib

. Augmented vertical recti transposition with intraoperative botulinum toxin for complete and chronic sixth nerve palsy. Eye 2017; 31: 148–151.

12.

McPhee

Dyer

Ilstrup

. Marginal myotomy of the medial rectus with lateral rectus resection as a secondary procedure for esotropia. Graefes Arch Clin Exp Ophthalmol 1988; 226: 197–200.

13.

Zak

Morin

. Surgery of infantile esotropia: a critical evaluation of marginal myotomy of the medial recti as a primary and secondary procedure. J Pediatr Ophthalmol Strabismus 1983; 20: 52.

14.

Wang

L-H

. Surgical treatment for residual or recurrent strabismus. Int J Ophthalmol 2014; 7: 1056–1063.

15.

Kinori

Miller

Cochran

, et al. Plication augmentation of the modified hummelsheim procedure for treatment of large-angle esotropia due to abducens nerve palsy and type 1 duane syndrome. J AAPOS 2015; 19: 311–315.

16.

Inal

Gokyigit

Ocak

, et al. Vertical rectus muscle union combined with lateral rectus plication for complete abducens nerve palsy. Int Ophthalmol 2020; 40: 423–429.

17.

Currie

Feibel

. Early American strabismus surgery: 1840–1845. Strabismus 2015; 23: 182–190.

18.

Liao

Wei

Chuang

. The role of rectus muscle myectomy in the management of large-angle strabismus for Graves’ ophthalmopathy. Eye 2017; 31: 1027.

19.

Morad

Kowal

Scott

. Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall. Br J Ophthalmol 2005; 89: 983–985.

20.

Velez

Thacker

Britt

, et al. Rectus muscle orbital wall fixation: a reversible profound weakening procedure. J AAPOS 2004; 8: 473–480.

21.

Shih

M-H

M-L

Huang

F-C

. A preequatorial Gore-Tex sling to restore rectus muscle pathways in myopic strabismus fixus. J AAPOS 2012; 16: 80–82.

22.

Murthy

. Lateral fixation of sclera to the periosteum with medial rectus disinsertion for severe myopic strabismus fixus. Indian J Ophthalmol 2008; 56: 419.

23.

Choe

C-U

Kim

S-D

Kim

J-D

. A case of surgical repair for convergent strabismus fixus with bilateral abducens nerve palsy. J Korean Ophthalmological Soc 2006; 47: 1708–1712.

24.

Hakim

El-Hag

Maher

. Persistence of eye movement following disinsertion of extraocular muscle. J AAPOS 2008; 12: 62–65.

25.

Serafino

Granet

Kushner

, et al. Definition of successful outcomes after surgery for each type of strabismus: a delphi study. J AAPOS 2021 Feb; 25: 3.e1–3.e5.