Early Onset Sixth-Nerve Palsy with Eccentric Fixation

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Intrroduction Sixth nerve palsy is the most common type of extraocular muscle palsy. The therapy options in sixth nerve palsies include monitoring with or without conservative treatment, botulinum toxin injections or strabismus surgery. The aim of this retrospective study was to compare botulinum toxin (BT) injections into the medial rectus to conservative treatment in sixth nerve palsies. The rate of patients improved after intervention and treatment outcomes for the two treatment options were be evaluated at a German tertiary referral center. Methods A service evaluation was conducted on adult patients with sixth nerve palsy. Patient files were reviewed and data including abduction deficit and size of deviation were collected retrospectively. Patients which presented between January 1987 and April 2022 were considered. Patients were allocated into two treatment groups: BT injected into medial rectus or conservative treatment, which included observation, providing occlusion and Fresnel prisms. Inclusion criteria were attendance of two visits with orthoptic assessment. Exclusion criteria included presence of further oculomotor palsies, strabismus, strabismus surgery and suppression. Non-parametric statistical analysis was conducted using IBM® SPSS Statistics. Results A total of 606 adult patients with unilateral or bilateral sixth nerve palsy attended during the named period. A total of 137 adult patients met the inclusion criteria. Of which, 36 had a bilateral palsy, 101 had a unilateral palsy. 45.26% (n = 62) were treated with BT injections and 54.75% (n = 75) were treated conservatively. The median initial abduction deficit was greater in the BT group, (−4 to −5 after Scott and Kraft) than in the conservative treatment group (−1). The initial angle of deviation at distance was significantly larger in the BT group than in the conservative treatment group (p = <0.001). The rate of improvement in the BT group was 24.19% (n = 15) and 20% (n = 15) in the conservative treatment group. When excluding longstanding palsies rates of improvement in both groups increased to 28.85%. The improvement of the angle of deviation at distance in all patients was greater in the BT group (p = <.001). The improvement of abduction in bilateral palsies were greater in the BT group (p = .016), but in unilateral palsies, there was no significant difference in abduction improvement in the two treatment groups (OD p = .3, OS p = .406). Conclusion This service evaluation found that BT injection into medial rectus in unilateral and bilateral sixth nerve palsies did not increase the rate of improvement compared to conservative treatment. But BT injections reduced the angle of deviation to a greater extent than conservative treatment. Additionally, BT was able to improve abduction in bilateral palsies to a greater extent than conservative treatment. It is recommended a BT injection is considered in symptomatic bilateral sixth nerve palsies to enable fixation and improved ocular motility. More research is needed to verify reliable clinical guidelines for the use of BT in sixth nerve palsies.

Unilateral medial rectus recession is a treatment option to surgically correct consecutive esotropia. This study evaluated the surgical outcomes of patients who underwent unilateral medial rectus recession for the treatment of consecutive esotropia after surgery for intermittent exotropia. The medical records of 16 patients who underwent surgical correction of consecutive esotropia with unilateral medial rectus recession were retrospectively reviewed. Patients with intermittent exotropia who were previously treated with one or multiple surgical procedures (8 bilateral lateral rectus recession, 7 recess-resect procedure, or 1 bilateral medial rectus resection) were included in the study. Three patients were adults and 13 patients were children. The mean age was 5 years for children and 50.3 years for adults. Consecutive esotropia was defined as residual manifest esodeviation of 10 prism diopters (PD) at 6 months postoperatively. Successful correction of consecutive esotropia was defined as the lack of manifest or intermittent tropia and esophoria/exophoria within 8 PD. Patients with monofixational exotropia were excluded from the study. Unilateral medial rectus recession was successful in the correction of consecutive esotropia in 10 of 16 cases (62.5%). Six of 16 (37.5%) patients had unsatisfactory postoperative alignment, with 5 patients showing recurrence of exotropia. Only one patient was undercorrected. The success rate of surgical correction of consecutive esotropia with single muscle surgery was good. Recurrence of exotropia accounted for most of the failures, and all recurrences occurred in the group of patients initially treated surgically for intermittent exotropia with a recess-resect procedure.

Purpose: To compare the effect of bilateral medial rectus injection of botulinum toxin A (BTX-A), bilateral medial rectus muscle recession surgery (BMR rc), or unilateral medial rectus muscle recession combined with lateral rectus muscle resection surgery (R&R), in the management of partially accommodative esotropia (PAET) in children.Design: Retrospective comparative clinical study.Methods: The study cohort included 98 patients diagnosed with PAET who had BTX-A injection or incisional surgery between December 2014 and January 2023. The main outcome measures included motor and sensory results as well as complications. Follow-up was at least 12 months for all patients.Results: There were 28 patients in the BTX-A group, 45 in the R&R group, and 25 in the BMR rc group. The motor success rates at distance and near fixation respectively were 50% (14/28) and 54% (15/28) in the BTX-A group, which were lower than that of the R&R group [78% (35/45), 84% (38/45)] and the BMR rc group [72% (18/25), 84% (21/25)] (P = 0.042 for near and P=0.006 for distance). For patients with onset age <2.5 years old, there was no statistical difference amongst the three surgical approaches (P=0.656). For patients with onset age ≥2.5 years, the motor success rate of the R&R group [81% (26/32)] and the BMR rc group [88% (14/16)] was higher than that in the BTX-A group [38% (5/13); P=0.004]. There was no statistical difference in sensory outcomes for patients regardless of onset age or treatment methods (P>0.05 for all). During follow-up, 4% (2/45) of patients in the R&R group and 20% (5/25) in the BMR rc group developed consecutive exotropia; no patient in the BTX-A group was overcorrected (P=0.017).Conclusions: Bilateral medial rectus muscle injection with BTX-A in patients with PAET is a safe, accessible, and low-cost alternative. Although motor success rates were higher, overall, in patients treated with incisional surgery, for patients with earlier age of onset (≤ 2.5 years old), BTX-A injection may be preferred to incisional surgery. In older children treated with unilateral recession-resection surgery, fewer developed consecutive exotropia.

Vertical rectus muscle transposition and botulinum toxin for complete sixth nerve palsy

We present an audit of the clinical characteristics and strabismus surgery outcomes for Acute Acquired Commitant Esotropia (AACE) cases managed by our paediatric ophthalmology team at the Royal Victoria Infirmary,...

Traumatic rupture of the inferior rectus muscle: clinical presentation and surgical management

Transposition of the vertical rectus muscle to the insertion of a paralytic or aberrantly innervated lateral rectus muscle is useful in treating esotropia associated with abducens palsy and Duane syndrome. However, this procedure may cause a manifest vertical deviation, requiring either prismatic or additional surgical correction. In an attempt to reduce the incidence of this surgical complication, we performed vertical rectus muscle transposition surgery, using an adjustable suture technique on each muscle, in 10 consecutive patients with abnormal lateral rectus function. Preoperative diagnoses included abducens palsy (70%) and Duane syndrome (30%). Preoperative deviations ranged from 14 to 85 prism diopters esotropia (mean, 39 delta) in the primary position. No vertical deviation was present preoperatively. Following transposition surgery, 8 of 10 patients were esotropic, 1 of 10 patients was exotropic, and 4 of 10 patients had a manifest vertical deviation. At the time of adjustment, all vertical deviations were corrected by "recessing" the appropriate vertical rectus muscle. Additionally, exotropia was lessened by "recessing" both vertical muscles in one patient.

Background and Objective: Consecutive exotropia after unilateral or bilateral medial rectus recession is a common clinical problem. One surgical intervention to address the misalignment involves isolating and reattaching healthy muscle to the globe. The purpose of this study was determining factors indicative of surgical success in medial rectus resection and advancement with non-adjustable sutures for consecutive exotropia. Methods: Through retrospective chart review, 118 patients were identified to have consecutive exotropia using billing codes from June 2016 to October 2020 at Indiana University Health. 60 of these patients who maintained adequate follow-up either underwent the above intervention (n = 49) or underwent resection only (n = 11). Exclusion criteria included lack of medial rectus procedure or poor postoperative documentation. Patient demographics and data were gathered, including preoperative and intraoperative measurements, final postoperative deviation, and whether additional surgeries were necessary. Chi-squared and two-sample t-tests were performed to analyze the effect of each parameter on surgical success, defined as distance deviation ≤ 10 prism diopters of esotropia or exotropia at final postoperative visit. Results: Smaller total intraoperative adjustment–resection plus advancement–was significantly associated with surgical success (p = 0.044). Additionally, smaller preoperative deviations were significantly associated with patients who underwent unilateral surgery (p = 0.0093 near and 0.0021 distance). Conclusion: Patients with smaller preoperative deviations tended to have better outcomes, and those patients tended to have unilateral surgery. It is unclear whether a smaller deviation might have led surgeons to select unilateral medial rectus surgery or if the smaller deviation itself is a predictor of success. Relatively limited time of follow-up is a limitation in this study, as there is well-documented postoperative drift of increasing exotropia over time. A larger cohort or randomized controlled trial may provide additional insight that could increase the percentage of successful outcomes with a single surgery.

Divergence insufficiency

A number of vertical rectus transposition procedures have been described for nonresolving complete sixth nerve palsy. Overcorrections following transposition procedures may be treated by reversing/adjusting the transposition or advancing the medial rectus (if previously recessed). Undercorrections require transposing an additional vertical rectus or recessing the medial rectus. Of the many available transposition procedures for sixth nerve palsy, Nishida's procedure offers the advantage of not having to disinsert the vertical recti and sparing the ciliary circulation. There are no reports on management of overcorrections following this procedure to the best of our knowledge. We report a patient with complete sixth nerve palsy, who developed a consecutive exotropia and anterior segment ischemia after Nishida's transposition with medial rectus recession. He was successfully treated by cutting the transposition suture on superior rectus.

ABSTRACTPurpose: To evaluate the surgical outcome of exotropic Duane syndrome and the factors that can influence the outcome.Methods: A retrospective study was performed on patients who had surgery for exotropic Duane syndrome with a minimum follow-up of 3 months. The ocular motility, the angles of deviation, the presence of abnormal head turn or overshoots, the surgical procedures performed, and their outcome were analyzed.Results: Sixty-seven patients were identified (mean age, 11.3 years). In unilateral cases with exotropia <25 PD (n = 28), ipsilateral lateral rectus (LR) recession was performed in all cases, and orthophoria was achieved in 25 patients (89.3%). In unilateral cases with angle ≥25 PD, ipsilateral LR recession was performed in 13 patients, bilateral symmetrical LR recession in eight patients, and unilateral LR recession and medial rectus (MR) resection in seven patients. Sequential contralateral LR recession for undercorrection was performed in seven patients. The success rate was highest in those who had unilateral LR recession and MR resection (66.7%). An increase in face turn occurred in 6 of 15 patients (40%) who had a simultaneous or sequential bilateral LR recession. In bilateral Duane syndrome, bilateral LR recession was performed in 10 patients, and was combined with ipsilateral MR resection in two patients with a success rate of 75%. Higher success rate was associated with young age at surgery (P = .03) and smaller angle of deviation (p = .04). The mean follow-up was 6.3 months.Conclusions: Surgical results in exotropic Duane syndrome are better in small angles of deviation and in younger age groups.

Blepharophimosis-ptosis-epicanthus inversus (BPES) is a rare genetic disease involving a complex eyelid malformation. The surgical treatment approach for BPES is highly complex and a subject of controversy. This study reports the results of a one-stage frontalis muscle transfer technique to correct BPES. This retrospective, interventional study included 21 patients with BPES who had been followed-up for a minimum of 1 year. The one-stage intervention was a combination of three surgical techniques: Mustardé medial canthoplasty, Fox lateral canthoplasty, and the frontalis muscle transfer technique. Preoperative and postoperative measurements of the horizontal lid fissure length (HLFL), vertical lid fissure width (VLFW), inner intercanthal distance (IICD), and the IICD/HLFL ratio were analyzed by Wilcoxon's signed rank test. The mean preoperative measurements were 4.73 ± 0.32 mm for VLFW, 19.98 ± 3.74 mm for HLFL, 40.85 ± 4.46 mm for IICD, and 2.11 ± 0.45 mm for the IICD/HLFL ratio. The mean postoperative measurements were 7.86 ± 0.41 mm for VLFW, 24.47 ± 3.35 mm for HLFL, 32.52 ± 4.16 mm for IICD, and 1.35 ± 0.22 mm for the IICD/HLFL ratio (p < 0.0001 for all preoperative vs postoperative values). Postoperative complications included eyelid fold deformities, lagophthalmos, and conspicuous scars. Most of these complications gradually resolved. One-stage correction of BPES is safe and efficient with the surgical techniques described.

Purpose: To evaluate the effect of uni- and bilateral medial rectus recession on squint angle and ductions in Graves’ Orbitopathy (GO) patients.Design: Retrospective case series.Materials and methods: Consecutive GO patients seen between January 2000 and March 2012 who were operated on one or both medial rectus muscles were selected for the study. Data regarding squint angle, abduction, and adduction were collected starting 3 months before surgery and 3 and 6–12 months after surgery.Results: 102 patients were eligible for inclusion. Of these, 24 patients were operated on one medial rectus and 78 on two medial rectus muscles. The dose-effect response was 1.0 [−0.6–3.8]°/mm in the unilateral and 1.4 [0.2–3.0]°/mm in the bilateral group (p = 0.000). In the bilateral group, the maximal abduction and adduction changed significantly (p = 0.000). However, the total duction range remained unchanged (unilateral: p = 0.525; bilateral: p = 0.137). The extent of the preoperative abduction did not influence the dose-effect response (r = −0.234; p = 0.040), nor did the muscle volume (unilateral p = 0.989; bilateral p = 0.397). Twenty-three patients (23%) needed additional horizontal squint surgery.Conclusion: In this large series of medial rectus recessions in patients with Graves’ disease we found significantly lower dose-effect response ratios as compared to other studies. The amount of abduction deficit does not influence outcome.

To report the results of a series of patients with acquired distance esotropia (ET) who underwent lateral rectus resection.We retrospectively analysed data from 21 symptomatic patients with acquired esotropia who...