An approach to the surgical management of total oculomotor nerve palsy

Abstract

The goal of the procedure was to keep the eyes of patients with total oculomotor palsy in the straight ahead position by means of surgery on the horizontal and inferior rectus muscles in one session, without involving the superior oblique muscles. Six patients underwent surgery for total oculomotor nerve palsy. All of the surgical procedures were carried out on the muscles of the paralytic eye. We performed hemi-hangback recession of the lateral rectus and resection of the medial rectus for exotropia in all patients. Depending on the magnitude of vertical deviation, the insertions of the horizontal rectus muscles were moved upward, alone or in combination with hemi-hangback recession of the inferior rectus. The mean preoperative horizontal deviation was 66.6 PD. Two years after the operation, the horizontal deviation was measured to be 11.6 PD. Similarly, the mean preoperative vertical deviation of 16 PD decreased to 6.6 PD in two years. This procedure did not disturb normally functioning superior oblique and lateral rectus muscles. Subjectively, all of the patients were satisfied with their alignment two years after the operation. We are of the opinion that this technique is a safe, simple and effective procedure and can be regarded as a first-choice operation in total oculomotor palsy. If one fails to maintain the eye position with this procedure, one can still perform a second operation on the superior oblique muscle, which remains untouched in our procedure.

Periosteal fixation procedures in the management of incomitant strabismus

“…The most common cause of unsatisfactory results in cases of oculomotor nerve palsy and exotropic Duane retraction syndrome (DRS) is the tight lateral rectus muscle. 23 24 25 Although myotomies or myectomies may completely detach the muscle from the globe, the results are unpredictable due to the muscle's tendency to reattach to the globe. 26 …”

Predictive factors of surgical outcome in oculomotor nerve palsy

“…Results from the largest published series of surgery for oculomotor nerve palsy surgery are compared in Table 5. [14][15][16][17][18][19][20] In conclusion, only time from onset to surgery and amount of eye deviation are valuable in estimating the prognosis of surgery for oculomotor nerve palsy. To our knowledge, there are no previous studies on predictive factors of outcome for surgery of third cranial nerve palsy.…”

Rectus muscle orbital wall fixation: A reversible profound weakening procedure

“…Residual abduction may be caused by periocular connective tissue contracture due to a longstanding deviation and the abducting action of the oblique muscles combined with poor adducting force. [1][2][3][4][5][6][7][8][9][10] Functional inactivation of the lateral rectus muscle should be combined with a medial fixation procedure such as an apically based periosteal flap fixation as in Case 3, or superior oblique transposition to achieve permanent ocular alignment in the primary position. Anomalous ocular movements related to aberrant innervation to the rectus muscles may be reduced or eliminated if the insertion of the affected muscle is detached from the globe and sutured to the orbital periosteum.…”

“…Large lateral rectus recession is usually a major component of any surgical strategy, but recurrent exotropia is common since there is no adducting force to balance the residual lateral rectus force. [1][2][3][4][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25] Complete inactivation of lateral rectus force by orbital wall fixation could eliminate all residual lateral rectus function (Alan B. Scott, MD, verbal communication).…”

“…[1][2][3][4][5][6][7] Active and passive forces regulate ocular alignment and rotations. The balance among contracting agonist extraocular muscles, relaxed antagonist extraocular muscles, and the periocular connective tissue determine the final position of the eye.…”