Hummelsheim procedure combined with medial rectus recession in complete sixth nerve palsy and esotropic Duane Retraction Syndrome

Abstract

Purpose: To evaluate the effect of half tendon vertical rectus muscle transposition (HVRT) combined with medial rectus muscle recession (MRrec) in complete sixth nerve palsy (CSNP) and esotropic Duane Retraction Syndrome (eDRS). Methods: A retrospective study of patients with unilateral CSNP or eDRS who underwent HVRT combined with medial rectus recession over the course of 18 years. The patients with previous strabismus surgery and follow up less than 3 months were excluded. Overcorrection was defined as any amount of exotropia, and undercorrection was defined as residual esotropia of ⩾10 prism diopter (PD). Results: A total of 39 patients were enrolled including 22 CSNP and 17 eDRS patients. Esotropia improved from 45.8 ± 22 and 22.5 ± 6.4 PD to 0.8 ± 2.5 and 0.3 ± 1 PD in CSNP group and eDRS group respectively. The angle of face turn improved from 34.3 ± 8.4° and 26.5 ± 9° to 0.6 ± 2.4° and 0.8 ± 1.6° in the CSNP group and eDRS group respectively. Abduction limitation improved from −4.5 ± 0.5 and −4 ± 0 units to −2.9 ± 0.5 and −2.7 ± 0.5 units in CSNP group and eDRS group respectively. No patient developed a new vertical deviation. An overcorrection occurred in one patient of the eDRS group who improved after botulinum toxin injection in the ipsilateral lateral rectus muscle. Undercorrection was seen in two patients. Conclusion: HVRT combined with MRrec is an effective procedure to improve esotropia, face turn, and abduction limitation in CSNP and eDRS.

Medial rectus disinsertion for management of chronic complete sixth nerve palsy

“…Undercorrected ET is not uncommon after surgical management of sixth nerve palsy. 4,5,[9][10][11] Various approaches have been used to correct residual ET after muscle transposition surgeries in patients with complete abducens palsy. Akar et al 4 performed botulinum toxin injection to the ipsilateral MR, ipsilateral MR recession, and contralateral MR recession in patients with undercorrected ET after augmented vertical muscle transposition which resulted in 95% reduction in ET in the PP.…”

“…1 Transposition of the vertical rectus muscle to the LR may include transposition of one or two vertical muscles, transposition of full-or half-tendon width of the muscle, using belly union techniques and may or may not be combined with the recession of the MR muscle. [2][3][4][5][6] All of these procedures aim to improve ET and diplopia in the Primary position (PP) and expansion of the field of single binocular vision. Nonetheless, some patients with complete sixth nerve palsy do not achieve orthotropia or single binocular vision in their central visual field despite multiple strabismus procedures, including transposition surgeries.…”