Predictors of Good Motor and Sensory Outcomes Following Strabismus Surgery for Patients with Third Nerve Palsies

Abstract

Strabismus from third nerve palsy (3NP) is difficult to treat. Our goal was to explore factors associated with successful surgical outcomes in 3NP. Institutional records of all adult patients (418 years) from 1988 to 2012 with 3NP who underwent strabismus surgery or botulinum toxin injections were retrospectively reviewed. Success was defined as absence of diplopia, vertical deviation 2 prism dioptres (PD), and horizontal deviation 10 PD. Fifty-six patients from four surgeons were included. Thirty (54%) were female; mean age was 48 (range: 20-80). Forty-four (79%) had unilateral 3NP; 9 (16%) had other ocular motor nerve palsies. 3NP were complete in 24 (43%). Underlying aetiology was idiopathic/microvascular in 5 (9%), traumatic in 13 (23%), neoplastic in 12 (21%), aneurysmal in 10 (18%), and other central nervous system related in 16 (29%). Trauma was associated more frequently with aberrant regeneration than other aetiologies: 9/13 (69%) versus 4/43 (9%) (p50.01). Ten patients (18%) had 41 surgery. Surgical success was achieved in 28/56 (50%). Success rate was unaffected by aetiology, degree of palsy, pupillary involvement, presence of aberrant regeneration, or number of other cranial nerves involved. However, adjustable sutures were used in 27 patients (48%), and there was a trend toward higher success rates when adjustable versus nonadjustable sutures were used (63% versus 38%; p = 0.06). Unlike with sixth nerve palsies, the aetiology and degree of 3NP does not appear to affect the success rates or number of procedures performed. Strabismus surgeries for 3NP with adjustable sutures may be associated with better outcomes.

Adjustable Versus Nonadjustable Sutures in Strabismus Surgery—Who Benefits the Most?

“…The available research does not favor AS if statistical significance is the only criterion; however, some clinical results suggest a tendency for better postoperative outcomes with the use of AS [2,21]. Nevertheless, the possibility of substantial postoperative drift must be taken into consideration when using AS in vertical strabismus [22].…”

“…Adjustable sutures (AS) have been used in strabismus surgery for a few decades since their first description by Jampolsky in 1974; however, controversy remains regarding their application in clinical practice [1]. Many surgeons advocate for AS during surgery for the management of most cases of strabismus, while others limit their use to when treating adults or in selected complicated cases such as paralytic strabismus, restrictive strabismus, and reoperations [2].The question of careful selection of patients suitable for AS is often brought up [3]. AS surgery is reported to be used less frequently than classic nonadjustable sutures (NAS).…”

Aberrant regeneration in an international registry of patients with 3rd-nerve palsy

“…Aberrant regeneration occurred most often in oculomotor palsies from trauma 69% (9/13), and traumatic 3 rd -nerve palsies were associated with an increased risk of aberrant regeneration compared to all other aetiologies. 19 They found a comparable success rate after a variety of different surgical procedures for patients with and without aberrant regeneration (51% vs. 46%; p = 0.75). 19 In a predominantly paediatric cohort, Ng et al found a high rate (83% [5/6]) of aberrant regeneration among congenital 3 rd -third nerve palsies.…”

“…Our report of the prevalence of aberrant regeneration fits well within the 7-32% range of previously reported estimates from single-centre case series and population-based studies. [14][15][16][17][18][19][20][21] In a retrospective study of 1400 consecutive patients with acquired 3 rd -nerve palsy examined by a single physician, 95 cases of aberrant regeneration were identified, the majority resulting from trauma (65%) and aneurysm (13%). 16 Peragallo et al reviewed the surgical outcomes of all patients with 3 rd -nerve palsy in a single institution and found 23% (13/56) had evidence of aberrant regeneration.…”

Aberrant regeneration of third nerve with characteristic lid signs: operating the normal fellow eye

“…In a retrospective series of 46 operated patients for third nerve palsy, the authors observed that the success rate was unaffected by the presence of aberrant regeneration [ 4 ]. They also found a slightly higher success rate with adjustable versus nonadjustable sutures.…”