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Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 145-147

Large-angle hypertropia managed by modified Nishida's procedure

Department of Pediatric Ophthalmology and Strabismus, Sankara Eye Hospital, Bengaluru, Karnataka, India

Date of Submission25-Feb-2020
Date of Acceptance13-Jul-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Sowmya Raveendra Murthy
Department of Pediatric Ophthalmology and Strabismus, Sankara Eye Hospital, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_380_20

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Treating vertical squints especially large-angle hypertropia caused by inferior rectus palsy is a challenge. Superior rectus recession in presence of positive forced duction tests is the first step in surgical management. Following this, full tendon transposition of horizontal recti inferiorly (Inverse Knapp's procedure) is the standard procedure of choice. Modified Nishida's procedure has been described to treat vertical deviations like MED and inferior rectus aplasia. We describe a case of large-angle hypertropia treated by Modified Nishida's procedure.

Keywords: Hypertropia, modified Nishida's procedure, Inferior rectus

How to cite this article:
Murthy SR, Tripathi P. Large-angle hypertropia managed by modified Nishida's procedure. Indian J Ophthalmol Case Rep 2021;1:145-7

How to cite this URL:
Murthy SR, Tripathi P. Large-angle hypertropia managed by modified Nishida's procedure. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Feb 26];1:145-7. Available from: https://www.ijoreports.in/text.asp?2021/1/1/145/305526

Modified Nishida's procedure is a no split-no tenotomy transposition procedure described as a treatment option for sixth nerve palsy.[1] Studies have shown that it can also be used in vertical strabismus like MED[2] and inferior rectus aplasia.[3],[4] However, it has not been tried for inferior rectus palsy. The standard procedure of choice for inferior rectus palsy is inverse Knapp's procedure.[5] This combined with superior rectus recession carries the risk of anterior segment ischemia when done simultaneously.

This report describes, a case of Large hypertropia due to Inferior Rectus palsy in an elderly, managed with Modified Nishida's procedure.

  Case Report Top

A 74-year-old lady, presented to us with upward deviation of the left eye since 8 months following a trauma on her left side of face following a fall. She was known hypertensive on treatment. She had undergone cataract surgery in both eyes 2 years back elsewhere. On examination, her best-corrected visual acuity was 20/20 N6 in the right eye and 20/200, N8 in the left eye. Hirschberg's test showed marked hypertropia in the left eye and -3 to -4 limitation of depression in the left eye [Figure 1]. Ocular motility was normal in the right eye. Modified Krimsky test showed >50 prism dioptre of hypertropia of the left eye (as vision of left eye was 20/200, cover tests could not be done). Inferior floating saccades was noted in the left eye indicative of palsy . Intraocular pressure was 14 mm of Hg OD and 16 mm of Hg in OS.
Figure 1: Nine gaze photograph showing >50 pd primary gaze left hypertropia and limitation of depression of left eye

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Slit-lamp examination showed (OD) normal anterior segment with pseudophakia. Pupil in the Right eye round regular and reacting to direct and indirect light. Left eye examination showed pseudophakia with updrawn eccentric pupil which was sluggishly reacting to direct and indirect light. Fundus showed normal disc and macula and no evidence of torsion in both eyes.

A provisional diagnosis of left post traumatic inferior rectus palsy was made. Neuroimaging (MRI brain and orbits) was normal with slight thinning of the left inferior rectus muscle. Intra-operative force duction tests (FDT) showed tightness of Superior rectus. FGT for left inferior rectus showed no tug. Hence, a surgical plan of Modified Nishida's procedure of horizontal recti muscles with recession of superior rectus was made.

First, standard fixed scleral 4mm recession of superior rectus was performed with 6-0 vicryl (polyglactin 910) under peribulbar anesthesia. This was followed by modified Nishida's procedure. The horizontal recti (medial rectus and lateral rectus) were explored and isolated, 5-0 polyester sutures were placed through the inferior 1/3rd of each muscle at a distance of 9 mm behind their insertion points. Then the same sutures were passed through the sclera at a distance of 12 mm in the inferonasal and inferotemporal limbus [Figure 2]. Thus, anchoring the inferior margin of each horizontal rectus muscle inferiorly (inferonasal and inferotemporally) contributing to the depressing force.
Figure 2: Schematic diagram of the surgical procedure

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On first postoperative day, a hypertropia with 15-20 Prism dioptre in left eye with improvement in depression to -2 to -3 was noted. One month postoperatively, residual hypertropia of 20-25 Prism dioptre was noted in the left eye. Hence a revised surgery was planned. Introperative FDT showed tightness of superior rectus muscle. So, superior rectus muscle was explored and was further recessed by 6 mm. (first surgery of 4 mm SR recession summing to a total of 10 mm recession). Postoperatively, primary gaze of 10-12 pd hypertropia was noted on first day. Primary gaze alignment continued to be 10pd left hypertropia after 1 month and 3 months. Ocular movements showed minimal improvement in the depression of left eye to -2 to -3. [Figure 3].
Figure 3: Post operative photograph showing small residual hypertropia of 10-12 pd in left eye with improved depression

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  Discussion Top

Superior rectus recession or tenotomy with transposition (Inverse Knapp) is the standard treatment for such large hypertropia.[6],[7] Muscle transposition can be performed in two ways: either a full tendon transposition of the medial and lateral rectus muscles inferiorly (inverse Knapp's procedure), or transposition of half or two-thirds of the tendons of the medial and lateral rectus muscles (a modification of the Hummelsheim procedure) to the putative location of the missing inferior rectus muscle insertion or paralyzed inferior rectus.[7],[8],[9] Muscle transposition works on rationale that EOM transposition alters the point of tangency of the muscle with the globe, thereby changing the point of mechanical action. Foster[10] described using posterior fixation suture along with transposition that augments the transposition and thus avoiding surgery on another muscle. However, all these procedures involve a risk of anterior segment ischemia[11] and cannot be combined with another rectus muscle surgery in the same eye.

Nishida et al.[1] developed a new transposition procedure that did not involve tenotomy or muscle splitting for sixth nerve palsy. We have previously reported a case series of successful outcome of modified Nishida's procedure for monocular elevation deficit.[2] We tried the same procedure here for inferior rectus palsy. Case reports of modified Nishida's procedure in the case of medial rectus aplasia[4] had been found in literature giving a good scientific evidence of its usage in inferior rectus palsy.

We chose modified Nishida's procedure here over muscle transposition as the patient was an elderly hypertensive making her more prone for the risk of anterior segment ischemia with the latter. Further, modified Nishida's procedure is relatively simpler to perform and is reversible in the initial postoperative period than muscle transposition.

  Conclusion Top

Modified Nishida's procedure is a good alternative to Inverse Knapp's procedure for inferior rectus palsy. Being easy to perform, reversible with no risk of anterior segment ischemia, it becomes a choice in large hypertropia, especially in elderly.

To the best of our knowledge, this is a first reported case where Modified Nishida's procedure was performed successfully to treat large hypertropia of Inferior Rectus palsy due to trauma with a satisfactory result. Further long-term follow-up and additional cases are necessary to further evaluate the utility of this procedure in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Nishida Y, Hayashi O, Oda S, Kakinoki M, Miyake T, Inoki Y, et al. A simple muscle transposition procedure for abducens palsy without tenotomy or splitting muscles. Jpn J Ophthalmol 2005;49:179-80.  Back to cited text no. 1
Murthy SR, Pappuru M. Modified Nishida's procedure for monocular elevation deficiency. J AAPOS 2018;22:327-9.e1. doi: 10.1016/j.jaapos. 2018.01.018.  Back to cited text no. 2
Makino S, Hozawa K, Kondo R, Kanai M, Suto H, Mawatari G, et al. Modified muscle transposition procedure for a case of inferior rectus muscle aplasia. Case Rep Ophthalmol 2014;6:1-6.  Back to cited text no. 3
Sharma P, Chaurasia S, Rasal A. Bilateral medial rectus aplasia and a modified surgical approach of transposition myopexy of vertical recti. BMJ Case Rep 2017;2017:bcr2017220404. doi: 10.1136/bcr-2017-220404.  Back to cited text no. 4
Burke JP. Inverse Knapp procedure. Eye 2001;15:5.  Back to cited text no. 5
Taylor RH, Kraft SP. Aplasia of the inferior rectus muscle. A case report and review of the literature. Ophthalmology 1997;104:415-8.  Back to cited text no. 6
Matsuo T, Watanabe T, Furuse T, Hasebe S, Ohtsuki H. Case report and literature review of inferior rectus muscle aplasia in 16 Japanese patients. Strabismus 2009;17:66-74.  Back to cited text no. 7
Burke JP, Keech RV. Effectiveness of inferior transposition of the horizontal rectus muscles for acquired inferior rectus paresis. J Pediatr Ophthalmol Strabismus 1995;32:172-7.  Back to cited text no. 8
Maurino V, Kwan AS, Lee JP. Review of the inverse Knapp procedure: Indications, effectiveness and results. Eye 2001;15:7-11.  Back to cited text no. 9
Foster RS. Vertical muscle transposition augmented with lateral fixation. J AAPOS 1997;1:20-30.  Back to cited text no. 10
Bansal RK, Bamotra RK. Anterior segment ischemia following Hummelsheim procedure in a case of sixth nerve palsy. Indian J Ophthalmol 2015;63:543-4.  Back to cited text no. 11
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