|Year : 2021 | Volume
| Issue : 2 | Page : 299-301
Choroidal effusion with neurosensory detachment after medial transposition of Y-split lateral rectus in third nerve palsy
Neha Yadav, Pradeep Sharma, Vikash Panwar, Jyoti Shakrawal, Shorya Vardhan Azad
Dr RP Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
|Date of Submission||01-May-2020|
|Date of Acceptance||13-Sep-2020|
|Date of Web Publication||01-Apr-2021|
Dr. Pradeep Sharma
Pediatric Ophthalmology and Neuro Ophthalmology, RP Centre AIIMS, New Delhi
Source of Support: None, Conflict of Interest: None
Transposition of lateral rectus to medial rectus, though an alluring and effective method in managing complete third nerve palsy, is not without its complications. We report a rare but known complication of choroidal effusion with neurosensory detachment after medial transposition of Y split lateral rectus, in a case of posttraumatic complete third nerve palsy with aberrant regeneration. This led to a severe drop in visual acuity which did not resolve spontaneously and was managed by release of the scleral suture and topical, intravenous, and oral steroids subsequently leading to its complete resolution and restoration of visual acuity.
Keywords: Choroidal effusion, lateral rectus to medial rectus transposition, neurosensory detachment, secondary glaucoma, third nerve palsy, vortex vein compression
|How to cite this article:|
Yadav N, Sharma P, Panwar V, Shakrawal J, Azad SV. Choroidal effusion with neurosensory detachment after medial transposition of Y-split lateral rectus in third nerve palsy. Indian J Ophthalmol Case Rep 2021;1:299-301
|How to cite this URL:|
Yadav N, Sharma P, Panwar V, Shakrawal J, Azad SV. Choroidal effusion with neurosensory detachment after medial transposition of Y-split lateral rectus in third nerve palsy. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Apr 20];1:299-301. Available from: https://www.ijoreports.in/text.asp?2021/1/2/299/312320
Choroidal effusion is the accumulation of fluid in the suprachoroidal space which can be due to various causes including inflammatory, trauma, infections, neoplasms, post intraocular surgery (commonly glaucoma), and idiopathic. The incidence of choroidal effusion post strabismus surgery is rare but a known complication in myopic eyes and after transposition surgeries. To the best of our knowledge, this is a first case report describing the importance of undoing of transposition procedure by releasing muscle sutures to release vortex vein compression which eventually resolves choroidal effusion.
| Case Report|| |
A 26-year-old, female with a history of road traffic accident 1 year back presented to our squint clinic with a complete pupil involving oculomotor nerve palsy with aberrant regeneration (adduction miosis, elevation with ptosis correction on adduction) in the right eye (OD). Her preoperative visual acuity (VA) was 20/40 OD and 20/20 OS and an exotropia of 50 prism diopter, (PD) and L/R of 12 PD [Figure 1]a on orthoptic examination. A two-staged procedure was planned with a 7.5 mm recession of superior rectus (SR) in OS, utilizing the fixation duress, to correct the hypotropia and ptosis. In the second sitting, a medial transposition of the Y split lateral rectus, as described by Gokyigit and colleagues along with posterior tenectomy of superior oblique (SO) fibers was performed in the right eye for exotropia correction.
|Figure 1: (a) Preoperative right eye clinical photograph. Note the improvement in; adduction on attempt of elevation and ptosis on adduction. (b) Post-operative right eye clinical photograph after lateral rectus to medial rectus transposition|
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On postoperative day 3, she complained of severe pain with diminution of vision. On examination, the VA dropped to counting fingers at 30 cm and an intraocular pressure (IOP) of 40 mm Hg in OD. A slit-lamp biomicroscopy examination revealed an anterior shift of the lens iris diaphragm along with a shallow anterior chamber (AC) with 1+ cells and flare. Examination of the fundus showed serous choroidal detachment (CD) in the periphery with central multiple neurosensory detachments (NSD) which was confirmed by B scan ultrasonography [Figure 2]a and [Figure 2]b, swept-source optical coherence tomography (DRI OCT Triton, Topcon, Oakland, NJ) [Figure 3]a and fundus photography [Figure 3]b. On grounds of suspicion of possible compression of the vortex vein, both the sutures securing the split LR to the sclera on the medial side were released and a pulse steroid 100 mg (dexamethasone) for 3 days along with antiglaucoma medications, topical steroids, and oral steroids subsequently was given, which was tapered off weekly. On the 5th day, postintervention her VA improved to 20/200 with complete resolution of the serous CD and NSD [Figure 3]c and [Figure 3]d.
|Figure 2: (a) Ultrasonography picture of right eye showing neurosensory detachment (red arrow). (b) peripheral choroidal detachment (white arrow)|
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|Figure 3: (a) Multiple neurosensory detachment (red arrow) in right eye on swept source OCT. (b) Fundus photograph of right eye showing choroidal detachment (blue arrow) and neurosensory detachment (white arrow). (c) Resolution of the neurosensory detachment in right eye on swept source OCT. (d) Fundus photograph of right eye showing resolution of the choroidal detachment and neurosensory detachment|
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Six weeks postsurgery the patient gained a VA of 20/63 with a refractive correction of –0.75 diopter sphere (DS) and axial length was 22.1 mm. She was orthophoric [Figure 1]b in the primary position.
| Discussion|| |
Management of third nerve palsies is a challenge for the strabismus surgeon due to its limited surgical option. Nasal transposition of LR was first described by Taylor in 1989, where the LR is Y split and transposed close to the nasal vortex veins superiorly and inferiorly at a retro equatorial point of 20 mm from the limbus or at points 1 mm behind the upper and lower borders of the medial rectus insertion or additional reinforcements with posterior fixation sutures have been described.,,,,
Transposition procedures are not without its complications. There have been reports of perforation, orbital hemorrhage due to injury to vortex veins, central serous chorioretinopathy, choroidal effusion, and compressive optic neuropathy. In our case after ensuring the force duction test for LR was free, the muscle was hooked with Jameson's hook and split 15 mm posteriorly prior to disinsertion. The split halves were brought nasally, passing under the SR and SO superiorly and under the inferior rectus inferiorly. The superior and inferior borders were then sutured with 6-0 polyglactin close to medial rectus insertion.
The pathophysiology behind the choroidal effusion in our case is attributed to possible compression of the vortex vein leading to an increase in choroidal vascular pressure causing serous CD in the periphery with multiple NSD which brought about an anterior shift of the lens iris diaphragm complex resulting in angle-closure glaucoma. Microperforation was ruled out after detailed fundus examination and confirmed by Optos ultrawide field fundus photography (California P200DTx icg, Marlborough, MA).
The exit position of the vortex veins in the sclera range from 13.75 to 25 mm behind the limbus. We need to be careful as the supero-temporal vortex vein is close to the temporal end of the SR insertion and behind the SO tendon's nasal insertion. The vortex vein traverse about 5 to 10 mm between the bulbar fascia and sclera before exiting, the episcleral course being the longest for the superotemporal vein. Thus, in spite of proper visualization and preventive measures there can be a possibility of inadvertent compression of the vortex vein at its exit or due to its episcleral course leading to such complications. A review of the literature showed few case reports that have reported such complications after nasal transposition of lateral rectus. Shah et al. in their case series of 6 patients, reported transient choroidal effusion in one patient which resolved spontaneously and have reported the risk associated with such procedure. Sorenson et al. reported a case of central serous choroidopathy after surgery which was attributed to Type A personality and steroid use. Casteels et al. reported a case of choroidal effusion with serous retinal detachment after uneventful strabismus surgery for divergent squint in a 12-year-old girl with hypermetropia of 8 DS, which resolved on parabulbar and topical steroids.
| Conclusion|| |
Choroidal effusion leading to CD with multiple NSD is a dreaded complication after nasal transposition of split LR which can induce considerable anxiety both for surgeon and the patient. Though it is the procedure of choice for large-angle exotropia with no medial rectus function, but it should be done with caution and with the foresight to detect and manage such complications if they occur unfortuitously.
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.
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[Figure 1], [Figure 2], [Figure 3]