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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 360-362

Temporal hemi-transposition of a split medial rectus muscle: A novel technique for the management of complete lateral rectus palsy

1 Department of Paediatric Ophthalmology, Jyotirmay Eye Clinic and Ocular Motility Laboratory, Thane; Department of Paediatric Ophthalmology, Mahatme Eye Hospital, Nagpur, Maharashtra, India
2 Department of Paediatric Ophthalmology, Jyotirmay Eye Clinic and Ocular Motility Laboratory, Thane, Maharashtra, India

Date of Submission23-Apr-2020
Date of Acceptance07-Sep-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Mihir Kothari
Jyotirmay Eye Clinic, 104/105 Kaalika Tower, Opp. Pratap Cinema, Kolbad Road, Thane West - 400 601, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1071_20

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A 9-year-old boy with complete lateral rectus palsy, following the treatment for his embryonal rhabdomyosarcoma of the right lateral rectus muscle, underwent temporal hemi-transposition of lower 2/3rd of medial rectus muscle beneath the inferior rectus muscle. Satisfactory alignment and resolution of diplopia was achieved postoperatively. He developed staphylococcal scleromalacia after surgery that was successfully managed with scleral patch graft, oral and topical antibiotics, and steroids.

Keywords: Abducens palsy, esotropia, lateral rectus, medial rectus, transposition

How to cite this article:
Kothari M, Solanki M, Sugathan S. Temporal hemi-transposition of a split medial rectus muscle: A novel technique for the management of complete lateral rectus palsy. Indian J Ophthalmol Case Rep 2021;1:360-2

How to cite this URL:
Kothari M, Solanki M, Sugathan S. Temporal hemi-transposition of a split medial rectus muscle: A novel technique for the management of complete lateral rectus palsy. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Aug 3];1:360-2. Available from: https://www.ijoreports.in/text.asp?2021/1/2/360/312318

Temporal transposition of split medial rectus (TTSMR) for complete lateral rectus (LR) palsy was recently described.[1] The potential complications include overcorrections, lack of adduction, residual vertical deviation, uveal effusion, and optic nerve compression. A hemi (only one half) transposition of a split medial rectus muscle (THTSMR) could arguably reduce such complications albeit preserve the therapeutic effectiveness of the surgery. Here we present results of a THTSMR in a child, previously treated for rhabdomyosarcoma (RMS), who developed staphylococcal scleromalacia that was successfully managed with scleral patch graft, oral and topical antibiotics, and steroids.

  Case Report Top

A nine years old boy presented with double vision and right eye esotropia following lateral orbital rim recession, lateral rectus muscle removal, and partial removal of orbital fat for the recurrence of orbital RMS a year prior. He had completed seven cycles of chemotherapy (carboplatin, etoposide, and ifosfamide) and 45Gy radiotherapy over 3 months. Previously, at 5 years of age, he had undergone an incision biopsy and four cycles of chemotherapy for right lateral rectus embryonal RMS associated with axial proptosis [Figure 1].
Figure 1: Photo-collage demonstrating proptosis (yellow arrow) at the time of initial presentation and orbital changes after partial exenteration with v pattern esotropia and complete 6th nerve palsy

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His examination revealed partial absence of the lateral orbital wall [Figure 1], -35PD V-pattern right esotropia, -6 abduction limitation, and a small hypertropia. He was emmetropic with 20/200 vision in the right eye and 20/20 in the left. There was no clinical evidence of optic neuropathy or radiation retinopathy in the right eye.

He underwent right eye THTSMR as described below [Figure 2].
Figure 2: Operative photographs showing Holmes dots and (eso) postion of the eye under anesthesia prior to surgery (a), forced duction test for medial tectus (b), split MR (c), recession of upper 1/3rd (d, yellow arrow), transposition of the lower 2/3rd (e and f, green arrow), attachment of the temporally transposed portion of the MR below the lateral rectus muscle and the position of the posterior fixation suture (black arrow) (g) and free FDT (h and i)

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  1. Marking of the limbus and forced duction testing (FDT).

  2. Before induction of general anesthesia, 9 o'clock and 3 o'clock limbus were marked for intraoperative monitoring of torsion.[2] After confirming a tight medial rectus on forced duction testing, decision to perform THTSMR was confirmed.

  3. Creating the Split MR and management of the split portions.

  4. Splitting of the MR longitudinally, for 15 mm posteriorly, in the ratio of upper 1/3rd and lower 2/3rd was done ensuring minimal trauma to the ciliary vessels. Upper one-third was recessed by 12 mm to obtain free FDT and inferior two-thirds was secured on a 6-0 vicryl and disinserted.

  5. Transposition and augmentation.

A Gass hook was passed under the inferior rectus (IR) muscle and the suture needle of the inferior 2/3rd of MR was threaded in to the Gass hook and retrieved temporally beneath the IR and inferior oblique [Figure 2]. The transposed MR was mobilized temporally ensuring that the posterior surface of the globe was prolapsed between the two split portions of the MR without inducing torsion (confirmed by identifying horizontal orientation of Holmes dots) or tension (confirmed by ensuring free FDT). The transposed MR was then sutured below the inferior border of lateral rectus insertion. A 6'0 prolene was placed 10 mm posterior to the attachment. The adequacy of the transposition was assessed by confirming a small exotropia on spring back balance test.

Postoperatively, vicryl suture on the transposed MR was cut in the OPD for a consecutive exotropia of -25PD [Figure 3]. Topical Tobramycin, flourometholone, and moxifloxacin was continued postoperatively.
Figure 3: Photo-collage showing consecutive exotropia on the first post operative day (a), subtenones abscess (b), scleromalacia perforans (c) and healed scleral graft (d)

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On seventh postoperative day the patient came back with swelling and eye pain, headache and yellowish discharge for two days. He was treated with tablet Amoxicillin/Clavulonic acid 250 mg twice a day and pus was sent for culture.

His chemosis and swelling worsened over 48 hours when the culture report indicated methicillin-resistant staphylococcus aureus which was sensitive to chloramphenicol, linezolid, mupirocin, meropenam, and vancomycin. He responded well to systemic linezolid, topical chloramphenicol, tablet wysolone 1 mg/kg for 6 days and topical dexamethasone. However, by post-operative day 21, he developed a large scleral defect for which an emergency scleral patch graft was performed successfully. Now, 3 months postoperatively, his diplopia has resolved, Now, 3 months postoperatively, his diplopia has resolved, ocular alignment is satisfactory and adduction as well as abduction are restricted [Figure 4].
Figure 4: Post op photographs showing satisfactory ocular alignment and motility

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  Discussion Top

This is the first report of successful correction of esotropia in complete LR palsy utilizing the transposition of only one half of the split medial rectus muscle. It is simply a modification of what is reported by Tsai et al.[1] with some advantages.

  1. Partial preservation of adduction.
  2. The untransposed portion of the MR can be supraplaced/infraplaced, recessed or put on an adjustable suture to increase/decrease the adductive force postoperatively to fine tune the ocular alignment and movements.
  3. Better preservation of ciliary vasculature.

THTSMR, in this patient, was specifically chosen to avoid operating on vertical recti. The decision to transpose the inferior portion instead of the superior portion of MR was based on two factors. 1) Infraplacement of both the horizontal portions was done to correct a small hypertropia. 2) Superior oblique muscle and its attachment on sclera and bulbar surface of superior rectus would require much more surgical manipulation than slipping the MR temporally beneath the inferior rectus. Nevertheless, passing the portion of MR beneath IR muscle and then applying a posterior fixation suture anterior to the IO muscle may offer significant difficulty for inexperienced surgeons. In addition, co-contraction and globe retraction in adduction is also a distinct possibility but it was not observed in our patient due to a large recession of the untransposed portion of the MR required for his tight MR. In comparison with the other established transposition procedures such as Nishida's procedure, Johnston procedure (superior rectus transposition) and inferior rectus transposition, THTSMR is more aggressive, technically challenging, and may have higher chances of complications such as effusion, necrosis, and neuropathy. Hence, THTSMR should not be used for routine management of LR palsy cases.

Post strabismus surgery infections are more likely in an immunocompromised patient such as this[3],[4],[5] hence strict aseptic precautions are necessary even for suture adjustment in the OPD.

  Conclusion Top

THTSMR is a unique and novel management strategy to correct esotropia in complete LR palsy when vertical recti transposition is contraindicated or has failed.

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

Tsai CB, Fang CL, Chen MS. Temporal transposition of the split medial rectus muscle when the medial rectus is the sole functioning rectus muscle. J AAPOS 2020;24:33-6.  Back to cited text no. 1
Holmes JM, Hatt SR, Leske DA. Intraoperative monitoring of torsion to prevent vertical deviations during augmented vertical rectus transposition surgery. J AAPOS 2012;16:136-40.  Back to cited text no. 2
House RJ, Rotruck JC, Enyedi LB, Wallace DK, Saleh E, Freedman SF. Postoperative infection following strabismus surgery: Case series and increased incidence in a single referral center. J AAPOS 2019;23:26.e1-7.  Back to cited text no. 3
Bradbury JA, Taylor RH. Severe complications of strabismus surgery. J AAPOS 2013;17:59-63.  Back to cited text no. 4
Kivlin JD, Wilson ME Jr. Periocular infection after strabismus surgery. The Periocular Infection Study Group. J Pediatr Ophthalmol Strabismus 1995;32:42-9.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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