Overcorrection after modified Nishida's procedure and medial rectus recession for sixth nerve palsy reversed by cutting one transposition suture

Muralidhar Rajamani; Ramamurthy Dandapani

doi:10.4103/ijo.IJO_2433_20

CASE REPORT

Year : 2021 | Volume : 1 | Issue : 2 | Page : 365-367

Overcorrection after modified Nishida's procedure and medial rectus recession for sixth nerve palsy reversed by cutting one transposition suture

Muralidhar Rajamani, Ramamurthy Dandapani
Department of Strabismus and Pediatric Ophthalmology, The Eye Foundation, Coimbatore, Tamil Nadu, India

Date of Submission	28-Jul-2020
Date of Acceptance	18-Dec-2020
Date of Web Publication	01-Apr-2021

Correspondence Address:
Dr. Muralidhar Rajamani
Department of Strabismus and Pediatric Ophthalmology, The Eye Foundation, 582A, D.B. Road, R.S. Puram, Coimbatore - 641 002, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_2433_20

Abstract

A number of vertical rectus transposition procedures have been described for nonresolving complete sixth nerve palsy. Overcorrections following transposition procedures may be treated by reversing/adjusting the transposition or advancing the medial rectus (if previously recessed). Undercorrections require transposing an additional vertical rectus or recessing the medial rectus. Of the many available transposition procedures for sixth nerve palsy, Nishida's procedure offers the advantage of not having to disinsert the vertical recti and sparing the ciliary circulation. There are no reports on management of overcorrections following this procedure to the best of our knowledge. We report a patient with complete sixth nerve palsy, who developed a consecutive exotropia and anterior segment ischemia after Nishida's transposition with medial rectus recession. He was successfully treated by cutting the transposition suture on superior rectus.

Keywords: Nishida procedure, overcorrection, sixth nerve palsy, transposition suture

How to cite this article:
Rajamani M, Dandapani R. Overcorrection after modified Nishida's procedure and medial rectus recession for sixth nerve palsy reversed by cutting one transposition suture. Indian J Ophthalmol Case Rep 2021;1:365-7

How to cite this URL:
Rajamani M, Dandapani R. Overcorrection after modified Nishida's procedure and medial rectus recession for sixth nerve palsy reversed by cutting one transposition suture. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Apr 14];1:365-7. Available from: https://www.ijoreports.in/text.asp?2021/1/2/365/312377

Nishida's procedure for transposing the vertical recti is done for non-resolving complete sixth nerve palsy with deviations of up to 40 prism diopters (PD). For larger deviations ipsilateral medial rectus recession is generally combined.^[1],[2] Further augmentation of Nishida's procedure may be done by transposing the vertical recti closer to the lateral recctus.^[3] We report a patient who developed a consecutive overcorrection and mild anterior segment ischemia after right eye medial rectus recession with modified Nishida's procedure. The overcorrection and anterior segment ischemia were reversed by cutting the superior rectus transposition suture.

Case Report

A 26-year-old male patient presented to us with a history of binocular diplopia for 5 years. There was no history of trauma, ocular surgery or systemic ailment. His unaided visual acuity was 20/20 OU. He had a right esotropia of 64 PD for distance and 50 PD for near. Abduction in the right eye was restricted 4- (on a scale of 1 to 4 – [Figure 1]) with slow abduction saccades suggestive of right sixth nerve palsy. The forced duction test (FDT) for abduction was moderately positive and force generation for the right lateral rectus revealed an absent tug. Remainder of the ocular and neurological examination was unremarkable. A contrast enhanced MRI of the brain and orbit was normal.

Figure 1: Preoperative photograph showing esotropia in primary position with right abduction restriction (a) Right gaze, (b) Primary position, (c) Left gaze

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He underwent strabismus surgery in the right eye under subtenon's anesthesia. The right medial rectus was recessed 4.5 mm on an adjustable suture through an inferior fornix incision. The superior and inferior rectus muscles were approached through superotemporal and inferotemporal fornix incisions and cleared of intermuscular septa. A 5-0 polyester suture was secured on the temporal 1/3^rd of the vertical recti 8 mm from the insertion. Suture bites were then taken in the superotemporal and inferotemporal quadrants 12 mm from the limbus, a little towards (approximately 2 mm away from the center of the quadrant towards the lateral rectus) the lateral rectus. The patient was put on a tapering regime of topical steroids and antibiotics.

On the first postoperative day, he had a consecutive exotropia of 20 PD. The abduction was restricted 2- (on a scale of 1 to 4) and the adduction was restricted 3- [Figure 2]. The cornea was clear and the iris pattern was normal. He had anterior chamber cells 1+ (non- pigmented cells) and flare 1+. The cornea and iris were normal. Under surgical asepsis and topical anesthesia, the FDT for adduction was moderately positive and the FDT for abduction was negative. The superior rectus was mildly pale and the inferior rectus appeared normal. The superior rectus transposition sutures were cut. The forced duction test for adduction was repeated and was noted to be mildly positive. The medial rectus was noted at 4.5 mm from the insertion and the sutures were tied off without adjustment.

Figure 2: First day postoperative photograph showing consecutive exotropia. The abduction was restricted 2- and the adduction was restricted 3- (a) Right gaze, (b) Primary position, (c) Left gaze)

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The next day, the patient was orthophoric in primary position and the anterior chamber inflammation had resolved. Six months after surgery, the patient was orthophoric in primary position for distance and near. On right gaze, he had a residual esotropia of 20 PD and on left gaze, he had a consecutive exotropia of 10 PD. The adduction and abduction were both restricted 2—[Figure 3]. Forced duction test for adduction was moderately positive and forced duction test for abduction was negative. The patient was diplopia free in primary position and left gaze. Therefore no further intervention was advised. No torsional changes were noted on fundus examination.

Figure 3: Photograph taken three months after surgery showing orthotropia in primary position. The adduction and abduction are restricted 2- (a) Right gaze, (b) Primary position, (c) Left gaze)

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Discussion

Nishida's procedure corrects between 24 to 36 PD of esotropia in patients with non –resolving sixth nerve palsy. When combined with ipsilateral medial rectus recession, the correction achieved increases to 50-62 PD. The authors reported one patient with overcorrection of 20 PD. This patient however declined further surgical correction.^[2] The procedure has the advantage of not having to split/disinsert the extraocular muscles thereby preserving the ciliary circulation.^[1],[2] Anterior segment ischemia has not been reported after this procedure. However augmenting it by moving the transposition sutures closer to lateral rectus may risk anterior segment ischemia possibly by kinking ciliary vessels on the vertical recti. Releasing one of the transposition sutures resulted in resolution of anterior chamber reaction supporting this conclusion. Resolution of anterior segment ischemia and reversal of overcorrection by cutting Foster augmentation sutures in partial vertical rectus transposition has been previously reported.^[4] The anterior segment ischemia was very mild in our patient. Confirmation could have been done with anterior segment fluorescein angiography, but prompt resolution after removal of the sutures precluded need for the same.

Considering a preoperative positive FDT for abduction, it was decided not to advance the right medial rectus. Further a positive FDT for adduction, together with signs of anterior segment ischemia and a pale appearing superior rectus prompted us to release the transposition suture. It is likely that placing the transposition closer to the lateral rectus, rather than in the center of inferotemporal and superotemporal quadrants 10-12 mm from the limbus (as classically described)^[1],[2] resulted in the positive FDT.

Single vertical rectus (superior/inferior rectus) transposition with Foster augmentation has been described for non-resolving complete lateral rectus palsy.^[5],[6] To the best of our knowledge the same has not been reported for a Nishida type procedure. Transposing the second vertical rectus has been used to address under-corrections after single vertical rectus transposition for sixth nerve palsy. It is possible that transposing two vertical recti to the lateral rectus muscle may correct a larger deviation.^[7],[8]

Conclusion

To conclude our report suggests that single vertical rectus transposition in a Nishida type procedure with medial rectus recession for abducens nerve palsy may be effective. Overcorrections after the Nishida procedure may be relieved by cutting one transposition suture if two vertical recti have been transposed and the forced duction test for adduction is positive.

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

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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