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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 1  |  Page : 201-203

Modified split tendon nasal transposition of lateral rectus muscle in third nerve palsy


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

Date of Submission04-Jul-2021
Date of Acceptance16-Aug-2021
Date of Web Publication07-Jan-2022

Correspondence Address:
Dr. Sowmya Raveendra Murthy
Consultant, Sankara Eye Hospital, Varthur Main Road, Kundlahalli Gate, Bengaluru - 560 037, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_1790_21

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  Abstract 


Complete third nerve palsy presents with large-angle exotropia and hypotropia in varying degrees, posing a challenge for surgical correction. Nasal transposition of lateral rectus, either full tendon or split tendon or in its adjustable and enhanced modifications, have shown to correct exotropia in third nerve palsy. We present a further modification of split tendon nasal transposition of lateral rectus to correct the large vertical deviation in complete third nerve palsy.

Keywords: III nerve palsy, lateral rectus transposition, split tendon


How to cite this article:
Murthy SR. Modified split tendon nasal transposition of lateral rectus muscle in third nerve palsy. Indian J Ophthalmol Case Rep 2022;2:201-3

How to cite this URL:
Murthy SR. Modified split tendon nasal transposition of lateral rectus muscle in third nerve palsy. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Jan 23];2:201-3. Available from: https://www.ijoreports.in/text.asp?2022/2/1/201/334910



Complete third nerve palsy corrections involve either globe fixation or transposition techniques. Globe fixation in the form of a medial periosteal anchor with or without lateral periosteal fixation is established.[1],[2] While transposition techniques involving lateral rectus have rekindled interests in recent times, the split tendon nasal transposition of lateral rectus is shown to correct large horizontal deviations and smaller vertical deviations.[3],[4] The horizontal correction obtained can be further augmented by posterior fixation sutures and adjustable crossed action techniques.[5],[6]

Further, full tendon transposition of lateral rectus corrected larger vertical deviations albeit under corrections were common.[7],[8]

We report a modification of split tendon nasal transposition in which the tendons are split into one-third and two-thirds, and both split ends are attached to the upper end of medial rectus insertion to correct large hypotropia and moderate exotropia in complete third nerve palsy.


  Case Report Top


A seven-year-old girl presented with strabismus and eyelid drooping since birth. Her visual acuity was 20/20, N6 in the right eye and 20/60, N12 in the left eye. Moderate ptosis with a pseudo ptosis component was present in the left eye. Modified Krimsky test showed a left hypotropia of 50Δ with 30-35Δ exotropia. Ocular motility examination showed limited adduction of −3, limited elevation of −5, and limited depression of −3 in the left eye [Figure 1]. The anterior and posterior segments were normal. Complete congenital third nerve palsy was diagnosed in the left eye. Forced duction testing under general anesthesia was negative.
Figure 1: Nine gaze photos of the case showing hypotropia with exotropia and limited elevation, adduction, depression in the left eye

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Surgical plan of split nasal transposition of lateral rectus with modification was made.

Surgical technique

Limbal conjuctival incision was taken over the lateral rectus muscle. Lateral rectus muscle was isolated and dissected free of attachments for a distance of 15 mm behind its insertion. Muscle was split into upper 2/3rd and lower 1/3rd divisions and secured separately with 6-0 vicryl sutures. Lateral rectus muscle was disinserted, and the lower segment of the split muscle was passed underneath the inferior oblique and inferior rectus muscle and brought out on the upper border medial rectus muscle insertion through the fornicial incision. The superior oblique muscle was isolated. Instead of posterior tenectomy, a hang-back recession of 7 mm posterior fibers of the muscle was performed using nonabsorbable 5-0 ethibond sutures considering the possibility of the latter being reversible. The upper segment of the split muscle was passed below the retained anterior fibers of the superior oblique and the superior rectus muscle and brought out on the upper border of the medial rectus muscle through a superonasal fornicial incision. Both ends were sutured at the upper border of medial rectus insertion [Figure 2].
Figure 2: Illustrative diagram of modified procedure showing the upper arm (blue cross) and lower arm (yellow cross) of split lateral rectus transposed to the upper end of medial rectus insertion

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Modifications done to split tendon transposition include the following:

  1. Lateral rectus muscle was split into upper 2/3rd and lower 1/3rd segments instead of half tendon split; larger division according to vertical deviation to be corrected
  2. Hang-back recession of posterior fibers of superior oblique instead of posterior tenectomy of superior oblique
  3. Both segments of lateral rectus sutured to the upper end of medial rectus insertion to correct the hypotropia with lower segment above the upper split end [Figure 3].
Figure 3: Intraoperative pictures of the procedure. (a) Split lateral rectus tendon as lower 1/3rd and upper 2/3rd secured with sutures, (b) upper split end of lateral rectus sutured (blue cross) at the superior end of medial rectus, (c) lower split end of lateral rectus brought under medial rectus (blue cross), and (d) both upper and lower split ends sutured at the superior end of medial rectus insertion (blue and yellow cross, respectively)

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Postoperatively, the child was orthotropic on the first postoperative day. Two months postoperatively, the child had a small 8-10△ left hypotropia [Figure 4].
Figure 4: Postoperative nine gaze photos showing small hypotropia in primary gaze with limited elevation, adduction, depression, and abduction in the left eye

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Pupil evaluation, vision, and fundus examination done pre and post operatively showed no evidence of choroidal effusion or optic nerve compression.


  Discussion Top


Full-tendon lateral rectus transposition in surgical correction of III nerve palsy was first described by Taylor which was modified to a split tendon transposition by Kaufmann.[3] Gokyigit and colleagues[3] further modified this by reattaching the split ends 1 mm posterior to superior and inferior borders of the medial rectus. However, they noted an undercorrection and a need for medial rectus strengthening in half their cases.

Shah and colleagues[4] modified the Gokyigit procedure by using adjustable sutures, allowing an intraoperative adjustment and thus achieving alignment. Further, Saxena et al.[5] augmented the correction obtained with equatorial fixation sutures using nonabsorbable material on split transposed ends. They proposed that these fixation sutures made lateral rectus split to extend posterior to globe and thus was an important factor for satisfactory alignment in primary gaze.

Saxena et al.[6] further augmented the effect by crossed action adjustable suture technique in which the split ends of lateral rectus are transposed to opposite poles of medial rectus with adjustable sutures. They reported a reduction of exotropia from 86△ ±8.79△ to 1△ ±7.02△., indicating that the split tendon transposition procedures corrected large-angle exotropia and small vertical misalignments.

Morad and Nemet[7] reported results of full-tendon transposition of lateral rectus to medial rectus in one patient with combined third and fourth nerve palsy.

Saxena and colleagues[8] reported the use of full-tendon transposition to correct both horizontal and large vertical deviation simultaneously. The full tendon was transposed superiorly or inferiorly with augmentation depending on hypotropia or hypertropia in primary gaze, respectively. Three of four cases reported had large vertical deviation: one 30 △ hypotropia and two cases of 40-50 △ hypertropia. Three out of four cases showed reversal of vertical alignment with residual exotropia postoperatively pointing to the unpredictability of the procedure.

As evident from the above mentioned studies, the varied angles of hypotropia and exotropia in every case of complete third nerve palsy prompts one to search for better techniques. Split tendon seemed to correct horizontal alignment and full tendon the vertical misalignments better. So, we explored combining the effects of splitting the muscle to correct the horizontal deviation and also gain the effect of full tendon transposition to correct the vertical deviation by placing split ends at the same end of medial rectus insertion.

We choose to suture the lower half to the upper border for the following reasons;

  1. Full-tendon transposition of lateral rectus for hypotropia is described by transposing the muscle superiorly[8]; thus, taking muscle superiorly is what is needed to correct hypotropia
  2. Medial transposition of the lateral rectus is based on fact that this would give an adducting force[7]


Working on the same principles, splitting the LR muscle and transposing lower and upper halves to the upper border of medial rectus would act similar to the full tendon of lateral rectus transposed superiorly and probably provide both adducting and elevating force, thus correcting hypotropia and exotropia.

This achieved satisfactory correction for both exotropia and hypotropia in the case described.

We propose that transposing both ends of the split tendon to the upper pole of medial rectus insertion corrects hypotropia better and probably differential splitting of tendon augments this effect, subject to more case studies.


  Conclusion Top


Modified split tendon LR transposition with transposing both split ends to the upper pole of medial rectus corrects exotropia and hypotropia satisfactorily subject to more case studies.

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 Top

1.
Srivastava KK, Sundaresh K, Vijayalakshmi P. A new surgical technique for ocular fixation in congenital third nerve palsy. J AAPOS 2004;8:371-7.  Back to cited text no. 1
    
2.
Saxena R, Sinha A, Sharma P, Phuljhele S, Menon V. Precaruncular approach for medial orbital wall periosteal anchoring of the globe in oculomotor nerve palsy. J AAPOS 2009;13:578-82.  Back to cited text no. 2
    
3.
Gokyigit B, Akar S, Satana B, Demirok A, Yilmaz OF. Medial transposition of a split lateral rectus muscle for complete oculomotor nerve palsy. J AAPOS 2013;17:402-10.  Back to cited text no. 3
    
4.
Shah AS, Prabhu SP, Sadiq MAA, Mantagos IS, Hunter DG, Dagi LR. Adjustable nasal transposition of split lateral rectus muscle for third nerve palsy. JAMA Ophthalmol 2014;132:963-9.  Back to cited text no. 4
    
5.
Saxena R, Sharma M, Singh D, Dhiman R, Sharma P. Medial transposition of split lateral rectus augmented with fixation sutures in cases of complete third nerve palsy. Br J Ophthalmol 2016;100:585-7.  Back to cited text no. 5
    
6.
Saxena R, Sethi A, Dhiman R, Sharma M, Sharma P. Enhanced adjustable nasal transposition of split lateral rectus muscle for surgical management of oculomotor nerve palsy. J AAPOS 2020;24:183-6.  Back to cited text no. 6
    
7.
Morad Y, Nemet P. Medial transposition of the lateral rectus muscle in combined third and fourth nerve palsy. J AAPOS 2000;4:246-7.  Back to cited text no. 7
    
8.
Saxena R, Sharma M, Singh D, Sharma P. Full tendon medial transposition of lateral rectus with augmentation sutures in cases of complete third nerve palsy. Br J Ophthalmol 2018;102:715-7.  Back to cited text no. 8
    


    Figures

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



 

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