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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 732-735

Modified Nishida: An innovative approach to tackle third nerve palsy


Department of Ophthalmology, Paediatric and Squint Services, B. W. Lion's Super-Speciality Eye Hospital, Bengaluru, Karnataka, India

Date of Submission24-Nov-2021
Date of Acceptance19-Mar-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Sonali Rao
SA 601, Shriram Surabhi Apts, Mallasandra Village, Holiday Village Road, Off Kanakpura Road, Bengaluru - 560 062, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2956_21

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  Abstract 


It is commonly acknowledged that surgery for correction of strabismus associated with third nerve palsy can be very challenging for an ophthalmologist. Understanding the difficulties, we present modified Nishida, an innovative approach to tackle third nerve palsy. The exotropia with hypotropia in an 8-year-old child with RE congenital third nerve palsy was corrected by a single-staged surgery – LR recession + MR plication + modified Nishida, followed by correction of severe ptosis with frontalis sling surgery 2 months after squint surgery. This innovative, simple, and effective technique with no anterior segment ischemia, giving adequate alignment and good stereopsis, is worth bearing in mind while tackling third nerve palsy.

Keywords: Exotropia, hypotropia, modified Nishida, ptosis, third nerve palsy


How to cite this article:
Rao S, Gupta A. Modified Nishida: An innovative approach to tackle third nerve palsy. Indian J Ophthalmol Case Rep 2022;2:732-5

How to cite this URL:
Rao S, Gupta A. Modified Nishida: An innovative approach to tackle third nerve palsy. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 30];2:732-5. Available from: https://www.ijoreports.in/text.asp?2022/2/3/732/351162



The surgery for correction of paralytic strabismus associated with third nerve palsy is generally accepted to be very challenging for an ophthalmologist,[1],[2] where any procedure employed aims at attaining adequate alignment of the two eyes in the primary gaze.[2]

Depending on the extent of extraocular muscle involvement, horizontal deviations can be corrected by (a) recession–resection, (b) transposition procedures, and (c) globe fixation procedures.[2] For the correction of vertical incomitance, we have (a) recession–resection of vertical recti, (b) advancement or weakening of superior oblique,[3] and (c) full tendon supra or infra displacement of horizontal recti.[3]

Several staged procedures are required to accomplish an optimal correction to assess results prior to considering further options and to avoid anterior segment ischemia.[2]

Understanding the difficulties, we present modified Nishida, an innovative approach to tackle third nerve palsy.


  Case Report Top


An 8-year-old child presenting with RE congenital third nerve palsy, with BCVA 6/24p in RE which improved to 6/12 after left eye patching, was subjected to thorough refraction and preoperative evaluation. An informed consent was obtained from the parents/guardian to use the images and clinical information for reporting.

RE showed severe ptosis with exotropia and hypotropia with good Bell's phenomenon. Pupil had anisocoria and fundus examination revealed intorsion.

As the RE was not able to adduct to midline, Krimsky's test was done, which showed a 35 PD of exotropia with 12 PD of L/R vertical deviation.

On extraocular movement evaluation, [Figure 1] RE showed a −5 limitation of superior rectus (SR), −4 limitation of medial rectus (MR), −3 limitation of inferior rectus (IR), and +4 movement of superior oblique (SO) and lateral rectus (LR). Thus, the functioning muscles of RE were LR, SO, and to some extent IR.
Figure 1: Extraocular movements of a patient with congenital third nerve palsy

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The LE was within normal limits with a BCVA of 6/6.

The surgical plan was aimed at correction of the RE exotropia and hypotropia, followed by ptosis correction.

Surgical procedure

Through a limbal conjunctival incision, the LR was approached and recessed by 9 mm, [Figure 2]a following which the MR was approached through a limbal conjunctival incision and plicated by 6 mm [Figure 2]b, consequently correcting the exotropia.
Figure 2: Surgical Procedure. (a) First step: Lateral rectus recession by 9 mm. (b) Second step: Medial rectus plication by 6 mm. (c) Third step: Modified Nishida's procedure to correct hypotropia. (d) Frontalis sling surgery to correct ptosis after 2 months of squint correction

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Next, to correct the hypotropia, 5-0 non-absorbable sutures were passed 10 mm behind the insertions of MR and LR and sutured in superonasal and superotemporal quadrant 12 mm from the limbus, respectively. The modified Nishida's procedure was thus performed [Figure 2]c.

Frontalis sling surgery was performed after 2 months of squint correction to correct the ptosis [Figure 2]d.


  Discussion Top


In the management of third nerve palsy, although several techniques have been described over the years, the outcomes have been less than satisfactory, with residual deviations in primary gaze or postoperative drifts.[4] Hence, the best surgical treatment technique remains divisive.[5]

Because the management depends on the extent of extraocular muscle involvement,[2] there are no adequate approaches to reinstate the sensory-motor balance.[6] Therefore, some authors endorse performing simple surgical procedures to avoid the undesirable side effects of more aggressive techniques.[6]

Considering our case of congenital third nerve palsy where the child lacked binocularity, we chose to proceed with surgery. As the functioning muscles of RE were LR, SO, and to some extent, IR, a decision to spare the IR was made because the muscle would be needed for reading. We performed a single-staged surgery – LR recession + MR plication + modified Nishida to correct the strabismus (exotropia + hypotropia).

Thus, similar to other paralytic strabismus management, where the surgeon has to balance the muscular forces acting on the globe,[2],[5] consequently eliminating the diplopia, achieving a good cosmetic appearance in the primary position, and if possible, restoring adduction function or creating or relocating a binocular single-vision area to the most suitable place for the patient,[5] we achieved the same.

An adequate alignment of the two eyes in the primary gaze [Figure 3] along with good results from the sling surgery was achieved [Figure 4], which was stable during the 1-year follow up period. The child was orthophoric for distance and near, with good stereopsis up to 100s of arc postoperatively. With this single-staged, simple, and effective technique, we had the benefit of operating on only two muscles, thereby preventing anterior-segment ischemia.
Figure 3: Extraocular movements in 9 gazes after squint correction, showing adequate alignment of the two eyes in primary gaze

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Figure 4: Patient with congenital third nerve palsy. (a) Preoperative; (b) Postoperative after squint and ptosis correction

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In 2003, when Nishida et al.[7] innovated a technique and later modified it in 2013,[8] it was to treat abducens nerve palsy.[9] They concluded that the modified procedure was simple to perform, requiring no tenotomy and splitting of muscles,[9] and its efficacy in treating abducens palsy was seconded by Murthy.[9]

Now, for the first time, modified Nishida's technique has been employed to manage a third nerve palsy, thereby broadening the utility horizons of this technique.


  Conclusion Top


Modified Nishida's procedure is a simple and effective technique worth bearing in mind while tackling third nerve palsy.

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.
Noonan CP, O'Connor M. Surgical management of third nerve palsy. Br J Ophthalmol 1995;79:431-4.  Back to cited text no. 1
    
2.
Ganger A, Yadav S, Singh A, Saxena R. A Comprehensive Review on the Management of III Nerve Palsy. DJO 2016;27:86-91.  Back to cited text no. 2
    
3.
Lee V, Bentley CR, Lee JP. Strabismus surgery in congenital third nerve palsy. Strabismus 2001;9:91-9.  Back to cited text no. 3
    
4.
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. 4
    
5.
Eraslan M, Cerman E, Onal S, Ogut MS. Superior oblique anterior transposition with horizontal recti recession-resection for total third-nerve palsy. J Ophthalmol 2015;2015:780139. doi: 10.1155/2015/780139.  Back to cited text no. 5
    
6.
Merino P, Gutierrez C, de Liaño PG, Srur M. Long term outcomes of strabismus surgery for third nerve palsy. J Optom 2019;12:186-91.  Back to cited text no. 6
    
7.
Nishida Y, Inatomi A, Aoki Y, Hayashi O, Iwami T, Oda S, et al. A muscle transposition procedure for abducens palsy, in which the halves of the vertical rectus muscle bellies are sutured onto the sclera. Jpn J Ophthalmol 2003;47:281-6.  Back to cited text no. 7
    
8.
Muraki S, Nishida Y, Ohji M. Surgical results of a muscle transposition procedure for abducens palsy without tenotomy and muscle splitting. Am J Ophthalmol. 2013 Oct;156(4):819-24  Back to cited text no. 8
    
9.
Murthy SR. No split, no tenotomy transposition procedure for complete abducens palsy. Indian J Ophthalmol 2017;65:636-8.  Back to cited text no. 9
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