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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 4  |  Page : 944-947

Modified Nishida procedure for hypertropia following traumatic laceration of the inferior rectus

1 Pediatric Ophthalmology and Strabismus Services, MGM Eye Institute, Raipur, Chhattisgarh, India
2 Cornea and Anterior Segment Services, MGM Eye Institute, Raipur, Chhattisgarh, India

Date of Submission23-Mar-2022
Date of Acceptance08-Jul-2022
Date of Web Publication11-Oct-2022

Correspondence Address:
Dr. Anupam Sahu
MGM Eye Institute, 5th Mile, Vidhan Sabha Road, Raipur - 493 111, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_723_22

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Isolated inferior rectus transection is a rare outcome of ocular trauma, leading to hypertropia and debilitating diplopia in primary and reading positions. The modified Nishida procedure is an easy-to-perform, minimally traumatizing, reversible, ciliary vessel sparing muscle transposition procedure that is ideal for post-traumatic scenarios. We report our experience with the modified Nishida procedure in a case of a lost inferior rectus after traumatic laceration.

Keywords: Inferior rectus, modified Nishida procedure, muscle transposition, trauma

How to cite this article:
Sahu A, Agrawal D. Modified Nishida procedure for hypertropia following traumatic laceration of the inferior rectus. Indian J Ophthalmol Case Rep 2022;2:944-7

How to cite this URL:
Sahu A, Agrawal D. Modified Nishida procedure for hypertropia following traumatic laceration of the inferior rectus. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Nov 27];2:944-7. Available from: https://www.ijoreports.in/text.asp?2022/2/4/944/358183

Isolated transection of the inferior rectus muscle is the rare outcome of a surgical procedure gone wrong or trauma.[1],[2] Following trauma, transection of the inferior rectus has been commonly described in the setting of orbital floor fracture and less commonly without significant involvement of the globe, orbit, or adnexa.[2],[3]

Trauma can lead to disinsertion of the muscle tendon or laceration/rupture of the inferior rectus belly. The induced hypertropia and the consequent diplopia and cosmetic disfigurement usually warrant surgical intervention. Re-attachment of a disinserted muscle tendon can usually be attempted early because the posterior retraction of the inferior rectus is limited by the pulleys and orbital ligaments to which it is attached.[4] The lacerated or ruptured muscle belly is usually difficult to find, and in such cases, horizontal rectus muscle transposition or anterior transposition of inferior oblique is attempted.[1],[2],[3],[5] However, rectus muscle transposition carries with it the risk of anterior segment ischemia, and inferior oblique anterior transposing has been known to cause anti-elevation syndrome.[2],[5]

Since the modified Nishida procedure was described in 2005 for abducens palsy, this 'no tenotomy, no splitting' muscle transposition procedure has been attempted under several other conditions.[6] Successful results have been obtained in Type 1 Duane's syndrome, monocular elevation deficiency, and medial rectus transection following endoscopic sinus surgery.[7],[8],[9] Herein, we present the first reported case of inferior rectus transection corrected using the modified Nishida procedure.

  Case Report Top

A 38-year-old male presented with an upward deviation of the left eye and associated diplopia in all gazes, following a road traffic accident 22 days back. Following the trauma, he had a penetrating trauma over the orbital margin inferiorly, which was sutured elsewhere. Computed tomography (CT) scan orbit was performed then, which showed mild diffuse periorbital soft tissue thickening around the left eye with normal globes and the bony orbit. The extra-ocular muscles appeared to be normal.

On examination, his visual acuity was 20/20, N6 in the right eye. The left eye vision was 20/30, N12. Contrast sensitivity was slightly reduced in the left eye (1.35 log unit) on the Pelli Robson chart. Color vision was normal on Ishihara charts with no relative afferent pupillary defect. The left eye conjunctiva showed congestion with fibrosis around inferior rectus insertion [Figure 1]a. The iris showed multiple sphincter tears from 2 to 10 o'clock with an irregular mid-dilated pupil. Ocular motility examination revealed left hypertropia with -4 limitation of depression in all downward gazes [Figure 2]. The prism cover test revealed 35 prism diopter (PD) hypertropia in the left eye with 8 PD exotropia in the primary position for distance and near. The hypertropia increased to 40 PD in downgaze and reduced to 25 PD in upgaze. Posterior segment findings were within normal limits. The forced duction test indicated moderate restriction in depression under both topical and later, local anesthesia. The force generation test was negative for the inferior rectus in the left eye.
Figure 1: (a) Congestion and scarring near the inferior rectus muscle insertion site. (b) Thin pseudo-tendon attached to inferior rectus insertion

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Figure 2: Pre-operative nine gaze photograph showing left eye hypertropia in the primary position with -4 limitation of movement in depression

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On surgical exploration of the left eye, dense fibrosis was noticed near inferior rectus insertion. Limbal peritomy from 4 to 8 o'clock was made, and careful dissection was performed to remove the fibrotic tissue. Near inferior rectus insertion, a pseudo-tendon was noticed [Figure 1]b. Careful posterior exploration beyond the inferior oblique muscle did not reveal any signs of the inferior rectus. The repeat forced duction test was negative, suggesting fibrosis near inferior rectus insertion as the cause for restriction in the downward gaze. The re-attached pseudo-tendon was unlikely to correct the large hypertropia in the primary position, and it was decided to go ahead with the muscle transposition procedure. To minimize the risk of anterior segment ischemia, the modified Nishida procedure was planned.[6] The horizontal recti were exposed, and 5-0 polyester sutures were woven through their inferior thirds, 10 mm behind insertion. Scleral bites were taken with the same sutures 12 mm from the limbus in the inferonasal and inferotemporal quadrants midway between the horizontal recti and inferior rectus.

The patient was comfortable on the first post-operative day with significant improvement in hypertropia. At 1 month, he had no complaints of diplopia in the primary position, with only occasional diplopia in the downgaze. The left eye showed inferior scleral show, suggesting lower lid retraction. Ocular motility examination showed improvement in the downgaze with -1 limitation of movement [Figure 3]. Prism cover test was orthophoric for distance and near in the primary position with 6 PD hypertropia in the downgaze.
Figure 3: Post-operative nine gaze photograph showing left eye inferior scleral show with orthotropia in the primary position and -1 limitation of movement in depression

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  Discussion Top

Isolated trauma to the inferior rectus can lead to debilitating diplopia because vision is usually spared. Transposition of the horizontal recti provides a viable alternative in cases where primary re-attachment of the inferior rectus is not possible. Kowal et al.[1] in 1998 described the use of the modified inverse Knapp procedure for the inferior rectus transected during strabismus surgery. Only one patient achieved orthotropia in the primary position after the primary surgery with others needing prisms or repeat surgery. Paysse et al.[3] performed the modified Jensen procedure on two patients. Both had persistent over-correction; one was corrected with prisms, and the other underwent another eye superior rectus recession. In the case where pre-operative deviation could be noted, they noted a correction of 40 PD. Batra et al.[2] reported good alignment with the Hummelsheim-type split tendon transposition procedure. In their case, 16 PD hypertropia was corrected fully after the procedure.

Anterior segment ischemia because of strabismus surgery occurs in 1/13000 to 1/30000 cases, and the risk of potential ischemia is higher when vertical muscles are tenotomized.[10] This risk theoretically increases whenever muscle transposition is attempted in the setting of inferior rectus trauma. The modified Nishida procedure is the least traumatizing ciliary vessel sparing muscle transposition procedure. Traumatic cases have unpredictable outcomes, and the easily reversible nature can be a savior. Under other conditions, this procedure has been proven to be highly effective. Muraki et al.[6] noted a correction of 24 to 36 PD with transposition alone in abducens palsy. Murthy et al.[8] noted a correction of 24 PD hypotropia in monocular elevation deficiency by transposition alone. In our case of the lost inferior rectus following traumatic laceration, we achieved a correction of 35 PD in the primary position and 36 PD in the downgaze.

  Conclusion Top

The modified Nishida procedure provides an easy, effective, and reversible option for muscle transposition in the setting of traumatic isolated rectus transection.

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

Kowal L, Wutthiphan S, McKelvie P. The snapped inferior rectus. Aust N Z J Ophthalmol 1998;26:29-35.  Back to cited text no. 1
Batra R, Gao A, Shun-Shin GA. The management of traumatic isolated inferior rectus rupture. Strabismus 2012;20:105-8.  Back to cited text no. 2
Paysse EA, Saunders RA, Coats DK. Surgical management of strabismus after rupture of the inferior rectus muscle. J AAPOS 2000;4:164-7.  Back to cited text no. 3
Zuo X, Gao L, Bao L, Chunyan L. Surgical repair of traumatic isolated inferior rectus muscle avulsion. Eur J Ophthalmol 2019;29:106-9.  Back to cited text no. 4
Aguirre-Aquino BI, Riemann CD, Lewis H, Traboulsi EI. Anterior transposition of the inferior oblique muscle as the initial treatment of a snapped inferior rectus muscle. J AAPOS 2001;5:52-4.  Back to cited text no. 5
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;156:819-24.  Back to cited text no. 6
Tanaka M, Nishina S, Ogonuki S, Akaike S, Azuma N. Nishida's procedure combined with medial rectus recession for large-angle esotropia in Duane syndrome. Jpn J Ophthalmol 2011;55:264-7.  Back to cited text no. 7
Murthy SR, Pappuru M. Modified Nishida's procedure for monocular elevation deficiency. J AAPOS 2018;22:327-9.e1.  Back to cited text no. 8
Kong M, Zhang LJ, Dai S, Li JH. A new application of modified Nishida muscle transposition procedure for medial rectus muscle transection following endoscopic sinus surgery without tenotomy or splitting muscles. J AAPOS 2019;23:287-9.  Back to cited text no. 9
Pineles SL, Chang MY, Oltra EL, Pihlblad MS, Davila-Gonzalez JP, Sauer TC, et al. Anterior segment ischemia: Etiology, assessment, and management. Eye (Lond) 2018;32:173-8.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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