|
 
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| CASE REPORT |
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| Year : 2023 | Volume
: 3
| Issue : 2 | Page : 488-489 |
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Surgical management of partial third nerve palsy in a single setting
Vidhya Chandran, N Nishant
Department of Pediatric Ophthalmology and Strabismus, Sankara, Eye Hospital, Bangalore, Karnataka, India
| Date of Submission | 09-Oct-2022 |
| Date of Acceptance | 13-Dec-2022 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Vidhya Chandran
Department of Pediatric Ophthalmology and Strabismus, Sankara, Eye Hospital, Bangalore, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/IJO.IJO_2634_22
We report a case of a middle-aged woman who presented to us 8 months after a road traffic accident with the complaint of binocular diplopia. She had limitation of elevation and depression of OD with ptosis, which improved on OD adduction. She underwent (OD) lateral rectus (LR) transposition to superior rectus with Foster augmentation, (OS) LR recession under adjustable suturing technique – 9 mm (5 + 4), and medial rectus (MR) plication 6 mm under local anesthesia. LR was re-recessed by 1 mm the next day. Postoperatively, at 3 months, prism bar cover test showed orthophoria for distance and near in primary gaze with − 3 limitation of elevation in OD.
Keywords: Fixation duress, inverse Duane's sign, pseudo-Von Graefe's sign, surgical management, third nerve palsy
How to cite this article:
Chandran V, Nishant N. Surgical management of partial third nerve palsy in a single setting. Indian J Ophthalmol Case Rep 2023;3:488-9 |
Management of third nerve palsy is the most difficult one among the three oculomotor nerves, as it supplies four of the six extraocular muscles in addition to the levator palpebrae superioris. Other associated findings like pupil involvement, aberrant regeneration, superior oblique overaction, and lateral rectus (LR) contracture may further complicate the management. Third nerve palsy contributes to 17%–41.7% of all ocular nerve palsies.[1],[2] The most common etiologies of third nerve palsy are trauma, ischemia, neoplasm, aneurysm, and undetermined causes.[3],[4] Secondary aberrant regeneration of third nerve is seen after trauma and tumor compression, but never after ischemic third nerve paresis.
Here, we report a case of partially resolved third nerve palsy with ptosis and aberrant regeneration managed with a single-setting strabismus surgery.
| Case Report | |  |
A 41-year-old female presented to us with a history of road traffic accident and head trauma 10 months back. She had loss of consciousness for 1 day along with complete inability to open the right eye for 3 months following the injury, which started slowly recovering. She now complained of binocular diplopia with horizontal and vertical separation of images. On examination, her best corrected visual acuity was 6/9, N6 (OD) and 6/6 N6 (OS). There was a slight left face turn. Prism bar cover test (PBCT) revealed primary deviation of 30 PD exotropia/15–20 PD L/R and 30 PD exotropia/12–15 PD L/R for distance and near, respectively, in primary gaze. The measurements persisted the same even during the next visit after 2 months. Ocular motility showed − 4 limitation of elevation and –1 limitation of depression of right eye [Figure 1]. There was no limitation of adduction and abduction in OD. Palpebral fissure height in the right eye was increased on adduction (inverse Duane's sign), and there was a lid lag on down gaze (pseudo-Von-Graefe's sign). There was moderate ptosis of the right upper eyelid in primary gaze. Anterior and posterior segment examination of both eyes was normal. | Figure 1: Preoperative photos showing limitation of elevation and depression of the right eye with ptosis in primary gaze; the palpebral fissure height was increased on adduction
Click here to view |
She underwent (OD) LR transposition to superior rectus with Foster augmentation, (OS) LR hemi-hangback (4 + 5) recession under adjustable suture 9 mm, and medial rectus (MR) plication 6 mm under local anesthesia. LR was re-recessed by 1 mm the next day under topical anesthesia. Postoperatively, at 3 months, PBCT showed orthophoria for distance and near in primary gaze. There was no abnormal head posture. There was − 3 limitation of elevation and − 1 limitation of depression with full adduction and abduction movements in OD. There was improvement in ptosis in OD [Figure 2]. The patient was comfortable without any diplopia. | Figure 2: Postoperatively, at 3 months, PBCT showed orthophoria for distance and near in primary gaze with − 3 limitation of elevation in OD. PBCT = prism bar cover test
Click here to view |
| Discussion | | |
Management of third nerve palsy presents a difficult surgical challenge as multiple extraocular muscles are involved. Replacing all the lost rotational forces on the globe is impossible; hence, the goal of surgery is adequate alignment for binocular function in the primary position and in slight downgaze for reading. Selection of the surgical procedure depends on the number of involved muscles and their condition, as well as the presence or absence of aberrant regenerations. Basic options in the management of third nerve palsy are a) maximal recession–resection of horizontal recti (same or the other eye), b) LR periosteal fixation + large MR resection, c) globe anchor to the medial orbital wall + large LR recession, and d) medial transposition of LR. Some of the commonly performed surgeries for third nerve palsy are presented in [Table 1].
Saxena et al.[9] modified medial transposition of LR by adding a Foster suture to have a larger transfer of the posterior vector. In case of large horizontal deviation with vertical deviation, full tendon transposition of LR with augmentation sutures from the side opposite to vertical deviation, that is, from inferiorly in hypertropia and from superiorly in hypotropia, can be done.[10]
In the present case, we have utilized the aberrant regeneration of inverse Duane's sign to correct the ptosis along with strabismus. Here, we have managed to correct the associated hypotropia by shifting only one muscle, that is, the LR to superior rectus insertion, with Foster augmentation, so that we have other muscles intact to proceed with second surgery if required.
In incomplete third nerve palsy with aberrant regeneration (inverse Duane's sign) and hypotropia, ipsilateral LR transposition to superior rectus (to correct the vertical misalignment) with contralateral recess resect procedure is effective in maintaining alignment, as we did in our case.
| Conclusion | | |
In patients with third cranial nerve palsy, management should be individualized depending on the functioning muscles and presence or absence of aberrant regeneration.
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 | | |
| 1. | Berlit P. Isolated and combined pareses of cranial nerves III, IV and VI a retrospective study of 412 patients. J Neurol Sci 1991;103:10-5.  |
| 2. | Tiffin P, MacEwen C, Craig E, Clayton G. Acquired palsy of the oculomotor, trochlear and abducens nerves. Eye 1996;10:377-84. |
| 3. | Rucker CW. The causes of paralysis of the third, fourth and sixth cranial nerves. Am J Ophthalmol 1966;61:1293-8. |
| 4. | Rush JA. Causes and prognosis in 4,278 cases of paralysis of the oculomotor, trochlear, and abducens cranial nerves. Am J Ophthalmol 1992;114:777-8. |
| 5. | 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. |
| 6. | Fraco JN. Surgical management of oculomotor nerve palsy with lateral rectus transplantation to the medial side of globe. Aust N Z J Ophthalmol 1989;17:27-32. |
| 7. | Kaufmann H. “ Lateralis splitting” in total oculomotor paralysis with trochlear nerve paralysis. Fortschr Ophthalmol 1991;88:314-6. |
| 8. | Fouad HM, Kamal AM, Awadein A, Del Monte MA. Contralateral surgery for the treatment of third nerve palsy with aberrant regeneration. Am J Ophthalmol 2021;222:166-73. |
| 9. | 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. |
| 10. | 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. |
[Figure 1], [Figure 2]
[Table 1]
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