Dr.Esha Jamal, E21644, Dr.S Priya
The goal of surgical intervention in lateral rectus palsy is two fold: improvement in primary position deviation and abduction improvement. Transposition of vertical recti is a common procedure for non recovered lateral rectus palsy. We compared Nishida’s transposition (NT)with partial vertical rectus (VRT) transposition for abduction improvement &primary position alignment.
A total of 20 patients with non-recovered Lateral rectus palsy were selected. Mean age was 46.5 +/- 11.6 years. Mean preoperative angle in NT group was 44.5+/- 5.9 prism diopters (pd) & in VRT group was 45.5 +/- 5.9 pd. Mean improvement in in primary position was 38.4 +/- 4.9 pd& 40.5 +/- 1.8 in NT and VRT group. Mean followup was 14.1 +/- 6.7 months.
The mean abduction preoperative in NT group was 2.35 +/- 0.7 mm & VRT group was 2.6 +/- 0.8 mm. The mean improvement in abduction was 2.4 +/- 0.6 mm & 3.55 +/- 0.4 mm in NT and VRT group.The improvement in angle was comparable in both group. The partial VRT group showed statistically significant improvement in abduction compared to NT.
For improvement in abduction in a lateral rectus palsy patient, partial VRT should be done.
A sixth nerve palsy results in abduction restriction of the eye along with esotropia in primary position. The palsy could be complete (palsy) or incomplete (paresis). The abduction restriction in sixth nerve palsy is variable. Multiple procedures like full tendon transposition, partial transposition, Nishida’s transposition and Jensen’s transposition have been described. We compared the efficacy of partial vertical rectus transposition with Nishida’s transposition with Medial rectus recession in patients having abduction restriction due to sixth nerve palsy.
Materials and Methods
A total of 20 patients with non-recovered Lateral rectus palsy were selected. Mean age was 46.5 +/- 11.6 years. All patients were diagnosed cases of 6th nerve palsy. All patients underwent surgery by the first author (JJ) by the standard technique as described elsewhere. 1-4The motility and abduction deficit was measured by the ocular motility tester in millimetres.
The patients were seen postoperatively and were followed up at day 1, day 30, 3 months, 6 months. Mean followup was 14.1 +/- 6.7 months.
At all followups the amount of deviation was measured in primary position and abduction was measured in milimeters
Results
Mean preoperative angle in NT group was 44.5+/- 5.9 prism diopters (pd) & in VRT group was 45.5 +/- 5.9 pd. Mean improvement in in primary position was 38.4 +/- 4.9 pd& 40.5 +/- 1.8 in NT and VRT group.
The mean abduction preoperative in NT group was 2.35 +/- 0.7 mm & VRT group was 2.6 +/- 0.8 mm. The mean improvement in abduction was 2.4 +/- 0.6 mm & 3.55 +/- 0.4 mm in NT and VRT group. The improvement in angle was comparable in both group. The partial VRT group showed statistically significant improvement in abduction compared to NT.
Discussion
Various procedures for improvement in esotropia following sixth nerve palsy have been described. However, the abduction improvement post surgery is also an important goal and less studied one. del Pilar González M and Kraft compared the results of various procedures for lateral rectus paresis. They used the 0 to -4 classification for abduction improvement and showed some improvement postoperatively. They didn’t include Nishida’s transposition in their study. Partial vertical rectus transposition involves partial tendon transfer and therefore a theoretical risk of anterior segment ischemia. Nishida’s transposition has off late become a good vessel sparing option for lateral rectus palsy. The improvement in primary position is significant as described by Nishida et al. 2-4However, the abduction improvement has not been much and the comparison between a partial tendon transposition has not been done.
Our study clearly shows that a mean improvement of 3.55 mm in abduction appears postoperatively after vertical rectus parital tendon transfer. The Nishida’s transposition shows an improvement of around 2.4 mm
The improvement in angle was comparable in both group (p =0.29 not significant). The partial VRT group showed statistically significant improvement in abduction compared to NT (p=0.00).
Conclusion
Although the improvement is similar in both the transposition groups the abduction improvement is greater when a partial vertical rectus transposition is done compared to Nishida’s transposition
References
- del Pilar González M, Kraft SP. Outcomes of three different vertical rectus muscle transposition procedures for complete abducens nerve palsy. J AAPOS. 2015 Apr;19(2):150-6.
- 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.
- Higashiyama T, Nishida Y, Muraki S, Ohji M. Long-Term Outcomes of Three Cases That Underwent a Muscle Transposition Procedure WithoutTenotomy Caused by Abducens Palsy. Neuroophthalmology. 2014 Nov 24;39(1):26-29.
- Nishida Y, Inatomi A, Aoki Y, Hayashi O, Iwami T, Oda S, Nakamura J, Kani K. 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 May-Jun;47(3):281-6
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