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      Combined Lateral Rectus Myectomy and Maximal Medial Rectus Resection in Complete Third Cranial Nerve Palsy

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          Abstract

          This study was performed to describe lateral rectus myectomy and maximal medial rectus resection for correction of eye deviation in complete third cranial nerve palsy. A retrospective review of thirteen patients (fourteen eyes) with complete third cranial nerve palsy, who underwent lateral rectus myectomy and maximal medial rectus resection, was performed. These procedures were combined with superior oblique tendon transposition in nine patients with a large angle of exotropia (more than 60 prism diopters [∆]), or significant hypotropia (more than 5 ∆). Preoperative deviations were exotropia of 50 to 120 ∆ in thirteen cases and hypotropia of 5 to 25 ∆ in eight cases. Six months after the surgery, eleven patients were within 10 ∆ of orthotropia in primary position. Revision surgery was performed for two patients, eight and 18 months after the first operation. Eventually, five patients (38%) achieved orthotropia in the primary position, and seven patients (54%) had < 11 ∆ exotropia and < 6 ∆ vertical deviation. In conclusion, this procedure can be considered as an acceptable approach for treatment of strabismus in complete third cranial nerve palsy. This procedure is simple and can be easily performed even in very young children.

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          Most cited references18

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          Rectus muscle orbital wall fixation: a reversible profound weakening procedure.

          Surgical treatment of third nerve palsy, sensory exotropia and strabismus secondary to anomalous innervation of the rectus muscles, frequently require large rectus muscle recessions in an attempt to maintain alignment in the primary position and reduce the effects of misinnervation. The aim of this study was to describe and evaluate the results of inactivation of a rectus muscle by its attachment to the adjacent orbital wall. Seven subjects diagnosed with third-nerve palsy (three cases), Duane syndrome (two cases), sensory exotropia (one case), and congenital aberrant innervation of vertical rectus muscles (one case) underwent rectus muscle inactivation by orbital wall fixation. The rectus muscle was disinserted from the globe and reattached to the adjacent orbital periosteum using non-absorbable sutures. This surgery was performed on the lateral rectus muscle in six subjects, and surgery was performed on both ipsilateral vertical rectus muscles in one. Postoperatively four of six patients were aligned within 12 prism diopters of orthotropia in primary position. All patients had improvement of the anomalous head posture. In Duane syndrome, lateral rectus inactivation markedly reduced co-contraction and globe retraction. No overcorrections resulted. A rectus muscle may be functionally inactivated when its insertion is attached to the orbital periosteum. Advantages of this procedure over extirpation and free tenotomy include permanent disinsertion of the muscle from globe and reversibility.
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            Superior oblique transposition for third nerve palsy.

            Four eyes of three adult patients underwent anterior transposition and advancement of the superior oblique tendon without trochleotomy in the surgical management of oculomotor nerve palsy. In each of the cases, this procedure proved unsatisfactory, either because of inadequate horizontal alignment, postoperative hyperdeviations, or paradoxical ocular movements. Even in these difficult cases, "supermaximum" horizontal rectus muscle surgery appeared to result in satisfactory ocular alignment.
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              Periosteal fixation in third-nerve palsy.

              We present a new technique of anchoring the eyeball to the nasal periosteum using a nonabsorbable suture in acquired isolated third-nerve paresis. This was a case series of 4 consecutive adult subjects with isolated third-nerve paresis. After a 12-mm lateral rectus muscle recession in all 4 subjects, we passed 5-O double-armed polyester (NW683 Ethibond; Ethicon, Division of Johnson and Johnson Ltd., Aurangabad, India) on spatulated needles through the periosteum overlying the anterior lacrimal crest (exposed as in a Dacryocystorhinostomy procedure) at its superior part. The needles were brought anterior to the medial rectus muscle insertion and tightened enough to align the eye in 8-10 prism diopters adducted position. Ocular alignment in the primary gaze was satisfactory at 6-12 months of follow up. The use of a nonabsorbable polyester suture to anchor the globe to the nasal periosteum is an additional technique that holds promise to align the eyes in the primary gaze.
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                Author and article information

                Journal
                Med Hypothesis Discov Innov Ophthalmol
                mehdiophth
                Medical Hypothesis, Discovery and Innovation in Ophthalmology
                Medical Hypothesis, Discovery & Innovation Ophthalmology
                2322-4436
                2322-3219
                Summer 2018
                : 7
                : 2
                : 83-88
                Affiliations
                [1 ]Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
                [2 ]Kerman University of Medical Sciences, Kerman, Iran
                Author notes
                [* ]Correspondence to: Majid Farvardin, MD, Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences , Zand Avenue, Shiraz, Iran. E-mail: farvardi@sums.ac.ir
                Article
                mehdiophth-7-083
                6146238
                b8156598-a197-4cb2-9aae-06a6ed945980
                ©2018, Med Hypothesis Discov Innov Ophthalmol.

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial 3.0 License (CC BY-NC 3.0) ( https://creativecommons.org/licenses/by-nc/3.0/) which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly.

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                Categories
                Original Article

                exotropia,lateral rectus myectomy,medial rectus resection,third cranial nerve palsy

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