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Original Investigation |

Adjustable Nasal Transposition of Split Lateral Rectus Muscle for Third Nerve Palsy

Ankoor S. Shah, MD, PhD1,3; Sanjay P. Prabhu, MBBS, FRCR2,4; Mohammad Ali A. Sadiq, MD1,3; Iason S. Mantagos, MD1,3; David G. Hunter, MD, PhD1,3; Linda R. Dagi, MD1,3
[+] Author Affiliations
1Department of Ophthalmology, Boston Children’s Hospital, Boston, Massachusetts
2Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
3Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
4Department of Radiology, Harvard Medical School, Boston, Massachusetts
JAMA Ophthalmol. 2014;132(8):963-969. doi:10.1001/jamaophthalmol.2014.756.
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Importance  Third nerve palsy causes disfiguring, incomitant strabismus with limited options for correction.

Objective  To evaluate the oculomotor outcomes, anatomical changes, and complications associated with adjustable nasal transposition of the split lateral rectus (LR) muscle, a novel technique for managing strabismus associated with third nerve palsy.

Design, Setting, and Participants  Retrospective medical record review appraising outcomes of 6 consecutive patients with third nerve palsy who underwent adjustable nasal transposition of the split LR muscle between 2010 and 2012 with follow-up of 5 to 25 months at a tertiary referral center.

Intervention  Adjustable nasal transposition of the split LR muscle.

Main Outcomes and Measures  The primary outcome was postoperative horizontal and vertical alignment. Secondary outcomes were (1) appraising the utility of adjustable positioning, (2) demonstrating the resultant anatomical changes using magnetic resonance imaging, and (3) identifying associated complications.

Results  Four of 6 patients successfully underwent the procedure. Of these, 3 patients achieved orthotropia. Median preoperative horizontal deviation was 68 prism diopters of exotropia and median postoperative horizontal deviation was 0 prism diopters (P = .04). Two patients had preoperative vertical misalignment that resolved with surgery. All 4 patients underwent intraoperative adjustment of LR positioning. Imaging demonstrated nasal redirection of each half of the LR muscle around the posterior globe, avoiding contact with the optic nerve; the apex of the split sat posterior to the globe. One patient had transient choroidal effusion and undercorrection. Imaging revealed, in this case, the apex of the split in contact with the globe at an anterolateral location, suggesting an inadequate posterior extent of the split. In 2 patients, the surgical procedure was not completed because of an inability to nasally transpose a previously operated-on LR muscle.

Conclusions and Relevance  Adjustable nasal transposition of the split LR muscle can achieve excellent oculomotor alignment in some cases of third nerve palsy. The adjustable modification allows optimization of horizontal and vertical alignment. Imaging confirms that the split LR muscle tethers the globe, rotating it toward primary position. Case selection is critical because severe LR contracture, extensive scarring from prior strabismus surgery, or inadequate splitting of the LR muscle may reduce the likelihood of success and increase the risk of sight-threatening complications. Considering this uncertainty, more experience is necessary before widespread adoption of this technique should be considered.

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Figures

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Figure 1.
Schematic Interpretation of Nasal Transposition of the Split Lateral Rectus (LR) Muscle

A, Anterior view, left eye. Left panel shows passage of Gass muscle hook after LR muscle has been detached and split; right panel shows position of upper and lower muscle halves adjacent to medial rectus (MR) insertion. B, Superior and inferior views of the left eye after transposition is complete. The superior view demonstrates the course of the LR muscle under the superior oblique tendon; the inferior view shows the course behind the inferior oblique muscle. The presumed orbital pulley directs the LR muscle forward before it courses behind the globe. IO indicates inferior oblique muscle; IR, inferior rectus muscle; SO, superior oblique muscle; and SR, superior rectus muscle.

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Figure 2.
Successful Treatment of a 7-Month-Old Boy (Case 2) With Bilateral Third Nerve Palsies

A, Preoperative clinical image (following ptosis repair). B, Postoperative clinical image 13 months after bilateral nasal transposition of the split lateral rectus (LR) muscle, which is maintained at 20 months postoperatively. C and D, Preoperative axial T2 turbo spin echo image shows the normal position of the LR muscle (C) and the postoperative, bilateral split of the LR muscle (arrowheads) posterior to the globe (D). E, Preoperative coronal T1 image at 3 months of age shows the attenuation of the superior, medial, and inferior rectus muscles (arrowheads in right orbit, similar appearance in left orbit) and the normal LR muscle. F, Postoperative coronal T1 image 15 months after surgery shows splitting of the LR muscle posterior to the globe (arrowheads).

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Figure 3.
Box Plot Showing Reduction of the Horizontal Misalignment With Surgery

The median horizontal misalignment is identified by the line in the center of each box and the 25th and 75th percentiles are shown by the lower and upper extents of the boxes, respectively. The whiskers show the extent of the data and the + indicates an outlier. Exotropia is defined as positive misalignment on the ordinate while esotropia is defined as negative misalignment.

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Figure 4.
Anterior Location of the Split in the Lateral Rectus (LR) Muscle in (A) Unsuccessful (Case 6) vs (B) Successful (Case 2) Cases

A, Axial T1 magnetic resonance image shows the LR muscle coursing slightly nasally but into the posterior sclera in the upper panel. Axial T1 image with fat suppression shows the LR muscle split juxtaposed to the posterior sclera with a broad adherence to the globe in this location in the lower panel. This image was obtained 5 months postoperatively. B, Axial T1 magnetic resonance image shows the split in the LR muscle occurring posterior to the sclera bilaterally (arrowheads). In comparison with part A, the split of the LR muscle is more posterior in part B. This image was obtained 15 months after surgery.

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Multimedia

Video 1.

Step by Step Surgical Technique of Adjustable Nasal Transposition of the Split Nasal LR Muscle

This edited video demonstrates the key steps of the procedure. This particular procedure was performed on Case 6, whose outcome was not ideal.

Video 2.

Retraction of the Globe on Attempted Abduction in Case 6

Obtained 5 wk after surgery, this video shows when the patient attempts to gaze right, abduction is limited; the globe can be seen retracting into the orbit.

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