J Korean Ophthalmol Soc.  2008 Jul;49(7):1203-1208. 10.3341/jkos.2008.49.7.1203.

Periosteal Fixation in Bilateral Total Third Nerve Palsy

• Suk KW
• Park JM
• Kim SS
• Lee SJ

• KMID: 1476980
• DOI: http://doi.org/10.3341/jkos.2008.49.7.1203

Abstract

PURPOSE: We present a new technique of anchoring the eyeball to the nasal periosteum with supramaximal recession of the lateral rectus muscle in one eye for exotropia management in bilateral total third nerve palsy combined with trochlear nerve palsy.
CASE SUMMARY
A 38-year-old man presented with drooping of both upper lids and exodeviation of the left eye with a history of intraventricular hemorrhage 9 months previously. We noted bilateral ptosis, dilated pupils, right fixing eye, left face turn, and left exotropia over 100 prism diopters (PD) in the primary position with an inability to move both eyes together except abduction. He was diagnosed with bilateral total third nerve palsy and trochlear nerve palsy. We fixated the left globe (sclera anterior to the insertion of the medial rectus muscle) to the nasal periosteum including the medial palpebral ligament using a nonabsorbable suture. A large recession of the left lateral rectus muscle (14 mm) was also performed. Ocular alignment in the primary position was exotropia of 25PD and cosmetically satisfactory after 6 months of follow-up.
CONCLUSION
Supramaximal recession of the lateral rectus muscle and periosteal fixation using nonabsorbable suture is an effective technique for the management of exotropia secondary to total third nerve palsy.

Keyword

Exotropia; Nonabsorbable suture; Periosteal fixation; Supramaximal recession; Total third nerve palsy

MeSH Terms

Adult
Exotropia
Eye
Follow-Up Studies
Hemorrhage
Humans
Ligaments
Muscles
Oculomotor Nerve Diseases
Periosteum
Pupil
Sutures
Trochlear Nerve Diseases

Figure

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  Figure 1. Preoperative photograph in 9 gazes shows bilateral total third nerve palsy and trochlear nerve palsy. The patient had ptosis and mid-dilated fixed pupil in both eyes and left exotropia over 100PD in the primary position. Both eyes had limitation in adduction, elevation, and depression.

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  Figure 2. The patient had left face turn and he fixated with the right eye.

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  Figure 3. Schematic drawings. (A) The anterior lacrimal crest and the insertion of the medial palpebral ligament were exposed. (B) Double armed 5-0 Ethibond suture was passed through the medial palpebral ligament insertion at the anterior lacrimal crest including the periosteum. (Insert) Second bite was taken just lateral to the first. (C) A small buttonhole was created in the medial orbital fascia up to the exposed periosteum by blunt scissors. (D) Ends of the 5-0 Ethibond were brought out into the subtenon space (toward the conjunctival side) using artery clamps. (E) The sutures were secured to the sclera anterior to the medial rectus insertion.

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  Figure 4. The postoperative 6 months photograph shows left exotropia of 25 PD without hypotropia in the primary position. Mild fullness and congestion over the medial rectus muscle area was observed.

Reference

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