J Korean Ophthalmol Soc.  2015 Aug;56(8):1294-1299. 10.3341/jkos.2015.56.8.1294.

A Case of Nishida Muscle Transposition Procedure for Abducens Palsy

• Oh IS
• Jang JH

• KMID: 2215086
• DOI: http://doi.org/10.3341/jkos.2015.56.8.1294

Abstract

PURPOSE
Herein we report a successful Nishida muscle transposition procedure (modified Jensen procedure) with right medial rectus recession for treating a right abducens palsy patient.
CASE SUMMARY
A 63-year-old male presented with a 30-year history of esotropia due to traumatic abducens palsy in his right eye. At initial examination, right eye visual acuity was 0.9 and intraocular pressure was 11 mm Hg. Ocular movement of the right eye was restricted in the lateral direction and prism cover-uncover test revealed 75 prism diopter right esotropia. For 2 years, the patient was treated as normal tension glaucoma and used his right eye as the dominant eye by turning his head due to glaucomatous field defect in the left eye. We performed 8.0 mm medial rectus recession and Nishida muscle transposition procedure in the right eye and inserted a suture through the temporal margin of each vertical rectus muscle. One week after surgery, the right eye maintained relatively straight alignment and prism cover-uncover test showed 20 prism diopter residual esotropia in the left eye.
CONCLUSIONS
The Nishida muscle transposition is a simple procedure and prevents postoperative risk of anterior segment ischemia without the occurrence of tenotomy and muscle splitting. We report a successful Nishida muscle transposition procedure in a patient with chronic abducens palsy.

Keyword

Abducens palsy; Anterior segment ischemia; Muscle transposition; Nishida procedure

MeSH Terms

Esotropia
Head
Humans
Intraocular Pressure
Ischemia
Low Tension Glaucoma
Male
Middle Aged
Paralysis*
Sutures
Tenotomy
Visual Acuity

Figure

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  Figure 1. Preoperative nine cardinal photographs showing approximately 75 prism diopters of right esodeviation (center) and limi-tation of abduction of right eye (left middle).

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  Figure 2. (A) Humphrey automated visual field examination of right eye. (B) Humphrey automated visual field examination of left eye showing more severe glaucomatous field defect. POS = positive; NEG = negative; SITA = Swedish interactive threshold algo-rithm; GHT = glaucoma hemifield test; VFI = visual field index; MD = mean deviation; PSD = pattern standard deviation.

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  Figure 3. (A) Diagram showing the muscle transposition procedure of Nishida. (Left) Suture the sclera and vertical rectus muscle where the same colored arrows are pointing. (Right) Superior rectus muscle is transposed to supero-laterally (red arrow) and inferior rectus muscle is transposed to infero-laterally (blue arrow). (B) Our intraoperative image of modified Jensen (Nishida’s) procedure. A 5-0 pro-lene suture was inserted through each temporal margin of vertical recti at approximately one third of the width from the edge at a dis-tance of 8.0 mm behind the insertion (blue arrow). The same suture also was inserted through each scleral wall at a distance of 12.0 mm behind the limbus at the superotemporal or inferotemporal quadrant (red arrow). Then, the lateral margin of each vertical rectus muscle was transposed superotemporally or inferotemporally and sutured to the sclera. LR = lateral rectus muscle; SR = superior rectus mus-cle; MR = medial rectus muscle; IR = inferior rectus muscle.

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  Figure 4. Postoperative 1 week nine cardinal photographs showing straight alignment in primary position and improved abduction of right eye. Moreover, vertical duction is preserved well even after the vertical transposition.

Reference

References

1. Korean Association of Pediatric Ophthalmology and Strabismus. Current concepts in strabismus. 3rd. Goyang: Naewae Haksool;2013. p. 314–5. 321.

2. Rush JA, Younge BR. Paralysis of cranial nerves Ⅲ,Ⅳ, and Ⅵ. Cause and prognosis in 1,000 cases. Arch Ophthalmol. 1981; 99:76–9.

3. Jang SG, Lee JH, Lew HM. Rectus muscle union in lateral rectus muscle paralysis. J Korean Ophthalmol Soc. 1987; 28:803–9.

4. Wright KW. Color Atlas of Strabismus Surgery: Strategies and Techniques, 3rd ed. New York: Springer,. 2007; 161–5.

5. Jensen CD. Rectus muscle union: a new operation for paralysis of the rectus muscles. Trans Pac Coast Otoophthalmol Soc Annu Meet. 1964; 45:359–87.

6. Simon JW, Price EC, Krohel GB. . Anterior segment ischemia following strabismus surgery. J Pediatr Ophthalmol Strabismus. 1984; 21:179–85.

7. Saunders RA, Phillips MS. Anterior segment ischemia after three rectus muscle surgery. Ophthalmology. 1988; 95:533–7.

8. von Noorden GK. Anterior segment ischemia following the Jensen procedure. Arch Ophthalmol. 1976; 94:845–7.

9. Nishida Y, Hayashi O, Oda S. . A simple muscle transposition procedure for abducens palsy without tenotomy or splitting muscles. Jpn J Ophthalmol. 2005; 49:179–80.

10. Muraki S, Nishida Y, Ohji M. Surgical results of a muscle trans-position procedure for abducens palsy without tenotomy and mus-cle splitting. Am J Ophthalmol. 2013; 156:819–24.

11. Nishida Y, Inatomi A, Aoki Y. . A muscle transposition proce-dure for abducens palsy, in which the halves of the vertical rectus muscle bellies are sutured onto the sclera. Jpn J Ophthalmol. 2003; 47:281–6.

12. Selezinka W, Sandall GS, Henderson JW. Rectus muscle union in sixth nerve paralysis. Arch Ophthalmol. 1974; 92:382–6.

13. Maruo T, Iwashige H, Kubota N. . Results of surgery for para-lytic esotropia due to abducens palsy. Jpn J Ophthalmol. 1996; 40:229–34.

14. Koo BS, Seo BR, Min BM. The effect of jensen procedure with me-dial rectus recession in lateral rectus palsy. J Korean Opthalmol Soc. 1996; 37:197–202.