The authors present a retrospective case review with the aim to compare two surgical procedures. Cases were operated on at a single centre, by a single surgeon, over a 14-year period. The inclusion criteria were cases with congenital or acquired total third nerve palsy and large angle exotropia and underwent either a lateral rectus deactivation with medial rectus resection (resection group) or with medial rectus fixation to the medial palpebral ligament (fixation group). Cases with high refractive error and / or had undergone previous extra / intraocular surgery were excluded. The surgical techniques are described. A total of 35 cases were included in this analysis, split across the groups: resection group (n=20) and fixation group (n=15). The two groups were similar in angles of horizontal and vertical deviation, with the exception of statistically significantly more in the fixation group had no vertical deviation. Surgical success was defined as <20Δ exotropia at follow-up. There were no significant differences in surgical success across the two groups at one day, one month or six months postoperatively. A larger number of the fixation group had a successful outcome at six months but was not significant. However, postoperative exotropic drift was found to be greater in the resection group at >10Δ difference between the mean. No notable postoperative complications were reported in the resection group, although in the fixation group over a quarter of cases reported complications including conjunctival congestion, suture granuloma, chemosis, and gross restriction of ocular movements. The authors acknowledge several limitations of the study including the retrospective methodology, lack of randomisation, short follow-up period and unbalanced numbers in each group. The study recommends lateral rectus deactivation with medial rectus fixation to the medial palpebral ligament procedure for this group of patients, despite taking more time and requiring more surgical expertise. Further investigation of these techniques is required in a larger sample in a multi-centre randomised-controlled trial.
Comparison of surgical procedures for third cranial nerve palsy with large-angled exotropia
Reviewed by Lauren Hepworth
Surgical management of oculomotor nerve palsy: a comparison of lateral rectus deactivation combined with either medial rectus resection or medial rectus fixation to the medial palpebral ligament.
CONTRIBUTOR
Lauren R Hepworth
University of Liverpool; Honorary Stroke Specialist Clinical Orthoptist, Northern Care Alliance NHS Foundation Trust; St Helen’s and Knowsley NHS Foundation Trust, UK.
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