Effectiveness of supramaximal horizontal surgery for third nerve palsy
Reviewed by Fiona Rowe

The purpose of this study was to present the outcomes and progress of third nerve palsy cases after supra-maximal recession / resection. The aim is for an initial overcorrection of 15-25PD at day one. This was a retrospective study of 91 cases with median age of five years (range 1-22). Of these, 46 were female and duration of deviation was seven years (range 3-17). Age at surgery was 21 years (range 12-33). Total amount of horizontal surgery was calculated as the sum (in mm) of lateral rectus recession, medial rectus resection, medial rectus plication and medial rectus advancement. A good outcome was defined as ≤10PD. Complete third nerve palsy was in 41 and partial in 50 cases; 40.7% were congenital. The most common cause of acquired cases was road traffic accident. Preoperative exotropia averaged 70.29PD ±31.9 and hypotropia of 9.8 ±19.21. Mean surgery was 18.52mm ±5.69 and mean effect of surgery was 2.66 degrees / mm ±0.73 and 4.42 PD / mm ±1.43. Postoperative deviation was -9.24PD ±14.84 exotropia and 4.07PD ±11.87 hypotropia at day one and, at two months, was 4.49PD ±12.69 exotropia and 3.62PD ±10.19 hypotropia. Those with poorer outcomes were significantly more likely to be complete palsies and with larger deviations. Success rate at final assessment was 60.6%. These results were for one-step surgery. There were further patients having surgery through separate stages in which surgical success rate was 64.8% for five patients and better results for partial than complete palsies. The authors conclude this surgery gives good results long-term, showing effectiveness with extreme exo deviations but requiring added fixation to globe technique with traction sutures.

Larger than larger: huge amounts of recession-resection surgery for third nerve palsy.
Wen Y, Shen T, Yan J.
JOURNAL OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS
2023;60(3):184-94.