Supramaximal Horizontal Rectus Recession–Resection Surgery for Complete Unilateral Abducens Nerve Palsy

Zhonghao Wang,Jianhua Yan,Tao Shen,Huangxuan Shen,Xinping Yu,Licheng Fu,Xuan Qiu

doi:10.3389/fmed.2021.795665

Abstract

PurposeTo review the surgical procedures and outcomes of supramaximal horizontal rectus recession–resection surgery for abduction deficiency and esotropia resulting from complete unilateral abducens nerve palsy.MethodsA total of 36 consecutive cases diagnosed as complete abducens nerve palsy, receiving supramaximal medial rectus recession (8.5 ± 1.4 mm, range: 6–10) combined with a supramaximal lateral rectus resection (11.1 ± 1.7 mm, range: 8–14) as performed over the period from 2017 to 2020, were reviewed retrospectively. All surgeries were performed by a single surgeon. Pre- and post-operative ocular motility, ocular alignment, forced duction test, binocular vision, abnormal head posture, and surgical complications were assessed.ResultsOf these 36 cases, 23 (63.8%) were followed up for greater than 2 months (Mean ± SD = 8.4 ± 6.0, range: 2–24) after surgery and the collected data was presented. Mean ± SD age of these patients was 41.7 ± 14.4 (range: 12–67) years with 73.9% being female. Trauma (52.2%, 12/23) and cerebral lesions (21.7%, 5/23) were the primary etiologies for this condition. Esodeviation in primary position improved from 55.5 ± 27.2 prism diopters (PD) (range: +25 to +123) to 0.04 ± 7.3 PD (range: −18 to +12) as assessed on their last visit. Pre-operative abduction deficits of −5.6 ± 1.0 (range: −8 to −4) reduced to −2.4 ± 1.4 (range: −4 to 0) post-operatively. The mean dose-effect coefficient of 2.80 ± 1.20 PD/mm (range: 1.07–6.05) was positively correlated with pre-operative esodeviation. Rates of overcorrection and ortho were 69.6 and 26.1%, respectively, on the first day after surgery, while on their last visit the respective levels were 4.3 and 82.6%.ConclusionSupramaximal horizontal rectus recession–resection surgery is an effective treatment method for complete abduction deficiency. The dose-effect was positively correlated with pre-operative esodeviation. Overcorrection on the first day post-operatively is required for a long-term satisfactory surgical outcome.

Highlights

The abducens nerve represents the most vulnerable ocular motor nerve, with abducens nerve palsy resulting in esodeviation and horizontal diplopia
A complete abduction deficiency always involves treatment with various surgical techniques consisting of vertical rectus transposition (VRT), including the Hummelsheim or Jensen procedure [4–8] and isolated superior rectus transposition (SRT) [9]
The purpose of this report is to review the outcomes of supramaximal horizontal rectus recession–resection surgery for complete unilateral abduction deficiency and esodeviation as resulting from an acquired complete sixth nerve palsy

Summary

Introduction

The abducens nerve represents the most vulnerable ocular motor nerve, with abducens nerve palsy resulting in esodeviation and horizontal diplopia Such a condition often involves a compensatory head turn to minimize or eliminate the diplopia. Horizontal rectus recession–resection without transposition of the vertical rectus can correct this deviation and improve the abduction in cases with partial paralysis [2, 3] This recession–resection surgery is not recommended for patients with complete lateral rectus paralysis, due to the lack of a successful outcome resulting from regression of ocular alignment and failure to restore abduction function [4]. The effects of transposition depend on the tension of the transposed muscle and may not effectively increase the abduction function of the affected eye In this way, the velocity of rotation into the paretic field is fairly slow and may not be useful when rapid pursuit or saccadic movements are required [12]

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