Traction sutures for exotropia in longstanding third nerve palsy

Abstract

Background: Exotropia in longstanding third nerve palsy presents a significant cosmetic problem and the management is difficult. Methods: A retrospective review of patients with longstanding exotropia secondary to third nerve palsy between 1996 and 2006 was carried out. Patients underwent large lateral rectus recession and medial rectus resection, combined with muscle traction sutures. Traction sutures were passed through superior and inferior rectus insertions and through the fornix to the medial canthus; the eye was adducted and sutures were brought through the lid to the skin surface and tied over bolsters. Traction sutures were left in situ for 6 weeks. Results: Thirty-three patients were treated, with a mean follow up of 16 months (range, 3-108 months). The age range was 3 to 66 years (mean, 28.8). The cause of third nerve palsy was congenital in 39%; orbital or intracranial tumor in 21%; traumatic in 15%; microvascular in 9%; complication of neurosurgery in 9%; and unknown in 6%. Prism cover test (PCT) measurements ranged from 25Δ to 95Δ exotropia preoperatively (mean, 60Δ exotropia). After removal of the traction sutures, the eye maintained a good cosmetic position in all but three cases. Final PCT ranged from 16Δ esotropia to 40Δ exotropia (mean, 14.5Δ exotropia). Postoperative motility was extremely limited. Very limited abduction was a good indicator of the final eye position. Complications included conjunctival hypertrophy, suture infection, and cheese wiring. Conclusions: Adducting traction sutures combined with large recess-resect of the horizontal recti are safe and effective in the management of longstanding strabismus in third nerve palsy.