Functional and Motor Outcomes of Strabismus Surgery for Chronic Isolated Adult Sixth Nerve Palsy

Abstract

Abducens nerve palsy is the most common acquired ocular motor nerve palsy in adults. Chronic cases of abducens palsy often require surgical intervention to relieve disabling diplopia. The goal of this study was to identify factors associated with surgical outcomes in isolated abducens palsy. Medical records of all adult patients from 1988 to 2012 with abducens palsies who underwent strabismus procedures were retrospectively reviewed. Motor alignment, extraocular motility, and sensory outcomes were recorded. Success was defined as absence of diplopia without prisms or face turn, vertical deviation 2 prism dioptres (PD), and horizontal deviation 10 PD. Eighty-one patients (age range: 20-86 years) met inclusion criteria. Success was achieved in 58% of patients. Final success rates for abducens palsy were 50% for neoplastic, 59% traumatic, 57% for microvascular/unknown, and 67% for other central nervous system causes (p40.05). Patients with an underlying neoplastic or traumatic aetiology required more than one strabismus procedure more often than those with microvascular/idiopathic or other central nervous system causes (48% vs. 24%; p = 0.03). For complete abducens palsies, patients who underwent Hummelsheim-type procedures had a higher success rate than those who underwent a full-tendon vertical rectus muscle transposition. (78% versus 35%; p = 0.049). Success rates for strabismus procedures in patients with abducens palsies are similar across all aetiologies. Frequency of re-operation is higher among those patients with neoplastic or traumatic aetiologies for their abducens palsies. Hummelsheim-type procedures have a higher success rate for complete abducens palsies than full-tendon vertical rectus transpositions.

<p>Outcomes of Extraocular Muscle Surgery for Diplopia or Abnormal Head Posture After Treatment of Brain Disease</p>

“…Nevertheless, the average number of operations (1.3) is not considered to be a high risk for reoperation, compared with other forms of incomitant strabismus. 9,10 The success rate for Peragallo et al 19 was 58% by surgery alone, but they did not use prism therapy. In an earlier report 20 on abducens palsy, the surgical success rate was 52%, but when that same study allowed the use of prisms or small face turns to correct diplopia, the success rate reached 75%.…”

“…In previous reports, 12 , 18 abducens palsy was the most frequent cause of acquired paralytic strabismus among adults, and abducens palsy was also the most frequent strabismus after severe brain disease in our study, reaching 53% in the BT group. A study of 81 cases by Peragallo et al 19 demonstrated that patients with traumatic or neoplastic causes had a higher rate of complete abducens palsy, in comparison to other etiologies (58% versus 24%, respectively), and required more surgical procedures to achieve a successful outcome (48%). In this study, complete abducens palsy accounted for 53% of patients with abducens palsy who underwent muscle transposition, and, furthermore, severe vertical deviation was found in 33% and cyclotorsion was found in 36%, suggesting that strabismus after severe brain disease might be refractory.…”

Effekt von Muskeltranspositionen nach dem Hummelsheim-Prinzip mit und ohne zeitgleiche Rücklagerung des M. rectus internus

“…In der Verlaufskontrolle verringerte sich der Tieferstand bei 6 der 7 Patienten auf < 5,0°. Peragallo et al fanden im Verlauf keine Vertikaltropien bei 9 Patienten nach modifizierter Hummelsheim-Operation (5 davon mit M.-rectus-internus-Rücklagerung) [14]. Wird eine posteriore Fixationsnaht benutzt, so steigt das Risiko für postoperative VDs deutlich an [22].…”

“…Die Pareseursache der 3 Patienten, die wegen einer Unterkorrektur im Verlauf Revisionen erhielten, war in 2 Fällen eine Tumorerkrankung, in 1 Fall ein Schädel-Hirn-Trauma. Auch Peragallo et al berichten über ein erhöhtes Risiko für Reoperationen bei zugrunde liegender neoplastischer oder traumatischer Erkrankung [14].…”

“…Patienten mit Hummelsheim-Prozedur erhielten dabei auch eine simultane Rücklagerung des M. rectus internus[14]. Esser et al maßen bei 17 Patienten, die nach der Modifikation nach Hummelsheim-Kaufmann operiert wurden, eine Schielwinkelverkleinerung von im Median 29,0°präoperativ auf − 3,0°ca.…”