surgical management of oculomotor nerve palsy

1. Surgical Management in 3rd Nerve
palsy
By-Dr Ruturaj sahoo
PG resident

2. • Third nerve is mainly motor nerve involved in
execution of movements in the eye
• Supplies all extraocular muscles except LR
and SO
• Helps in carrying out extraocular movements
efficiently and improving binocular field of
vision.

3. Causes
• Infections(CNS or local)
• Trauma
• Direct or indirect compression
• Vascular conditions (ischemic/aneurysms)
• Neoplastic
• Demyelinating diseases.

4. Types of 3rd nerve palsy
Complete Partial Pupil sparing
Pupil involving Isolated
Associated with
other neurological
symptoms

5. Abberant regeneration
Usually occurs in congenital 3rd nerve palsy
• Trauma
• Compression by slow growing tumour
• Due to breached myelin sheath and the perineurium
cause misdirection of the regenerating axons and
innervate the surrounding muscles such as the LPS,
superior oblique and occasionally iris sphincter
muscle .

6. Clinical manifestations of abberant
regeneration
• Elevation of the eyelid during attempted adduction
(Inverse Duane syndrome)
• Depression (Pseudo-Von Graefe’s sign)
• Miosis in an otherwise non-reactive pupil (Pseudo-
Argyll-Robertson pupil).

7. How to approach?
History Of the patient
-Onset
-Duration
-Diplopia
-Trauma
-Any associated systemic diseases

8. Examination
• Pupillary reaction
• Ocular motility
• Ptosis
• Other cranial nerves

9. Investigations
• FBS,PPBS,HbA1C,
• Lipid profile
• CBC,ESR,CRP
• CT scan /MRI Brain and orbit
• Cerebral angiography
• Hess charting

10. Treatment
Observation
Microvascular causes
shows signs of recovery
at 2 weeks and recover by
3-6 months
Temporary measures like
Fresnel stick-on prism.
Diplopia is prevented by
uniocular occlusion
Young children should be
treated with alternate
patching to prevent
amblyopia

11. Surgical treatment
• The surgical correction of oculomotor nerve palsy remains a
challenge for ophthalmologists
Main Goal
• To provide binocular vision and align the paralyzed eye in
a primary position
Duration-
Usually after spontaneous improvement has ceased not earlier
than 6-12 months of onset

12. Surgical management protocol

13. Surgical procedures in partial 3rd nerve palsy
Knapp Procedure-
-Paralysis of the upper division of
the oculomotor nerve
-transposition of medial and
lateral rectus adjacent to the
insertion of the superior rectus) on
the affected eye

14. Kushner procedure
• Isolated palsy of the
inferior division of the
oculomotor nerve
• transposition of the superior
rectus muscle to lie
adjacent to the medial
rectus and the lateral rectus
muscle toward the insertion
of inferior rectus muscle,
with tenotomy of the
ipsilateral superior oblique

15. • Complete oculomotor palsy is difficult to
correct because of involvement of most of
the extraocular muscles. Several surgical
options are available with acceptable results

16. Large recession and resection
Forced duction test
If adduction past midline
Supramaximal recession of the lateral rectus
muscle and resection of the medial rectus
muscle
Combined with posterior tenotomy of superior
oblique

17. Globe anchoring procedures
Absence of MR function
Active force generation test and saccadic velocities
assess function of Paretic MR in presence of contracture
of LR
Globe fixation to medial wall of the orbit at the anterior
lacrimal crest can be performed through precaruncular
approach
Another is The suture/T-plate anchoring platform system ,
anchors the globe by sutures to a titanium T-plate screwed
to the orbital wall .Advantage is prevents anterior segment
ischemia

18. Superior oblique transposition procedures
-The procedure was
described by Peter
and Jackson.
-Disadvantage-
consecutive
hypertropia.
The trochlea is
fractured
The superior oblique
tendon is removed
attached to the sclera
near the insertion of
the MR muscle

19. Modified Scott’s technique
transposition of the superior
oblique tendon without
involving the trochlea.
Superior oblique can be
disinserted shortened by
12mm and reinserted to the
medial rectus
Residual vertical residual
deviation may be corrected
by weakening inferior rectus
muscle in the other eye.

20. Lateral rectus transposition technique
Lateral rectus to Medial
Rectus transposition
• The lateral rectus muscle
disinserted then passed
beneath the superior rectus
muscle in the direction of
the medial rectus muscle.
• Lateral rectus is then
sutured near the superior
margin of the medial rectus
insertion

21. Medial transposition with Y splitting of lateral rectus
• Muscle is then split 15mm
posterior to the insertion.
• The upper half of the muscle is
then passed beneath the superior
rectus.
• inferior half is moved beneath the
inferior rectus and inferior oblique.
• The two halves of lateral rectus are
then inserted near the insertion of
medial rectus

22. Surgery for ptosis
• Management of ptosis depends on the presence or
absence of Bell’s phenomenon and aberrant
regeneration
• Ptosis with poor bells phenomenon can be managed
by crutch glasses

23. ptosis
Poor bells
phenomenon
Crutch
glasses
Frontalis
sling
Partial recovered oculomotor
nerve palsy with residual
Superior rectus action, ptosis
can be corrected ‘Fixation
duress’ in the non-involved
eye
Abberant
regeneration
recession-
resection
procedure in
contra lateral eye

24. Complications
• Anterior segment ischemia
• Under correction
• Induced vertical deviation
• Tenon’s prolapse
• Conjunctival prolapse
• Slipped muscle
• Scleral perforation