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Purpose: To compare the postoperative alignment, degree of improvement of abduction, and complications of the Hummelsheim procedure to the Jensen procedure in chronic sixth nerve palsy, and to calculate the dose-response of both procedures., Methods: A retrospective study was done on patients who either had Hummelsheim or Jensen procedure for chronic sixth nerve palsy. Demographic characteristics, details of surgical procedure, ductions, versions, and angles of misalignment before and after surgery were analyzed., Results: A total of 79 patients were identified: 38 Jensen and 41 Hummelsheim. There were no statistically significant differences in baseline characteristics of both groups. Medial rectus recession was performed in 35 patients in the Jensen group and in 30 patients in the Hummelsheim group. Success defined as orthotropia within 8 PD was achieved in 25 (66%) patients in the Jensen group and in 24 (59%) patients in the Hummelsheim group (P = 0.51). The mean improvement in the angle of deviation in the primary position was 42 ± 12 PD in the Jensen group and 42 ± 16 PD in the Hummelsheim group (P = 0.89). The mean improvement in abduction was slightly better in the Hummelsheim group (1.8 vs 1.5, P = 0.32). A new vertical deviation occurred in three patients in the Jensen group and in 4 patients in the Hummelsheim group. Anterior segment ischemia occurred in one patient in the Jensen group., Conclusions: There was no difference in the success rate between the Hummelsheim and Jensen procedures in cases of chronic sixth nerve palsy. Strabismus surgeons can choose between the two procedures according to their preference., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Superior rectus transposition (SRT) with medial rectus recession has been used for the treatment of sixth nerve palsy and esotropic Duane retraction syndrome (DRS). The purpose of this study was to compare the results of augmented SRT (with scleral fixation) without medial rectus recession in DRS and sixth nerve palsy., Methods: Patients with unilateral esotropic DRS (DRS group) and sixth nerve palsy were included in this prospective, comparative study and underwent SRT. Preoperative forced duction testing was negative or slightly positive in both groups. Prospective measurements were compared between the two groups., Results: There were 11 patients in the DRS group and 11 patients in the sixth nerve palsy group. The mean preoperative esotropia decreased from 20.9 ± 6.0 prism diopter (PD) at far to 13.2 ± 5.8 PD in the DRS group (P = 0.003). The same measurement improved from 28.0 ± 8.5 PD to 8.4 ± 7.3 PD in the sixth nerve palsy group (P = 0.003). In the sixth nerve palsy group, the improvement in primary gaze esotropia and abnormal head posture was more than the DRS group (Both P < 0.001).The average dose effect for SRT was 7.8 ± 2.2 PD in the DRS group and 19.2 ± 4.6 PD in the sixth nerve palsy group. Although objective intorsion was significantly induced after SRT, subjective torsion was not significant after surgery in both groups., Conclusion: SRT appears to be more effective in improving primary gaze deviation and head posture in sixth nerve palsy compared with DRS. Subjective torsional and vertical diplopia were rare in both groups.

We report a case of symptomatic ecchordosis physaliphora (EP) in a 34-year-old woman who presented with progressive diplopia due to palsy of the left sixth cranial nerve. Repeated magnetic resonance imaging (MRI) disclosed typical characteristics of a congenital EP lesion with compression of the left abducens nerve presumably because of a secondary herniation of the arachnoid mater. We performed an augmenting combined recess resect procedure on the left eye. No progression of the lesion was observed over a period of 5 years. For differential diagnostics an EP has to be distinguished from skull base tumors, such as chordoma and chondrosarcoma.

Purpose: Posttraumatic abducens nerve palsy is well documented following head injury, but only few case reports exist on sixth nerve palsy after cervical spine trauma. Bilateral abducens palsy following vertical C1-C2 ligamentous distraction has not been described yet., Methods: We report two patients who sustained motor vehicle accident-related C1-C2 distraction injury and were diagnosed with posttraumatic bilateral abducens nerve palsy., Results: Patients underwent surgical stabilization of the upper cervical spine and demonstrated a remarkable recovery of the sixth nerve deficit up to 1 year after injury., Conclusion: We hypothesize that ligamentous C1-C2 distraction leads to caudal displacement of the brainstem in relation to the cranial base causing traction injury to the abducens nerve at its entry into Dorello's canal in the cavernous sinus.

Background: Thoracic cerebrospinal fluid (CSF) hygroma is a rare and potentially devastating complication of the anterior thoracic approach to the spine. We present two cases in which this complication resulted in acute cranial nerve palsy and discuss the pathoanatomy and management options in this scenario., Case Reports: Two male patients presented to our department with neurological deterioration due to a giant herniated thoracic disc. The extruded disc fragment was noted pre-operatively to be calcified in both patients. A durotomy was performed at primary disc prolapse resection in the first patient, whereas an incidental durotomy during the procedure caused complication in the second patient. These were repaired primarily or sealed with Tachosil(®). Both patients re-presented with acute diplopia. Imaging of both patients confirmed a massive thoracic cerebrospinal fluid hygroma and evidence of intracranial changes in keeping with intracranial hypotension, but no obvious brain stem shift. The hemithorax was re-explored and the dural repair was revised. The first patient made a full recovery within 3 months. The second patient was managed conservatively and took 5 months for improvement in his ophthalmic symptoms., Conclusions: The risk of CSF leakage post-dural repair into the thoracic cavity is raised due to local factors related to the chest cavity. Dural repairs can fail in the presence of an acute increase in CSF pressure, for example whilst sneezing. Intracranial hypotension can result in subsequent hygroma and possibly haematoma formation. The resultant cranial nerve palsy may be managed expectantly except in the setting of symptomatic subdural haematoma or compressive pneumocephaly.

Introduction: Impacted knife injuries in the maxillofacial region are rare and infrequently reported. In cases of injury involving orbit or eye, these reports are even rarer., Discussion: Damage to the orbital contents may result in a rupture of the globe, extraocular muscle injury, lacrimal gland damage, and others. Orbital foreign bodies are not only difficult to detect, and clinical features vary according to its size, characteristics, shape, penetrating method, and site. In this report, a case of abducens nerve palsy after orbitoethmoidal knife injury is presented.

This article reviews the spectrum of possible motility disorders and ocular misalignment in patients with Möbius sequence. The various options for strabismus surgery are discussed and a stepwise algorithm is presented.

Purpose: The purpose of this study was to report the case of a patient with a saccular, intraorbital aneurysm of the ophthalmic artery and to analyze the correlation between clinical symptoms and aneurysm localization with regard to the literature., Method: We correlated the patient's clinical findings with anatomical substrates on magnetic resonance imaging and angiographic studies., Results: A 64-year-old woman presented with a rapidly progressive loss of visual acuity in her right eye, temporo-basal visual field defects, a temporal pallor of the optic disc and third and sixth nerve palsies. This apex orbitae compression syndrome was due to an aneurysm of the proximal intraorbital segment of the ophthalmic artery at a position inferolateral to the optic nerve, inferior to the third and medial to the sixth cranial nerve., Conclusion: The symptoms caused by an aneurysm of the ophthalmic artery depend on its localization and spatial relationship to neural structures. While aneurysms of the intracranial and distal intraorbital segments may remain asymptomatic, those arising from the intracanalicular segment become clinically apparent with optic nerve conduction disorders. Aneurysms in the proximal intraorbital segment additionally provoke oculomotor disturbances due to compression of the third and sixth cranial nerves.

Background: The pre- and postsurgical results after mono- and bilateral transposition surgery for abducens nerve palsy are reported., Patients and Methods: In 13 eyes from 11 patients with 6th nerve paralysis, transposition surgery modified after Kaufmann was performed after a median duration of 13 months (range 6-28 months). The actual angle of strabismus, the capability of abduction and the field of binocular single vision with the tangent screen according to Harms were measured prior to surgery, immediately after surgery (1-3 weeks) and in the later postsurgical period (9-12 months)., Results: Of the patients 7 achieved fusion with binocular single vision, 5 of these patients had to accept an ocular torticollis of 10 degrees (range 5-15 degrees) and 4 patients had a tendency to exclusion. Of the 11 patients, 9 were treated successfully with one single surgical procedure 2 of which had bilateral abducens nerve palsy and 2 patients needed 2 further operations. The median preoperative convergent angle in the primary position was reduced from 28 degrees (range 16 degrees-60 degrees) to a median angle of 0 degree, sometimes only latent (range D 7 degrees-C 4 degrees) in the late postoperative period. The median postoperative abduction over the midline was 10 degrees (range 3 degrees-25 degrees)., Conclusions: Bilateral 6th nerve paralysis was treated effectively with simultaneous transposition surgery in both eyes. In most cases an additional weakening of the medial rectus muscle was not necessary. An initial overcorrection with exotropia in the early postoperative period is desired and is a predictive factor for a good late postoperative result.

Background: In cases of unilateral paralyses of a lateral rectus, different operative procedures are recommended in the literature. Six typical cases are presented in this paper., Methods and Results: Fourteen days after neurosurgical transsection of the abducens nerve, no restriction of abduction was found. The transposition procedure according to Hummelsheim was performed with good results. In three long-standing cases, botulinum toxin was used to ameliorate the contracture of the tight medial rectus muscle. In all cases no limitation of abduction was found intraoperatively, making the transposition procedure much easier to perform. In another complicated case, a unilateral recession/resection procedure was carried out. The postoperative alignment was good, but the motility and the useful field of binocular vision were restricted. In the last case, the absent function of the lateral muscle was restored using a silicon rod fixed in the lateral wall of the orbit. The field of binocular single vision ranged from 12 degrees adduction to 23 degrees abduction 3 months after operation., Conclusions: Second operations are easy to perform on completely transposed muscles and in cases of recession/resection procedures, but not easy nor predictable after Hummelsheim operations. Botulinum toxin is a useful adjunct in cases of sixth nerve paralyses.