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Background: Trigeminal schwannomas are fifth cranial nerve tumors that originate from the nerve sheath. They rarely occur within the pediatric population and can cause dysfunction of the trigeminal nerve and surrounding structures. When patients become symptomatic, neurosurgeons should consider resection., Case Desription: We report the case of a 14-year-old adolescent boy who presented with an isolated sixth nerve palsy manifested by diplopia. The patient was found to have a trigeminal schwannoma involving the ophthalmic and maxillary branches of the trigeminal nerve. A modified mini-pterional craniotomy was performed for an extended middle fossa approach with an anterior petrosectomy to gain access to the inferior aspect of the posterior fossa tumor component. Intraoperatively, the sixth nerve was compressed within Dorello's canal. Postoperatively, the patient's sixth nerve palsy resolved, and magnetic resonance imaging demonstrated near-total resection with residual enhancement along the superior orbital fissure near the oculomotor nerve entry zone and foramen rotundum., Conslusions: We present a rare case of pediatric trigeminal schwannoma type Mp treated surgically with a near-total resection via a novel mini-pterional approach and use of cranial nerve diffusion tensor imaging., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To determine the magnitude of change between the preoperative and postoperative alignment and amount of postoperative drift for two vertical rectus muscle transpositions (VRTs)., Methods: Retrospective review of medical records of patients with total sixth cranial nerve palsy who underwent VRT procedures. The primary outcome measure was the magnitude of esotropia in prism diopters (PD) at the preoperative and postoperative visits., Results: Twenty-seven patients were included. Sixteen had full tendon transposition with Foster augmentation (FTT+FA) and 11 had partial tendon transposition with resection and simultaneous medial rectus recession (PTT+R+MRR). A larger correction was obtained with PTT+R+MRR (mean ± standard deviation [SD]: 52 ± 19 PD; range: 27 to 87 PD) when compared to FTT+FA (mean: 40 ± 13 PD; range: 15 to 68 PD). At postoperative month 2, a greater esotropic drift was noted in the PTT+R+MRR group (16 PD) than the FTT+FA group (6 PD). Although the difference in the amount of correction was not statistically significant (P = .071), the difference in the amount of drift was statistically significant (P = .009)., Conclusions: There was a trend toward greater correction with PTT+R+MRR than FTT+ FA, but it was not statistically significant. FTT+FA had significantly less postoperative drift than PTT+R+MRR. The results suggest that a small immediate postoperative overcorrection may be desirable in some VRT procedures. [J Pediatr Ophthalmol Strabismus. 2019;56(4):238-242.]., (Copyright 2019, SLACK Incorporated.)

Background: Abducens nerve function seldom shows complete recovery after removal of abducens nerve schwannoma. No cases with unclear course of the abducens nerve during surgery have been reported to achieve complete recovery of nerve function., Case Description: We report the case of a 44-year-old woman who presented with occasional dysgeusia without abducens nerve paresis. Magnetic resonance imaging showed a solid tumor about 2 cm in diameter at the left cerebellopontine cistern. Cranial nerves except the abducens nerve appeared intact. The tumor was removed via suboccipital craniotomy. The abducens nerve was totally invisible on the surface of the tumor throughout the procedure. Only short segments of abducens nerve were identifiable at around Dorello's canal and the root exit zone. The tumor was resected by subcapsular dissection, and part of the tumor capsule was preserved as a scaffold for nerve generation, although whether any abducens nerve was included remained uncertain. Histopathologic examination confirmed World Health Organization grade I schwannoma. Postoperatively, the patient presented with complete left abducens nerve paresis and diplopia, but abducens nerve function began to improve 3 months later and had completely recovered within 16 months after surgery., Conclusions: This represents the first description of abducens nerve schwannoma in which the course of the abducens nerve was intraoperatively unclear but complete recovery was achieved. In such cases, intentional subcapsular dissection may potentiate functional recovery., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Sixth-nerve palsy often develops as a result of trauma, neoplasm, or vascular disease affecting the pons. Less commonly, this palsy can be caused by pathology of the internal carotid artery in the cavernous sinus region. Here, we describe a rare case of spontaneous dissection of the internal carotid artery in the cavernous sinus accompanied by acute sixth nerve palsy that was successfully treated with surgery., Case Description: An 18-year-old man presented suddenly and spontaneously with isolated abducent nerve palsy. His magnetic resonance angiography identified a dissection of the right internal carotid artery in the cavernous sinus. We successfully treated it with high-flow bypass and ligation of the internal carotid artery (ICA)., Conclusions: Intracavernous ICA dissection is a possible cause of sixth nerve palsy. While most cases likely result from compromised arterial blood supply to the affected nerve, compression of the cranial nerves by the expanded artery can occur in some cases. Surgical treatment is a safe and effective option for relieving nerve compression after intracavernous ICA dissection., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: To report the results of dual augmentation of vertical rectus muscle transposition (VRT) in the treatment of chronic sixth nerve palsy., Design: Retrospective case series., Methods: This is a retrospective review of medical records of patients with chronic sixth nerve palsy who underwent dual augmented VRT with or without medial rectus (MR) recession from 2013 to 2016. Data collection included sex, age, laterality, and duration of postoperative follow-up. Pre- and postoperative limitation of abduction and adduction were recorded using a 6-point scale. Improvement of esotropia in prism diopter (PD), head turn in degrees, and limitation of abduction and adduction were reported and analyzed., Results: Fourteen cases were identified. Mean patients' age at the time of surgery was 22.5 years. Postoperatively, esotropia and head turn were corrected by a mean of 31.3 PD and 18.2 degrees, respectively. Limited abduction was improved from -4.3 to -1.6, while in cases that underwent MR recession, adduction declined from 0.4 to -0.3. Postoperative induced small-amplitude hypertropia was reported in 3 cases., Conclusion: Dual augmented VRT was effective in controlling esotropia, head turn, and limited abduction associated with chronic sixth nerve palsy with low rate of induced vertical deviation. Combined MR recession carries a risk of induced limitation of adduction., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Recently, the superior rectus transposition has been widely adopted for the treatment of complete abducens palsy and Duane syndrome. This procedure is useful in that there is a decreased risk of anterior segment ischemia compared to complete vertical rectus transposition, possibly decreased incidence of postoperative-induced vertical deviations than complete vertical rectus transposition, and improvement in abduction compared to simple medial rectus recession. One difficulty with this procedure is the lack of adjustability in most patients. Our group has adopted a new technique for an adjustable posterior fixation myopexy suture for use with patients under topical anesthesia., Methods: The superior rectus muscle is temporally transposed to the insertion of the lateral rectus muscle. The corner of the superior rectus muscle that is placed adjacent to the lateral rectus muscle is placed on an adjustable suture. Then, a posterior fixation myopexy suture consisting of a single-armed 6-0 vicryl suture is secured between the superior and lateral rectus muscles, approximately 10 mm from the lateral rectus insertion to drag the superior rectus muscle temporally. This suture is also placed on an adjustable suture. The patient is then positioned sitting up, fixing at a target at approximately 10 feet away from the patient's head. Cover testing is utilized to determine whether any vertical deviation has been induced. If there is a vertical deviation, the posterior fixation suture may be loosened., Results: We find that this technique to be useful if an induced vertical deviation or an overcorrection occur, and is thought to be due to the reported possible complication of restriction induced by the posterior fixation suture and the transposed rectus muscle., Conclusion: Our technique for performing superior rectus transposition with an adjustable posterior fixation myopexy suture may be useful to surgeons who wish to have an adjustable option as a way to decrease the risk of postoperative complications such as induced vertical deviations and overcorrections.

Background: We report results of a modified vertical muscle transposition procedure according to the Hummelsheim principle - with and without simultaneous rectus muscle recession - for unilateral sixth nerve palsy. We examine the influence of the duration of the palsy, preoperative angle of squint and preoperative abductive capacity on surgical results of the procedures., Patients and Methods: Retrospective study of 29 consecutive patients with unilateral abducens nerve palsy who underwent surgery between 2001 and 2012. 21 patients had a modified vertical rectus muscle transposition according to the Hummelsheim principle (HUM); 8 patients had this operation combined with simultaneous medial rectus muscle recession (HUM+I). Surgery was performed at least 9 months after onset of the palsy (HUM: 9 to 98, median 19, mean 30 months; HUM+I: 12 to 65, median 25, mean 29 months)., Results: The median preoperative angle of squint (far distance) for the HUM group was 27.0° (20.0 to 45.0; mean 28.1°), and for the HUM+I group 30.5° (21.8 to 50.0; mean 33.4°). The median preoperative abductive capacity was for - 1,6 mm before midline (- 8.0 to + 1.2; mean - 1.8 mm) for the HUM group, and - 3.0 mm before midline (- 10.0 to - 1.0; mean - 4.1 mm) for the HUM+I group. The median postoperative angle of squint (far distance) was 0° (- 11.3 to + 20.0; mean 0.1°) for the HUM group, and - 2.3° (- 11.3 to + 12.0; mean - 2.1°) for the HUM+I group. The median postoperative abductive capacity was 1.0 mm (0 to + 3.0; mean + 1.1 mm) for the HUM group, and 1.1 mm (- 1.2 to + 3.0; mean + 0.9 mm) for the HUM+I group. The median reduction of squint angle was 27.0° (9.1 to 45.0; mean 28.0°) for the HUM group, and 36.8° (25.2 to 41.4; mean 35.5°) for the HUM+I group. The median effect on abductive capacity was 2.5 mm (0 to 11.0; mean + 2.9 mm) for the HUM group, and 4.6 mm (2.4 to 8.8; mean + 5.0 mm) for the HUM+I group. In the HUM group, the effect on squint angle reduced with the duration of the palsy, whereas, in the HUM+I group, the effect improved with the duration of the palsy., Conclusions: For patients with unilateral sixth nerve palsy, simultaneous medial rectus recession increases the effect of modified vertical rectus muscle surgery according to the Hummelsheim principle. The duration of the palsy is a relevant parameter for the selection of a sole or combined intervention with medial rectus recession., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Since 1907 a variety of muscle transposition procedures for the treatment of abducens nerve palsy has been established internationally. Full tendon transposition of the vertical rectus muscle was initially described by O'Connor 1935 and then augmented by Foster 1997 with addition of posterior fixation sutures on the vertical rectus muscle. Full tendon transposition augmented by Foster belongs to the group of the most powerful surgical techniques to improve the abduction. Purpose of this study was to evaluate the results of full tendon vertical rectus transposition augmented with lateral fixation suture for patients with abducens nerve palsy., Methods and Results: Full tendon transpositions of vertical rectus muscles augmented with posterior fixation suture was performed in 2014 on five patients with abducens nerve palsy. Two of the patients received Botox injections in the medial rectus muscle: one of them three months after the surgery and another during the surgery. One of the patients had a combined surgery of the horizontal muscles one year before. On three of the patients, who received a pure transposition surgery, the preoperative deviation at the distance (mean: + 56.6 pd; range: + 40 to + 80 pd) was reduced by a mean of 39.6 pd (range 34 to 50 pd), the abduction was improved by a mean of 3 mm (range 2 to 4 mm). The other two patients, who received besides the transposition procedure additional surgeries of the horizontal muscles, the preoperative deviation at the distance (+ 25 and + 126 pd respectively) was reduced by 20 and 81 pd respectively. The abduction was improved by 4 and 8 mm respectively. After surgery two patients developed a vertical deviation with a maximum of 4 pd. None of the patients had complications or signs of anterior segment ischemia. The elevation and/or depression was only marginally affected. There was no diplopia in up- or downgaze., Conclusions: Full tendon transposition of vertical rectus muscles, augmented with lateral posterior fixation suture is a safe and effective treatment method for abducens nerve palsy and in most cases recession of the medial rectus can be avoided. Upgaze and downgaze are affected very slightly. Diverse studies have shown that the risk of anterior segment ischemia is low., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To assess the indications and results obtained with partial vertical recti recessions in patients with diplopia and small-angle vertical strabismus (≤10 dp)., Material and Methods: A retrospective study was conducted on 9 patients that were operated on with partial temporal or nasal recession of the superior (SR) or inferior rectus (IR), during 2017. A good outcome was considered when diplopia was resolved in primary position and infraversion, at the end of follow-up., Results: A total of 9 cases were included, with a mean age 66.3 years (55.5% women), diagnosed with sixth nerve palsy (3), incomplete third nerve palsy (2), sagging eye (2), age related strabismus (1), and restrictive strabismus post-retinal surgery (1). Mean preoperative vertical deviation was 8.2 dp in primary position and the post-operative vertical deviation was 0.8 dp (mean difference was statistically significant, P=.007). In 4 cases, the SR was operated on (temporal pole in 3 and nasal in 1). The IR was operated on in 5 patients (temporal pole in 4 and nasal in 1). Mean recession was 3.77mm. In 55.5% of case diplopia was eliminated, and in a 33.3% a well-tolerated, intermittent diplopia persisted. A good outcome was obtained in 88.8% of the cases at the end of follow-up (mean: 7. 1 months), with no over-corrections., Conclusions: Partial SR or IR recessions obtained good results in most of the cases with small angle vertical strabismus and diplopia. Although post-operative torsion or modification of the pre-operative torsion was not observed, a prior study should be made of torsion., (Copyright © 2018 Sociedad Española de Oftalmología. Publicado por Elsevier España, S.L.U. All rights reserved.)

OBJECTIVE Compressive cranial nerve syndromes can be useful bedside clues to the diagnosis of an enlarging intracranial aneurysm and can also guide subsequent evaluation, as with an acute oculomotor nerve (cranial nerve [CN] III) palsy that is presumed to be a posterior communicating artery aneurysm and a surgical emergency until proven otherwise. The CN VI has a short cisternal segment from the pontomedullary sulcus to Dorello's canal, remote from most PICA aneurysms but in the hemodynamic pathway of a rupturing PICA aneurysm that projects toward Dorello's canal. The authors describe a cranial nerve syndrome for posterior inferior cerebellar artery (PICA) aneurysms that associates subarachnoid hemorrhage (SAH) and an isolated abducens nerve (CN VI) palsy. METHODS Clinical and radiological data from 106 surgical patients with PICA aneurysms (66 ruptured and 40 unruptured) were retrospectively reviewed. Data from a group of 174 patients with other aneurysmal SAH (aSAH) were analyzed in a similar manner to control for nonspecific effects of SAH. Univariate statistical analysis compared incidence and risk factors associated with CN VI palsy in subarachnoid hemorrhage. RESULTS Overall, 13 (4.6%) of 280 patients had CN VI palsy at presentation, and all of them had ruptured aneurysms (representing 13 [5.4%] of the 240 cases of ruptured aneurysms). CN VI palsies were observed in 12 patients with ruptured PICA aneurysms (12/66 [18.1%]) and 1 patient with other aSAH (1/174 [0.1%], p < 0.0001). PICA aneurysm location in ruptured aneurysms was an independent predictor for CN VI palsy on multivariate analysis (p = 0.001). PICA aneurysm size was not significantly different in patients with or without CN VI palsy (average size 4.4 mm and 5.2 mm, respectively). Within the PICA aneurysm cohort, modified Fisher grade (p = 0.011) and presence of a thick cisternal SAH (modified Fisher Grades 3 and 4) (p = 0.003) were predictors of CN VI palsy. In all patients with ruptured PICA aneurysms and CN VI palsy, dome projection and presumed direction of rupture were directed toward the ipsilateral and/or contralateral Dorello's canal, in agreement with laterality of the CN palsy. In patients with bilateral CN VI palsies, a medial projection with extensive subarachnoid blood was observed near bilateral canals. CONCLUSIONS This study establishes a localizing connection between an isolated CN VI palsy, SAH, and an underlying ruptured PICA aneurysm. CN VI palsy is an important clinical sign in aSAH and when present on initial clinical presentation may be assumed to be due to ruptured PICA aneurysms until proven otherwise. The deficit may be ipsilateral, contralateral, or bilateral and is determined by the direction of the aneurysm dome projection and extent of subarachnoid bleeding toward Dorello's canal, rather than by direct compression.

Background: Schwannomas of the parasellar region may arise from the trigeminal, oculomotor, trochlear, and abducens nerves., Objective: To define the tumor origin, location, and dural relationship (extradural vs extra-intradural vs cisternal) on preoperative magnetic resonance imaging (MRI), in order to plan the best surgical approach (purely extradural vs extra-intradural)., Methods: Twenty-four patients with parasellar schwannomas who underwent surgery were retrospectively analyzed. Twenty arose from the trigeminal nerve (7 intracavernous and 13 within the Meckel's cave), 3 from the oculomotor nerve, and 1 from the abducens nerve. The preoperative identification of the tumor location (extradural vs extra-intradural vs cisternal) and the nerve of origin was defined on MR sequences. All patients were operated on through a pterional approach (extradural or extra-intradural route)., Results: The tumor location was correctly defined on MRI in 22 out of 24 cases (92%) and the nerve of origin in 22 (92%). An extradural approach without intradural exploration was performed in all 5 intracavernous trigeminal schwannomas, in 11 out of 13 of the Meckel's cave, and in 2 schwannomas of the oculomotor nerve. Two schwannomas of the Meckel's cave with transgression of the medial dural wall, 1 of the oculomotor nerve, and the abducens nerve schwannoma required an extra-intradural approach. Complete tumor resection was obtained in 19 out of 24 cases (80%)., Conclusion: The pterional extradural approach is sufficient for Dolenc type I and II trigeminal schwannomas, excepting for those transgressing the inner dural layer. Schwannomas of the oculomotor and abducens nerves with cisternal location require an extradural-intradural approach.

Background: Late recurrence of visual symptoms associated with carotid-cavernous fistula (CCF), including diplopia, is uncommon and raises concern for new or recurrent fistula formation., Methods: We report 2 patients with traumatic CCFs, where cranial nerve paresis resolved after endovascular CCF treatment only to reappear years later., Results: No evidence of recurrent or new fistula formation was found. Both were treated successfully with strabismus surgery., Conclusions: Although the cause of delayed onset diplopia after successful treatment is still unknown, theories include late compression of cranial nerves within the cavernous sinus due to coil mass that can cause chronic ischemia, delayed inflammation due to a thrombophilic nidus created by the coil mass, or injury to the cranial nerves that manifests later due to decompensated strabismus.

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.

Purpose: To evaluate surgical outcome of superior rectus transposition (SRT) in esotropic Duane syndrome (DS) and abducens nerve palsy., Methods: Retrospective medical record analysis of all patients with esotropic DS and abducens nerve palsy treated with SRT at our center with minimum follow-up of 6 months. Primary outcome measures were esotropia in primary position and abduction limitation. Secondary outcome measures included head turn, stereopsis, and cyclovertical deviations., Results: A total of 20 eyes of 19 patients were included: 9 with DS and 10 with traumatic abducens nerve palsy. One patient had bilateral esotropic DS. Mean age of DS patients was 12.5 ± 10.1 years; of abducens nerve palsy patients, 25.4 ± 11.3 years. Medial rectus recession (MRc) of 3.5 mm was additionally performed in 5 DS eyes. An adjustable MRc 5.6 ± 2.2 mm with or without augmentation suture was performed in all abducens nerve palsy patients. In DS patients, esotropia improved from 27.5 Δ ± 5.4 Δ to 3.6 Δ ± 6.4 Δ (P < 0.001), abduction limitation reduced from -3.8 to -1.8 (P < 0.001), and head posture improved from 20° to 4° (P < 0.001) at 6 months. In abducens nerve palsy patients, esotropia improved from 51.5 Δ ± 18.8 Δ to 6.1 Δ ± 10.7 Δ (P < 0.001), abduction limitation reduced from -3.8 to -2, and head posture improved from 25° to 8° (P < 0.001). Stereopsis improved in 4 patients (P = 0.12). No patient had vertical deviation or torsional diplopia., Conclusions: In our patient cohort with esotropic DS or abducens nerve palsy, SRT reduced esotropia and improved abduction. Because of a long-term exotropic drift, initial undercorrection in the immediate postoperative period may prevent eventual overcorrection., (Copyright © 2017 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: Limited or no literature exists identifying factors associated with functional nerve recovery in patients undergoing resection of sixth cranial nerve (CN VI) schwannomas., Methods: A systematic review of literature was performed on CN VI schwannomas that were treated surgically. Synthesizing the findings pooled from the literature, we investigated associations of patient demographics and clinical characteristics with postsurgical CN VI functional recovery in multivariable regression models. In addition, we present the findings of an adolescent woman surgically managed for intracavernous CN VI schwannoma. Complete encasement of the cavernous segment of the internal carotid artery is unique to our case., Results: We synthesized data of 32 patients from 29 studies, and our index case. Overall, the mean age of the patients was 44.0 ± 16.5 years, and approximately 52% (n = 17) were female. Most tumors were left-sided (n = 18; 54.5%), with an average size of 3.46 ± 1.71 cm. The most common location was cisternal (n = 11; 33%), followed by cavernous sinus (CS) proper (n = 9; 27%), cisterocavernous (n = 8; 24%), orbital (n = 4; 12%) and caverno-orbital (n = 1; 3%). CN VI recovery was reported in less than half the cohort (n = 14; 45%). Tumor extension in the CS was significantly associated with lesser likelihood (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01-0.98; P = 0.048) of postsurgical CN VI recovery. Although female gender (OR, 0.86; 95% CI, 0.07-10.09; P = 0.906), large tumor size (>2.5 cm) (OR, 0.45; 95% CI, 0.07-2.89; P = 0.397), and solid consistency (OR, 0.37; 95% CI, 0.03-4.19; P = 0.421) were associated with lesser odds for recovery, these were not statistically significant. Likewise, although gross total resection (OR, 6.28; 95% CI, 0.33-118.25; P = 0.220) was associated with higher odds of nerve recovery, the estimates were statistically insignificant., Conclusions: CS involvement is associated with lesser odds for functional nerve recovery in patients undergoing surgical resection for CN VI schwannoma., (Copyright © 2017. Published by Elsevier Inc.)

Patients suffering from abducent nerve palsy are usually primary seen by a conservative medical Specialist. In most cases the ENT specialist is secondary involved for treatment. In the majority of cases abducent nerve palsy is a temporary symptom associated with neurologic or vascular diseases. Rarely inflammation, neoplasm or fracture of the skull base cause this symptom and lead to an intervention done by the ENT surgeon. This case series describes retrospectively the abducent palsy seen through the eyes of an ENT surgeon. From 2008 to 2011 15 patients suffering from abducent nerve palsy. One patient suffering from a temporal bone fracture has been treated conservatively while 14 patients needed surgery. 6 patients had a complicated inflammation of the skull base. In 7 patients skull base neoplasms were found in endoscopic surgery. In one case the underlying pathology remained unclear. 2 third of the patients that suffered from complications of inflammatory diseases completely recovered after a combined operative and conservative therapy. The patients who suffered from neoplasms of the skull base partially recovered in only one third, none, achieved full recovery. The patient with the temporal bone fracture achieved a partial recovery after 3 months. If the leading symptom of abducent palsy is caused by a severe extracranial inflammation, neoplasm or trauma an experienced skull base surgeon is mandatory. The recovery rate of abducent palsy in our case series was 60 %. The prognosis of abducent palsy in skull base inflammation is much better compared to patients with skull base neoplasm., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To compare the effectiveness of superior rectus transposition and medial rectus recession (SRT/MRc) vs inferior and superior rectus transposition (VRT) for acquired sixth nerve palsy., Design: Consecutive, interventional case series., Methods: The medical records of a consecutive series of patients with acquired sixth nerve palsy who underwent VRT or SRT/MRc by a single surgeon were reviewed. The preoperative and postoperative findings were compared between the 2 groups., Results: Eight patients (mean age, 46.8 years) underwent SRT/MRc and 8 patients underwent VRT (mean age, 51.1 years). Lateral fixation was performed on all but 4 patients in the VRT group. Preoperative esotropia in primary position and abduction deficit were similar in both groups (SRT/MRc, 41.9 prism diopter [PD], -4.6; VRT, 55.6 PD, -4.5; P = .195, 1.0). The SRT/MRc group underwent a mean MR recession of 6 (range, 5-7) mm. Four patients in the VRT later underwent MR recession (mean 5.3 mm, range 5-6 mm). In addition, 5 patients in the VRT group had 1 or more botulinum toxin injections in the medial rectus muscle. No additional procedures were performed in the SRT/MR group. Fewer additional procedures were performed with SRT/MR (SRT/MR, 0; VRT, 1.8 ± 1.2; P < .010). At last follow-up, residual esotropia (SRT/MRc, 7.1 PD; VRT, 10.3 PD; P = .442) was similar in both groups, but abduction was better in the SRT/MRc group (SRT/MR, -3.0 ± 0.7; VRT, -3.8 ± 0.4; P = .038). There were no new persistent vertical deviations or torsional diplopia., Conclusions: Final outcomes were similar with SRT/MRc vs VRT. However, fewer additional surgical procedures were needed with SRT/MR., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Superior rectus transposition has been popularized for the treatment of abduction deficiencies. Potential complications include induced vertical deviation and torsion. A new procedure, the inferior rectus transposition (IRT), may be similarly beneficial for patients at risk for postoperative vertical deviation or incyclotropia. The purpose of this study is to describe the outcomes of patients undergoing IRT., Design: Prospective, interventional case series., Methods: Five patients in an academic pediatric ophthalmology and strabismus practice with a complete lateral rectus palsy who underwent IRT were studied. Changes in anomalous head posture, ocular rotations, ocular alignment, and torsion preoperatively to postoperatively were compared., Results: The patients ranged in age from 19-89 years. There was a significant correction in the angle of esotropia (ET) from 39±17Δ (14-55Δ) to 12 ± 9.8Δ (0-22Δ) postoperatively (P = .02). Two of 5 patients had preoperative hypertropia of the affected eye (1.4 ± 2.2Δ; range, 2-5Δ). One of those had no vertical deviation postoperatively and 1 patient resulted in 2Δ hypotropia. One patient without vertical misalignment preoperatively developed a small postoperative vertical deviation. Torticollis significantly improved from 31.4 ± 11.6° to 5 ± 5.8° (P = .004). All patients improved abduction, with a mean of -4.4 ± 0.5 preoperatively to -3.4 ± 0.9 postoperatively (P = .07)., Conclusion: Initial postoperative follow-up in patients with abducens palsy undergoing IRT shows a significant improvement in ocular alignment and torticollis. In patients with preoperative hypertropia, IRT resulted in a downward shifting effect on the operated eye. IRT may be a beneficial procedure for patients with preoperative hypertropia or intorsion requiring transposition procedures. Future studies with larger populations and longer durations of follow-up will be required before this procedure can be recommended., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To study the clinical and etiological profile of patients with cavernous sinus syndrome (CSS) and identify factors which could determine the etiology and influence the outcome of these patients., Patients and Methods: This prospective observational study included 73 consecutive patients satisfying the criteria of CSS (i.e. involvement of any 2 of the 3rd, 4th, 5th and 6th cranial nerves or any one of them with radiological evidence of cavernous sinus involvement). All these patients were subjected to detailed haematological, biochemical and radiological investigations and diagnosed and treated as per guidelines. The clinical and investigational data was recorded and analysed meticulously., Results: A definitive etiological diagnosis of CSS could be achieved in 86% of patients. Tumours, fungal infections and Tolosa Hunt syndrome (THS) were most common causes. On univariate analysis, diabetes, severe vision loss (visual acuity of <3/60 in at least one eye), and presence of nasal discharge showed a significantly positive association with a fungal CSS. Evidence of paranasal sinusitis, bone erosion and ICA (internal carotid artery) involvement on Gadolinium enhanced MRI (magnetic resonance imaging) of brain were significantly associated with a fungal CSS (p=0.0001), whereas involvement of orbital apex had a negative association with a neoplastic etiology (p=0.014). On multiple logistic regression, orbital apex involvement on MRI was associated with diagnosis of THS (p=0.019, OR: 18.7; 95% CI: 1.6-217.4) while MRI evidence of paranasal sinusitis (p=0.014, OR: 45; 95% CI: 2.1-94.3) and bone erosion ((p=0.019, OR: 12.5; 95% CI: 1.5-103) correlated with diagnosis of fungal CSS. 65.2% of patients (fungal CSS- 70%) had a good prognosis at six months follow up., Conclusion: Most patients with CSS can be diagnosed accurately and managed properly with good outcomes., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: To report four cases of early onset sixth-nerve palsy all of whom had eccentric fixation., Methods: A retrospective case note review was undertaken of all cases presenting to the senior author's private and NHS practice with early onset sixth palsy between 2006 and 2012. As well as demographic information, details of ophthalmic, orthoptic, electrophysiological examinations, and radiological investigations that were extracted from the records., Results: Four children with unilateral or asymmetric early onset sixth-nerve palsy were identified, of which three were congenital. All four had MRI and only one had a normal MRI. Age at presentation ranged from 14-42 months, but all four had marked esotropia and poor visual acuities in the worst affected eye with eccentric fixation, which became more easily or only noticeable after surgical correction. Three patients with congenital sixth-nerve palsy underwent vertical muscle transposition with Botulinum Toxin A (BTXA) to the ipsilateral medial rectus, and two of these patients also had Foster sutures to the transposed vertical muscles. The fourth patient had unilateral medial rectus recession and lateral rectus resection. The mean preoperative measurement was 55 Δ ET (range 50-60 Δ ), and the mean postoperative measurement was 11 Δ ET (range 16XT-25ET) at near, and 2 Δ XT (range 15XT-14ET) at distance., Conclusions: We speculate that early onset paralytic strabismus due to congenital sixth-nerve palsy results in an inability to cross fixate which results in the development of eccentric fixation. Attempts to use reverse occlusion to negate the eccentric fixation failed. We therefore recommend early surgery for this condition to avoid this sequelae., (© 2017 Board of regents of the University of Wisconsin System, American Orthoptic Journal, Volume 67, 2017, ISSN 0065-955X, E-ISSN 1553-4448.)

PurposeTo evaluate the results of augmented vertical rectus muscle transposition (VRT) with intraoperative botulinum toxin (BTX) for complete and chronic sixth nerve palsy.MethodsDuring a 10-year period (2004-2014) all patients with chronic and complete sixth nerve palsy and contracted medial rectus (MR) who underwent augmented VRT and BTX injection into the MR enrolled in this study.ResultsIn total, 29 patients (5 bilateral) were enrolled in this study. Preoperative deviation was 45±17.5 Prism Diopter (PD), which was improved to -3.1±13.2 after the operation (P<0.001). Mean preoperative and postoperative abduction limitation was -4.4±1.1 and -1.8±0.9, respectively (P<0.001). The success rate was 76% (deviation within 10 PD of orthotropia). Four patients (13.7%) had hypotropia. In 19 patients with preoperative deviation ≤45 PD, four patients had consecutive exotropia.ConclusionIntraoperative BTX injection with augmented vertical rectus transposition is an effective procedure. In deviation ≤45 there is a risk of overcorrection.

A woman aged 60 years developed a Millard-Gubler syndrome after a diagnosis of a cavernous angioma in the median and paramedian areas of the pons. In this context, she presented a right VI nerve palsy, right conjugate gaze palsy, facial palsy and left hemiparesis. To improve the complete VI nerve palsy, we planned a modified transposition approach, in which procedure we made a partial transposition of vertical rectus with a silicone band that was fixated posteriorly. After the procedure, the patient gained the ability to slightly abduct the right eye. We found no compensatory torticollis in the primary position of gaze. There was also an improvement of elevation and depression movements of the right eye. We obtained satisfactory results with a theoretically reversible technique, which is adjustable intraoperatively with no need of muscle detachment, preventing anterior segment ischaemia and allowing simultaneous recession of the medial rectus muscles, if necessary., Competing Interests: Conflicts of Interest: None declared., (2016 BMJ Publishing Group Ltd.)

Purpose: To evaluate the surgical outcome of augmented superior rectus transposition (SRT) and medial rectus recession (MRc) in patients with abducens nerve palsy., Methods: The medical records of consecutive patients with abducens nerve palsy who underwent unilateral or bilateral simultaneous SRT with MRc from January 2012 to December 2014 were analyzed. Patients with previous strabismus surgery or botulinum toxin injection were excluded. Primary outcome measures were esotropia in primary position and abduction deficit. Data collected included age, sex, etiology, pre- and postoperative deviation, pre- and postoperative abduction deficit, anomalous head posture, induced vertical or torsional deviations postoperatively, reoperations, and details of other complications. Success was defined as postoperative alignment within 10 Δ of orthotropia; failure, as residual esotropia of ≥20 Δ ., Results: A total of 15 eyes of 13 patients were included. The most common cause of abducens nerve palsy was trauma (10 patients). The mean preoperative esotropia was 55.4 Δ ± 24 Δ , which improved postoperatively to 9.9 Δ ±10 Δ (P = 0.0000). The mean preoperative abduction deficit was -5 units, decreasing postoperatively to -3.1 (P = 0.000). Nine patients (69%) achieved success; 2 were classified as failures. One patient each developed postoperative hypotropia and intorsion; however, these were transient and did not require additional procedures. No patients developed anterior segment ischemia., Conclusions: Augmented SRT with MRc is effective in the management of abducens nerve palsy; however, its success in large deviations remains variable. Long-term follow-up is essential to determine the incidence of vertical and torsional deviations., (Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To study the binocular alignment and ocular motility in patients with large-angle esotropia due to sixth nerve palsy treated with double augmented vertical recti transposition., Methods: This was a prospective interventional study. Fifteen patients with non-resolving sixth nerve palsy who underwent surgical correction were included in the study. Fourteen patients also underwent an additional medial rectus recession. Two patients with an associated small vertical deviation had a selective augmentation of one vertical rectus muscle. Binocular alignment, ocular motility, duction limitation, improvement in head posture, induced vertical deviations, and field of diplopia-free binocular single vision (when possible) were analyzed. Successful outcome was defined as a residual horizontal deviation of 10 prism diopters (PD) or less with no vertical deviation at final follow-up (6 months)., Results: The double augmented Hummelsheim procedure improved esotropia from 58.3 ± 10.8 PD preoperatively to 7.2 ± 5.1 PD postoperatively (P = .001). Three (20%) patients had residual deviation of greater than 10 PD, of which 1 patient had diplopia and was treated with prisms. Postoperative binocular field of vision was performed in 6 patients, the mean of which was 20° for abduction and 45° for adduction. Three of 6 patients had elimination of face turn and the rest had residual head posture of less than 5°. Two patients had an induced vertical deviation of less than 4 PD. In patients who had selective augmentation, the vertical deviation was completely corrected., Conclusions: The patients operated on with double augmentation of the Hummelsheim procedure combined with medial rectus recession had reduced mean primary esotropia and improved diplopia-free field of vision postoperatively. [J Pediatr Ophthalmol Strabismus. 2016;53(6):369-374.]., (Copyright 2016, SLACK Incorporated.)

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.

Background: Advantages of radial access over brachial/axillary or femoral access have been well described for several decades and include decreased cost, patient preference, and decreased major access site complications. Despite these advantages, radial access is rarely employed or even considered for neurointerventional procedures. This attitude should be reconsidered given several recent large, randomized, controlled trials from the cardiovascular literature proving that radial access is associated with statistically lower costs, decreased incidence of myocardial infarctions, strokes, and even decreased mortality. Radial access is now considered the standard of care for percutaneous coronary interventions in most US centers. Although radial access has been described for neurovascular procedures in the past, overall experience is limited. The two major challenges are the unique anatomy required to access the cerebral vasculature given very acute angles between the arm and craniocervical vessels and limitations in available technology., Methods: We present a simplified approach to radial access for cerebrovascular procedures and provide a concise step-by-step approach for patient selection, ultrasound-guided single-wall access, recommended catheters/wires, and review of patent hemostasis. Additionally, we present a complex cerebrovascular intervention in which standard femoral access was unsuccessful, while radial access was quickly achieved to highlight the importance of familiarity with the radial approach for all neurointerventionalists., Results: We have found that the learning curve is not too steep and that the radial access approach can be adopted smoothly for a large percentage of diagnostic and interventional neuroradiologic procedures., Conclusions: Radial access should be considered in all patients undergoing a cerebrovascular procedure., (© The Author(s) 2015.)

Isolated bilateral abducens nerve palsy raises concern about a serious intracranial condition. Abducens nerve palsy is a common isolated palsy due to its susceptibility to injury along its long course. Non-traumatic isolated abducens nerve palsy is often caused by a mass that indirectly stretches and compresses the nerve. Pathological processes directly causing bilateral isolated involvement of the abducens nerve are rare. We describe a 24-year-old man who presented with isolated bilateral abducens nerve palsy. Radiological imaging and laboratory tests were consistent with an aggressive bacterial infectious process located in the sellar region with parasellar extension. If promptly addressed, sixth cranial nerve palsy appears to be reversible with aggressive medical therapy and endoscopic sinus surgery., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Traumatic brain injury (TBI) is less common in children than in adults. Posterior fossa lesions are even more uncommon, but, when present, are usually epidural hematomas. These lesions, even when small, may have a bad outcome because of the possibility of compression of the important structures that the infratentorial compartment contains, such as the brainstem and cranial nerves, and the constriction of the fourth ventricle, causing acute hydrocephalus. Although unusual, posterior fossa lesions are increasingly being diagnosed because of the better quality of and easier access to cranial tomography. In this paper, we report a case of a 12-year-old male patient who had suffered a TBI and presented with several pneumocephali, one of them in the retroclival region, causing a mass effect and then compression of the sixth cranial nerve which is the most susceptible to these injuries. We discuss these traumatic posterior fossa lesions, with an emphasis on retroclival pneumocephalus, not yet described in the literature in association with bilateral abducens palsy. In addition, we discuss associated lesions and the trauma mechanism., (© 2016 S. Karger AG, Basel.)

A 26-year-old Asian woman presented with diplopia occurring at 1 week after conservative treatment for left temporal bone fracture and left temporo-occipital epidural hematoma (EDH). At presentation, right abducens nerve palsy was observed with esotropia and abduction limitation in the right eye. Six weeks later, the abducens nerve palsy fully recovered with complete absorption of the EDH.

Too few cases of isolated abducent nerve palsy caused by neurovascular compression syndrome have been reported. We here report on a case of abducent nerve palsy caused by neurovascular compression syndrome that was successfully treated by microvascular decompression (MVD). A 46-year-old male presented with a 6-month history of right-sided persistent abducent nerve palsy. High-resolution magnetic resonance imaging revealed a neurovascular contact of the vertebral artery with the right abducent nerve. MVD was performed via a retrosigmoid craniotomy, with remarkable improvement of the palsy. Our report suggests that MVD might be considered as an optional treatment if the symptoms progress or persist.

Background: Multiple procedures have been described to treat a large-angle esodeviation with an associated abduction deficit. We report a plication augmentation of the Hummelsheim procedure for the management of esotropia and severe abduction deficit due to abducens nerve palsy or type 1 Duane syndrome., Methods: The medical records of patients operated on using the plication augmentation Hummelsheim procedure at two tertiary centers were retrospectively reviewed. The surgery involved ipsilateral lateral rectus plication, half muscle transposition of the vertical rectus muscles to the paralytic plicated lateral rectus, Foster augmentation sutures, and ipsilateral medial rectus recession or botulinum toxin injection if it was found to be tight on intraoperative forced duction testing. Pre- and postoperative deviations, ocular motility findings, and complications were noted., Results: A total of 13 patients were included, all of whom had an esotropia with profound abduction deficit (-4 or more). Postoperative deviations ranged from 14(Δ) of esotropia to 14(Δ) of exotropia, with significant improvement of the abductive motion. No patient developed anterior segment ischemia., Conclusions: The plication augmentation Hummelsheim procedure resulted in correction of even very large esodeviations and improvement of the abduction force. This procedure may also better preserve the blood supply to the anterior segment compared to other surgical approaches., (Copyright © 2015 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: There are many surgical options to address a sixth nerve palsy including transpositions of the vertical recti to the lateral rectus. This review will summarize the results from variations on transpositions as they apply to sixth nerve palsies., Recent Findings: Transposition of both vertical recti with posterior fixation creates the greatest correction of esotropia in primary position with largest field of single vision. Transposition of the superior rectus alone preserving anterior segment circulation achieves effects similar to transposition without posterior fixation. Augmentation with partial transposition also creates similar improvement in esotropia with possibilities for adjustable sutures and circulation preservation., Summary: These various options on transpositions allow options to specifically address surgeon preferences and patient needs to select the appropriate surgery.

A, 46-year-old Indian male, known hypertensive presented with left esotropia of 25  prism diopters (PD) after head injury in a roadside accident 9 months back. The deviation was constant in nature and was associated with complaints of diplopia in left lateral gaze. Traumatic sixth nerve palsy was diagnosed. The patient underwent left medial rectus recession of 5 mm and a split-tendon transposition of the left superior and inferior recti to the lateral rectus insertion (Hummelsheim procedure). On the first postoperative day, the patient developed corneal edema and anterior chamber reaction of flare 2+ and cells 2+. The pupil was semi-dilated and was sluggishly reacting to light. Anterior segment ischemia was diagnosed, which was managed with topical and systemic steroids.

Purpose: To compare the efficacy of three different vertical rectus muscle transposition (VRT) techniques performed as a sole procedure to correct ocular alignment and improve abduction in cases of complete abducens nerve palsy., Methods: The medical records of patients with complete abducens nerve palsy who underwent one of three different VRT procedures without simultaneous medial rectus weakening over a period of 20 years were retrospectively reviewed. The following procedures were used: full-tendon transposition (FTT), FTT with 4 mm resections before reinsertion (FTTR), and FTT with myopexy sutures (FTTM). We recorded the pre- and postoperative alignments, limitations of adduction and abduction, and complications. Follow-up was at least 6 months., Results: A total of 26 patients (age range, 8-74 years) were included: 25 unilateral and 1 bilateral. Follow-up ranged from 6 to 21 months. Among 25 patients having unilateral surgery, the mean changes in esotropia were: 36.0(Δ) for FTT (n = 9), 46.4(Δ) for FTTR (n = 7), and 41.3(Δ) for FTTM (n = 9). Mean improvements in abduction grading were 0.94 for FTT (9 eyes), 1.64 for FTTR (7 eyes), and 1.41 for FTTM (11 eyes). For both measures the means were not significantly different. Three patients (2 FTT and 1 FTTM) had new postoperative vertical tropias >3(Δ). Only 1 patient (with FTTR) had an overcorrection., Conclusions: FTTR corrected the most esotropia and improved abduction to the greatest degree, with the advantages of a low risk of creating a new vertical deviation and avoiding the risks of extra scleral sutures., (Copyright © 2015 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Objectives: Allergic fungal rhinosinusitis (AFRS) may present with significant bone erosion of the orbital walls or cranial base. Although proptosis is fairly common, cranial neuropathies are rarely reported. The objectives of this study are to describe strategies for AFRS-induced neuropathies and evaluate ophthalmologic outcomes following endoscopic sinus surgery., Study Design: Case series with chart review., Setting: Tertiary referral center., Subject and Methods: A retrospective review identified 9 patients treated from 2008 to 2014 with AFRS-induced cranial neuropathies. Data regarding patient demographics, preoperative imaging, ophthalmologic symptoms, surgical intervention, histopathologic findings, and postoperative sinonasal and ophthalmologic outcomes were recorded., Results: Patients with AFRS (average age, 38 years) presented with optic neuropathy or abducens nerve palsy. Clinical presentation included unilateral visual loss secondary to optic nerve compression (n=5), diplopia from unilateral (n=2) or bilateral (n=1) abducens nerve palsy, and bitemporal hemianopsia secondary to optic chiasm compression (n=1). On average, the duration of ocular symptoms was 17 days. All patients underwent endoscopic surgical decompression of the sinuses and oral steroid therapy. Two individuals had an additional optic nerve decompression at the time of surgery. Seven patients had complete return of nerve function, whereas 2 had partial recovery at an average of 5 weeks following surgery., Conclusion: Bone erosion of the sphenoid sinus walls by AFRS can lead to compression of surrounding neural structures producing cranial neuropathies. Identification of these symptoms and prompt surgical decompression and removal of disease, along with aggressive medical therapy, provided excellent outcomes in the current series of patients., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Background: Unilateral isolated sphenoid sinus disease (ISSD) is a rare diagnosis of the paranasal sinuses that can be associated with complications involving vascular, neurologic, and optic structures in close proximity., Case Presentation: A 62 year old female presented to a hospital in Georgetown, Guyana with right lateral rectus palsy, diplopia, and a severe progressively worsening headache. CT scan revealed an opaque left sphenoid sinus consistent with unilateral ISSD. A transnasal sphenoidotomy was performed without complication under local anesthetic in the absence of endoscopic guidance. The patient's headache resolved immediately after surgery while the diplopia and lateral rectus palsy resolved completely after 6 weeks., Conclusion: We present a rare complication of ISSD and highlight challenges associated with diagnosis and management of ISSD in a resource-limited setting. This is the second reported case of unilateral ISSD with contralateral lateral rectus palsy in the literature.

The abducens nerve schwannoma is one kind of rare intracranial tumor. We report an interesting case of abducens nerve schwannoma in the right cerebellopontine angle in a 68-year-old male patient presenting only vertigo and headache, without any symptom of abducens nerve palsy. This is the oldest patient with abducens nerve schwannoma to date. The patient received a craniectomy via suboccipital retrosigmoid approach and had total surgical excision.

Background: Superior rectus transposition with or without medial rectus recession has been advocated for the treatment of abducens nerve palsy and esotropic Duane syndrome. Early reports have focused mainly on postoperative ocular alignment, but there is concern that superior rectus transposition may induce torsional misalignment. The purpose of this study was to evaluate torsional outcomes after superior rectus transposition surgery using prospective preoperative and postoperative torsional assessments., Methods: Prospective measurements were performed on all patients undergoing superior rectus transposition. Preverbal infants were assessed using fundus torsion evaluating the position of the fovea relative to the optic nerve; older children/adults underwent double Maddox rod (DMR) assessment of torsion., Results: A total of 11 subjects met the study inclusion criteria. The etiology of strabismus was an abducens nerve palsy (n = 7) or Duane syndrome (n = 4). For the subjects evaluated by fundus torsion (n = 4), there was no significant change in torsion for 3 (75%). For those subjects undergoing DMR (n = 7), there was a significant change in subjective torsion (4.7 ± 3.8°excyclotorsion vs 0.0° ± 5.0° excyclotorsion; P = 0.004). Esotropic deviation improved significantly for all subjects (39(Δ) ± 23(Δ) vs 6.5(Δ) ± 13(Δ); P = 0.001) and no significant mean vertical deviation postoperatively, although 1 patient had a clinically significant postoperative hypertropia measuring 14(Δ). Abduction also improved significantly (-4.2 ± 0.9 vs -2.8 ± 1, P = 0.0001)., Conclusions: In this patient series, superior rectus transposition with medial rectus recession did not have clinically significant induction of torsional diplopia as a result of the procedure., (Copyright © 2014 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

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.

Schwannomas of the abducens nerve are uncommon. Nineteen cases have been reported in the literature and are classified into two types: Type 1, in the cavernous sinus, and Type 2, in the prepontine area. However, a dumbbell-shaped type has not yet been reported. Here we report the first case of a dumbbell-shaped abducens schwannoma and classify this type into a new category (Type 3). A 36-year-old woman presented with left hearing disturbance for 4 years, dizziness for 2 years, and dysphagia for 6 months. Neurological examination showed left sensorineural hearing impairment, hypesthesia in the distribution of the left first and second branches of the trigeminal nerve, left curtain sign, and gait disturbance. Computed tomography and magnetic resonance imaging revealed a dumbbell-shaped tumor located in the cavernous sinus that extended to the right cerebellopontine angle. She underwent a two-staged operation; the first operation was via ananterior transpetrosal approach for the lesion in the middle fossa and the upper part in the posterior fossa, and the second surgery was via alateral suboccipital approach for the lower part in the posterior fossa. In the first operation, the abducens nerve was sacrificed. Histological examination confirmed schwannoma. Postoperatively, hearing disturbance and ataxia were improved and complete abducens nerve paresis appeared. The dumbbell-shaped abducens schwannoma has novel clinical features, difficulty of sixth nerve preservation, and unique surgical approach.

Intracavernous sinus arachnoid cysts are rare intracranial congenital lesions. When present, their anatomic location frequently results in cranial nerve palsy. A 15-year-old boy was admitted to our hospital with diplopia, which had gradually worsened over the previous several months. An arachnoid cyst was identified within the right cavernous sinus and fenestration surgery was performed. The patient recovered well and three months after the surgery, diplopia was disappeared. Surgical decompression of the intracavernous sinus arachnoid cyst is beneficial for symptomatic patients with this condition.

Background: Malignant peripheral nerve sheath tumors are rare, and intracranial occurrences are even more rare. Treatment strategies have varied widely. This article reports the first case of a malignant peripheral nerve sheath tumor of the abducens nerve and provides a literature review that includes 61 cases of intracranial malignant peripheral nerve sheath tumors. Data were analyzed based on age, sex, treatment, survival, immunohistochemical staining, location, tumor grade, and neurofibromatosis association. These tumors more often affect male persons, and the patients affected have a mean age of 39 years. Most patients underwent subtotal or gross total resection and radiation. Intracranial location varied, but most tumors occurred in the cerebellopontine angle. The literature shows that intracranial malignant peripheral nerve sheath tumors are a heterogeneous group. Their association with neurofibromatosis is less clear than that of their extracranial counterparts. Prognosis is poor, but surgical resection and radiation can enhance chances for longer survival. Our aim was to elucidate information about these tumors., Case Description: A 30-year-old woman presented with a 6-month history of headaches and diplopia., Results: Neurological examination revealed no focal deficit. Imaging revealed a heterogeneously enhancing retroclival mass without bony destruction. The tumor originated from the ipsilateral abducens nerve and extended into the Dorello canal; it adhered to the brainstem and cranial nerves. Pathology was consistent with low-grade malignant peripheral nerve sheath tumor., Conclusions: At 3-month follow-up, the patient walked with a cane with no further deficits except mild ataxia, which resolved within 6 months. Magnetic resonance imaging revealed a small residual tumor adherent to the basilar artery. At 1-year follow-up and after ocular surgery to correct lateral rectus palsy, the patient was neurologically intact., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To report a simple muscle transposition procedure without tenotomy or muscle splitting to treat abducens palsy., Design: Retrospective, interventional, consecutive case series., Methods: Nine patients with esotropia resulting from abducens palsy whose eyes could not abduct beyond the midline underwent this muscle transposition procedure, in which a suture was inserted through the temporal margin of each vertical rectus muscle. The same monofilament suture also was inserted into each inferotemporal or superotemporal sclera. The lateral margin of each vertical rectus muscle was transposed superotemporally or inferotemporally and was sutured onto the sclera. All 9 patients underwent unilateral muscle transposition, and 6 of the 9 underwent a medial rectus muscle recession combined with muscle transposition in the same eye., Results: The surgical correction by muscle transposition alone ranged from 24 to 36 prism diopters, and that by muscle transposition and recession of the medial rectus muscle ranged from 50 to 62 prism diopters. The mean correction was 46.3 ± 13.1 prism diopters per eye. All paretic eyes could abduct beyond the midline. No major vertical ductional disturbances developed. Anterior segment ischemia did not occur in any patients., Conclusions: This procedure, which achieved the same corrective results as other popular procedures, is simple to perform because it requires only a suture from the muscle to sclera. Tenotomy or splitting of the transposed muscles is unnecessary., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: To report the postoperative results of full-tendon vertical rectus transposition (VRT) augmented with lateral fixation suture for the treatment of type 1 Duane syndrome and sixth nerve palsy and to determine whether there was a decrease in the effect of the Foster suture over time., Methods: This retrospective, consecutive case series included patients who underwent a full-tendon VRT transposition with lateral fixation for type 1 Duane syndrome or sixth nerve palsy. The primary outcome measures included deviation, abnormal head posture(AHP), abduction deficiency, and postoperative binocular single visual field (BSVF)., Results: Eighty-seven patients (87 eyes: 40 eyes with Duane syndrome and 47 eyes with sixth nerve palsy) were included in this study. In Duane syndrome patients, the deviation was reduced by a mean of 95%, the AHP was eliminated in 86% of patients, the abduction was improved by 42%, and a useful BSVF of ≈ 67% of normal was achieved at 1 year post operation. In sixth nerve palsy patients, the deviation was reduced by 99%, the abduction was improved by 59%, and a useful BSVF of ≈ 71% of normal was achieved at 1 year post operation. In both groups, the improvements in deviation angle and abduction were stable postoperatively. Sixteen patients needed reoperation for undercorrection., Conclusion: VRT surgery with posterior fixation is an effective treatment method for complete sixth nerve palsy and Duane syndrome with esotropia, AHP, and abduction deficiency. The procedure carries a small risk of reoperation for undercorrection. The effect of the Foster suture did not decline over time.