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Abducens nerve palsy caused by neurovascular conflicts is rare and requires further exploration. This study aimed to investigate the clinical features and surgical outcomes of abducens palsy caused by neurovascular conflict. Twenty-six patients with abducens palsy caused by neurovascular conflict were included in present study. The clinical data and treatment outcomes were retrospectively analyzed. Symptom improvement score was used to evaluate the changes in diplopia, which include five grades: complete remission, significant relief, partial relief, no improvement, and worsening of symptoms. Neurovascular conflict was determined in 26 patients (12 male and 14 female) with a mean age of 60.54 ± 13.55 years (range, 35 to 84 years). The mean duration of symptoms was 10.19 ± 11.30 months (range, 1 to 60 months). Ten patients underwent microvascular decompression (MVD) while 16 patients received observation and drug therapy. No fatal complications occurred in any patient. In the MVD group, 9 patients achieved remission of diplopia, while 1 patient showed no change in symptoms. In observation group, only 4 patients achieved symptom relief and 12 patients showed no improvement or worsened. The symptom improvement score of MVD group was significantly higher than that of observation group at last follow-up (3.50 ± 0.97 vs. 1.38 ± 0.95, P < 0.001). Neurovascular compression, although rare, should be considered as a possible underlying cause of isolated abducens nerve palsy. Microvascular decompression can be considered a treatment option based on the comprehensive preoperative evaluation. Patients with significant atrophy of the extraocular muscles are unsuitable for MVD surgery., Competing Interests: Declarations Ethical approval It does not need ethical approval because it’s a retrospective study, but it conformed to the provisions of the Declaration of Helsinki. Patient or volunteer consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Competing interests The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: To report the outcomes of "our modified Jensen technique" for treating esotropia in cases with complete sixth cranial nerve (CN VI) palsy., Methods: This study is a 30-year case series of isolated complete CN VI palsy who underwent combined medial rectus recession and our modified Jensen operation. We modified the original technique by anchoring the muscle-unifying sutures to the sclera near the equator using a non-absorbable suture. Major outcomes such as postoperative diplopia, face turn, horizontal and vertical eye deviations, and abduction limitation were assessed. Successful surgery was defined as orthotropia or esotropia equal to or less than 8 prism diopters (PD) and the absence of any vertical deviation., Results: Fifty-three cases with a mean age of 28 years old were included in this study. The male-to-female ratio was 3 to 1. Forty-five cases (85%) presented with unilateral palsy, whereas 8 patients (15%) had bilateral palsy. Trauma was the most common etiology (85%). Diplopia or face turn, presented in 42 patients before the operation, remained in seven cases after the operation. Primary position esotropia, which was the main complaint in all patients, decreased from 49 PD to 4 PD in unilateral palsy and from 101 PD to 10 PD in bilateral palsy. The mean reduction of abduction deficit was 1.78 in unilateral and 1.75 in bilateral palsy. The success rate was 76% in unilateral and 62% in bilateral palsy., Conclusion: Our modified Jensen operation was effective in treating patients with complete CN VI palsy, producing no significant permanent complications., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The modified Nishida muscle transposition procedure, in which one-third of each vertical rectus muscle belly is sutured onto the sclera in the infero- and superotemporal quadrants without either tenotomy of the vertical rectus muscles or splitting of the vertical rectus muscle is an effective treatment for abducens nerve palsy. We report a case of inferior rectus muscle aplasia treated using the modified Nishida procedure to transpose both horizontal rectus muscles inferiorly combined with superior rectus tenotomy., (Copyright © 2024 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Background: Abducens nerve (AN) schwannomas are extremely rare tumors. Clinical characteristics and factors that influence postoperative outcomes are not well defined., Objective: To characterize clinical features of AN schwannomas and predictors of surgical outcomes., Methods: PRISMA-guided systematic review of the literature on AN schwannomas was performed. Subsequently, univariate and multivariate regression analyses were performed to identify the predictive value of variables that influence postoperative outcomes., Results: A total of 42 studies with 55 patients were evaluated. The mean age at presentation was 43.9 ± 14.6 years. The most common presenting symptom was cranial nerve VI palsy (69.1%). Cavernous sinus (49.1%) and prepontine cistern (36.3%) were the most commonly involved locations. Complete recovery after surgery was seen in 36.3% at a median follow-up of 28.4 ± 25.8 months. Preoperative AN palsy (P < 0.001), suboccipital approach (P = 0.007), and subtotal resection of tumor (P = 0.044) were significant protective factors for postoperative complications. Prepontine location and postoperative complications were poor prognostic indicators of AN recovery (odds ratio [OR], 0.10, P = 0.030 and OR, 0.10, P = 0.028, respectively). Subtotal resection was significantly correlated with higher odds of AN recovery (OR, 6.06; P = 0.040)., Conclusions: AN schwannomas are rare but serious tumors that can cause significant morbidity, with only approximately one third of patients showing complete recovery after surgery. The suboccipital approach was a protective factor for postoperative complications, especially when combined with subtotal resection. Knowledge of these factors along with tumor characteristics helps optimize surgical planning and preoperative counseling., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Significance: Intracranial hypotension is a condition that occurs from a cerebrospinal fluid leak. Various visual symptoms have been associated with this condition. Cranial nerve VI (CN VI) palsies are the most common ocular manifestation, as the abducens nerve is prone to injury because of its intracranial anatomical course., Purpose: This case report presents a CN VI palsy secondary to intracranial hypotension from ventriculoperitoneal shunt overfiltration. Diagnosis, treatment, and management considerations are discussed. No identifiable health information was included in this case report., Case Report: A 70-year-old White man was referred to the eye clinic for evaluation of binocular horizontal diplopia. The patient had a recent history of a left ventriculoperitoneal shunt for a persistent cerebrospinal fluid leak after complex mastoid surgery. The patient was also symptomatic for positional headaches, which improved in a recumbent position. He was diagnosed with a left CN VI palsy secondary to intracranial hypotension from a ventriculoperitoneal shunt overfiltration. The patient was followed up by neurosurgery for shunt adjustments to resolve the overfiltration. Binocular horizontal diplopia was managed conservatively with Fresnel prism., Conclusions: Intracranial hypotension should be considered in patients presenting with cranial nerve palsies and positional headaches. Obtaining neuroimaging and comanaging with neurology or neurosurgery are advised to make prompt diagnosis and treatment. Careful clinical monitoring and conservative diplopia therapy are recommended as visual symptoms improve upon resolution of the cerebrospinal fluid leak., Competing Interests: Conflict of Interest Disclosure: The author has reported no financial conflict of interest., (Copyright © 2023 American Academy of Optometry.)

This interventional case series presents a novel surgical procedure involving double interlacing for the correction of esotropia in individuals with sixth cranial nerve palsy. The technique involves first splitting the tendons of the superior rectus, inferior rectus, and lateral rectus muscles. Subsequently, the superior half of the lateral rectus muscle is passed through the undisinserted superior rectus muscle, and the inferior half of the lateral rectus muscle is passed through the undisinserted inferior rectus muscle. Finally, the two halves of the lateral rectus muscle are sutured together and reattached at the original insertion point. The surgical outcomes demonstrate a significant improvement in alignment, abduction, and binocular vision. [ J Pediatr Ophthalmol Strabismus . 2023;60(5):e58-e64.] .

Aims: To report the effect of two three-muscle surgeries, inferior rectus belly transposition plus augmented superior rectus transposition plus medial rectus recession (ISM) and modified vertical rectus belly transposition plus medial rectus recession (VM), in the management of large-angle esotropia in Chinese patients with chronic sixth nerve palsy., Methods: Twenty-eight consecutive patients with large-angle esotropia ≥50 Δ were prospectively enrolled and underwent either ISM or VM. Main outcomes included preoperative and postoperative deviation in primary position, abduction limitation and complications. Follow-up was at least 6 months., Results: Of the included patients, 13 underwent ISM and 15 underwent VM. Preoperatively, ISM group displayed larger esotropia and more severe abduction limitation. 27 patients completed the follow-up. The postoperative horizontal deviation and abduction limitation were similar in both groups. At the last follow-up, ISM group demonstrated greater improvement of abduction limitation than VM group in both grading (group difference -2.1, p<0.001) and quantitation (group difference 2.6 mm, p=0.001). However, eight (30%) patients revealed an induced adduction limitation ≤-1. Of the 22 patients with unilateral palsy, more esotropia of 14.8 Δ was corrected in ISM group, compared with VM group (p=0.003). Three patients (14%) developed vertical diplopia and three (14%) developed torsional diplopia. Unexpectedly, keratitis was observed in 4 of 27 (15%) patients, all with concurrent fifth and/or seventh nerve palsy. Three patients aggravated to corneal ulceration., Conclusions: Two three-muscle surgeries, ISM and VM were both effective for large-angle esotropia in Chinese patients with chronic sixth nerve palsy. However, attention should be paid to potential complications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We present a unique case of 6th nerve palsy following accidental durotomy in endoscopic lumbar spine surgery, which has not been reported in the literature before. A 72- year-old female patient was admitted to our outpatient clinic complaining of right leg pain for 6 months. A 4/5 motor paresis was observed on her right toe with a positive Lasegue test at 45°. On her magnetic resonance imaging (MRI), a L5-S1 disc herniation was detected. The patient was planned for percutaneous endoscopic interlaminar disc surgery. The extruded disc was adherent to the dura. During removal, a dural tear was observed. She was relieved of her right leg pain immediately after surgery, but after 30 min postoperatively, she complained of double vision with left abducens nerve paralysis. On cranial MRI, no abnormality could be observed. Intravenous fluids were administered and the paralysis resolved on the postoperative 24th hour. The patient was discharged from the hospital and did not show any complaints on her follow-ups. A 6th nerve palsy can be caused due to alterations of intracranial pressure or mechanic injury. We believe that the durotomy following removing of the disc fragment caused a rapid drainage of CSF, leading to intracranial hypotension and injury of the abducens nerve. Intracranial pressure should be monitored perioperatively and brisk deteriorations has to result in immediate finishing of the surgery to avoid further secondary damage., (© 2022 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

We report the outcomes in 2 patients with acquired abducens nerve palsy with residual esotropia following superior rectus transposition and medial rectus recession who subsequently underwent inferior rectus transposition as a second procedure. Both patients showed improved abduction and reduced esotropia, with no induced cyclotorsion or vertical deviation. Inferior rectus transposition as a secondary procedure in these 2 patients with abducens nerve palsy appeared to augment the effect of prior superior rectus transposition and medial rectus recession., (Copyright © 2023 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess ocular alignment outcomes and their stability for patients who underwent strabismus surgery for abducens nerve palsy and to identify preoperative patient variables that predict surgical success or repeated surgeries., Methods: We retrospectively reviewed the medical records of patients diagnosed with abducens nerve palsy and who subsequently underwent strabismus surgery., Results: A total of 209 patients (386 procedures) were included. The mean number of surgeries for patients was 1.9 ± 1.4. Success was achieved after a single surgery for 112 patients (53.6%), and success was achieved for an additional 42 patients, for a total of 154 patients (73.7%), following all surgeries. Preoperative abduction deficit severity was the only variable predictive of surgical success, with mild deficits having the highest odds of both initial success (OR = 5.555; CI, 2.722-11.336) and final success (OR = 5.294; 95% CI, 1.931-14.512). When analyzing survival time until additional surgery, the median survival was 406 days; abduction deficit severity, older age, other coincidental motility abnormalities, greater magnitude esotropia, and surgical technique were predictive of repeat surgical incidence., Conclusions: In our patient cohort, preoperative abduction deficit was an important predictor of both surgical success and repeat surgical incidence for abducens nerve palsy. Older patient age, additional motility abnormalities, and greater amounts of baseline strabismus were also associated with greater likelihood of multiple surgeries., (Copyright © 2023 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

For patients with a complete, chronic abducens nerve palsy and resulting abduction deficit, a transposition procedure is often the procedure of choice. One such transposition procedure involves transposing the superior rectus (SR) and inferior rectus (IR) laterally without disinserting or splitting either muscle. While effective, this procedure - like many transposition procedures - carries with it the risk of induced torsional or vertical misalignment. Here, we describe an adjustable variation of the above transposition procedure, one which potentially would allow for post-operative correction of induced vertical or torsional deviations.

Anterior segment ischemia (ASI) can occur following strabismus surgery on multiple muscles. Procedures such as modified Nishida procedure (MNP) have been developed to reduce the risk of ASI. We report the case of a 68-year-old patient presenting with traumatic bilateral abducens nerve palsies who required surgical intervention. We performed MNP with medial rectus recession. The patient presented with reduced vision, corneal edema, anterior chamber reaction, and pupillary dilation 24 hours after surgery. A diagnosis of ASI was made, and immediate reversal of the Nishida procedure was performed. Symptoms improved within 24 hours. In this case, ASI may have been caused by ligation and compression of ciliary arteries due to overstretching of the vertical rectus muscles during transposition., (Copyright © 2022 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the outcomes of no-split, no-tenotomy transposition of only the superior rectus muscle combined with medial rectus recession in patients with complete abducens nerve palsy., Methods: In this procedure, the temporal margin of the superior rectus muscle, 10 mm posterior to the insertion, was secured with a nonabsorbable suture and sutured to the sclera at a distance of 12 mm from the limbus in the superotemporal quadrant, halfway between the superior rectus and lateral rectus. Success was defined as distance and near alignment of ≤8 Δ and no diplopia in primary position 6 months after surgery., Results: A total of 8 patients with abducens nerve palsy underwent the procedure. At the last follow-up, the mean postoperative change in primary position deviation was 42.6 Δ ± 8.1 Δ (range, 34 Δ -57 Δ ) for distance and 42.1 Δ ± 7.5 Δ (35 Δ -57 Δ ) for near, a significant reduction (P = 0.012). Abduction deficit also improved significantly (P = 0.010). Postoperatively, no vertical deviation or torsional diplopia was induced. At the 6 months' follow-up, compared with the first postoperative visit, an esodrift at near developed in 1 patient. Of the 8 cases, 6 fulfilled the criteria for success., Conclusions: In our small study cohort, no-split, no-tenotomy superior rectus transposition and medial rectus recession improved esotropia and abduction limitation without inducing significant vertical deviations or torsional diplopia., (Copyright © 2023 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To report a series of cases, who developed consecutive exodeviation after vertical muscle transposition (VRT) performed for sixth nerve palsy, describe their management and analyse their outcome., Design: Retrospective case series., Methods: This is an institutional study on patients who developed consecutive exotropia following VRT for sixth nerve palsy in two different centres. The age, gender, cause, and time to surgery were reviewed. Ductions, versions and angles of misalignment were analysed. In those who developed an exotropia >10 PD after surgery, a second surgery was performed. The time to the second surgery, intra-operative findings, surgical procedure and outcome were studied., Results: A total of 164 cases of VRT for sixth nerve palsy were identified. Nine patients developed consecutive exotropia >10 PD (5.5%). There were no significant differences in the characteristics of those who developed overcorrection compared to those who did not. Five patients had full-tendon muscle transposition, three patients had Hummelsheim procedure and one patient had Jensen procedure. The average angle of consecutive exotropia was 26 ± 9 Δ (range 10-40 Δ). After the second surgery, angle of exotropia decreased to 21 ± 15 PD. Seven patients still had residual exotropia ≥10Δ and the exotropia was corrected in the remaining two patients. The time to second surgery in those two patients was much shorter than the other seven patients., Conclusions: Patients who undergo VRT should be followed up in the early post-operative period and revisiting the transposition should be done immediately in case of consecutive exotropia to avoid permanent overcorrection., (© 2021. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Purpose: To compare the effectiveness of three procedures: modified Nishida procedure alone vs modified Nishida procedure combined with medial rectus recession (MRc) vs modified Nishida procedure combined with MRc and botulinum toxin (BT) for severe unilateral sixth nerve palsy., Design: Consecutive, interventional case series., Methods: The medical records of a consecutive series of patients with severe unilateral sixth nerve palsy who underwent modified Nishida procedure in multiple centres were reviewed. Surgical technique was decided preoperatively at the surgeon's discretion. The preoperative and postoperative findings were compared., Results: Of the 43 patients with abducens palsy that received the procedure, 32 were included (mean age 38.6 ± 19.8 years). Mean preoperative deviation was 63.0 ± 27.3 prism dioptres (PD) and mean limitation of abduction -4.5 ± 1.2. Five patients underwent a modified Nishida procedure alone, 24 patients had an additional MRc and 3 patients were also injected with BT. Overall, the average correction of modified Nishida technique by itself was 29.4 ± 6.6 PD (range 20-36) and adding a MRc corrected 62.6 ± 23.8 PD (range 24-120). Modified Nishida procedure, MRc and BT altogether corrected 95.0 ± 18.0 PD (range 75-110). No postoperative complications were observed in any of the patients., Conclusions: Excellent outcomes with fewer complications are obtained with modified Nishida procedure alone. The need for additional procedures such as MRc and BT which increase the effect in primary position can be determined depending on passive duction and preoperative horizontal deviation., (© 2021. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Background: The cavernous sinus, which has several important structures, can be affected by various lesions, including tumor, vascular, infection, and inflammation., Case Report: We reported a rare case of abscess of the cavernous sinus in a child presenting with headache and abducens paralysis. Exploratory surgery was performed via the Dolenc approach, and the patient recovered from abducens paralysis 3 months later., Conclusion: Abscess of the cavernous sinus is rare.  Inspection of cavernous sinus can confirm the characteristics of the lesion and decompress the cavernous sinus, which may be beneficial for nerve function recovery., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To evaluate the efficacy and safety of superior rectus transposition (SRT) with/without augmented suture and vertical rectus transposition (VRT) for the treatment of strabismus caused by complete abducens nerve palsy. Methods: This was a retrospective cohort study. Forty-two patients (42 eyes) with complete abducens nerve palsy underwent strabismic surgeries from January 2015 to November 2020 in Tianjin Eye Hospital. According to the different procedures, the patients were divided into three groups: SRT group (16 cases, SRT with medial rectus recession), superior rectus transposition with augmented suture (SRTA) group (13 cases, SRT with Buckley suture and medial rectus recession) and VRT group (13 cases). The preoperative and postoperative (1, 6 and 12 months) data including deviations, ocular motility, binocular vision and surgical complications among three groups were analyzed and compared. χ 2 test was used for comparison of count data among three groups. The measurement data were compared among three groups by the repeated measures ANOVA. LSD- t test was used for within-group comparison and between-group comparison. Results: There was no difference in sex ratio, age and course of disease among the groups (all P >0.05). The horizontal deviations of the three groups at 1, 6 and 12 months after surgeries was lower than that before surgeries, and the difference was statistically significant (all P <0.001). The horizontal deviations of the SRT group, SRTA group and VRT group at 12 months after surgeries were (+0.8±5.8), (+0.8±4.5), (+1.2±2.5) prism diopters (PD), respectively, lower than that of the preoperative (+82.8±17.2), (+77.7±26.1), (+71.5±18.6) PD. However, there was no significant difference among different postoperative follow-up timepoints (all P >0.05). There was no difference in horizontal deviations before surgeries and at 1, 6 and 12 months after surgeries among three groups ( P >0.05). There were significant differences in the scales of abduction motility among preoperative, postoperative 1, 6 and 12 months measurements for three group (all P <0.001). The scales of abduction before surgeries in the SRT group, SRTA group, and VRT group were (-4.4±0.5), (-4.4±0.5), (-4.5±0.5) scale and at 12 months after surgeries were (-2.3±0.7), (-2.2±0.5), (-2.1±0.6) scale respectively. But there was no change among different postoperative follow-up timepoints (all P >0.05). Preoperative and postoperative 1-, 6-and 12-month abduction motility was similar among three groups ( P >0.05). There were significant differences in the scales of adduction limitation among preoperative, postoperative 1-, 6-and 12-months measurements for three group (all P <0.05). But there was no change among different postoperative follow-up timepoints (all P >0.05). There were significant differences between the SRT group [(-0.9±0.6), (-0.8±0.6) scale] and the SRTA groups [(-1.5±0.5), (-1.4±0.5) scale] ( t =-2.62, -2.52) and between the SRTA group and the VRT group [(-0.8±0.8), (-0.6±0.7) scale] ( t =2.62, 3.01) at 6 and 12 months after surgeries (all P <0.05). The outcomes of binocular vision at postoperative 12 months were similar among three groups ( P >0.05). No patient had torsional diplopia and anterior segment ischemia. Only 2 patients from the SRTA group had hypotropia of 4 to 5 PD in the primary position associated with supraduction limitation. Conclusions: SRT with/without augmented suture and VRT are effective and safe procedures for the treatment of strabismus caused by complete abducens nerve palsy. They could correct deviations, improve abduction motility and restore binocular vision, with stable outcomes and a small risk of vertical and torsional diplopia.

Purpose: To report the outcomes of the medial rectus (MR) disinsertion procedure for the management of refractory esotropia (ET) with or without Abnormal head posture (AHP) in chronic complete sixth nerve palsy., Methods: This is a retrospective case series of patients with sixth nerve palsy who suffered from residual ET and diplopia following the conventional strabismus surgeries and underwent MR disinsertion procedure between April 2017 and February 2020. This procedure was offered to the patients who declined to use prism and did not wish to perform surgery on the fellow eye. The demographic and clinical data, including sex, age, visual acuity, pre and postoperative angle of strabismus, duction limitations, results of forced duction and force generation tests, details of prior strabismus surgeries, orbital CT scan findings, and follow up duration were collected from the medical records., Results: Six patients were enrolled in this study. Mean age was 35.0  ±  14.0 years, and mean follow-up was 15.3  ±  5.9 months. The ET at the Primary position (PP) was 35.0  ±  18.4 prism dioptre (PD) before MR disinsertion, which decreased to 14.2  ±  17.4 PD after MR disinsertion procedure. Four cases needed additional complementary surgeries to improve residual ET in PP. No case developed overcorrection. Abduction deficiency was -5.0  ±  1.3 before MR disinsertion, which improved to - 2.8  ±  0.5 units at last follow-up. The mean of induced adduction deficiency was - 2.9  ±  0.4 at last follow-up., Conclusions: MR disinsertion can be considered in patients with chronic complete sixth nerve palsy and refractory diplopia when the conventional methods have failed.

Importance: Both vertical rectus belly transposition (VRBT) and superior rectus transposition (SRT) can be performed simultaneously with ipsilateral medial rectus recession (MRc) and have been shown to be effective for chronic sixth nerve palsy. However, it is unclear whether VRBT is superior to SRT in correcting esotropia., Objective: To compare the effectiveness of modified VRBT plus MRc (mVRBT-MRc) vs augmented SRT plus MRc (aSRT-MRc) in Chinese patients with chronic sixth nerve palsy., Design, Setting, and Participants: This parallel-design, double-masked, single-center, randomized clinical trial was conducted from January 15, 2018, to May 24, 2021. The follow-up visits were scheduled at 1 month and 6 months. Eligible Chinese participants with unilateral chronic sixth nerve palsy were randomly assigned to receive either mVRBT-MRc (VRBT group) or aSRT-MRc (SRT group)., Interventions: mVRBT-MRc or aSRT-MRc., Main Outcomes and Measures: Change of horizontal deviation in primary position from baseline to 6 months., Results: Of the total 25 eligible participants, the mean (SD) age was 45.4 (12.6) years, with 10 male participants (40%) and 15 female participants (60%). Thirteen participants (52%) were randomly assigned to the VRBT group, and 12 (48%) were randomly assigned to the SRT group. At baseline, the mean (SD) horizontal deviation was 65.7 (10.8) prism diopters (Δ) in the VRBT group and 60.5Δ(14.1Δ) in the SRT group. Similar amounts of MRc were performed in both groups. At 6 months, the horizontal deviation changed from baseline by 66.3Δ in the VRBT group and by 51.5Δ in the SRT group. The adjusted group difference was 10.9Δ (95% CI, 5.3Δ-16.6Δ), favoring the VRBT group (P = .001). Four times as many participants corrected more than 60Δ with mVRBT-MRc compared with aSRT-MRc. The group difference of the improvement of abduction limitation was -0.2 (95% CI, -0.8 to 0.5; P = .64). Although there was a higher proportion of undercorrection in the SRT group (difference, 45%; 95% CI, 16%-75%; P = .01), no differences were identified for other suboptimal outcomes between groups., Conclusions and Relevance: Compared with aSRT-MRc, mVRBT-MRc showed better effect in correcting esotropia with no differences detected for other suboptimal outcomes. mVRBT-MRc may be a promising alternative surgical procedure for chronic sixth nerve palsy, particularly for large esotropia of more than 60Δ, if these results are confirmed in larger, diverse cohorts with longer follow-up., Trial Registration: ChiCTR Identifier: ChiCTR-INR-17013705.

Background: to report the results of augmented inferior rectus muscle transposition (IRT) in management of chronic sixth nerve palsy., Methods: a retrospective review of medical records of patients with chronic complete sixth nerve palsy who were treated by augmented full thickness IRT to the lateral border of the paralyzed lateral rectus muscle. Patients were selected for IRT if there was more limitation of abduction in inferior gaze associated with V- pattern esotropia. Medial rectus recession (MRRc) was performed in case of positive intraoperative forced duction. Effect on primary position esotropia, face turn, amount of V-pattern and limitation of ocular ductions were reported and analyzed., Results: the review revealed 11 patients (7 males) with chronic unilateral sixth nerve palsy who were treated by simultaneous augmented IRT and MRRc. Causes of sixth nerve palsy were trauma (6 cases), vascular (3 cases), inflammation and congenital (one case each). Mean age of the patients at the time of surgery was 35.6 years (range; 11-63) and mean follow up was 8.6 months (range; 6-13). Postoperatively, average correction of esotropia, V-pattern, face turn and limited abduction were 35.9 PD, 11.4 PD, 25.9° and 2.2 unit, respectively (p < .00). Postoperative complications in the form anterior segment ischemia, symptomatic induced vertical deviations were not found., Conclusions: In cases of chronic unilateral sixth nerve palsy associated with more limitation of abduction in downgaze and V-pattern esotropia, augmented IRT could be considered as an effective and safe modality., (© 2022. The Author(s).)

Abducens nerve palsy is a severe dysfunction after petroclival meningioma (PC MNG) surgery. The objective of this investigation was to analyze abducens nerve outcomes in patients who underwent the retrosigmoid approach in relation to the MIB-1 index. Thirty-two patients with primary sporadic PC MNG were retrospectively analyzed. Mean follow-up was 28.0 months. Analysis of the MIB-1 index was performed to evaluate the abducens nerve outcome. An optimal MIB-1 index cut-off value (<4/≥4) in the association with postoperative CN VI palsy was determined by ROC analysis (AUC: 0.74, 95% CI: 0.57−0.92). A new-onset CN VI palsy was present in 7 cases (21.88%) and was significantly associated with an increased MIB-1 index (≥4%, p = 0.025) and a peritumoral edema in the brachium pontis (p = 0.047) which might be caused by the increased growth rate. Tumor volume, cavernous sinus infiltration, auditory canal invasion, and Simpson grading were not associated with new CN VI deficits. Six (85.7%) of the 7 patients with both an increased MIB-1 index (≥4%) and new abducens nerve palsy still had a CN VI deficit at the 12-month follow-up. A peritumoral edema caused by a highly proliferative PC MNG with an elevated MIB-1 index (≥4%) is associated with postoperative abducens nerve deficits.

Abducens nerve schwannomas are incredibly rare, with very few cases being reported previously. Our patient is the first to have been treated through use of an endoscopic endonasal approach. A 61-year-old woman presented with diplopia over a 1-year period. Magnetic resonance imaging identified a 2.8-cm lesion expanding into her right sphenoid sinus. She underwent an endoscopic endonasal approach for histological diagnosis and clearance of the lesion. Intraoperative exploration found the lesion to be originating from Dorello canal. Histological analysis confirmed a benign schwannoma. Following a multidisciplinary case review, we have followed a conservative approach and she remains well on radiological surveillance. In patients presenting with a sixth nerve palsy/paresis and a concomitant sphenoid lesion, clinicians should consider an abducens schwannoma as a possible diagnosis.

Background: We report a rare case of Godtfredsen syndrome caused by clival chondrosarcoma and perform a review of literatures. This article also explains the clinico-anatomical correlation of this rare neurological syndrome., Case Presentation: A 22-year-old gentleman presented with binocular diplopia. Clinical examination revealed an isolated right abducent nerve and right hypoglossal nerve palsy, with other cranial nerves intact. Neuroimaging revealed a right clival mass. Supraorbital craniotomy and tumour debulking were done in the same year. Histopathological examination showed low-grade chondrosarcoma. After 5-years of default, he came back with the tumour enlarged. He underwent a right orbitozygomatic craniotomy and tumour excision with 33 cycles of radiotherapy. Despite two surgeries and radiotherapy, the abducent nerve and hypoglossal nerve did not improve throughout 6 years of follow-up. Cranial nerve VI palsy is not always a false localizing sign, in Godtfredsen syndrome it serves as a localizing sign., Conclusion: To the best of our knowledge, this is the first case report of Godtfredsen Syndrome secondary to clival chondrosarcoma. Cranial nerve VI and XII palsy with no involvement of other cranial nerves, most likely the pathology is located at the clivus., (© 2022. The Author(s).)

Background: During the surgical resection of petroclival meningiomas, preserving the cranial nerves is crucial. The abducens nerve is particularly vulnerable during surgery. However, the preoperative risk factors and postoperative prognosis of abducens nerve palsy (ANP) are poorly understood., Methods: We retrospectively analyzed 70 patients who underwent surgery for petroclival meningiomas between May 2010 and December 2019, divided into gross-total resection (GTR) and subtotal resection (STR) groups. The relationship of preoperative clinical factors with the incidence and recovery of postoperative ANP was analyzed., Results: Postoperative ANP was observed in 23 patients (32.9%). Multivariable logistic regression revealed that the tumor-to-cerebellar peduncle T2 imaging intensity index (TCTI) (P < 0.001) and internal auditory canal invasion (P = 0.033) contributed to postoperative ANP. GTR was achieved in 37 patients (52.9%), and 10 (27.0%) of them showed ANP. STR was achieved in 33 patients (47.1%), and 13 (39.4%) of them showed ANP. Recovery from ANP took a median of 6.6 months (range, 4.5-20.3 months). At 6 months after the operation, recovery of the abducens nerve function was observed in 16 patients (69.0%); of whom, 4 (40.0%) were in the GTR group and 12 (92.3%) were in the STR group (P = 0.025)., Conclusions: TCTI and internal auditory canal invasion were the risk factors for postoperative ANP. Although intentional STR did not prevent ANP immediately after the operation, recovery of the abducens nerve function after surgery was observed more frequently in the STR group than in the GTR group., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 by North American Neuro-Ophthalmology Society.)

Purpose: This study was done to evaluate the clinical profile in pediatric patients (0-16 years) presenting with acute onset esotropia due to sixth nerve palsy and its management options in a tertiary care set up of Southern India., Methods: A total of 12 patients presenting to our OPD with acute onset esotropia due to sixth nerve palsies were included in this retrospective study. All patients were observed for 6 months and managed with prism and/or patching while waiting for spontaneous resolution and later managed surgically. Neuroimaging was done in all cases., Results: The mean deviation of esotropia at presentation was 30.17 ± 5.7 Prism Diopter (range 12-50 Prism Diopter 95% CI, SD 10.11). Mean age of the patients during presentation was 8.6 ± 2.4 years (range: 1-15 years, SD 4.27). Among the common causes of sixth nerve palsy in our study population were trauma and idiopathic intracranial hypertension followed by tumor and miscellaneous causes. Only three patients underwent surgical correction of residual deviation after a waiting period of 6 months for self-resolution. Spontaneous resolution was observed in 41.6% patients, and surgical correction (unilateral resection-recession) was done in 25% of the patients with good surgical outcome., Conclusion: At 1-year follow up, the motor outcome was satisfactory except for one patient who had diffuse pontine glioma and had worsening neurological symptoms on follow-up., Competing Interests: None

Purpose: To evaluate the effect of half tendon vertical rectus muscle transposition (HVRT) combined with medial rectus muscle recession (MRrec) in complete sixth nerve palsy (CSNP) and esotropic Duane Retraction Syndrome (eDRS)., Methods: A retrospective study of patients with unilateral CSNP or eDRS who underwent HVRT combined with medial rectus recession over the course of 18 years. The patients with previous strabismus surgery and follow up less than 3 months were excluded. Overcorrection was defined as any amount of exotropia, and undercorrection was defined as residual esotropia of ⩾10 prism diopter (PD)., Results: A total of 39 patients were enrolled including 22 CSNP and 17 eDRS patients. Esotropia improved from 45.8 ± 22 and 22.5 ± 6.4 PD to 0.8 ± 2.5 and 0.3 ± 1 PD in CSNP group and eDRS group respectively. The angle of face turn improved from 34.3 ± 8.4° and 26.5 ± 9° to 0.6 ± 2.4° and 0.8 ± 1.6° in the CSNP group and eDRS group respectively. Abduction limitation improved from -4.5 ± 0.5 and -4 ± 0 units to -2.9 ± 0.5 and -2.7 ± 0.5 units in CSNP group and eDRS group respectively. No patient developed a new vertical deviation. An overcorrection occurred in one patient of the eDRS group who improved after botulinum toxin injection in the ipsilateral lateral rectus muscle. Undercorrection was seen in two patients., Conclusion: HVRT combined with MRrec is an effective procedure to improve esotropia, face turn, and abduction limitation in CSNP and eDRS.

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: This study aimed to assess the outcomes of partial vertical rectus transposition (PVRT) in acquired sixth nerve palsy (SNP) on distance ocular deviation in primary position (PP), binocular diplopia in PP, head turn, and limitation of abduction., Methods: This retrospective, single center study was conducted at the Regional University Medical Center of Tours between 2004 and 2019. All patients underwent comprehensive orthoptic and ophthalmic examination before and after surgery. Total success was defined as horizontal distance deviation in PP≤10 prism diopters (PD), absence of permanent diplopia in PP, head turn≤5 degrees and absence of any induced vertical deviation at last examination., Results: Ten patients underwent PVRT with a median delay of 3.3 years (2.3 to 7.3) following the diagnosis of SNP. The median duration of postoperative follow-up was 13 months (3.25 to 25). Seven patients (70%) were considered a total success. The mean distance horizontal deviation in PP was reduced from 25.4±11.7 PD preoperatively to 9.2±11 PD postoperatively. Preoperatively, 10 patients did not cross midline in abduction, compared to 8 patients at the last follow-up examination. Postoperatively, 3 patients had permanent binocular diplopia in PP, and 2 patients had an anomalous head turn., Conclusion: Although further prospective investigations are needed, PVRT can be considered a safe and effective procedure for acquired SNP., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Purpose: Patients with chronic sixth nerve palsy (CSNP) comprise a heterogeneous population, and the optimal surgical solution remains uncertain. Here, we present the success rate and factors associated with the success of strabismus surgeries for CSNP., Methods: This was a retrospective cohort study of patients with strabismus due to CSNP operated on between 2015 and 2019 in a tertiary eye hospital in central Saudi Arabia. Surgical success was defined as a horizontal deviation of ≤10 prism diopters (PDs) assessed at least 12 months after surgery. Differences between groups with respect to the primary outcome were assessed., Results: Fifty-five patients were analyzed with a median follow-up of 24 (range 12-48) months. Superior rectus and inferior rectus transposition (34.5%) and medial rectus recession with lateral rectus resection (32.7%) were the main surgeries performed. The overall success rate was 67.3% (95% confidence interval 54.9-79.7). Bilateral CSNP ( P = 0.05), a higher preoperative angle of deviation ( P = 0.002), or a greater degree of preoperative limitation of abduction ( P = 0.012), but not the type of surgery ( P = 0.09), were more likely to result in an under-corrected outcome of >10 PD. The preoperative deviation angle showed a trend toward being associated with a poor outcome after surgery ( P = 0.06). Six patients with high-angle deviation before surgery required second surgery., Conclusion: While the surgical procedure does not impact outcomes, the severity of preoperative horizontal deviation might impact surgical success and the need for reoperation. Patients with severe CSNP should be counseled appropriately about the chances of surgical success and the potential need for further interventions., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Middle East African Journal of Ophthalmology.)

Purpose: To describe our surgical outcomes using a novel muscle transposition procedure, or double-under muscle transposition (DUT), in the treatment of paralytic strabismus., Methods: In this surgery, the split halves of the superior and inferior rectus muscles opposite the paralyzed muscle are disinserted, crossed under both the remaining half and the paralyzed muscle, and anchored at opposite corners of the insertion of the paralyzed muscle. The medical records of consecutive patients who underwent DUT were retrospectively reviewed. Outcome measures were angle of deviation and duction deficit., Results: Seven patients were included. Diagnoses included WEBINO (n = 1), rupture of the medial rectus muscle (n = 1), and abducens nerve palsy (n = 5). DUT alone was performed in 3 patients; DUT combined with antagonist muscle recession, in 4 patients. One patient underwent the surgery bilaterally. Mean follow-up was 17 ± 18+ months (range, 7-57). Preoperative angles of distance deviation ranged from 25 Δ to 142 Δ in magnitude. All except a single patient had duction limitation of grade -5. The mean change in distance deviation for DUT alone for each operated eye was 60 Δ ± 6 Δ (53 Δ -65 Δ ); for combined surgery, 69 Δ  ± 23 Δ (range, 52 Δ -103 Δ ). Final mean angle of deviation at distance was +2 Δ ± 3 Δ (-4 Δ to 0 Δ ), although an additional surgery was required for large overcorrections in 2 patients. Duction limitation improved in all patients. One patient experienced a postoperative vertical deviation., Conclusions: DUT may be an alternative for patients with severely paralytic strabismus not likely to resolve with previously reported muscle transposition surgeries. Overcorrection may occur in some cases., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Abducens nerve palsy (ANP) is the most common oculomotor palsy. This study aimed to evaluate the efficacy of medial rectus recession with lateral rectus plication in patients with unilateral acquired ANP and to describe the etiologies of this condition., Methods: Thirty-one patients were included in this retrospective single-center study conducted between 2000 and 2019 at the university research hospital in Tours. The following data were collected before and after surgery: diplopia, oculomotor deviations, ocular motility, and head posturing., Results: The mean age was 55.9±18.9 years and the mean postoperative follow-up was 11±4 months. Postoperatively, the patients had significant reduction in diplopia in primary position (P<0.001), in abduction of the affected eye (P<0.001) and in distance and near horizontal deviations (P<0.001). Abduction of the affected eye was significantly improved (P<0.001), but reduction in head posturing was insignificant (P=0.27). The etiologies were as follows: trauma (8 patients, 26%), neoplasm (6 patients, 16%), stroke-related (5 patients, 16%), compressive (5 patients, 16%), undetermined (5 patients, 16%) and inflammatory (2 patients, 6%)., Conclusion: Medial rectus recession with lateral rectus plication is an effective procedure in reducing diplopia and ocular deviation in unilateral acquired ANP and may be used as a first-line intervention regardless of the initial ocular motility limitation in abduction. The causes are mainly traumatic but remain undetermined in one case out of six., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

We report the case of a 38-year-old man with abducens palsy following a traumatic skull injury who failed multiple strabismus surgeries. A suture-armed 5 mm micro bone screw was placed on the anterior face of the lateral orbital rim and used to tether and abduct the globe. The patient remained orthotropic in primary position 12 months postoperatively., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose : To evaluate the outcome of augmented superior rectus transposition (SRT) with medial rectus (MR) recession in patients with Duane Retraction Syndrome (DRS) and sixth nerve palsy. Methods : Twenty four patients (16 DRS and 8 sixth nerve palsy) that underwent the procedure were included. The superior rectus muscle was secured, detached, and re-attached to the sclera along the spiral of Tilaux, adjacent to lateral rectus insertion. A non-absorbable augmentation suture was passed through the sclera, 8 mm posterior to the insertion of the lateral rectus. Results : At the last follow-up, the effect of surgery in decreasing esotropia in both groups was significant ( P = .001 for DRS group, P = .002 for sixth nerve palsy). In both groups, abduction deficit improved significantly ( P < .001 for DRS and P = .008 for sixth nerve palsy). After the surgery, small, asymptomatic vertical deviation in primary position was induced in five patients (20.8%). Post-operatively, none of the patients complained of torsional diplopia. In the 6-month follow-up, compared with the first postoperative visit, an eso-drift at distance or near developed in 11 patients (45.8%). Of the 11 patients with eso-drift, overcorrection (exotropia of 3-14 PD) was present at the first post-operative visit in 5 cases. Four cases showed an exo-drift (2-5 PD) at distance or near over time. Conclusion : SRT with medial rectus recession improves esotropia and abduction limitation without inducing significant vertical deviations and torsional diplopia. Some of the cases that underwent SRT with MR recession may show an eso-drift. The eso-drift can correct initial exotropia in some cases.

Background: Surgical treatment of abducens nerve palsy depends on the remaining function of the lateral rectus muscle. Vertical rectus transposition surgery is indicated if the attempted maximal abduction effort does not rotate the eye beyond the midline. After the first description more than 100 years ago, a variety of muscle transposition modifications have been suggested. Nishida's minimally-invasive adaptation has attracted a great deal of attention in recent years., Patients and Methods: Retrospective case series of four patients with abducens nerve palsy who were treated with Nishida muscle transposition surgery. Patients' characteristics with special emphasis on comparison between pre- and postoperative angle of deviation and ocular motility are reported., Results: Four patients (2 females, 2 males) were included in this study. Unilateral transposition surgery was performed in a 7-year-old girl and a 37-year-old woman with a left abducens nerve palsy. In a 56-year-old male with a left sixth nerve palsy and in an 82-year-old male with a right sixth nerve palsy the transposition maneuver was combined with a recession of the medial rectus muscle in the same eye. In all patients, ocular motility was improved and the angle of deviation was reduced., Conclusions: Transposition of vertical rectus muscles is well established in the surgical treatment of abducens nerve palsy. Nishida's adaptation is a safe, effective and minimally-invasive treatment option. This vessel-sparing technique also allows for equilateral weakening of the medial rectus muscle., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Purpose: To compare the surgical outcomes of modified vertical rectus belly transposition (mVRBT) and medial rectus recession (MRc) versus augmented superior rectus transposition (aSRT) and MRc in Chinese patients with chronic abducens nerve palsy., Methods: The medical records of patients with chronic abducens nerve palsy who underwent mVRBT/MRc or aSRT/MRc were retrospectively reviewed. Pre- and postoperative deviation in primary position, pre- and postoperative abduction limitation, and complications were recorded. Follow-up was at least 6 months., Results: A total of 26 patients (mean age, 37.9 ± 19.6 years; 16 males [62%]) were included. Fourteen patients underwent mVRBT/MRc (mVRBT group) and 12 underwent aSRT/MRc (aSRT group). Both groups had similar amounts of recession (t = 0.27; P = 0.79). After surgery, statistically significant changes of abduction limitation and esotropia were observed (both P < 0.05). However, the difference in abduction improvement between groups was not statistically significant (mVRBT vs aSRT, 2.3 ± 0.91 vs 2.3 ± 0.97; t = 0.10, P = 0.92). Of the 19 patients who underwent unilateral surgery, preoperative esotropia was similar in both groups (t = 1.3; P = 0.21), but more esotropia was corrected in the mVRBT group than in the aSRT group (mVRBT vs aSRT, 57.8 Δ  ± 14.3 Δ vs 44.6 Δ  ± 9.8 Δ ; t = 2.1; P = 0.047). There was no symptomatic vertical or torsional deviation., Conclusions: In our patient cohort, mVRBT/MRc showed a better effect in correcting esotropia and a similar effect in improving abduction limitation compared with aSRT/MRc., (Copyright © 2021 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the incidence of symptomatic vertical and torsional diplopia after superior rectus transposition (SRT) for esotropic Duane syndrome and abducens nerve palsy., Methods: The medical records of patients with esotropic Duane syndrome or abducens nerve palsy seen at Boston Children's Hospital (2006-2018) and treated with unilateral SRT with or without augmentation was performed. The primary outcome was incidence of postoperative vertical or torsional diplopia in primary position. The secondary outcome was induced vertical deviation in affected side gaze., Results: A total of 69 patients met inclusion criteria: 32 with abducens nerve palsy and 37 with esotropic Duane syndrome. Vertical alignment changed in both hyper- and hypotropic directions. Median pre- and postoperative vertical deviation in primary gaze was 1.1 Δ (10th-90th percentile, 0 Δ -6 Δ hypertropia) and 0.4 Δ (10th-90th percentile, 6 Δ hypotropia to 8 Δ hypertropia), respectively. Postoperative vertical diplopia occurred in 7%, including 4 of 49 treated with loop myopexy (8%), 1 of 13 without augmentation (8%), and 0 of 7 treated with sclera-fixated augmentation. All but one was successfully treated with prism or secondary surgery. Intorsional change predominated, but no patient had torsional diplopia post adjustment. Vertical misalignment in affected side gaze increased from 19% to 45% after SRT (P = 0.01)., Conclusions: In this largest-to-date review of patients treated with SRT, with or without MR recession, no patient developed persistent torsional diplopia, while 7% developed symptomatic vertical diplopia in primary position, similar to the reported incidence after balanced vertical rectus transposition. Vertical misalignment in affected side gaze increased, however fusion is already limited by unresolved esotropia in this field., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Purpose: To report the results of adjustable graded augmentation of superior rectus transposition, a novel modification of superior rectus transposition (SRT) designed to reduce postoperative vertical or torsional diplopia., Methods: The medical records of patients who underwent adjustable graded augmentation of SRT with or without adjustable medial rectus recession (MRc) from February 2017 to December 2019 were reviewed retrospectively. A Mendez ring was used to monitor torsional change after transposition of the superior rectus muscle to the lateral rectus muscle and after sequential placement of 2 or 3 augmentation sutures by superior rectus-lateral rectus loop myopexy. If excessive mechanical intorsion was induced, the responsible augmentation suture was severed intraoperatively. If torsional or vertical diplopia was noted after recovery, the distal-most augmentation suture was cut. Exotropia was managed by severing the distal-most augmentation suture or by medial rectus adjustment., Results: A total of 8 patients who underwent adjustable graded augmentation of SRT were included (6 using the 3-suture technique): 3 for esotropic Duane syndrome, 2 for abducens nerve palsy, 1 for Moebius syndrome, and 2 for combined trochlear and abducens nerve palsies. Of the 8 patients, 4 had prior strabismus surgery, and 1 patient had previously undergone treatment with botulinum toxin. Severing one augmentation suture in 3 cases resolved vertical (n = 2) or torsional (n = 1) diplopia and consecutive exotropia (n = 2), resulting in excellent alignment and reduction of torticollis to ≤4° in 7 cases. The technique proved insufficient in 1 patient, who had undergone 3 prior strabismus procedures., Conclusions: In this study cohort, adjustable graded augmentation of SRT effectively managed the risk of postoperative vertical or torsional diplopia., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

We introduce a novel method for managing residual esotropia after vertical muscle transposition, with minimal risk of anterior segment ischemia, and report 3 patients with chronic abducens nerve palsy who underwent inferior rectus belly transposition subsequently or simultaneously after augmented superior rectus transposition and medial rectus recession., (Copyright © 2020 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved.)

The presigmoid approach (PSA) is selected to obtain more lateral access to cerebellopontine angle tumors, brainstem cavernous malformations, or vertebrobasilar artery aneurysms than the standard retrosigmoid approach. However, mastoidectomy for the PSA can be considered time-consuming and to carry a higher risk of complications due to the anatomical complexity of the region. The authors established a method of minimized mastoidectomy focused on exposing Trautmann's triangle as the corridor for the PSA while maximizing procedural simplicity and safety and maintaining a sufficient operative view. The authors present their method of minimized mastoidectomy in a cadaver dissection and operative cases, showing potential as a useful option for the PSA.

Objective: The ventral jugular foramen and the infrapetrous region are difficult to access through conventional lateral and posterolateral approaches. Endoscopic endonasal approaches to this region are obstructed by the eustachian tube (ET). This study presents a novel strategy for mobilizing the ET while preserving its integrity. Qualitative and quantitative comparisons with previous ET management paradigms are also presented., Methods: Ten dry skulls were analyzed. Four ET management strategies were sequentially performed on a total of 6 sides of cadaveric head specimens. Four measurement groups were generated: in group A, the ET was intact and not mobilized; in group B, the ET was mobilized inferolaterally; in group C, the ET underwent anterolateral mobilization; and in group D, the ET was resected. ET range of mobilization, surgical exposure area, and surgical freedom were measured and compared among the groups., Results: Wide exposure of the infrapetrous region and jugular foramen was achieved by removing the pterygoid process, unroofing the cartilaginous ET up to the level of the posterior aspect of the foramen ovale, and detaching the ET from the skull base and soft palate. Anterolateral mobilization of the ET facilitated significantly more retraction (a 126% increase) of the ET than inferolateral mobilization (mean ± SD: 20.8 ± 11.2 mm vs 9.2 ± 3.6 mm [p = 0.02]). Compared with group A, groups C and D had enhanced surgical exposure (142.5% [1176.9 ± 935.7 mm2] and 155.9% [1242.0 ± 1096.2 mm2], respectively, vs 485.4 ± 377.6 mm2 for group A [both p = 0.02]). Furthermore, group C had a significantly larger surgical exposure area than group B (p = 0.02). No statistically significant difference was found between the area of exposure obtained by ET removal and anterolateral mobilization. Anterolateral mobilization of the ET resulted in a 39.5% increase in surgical freedom toward the exocranial jugular foramen compared with that obtained through inferolateral mobilization of the ET (67.2° ± 20.5° vs 48.1° ± 6.7° [p = 0.047]) and a 65.4% increase compared with that afforded by an intact ET position (67.2° ± 20.5° vs 40.6° ± 14.3° [p = 0.03])., Conclusions: Anterolateral mobilization of the ET provides excellent access to the ventral jugular foramen and infrapetrous region. The surgical exposure obtained is superior to that achieved with other ET management strategies and is comparable to that obtained by ET resection.

The authors describe a case of unilateral abducens nerve palsy following perinatal stroke of the middle cerebral artery. A 1-year-old boy presented with left eye esotropia but no other ocular abnormalities. The patient's history, examination, and diagnostic tests were consistent with abducens nerve palsy. He underwent left medial rectus recession of 5.5 mm and left lateral rectus resection of 7 mm followed by patching. At 15 months after surgery, primary gaze by prism alternate cover testing revealed a 4 prism diopter (PD) esophoria (small angle in left gaze with essentially no action of lateral rectus) and 2 PD right hyperphoria. Ophthalmologic management of abducens nerve palsy entails addressing neurological sequelae in a timely manner, treating the esotropia and strabismic amblyopia to optimize visual system development. [J Pediatr Ophthalmol Strabismus. 2020;57:e30-e33.]., (Copyright 2020, SLACK Incorporated.)

Purpose: The aim of this study was to report our postoperative results concerning the vertical rectus (VR) muscle union combined with lateral rectus (LR) plication for the treatment of large-angle esotropia (ET) in complete abducens nerve palsy., Methods: Medical records from 36 patients who had undergone the VR union procedure for ET treatment due to sixth-nerve palsy between July 2014 and July 2018 at Beyoglu Eye Research and Training Hospital were reviewed. One week before surgery, all patients underwent a 4-IU botulinum toxin A (btx) injection into the ipsilateral medial rectus (MR). All patients then underwent a VR muscle union procedure. A non-absorbable suture was inserted through the lateral muscular margin of each VR muscle at approximately 1/5 the width from the edge at 10 mm distance from the VR insertion. Both sutures were then tied to each other above the LR. Plication of the LR muscle using a non-absorbable suture was performed in all cases., Results: The study population consisted of 14 (38.9%) females and 22 (61.1%) males. The mean age was 36.31 ± 19.16 years. The mean preoperative deviation angle in primary gaze into distance was 47.77 ± 18.48 prism diopter (PD). The mean deviation angle 1 year after surgery was - 1.0 ± 6.62 PD. Abduction improved from - 4.27 ± 0.46 to - 1.88 ± 0.96., Conclusion: The VR muscle union in combination with LR plication appears to be an effective treatment procedure for complete abducens nerve palsy patients.

Multiple transposition procedures have been described for management of lateral rectus palsy. However, relative effect and indications of each procedure are unclear. This systematic review was planned to evaluate functional and anatomical outcomes of vertical rectus transposition (VRT) surgery in patients with lateral rectus palsy. We searched databases in English language, namely, MEDLINE, PubMed Central, EMBASE, Google Scholar, Scopus, and Index Copernicus without any date restrictions in electronic searches, using the search words 'vertical rectus transposition for lateral rectus palsy," "vertical rectus transposition for abducens palsy," "superior rectus transposition," "inferior rectus transposition," and "Hummelsheim procedure." References of the selected publications were also searched to find any relevant studies. We searched for studies that provided data on single VRT and double VRT surgeries for lateral rectus palsies. Three authors independently assessed the related studies gathered from electronic and manual searches. We found 27 studies which were relevant to the review question. As there were no randomized control trials (RCTs) available related to our study question, nonrandomized studies were used to arrive at summarization of outcomes of different transposition procedures. There is a need for prospective RCTs to investigate the different types of transposition procedures for lateral rectus palsy., Competing Interests: There are no conflicts of interest.

Background: Antiplatelet agents are typically administered before and after treatment using flow-diverter stents (FDS) to prevent thrombotic complications, but the effects of anticoagulants are unclear. We present a patient with a giant aneurysm treated with an FDS. The thrombus within the aneurysm was dissolved when a direct factor Xa inhibitor was administered to treat lower limb venous thrombosis that occurred secondary to steroid use., Case Description: A 60-year-old woman with a 30-mm giant thrombosed aneurysm in the cavernous segment of the right internal carotid artery presenting with headache and right abducens nerve palsy was treated by placing an FDS. Diplopia and increased pain in her right eye appeared on postoperative day 7, and both were alleviated by continuous oral administration of prednisolone. Angiography 3 months postoperatively revealed that the aneurysm thrombosis had progressed, and there were signs of healing. However, at the same time, lower limb venous thrombosis occurred, which was treated by continuous edoxaban. Six months after surgery, her headaches worsened and angiography showed that the aneurysm was again contrast enhanced and that the thrombus within the aneurysm had dissolved. After discontinuing edoxaban 9 months after surgery, the aneurysmal thrombosis had again rapidly progressed., Conclusions: Administration of a direct factor Xa inhibitor during healing after placing an FDS may cause dissolution of an existing thrombus; therefore factor Xa inhibitors must be used with caution., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Vertebrobasilar artery dolichoectasia may result in neural element compression anywhere along its course within the cervical region, the craniocervical junction or in the posterior fossa. The clinical syndromes most often observed include cranial neuropathy, bulbar dysfunction, myelopathy and cervical radiculopathy. When indicated, the operative techniques utilized to address vertebrobasilar artery dolichoectasia must be individually tailored, can be technically challenging, and have been rarely expounded., Objective: To share selected cases that demonstrate the variety of pathological states caused by vertebrobasilar artery dolichoectasia as well as our experience in managing this condition., Methods: Here we review examples of pathological impingement of neural elements compressed by ectasia within the vertebrobasilar arterial system throughout its anatomic course. The surgical techniques we have employed to alleviate the compression, including simple decompression as well as sling-assisted arterial transposition, are described. The evolution and refinement of our transposition technique are detailed., Results: A wide range of pathological conditions may result from compression of neural structures throughout the course of the vertebrobasilar system. Compression of cervical nerve roots, the spinal cord, brainstem, and cranial nerves can be seen. Microsurgical management may be indicated in selected cases with gratifying results., Conclusion: Pathological compression of neural structures throughout the course of the vertebrobasilar system should be recognized. When indicated, microsurgical decompression must be tailored to the individual symptomology and the unique anatomic relationship in each case with the potential to prevent neurological worsening and, in many cases, improve functional outcome., (Copyright © 2018 by the Congress of Neurological Surgeons.)

The modified Nishida muscle transposition procedure, in which the one-third of the vertical rectus muscle bellies are sutured onto the sclera in the infero- and superotemporal quadrants without either tenotomy of the vertical rectus muscles or splitting of the vertical rectus muscle is an effective treatment for abducens nerve palsy. We report 2 cases of large-angle exotropia caused by medial rectus transection following the endoscopic sinus surgery treated using the modified Nishida procedure to transpose both vertical rectus muscles nasally, combined with lateral rectus muscle recession., (Copyright © 2019 American Association for Pediatric Ophthalmology and Strabismus. All rights reserved.)

A 53-year-old woman presented with diplopia and deviation of the left eye for the past 3 years. She had non-resolving isolated left lateral rectus palsy. She underwent a medial rectus recession and Hummelsheim (Wright's modification) procedure in her left eye. Postoperatively, the anterior segment ischemia resolved with steroids. [J Pediatr Ophthalmol Strabismus. 2019;56:e53-e56.]., (Copyright 2019, SLACK Incorporated.)