Precaruncular approach for medial orbital wallperiosteal anchoring of the globe in oculomotornerve palsyRohit Saxena, MD, Ankur Sinha, MD, Pradeep Sharma, MD, Swati Phuljhele, MD,and Vimla Menon, MS

PURPOSE To evaluate a precaruncular approach for fixation of the globe to the medial orbital wall

Author affiliations: Dr Rajendraof Medical Sciences, New Delhi,

Presented in part as a free papKong, June 28-July 2.

Submitted April 15, 2009.Revision accepted September 3Reprint requests: Rohit Saxena

Ophthalmic Sciences, AIIMS, NCopyright � 2009 by the Am

Strabismus.1091-8531/2009/$36.00 1

doi:10.1016/j.jaapos.2009.11

578

periosteum for management of complete third (oculomotor) nerve palsy.

METHODS Consecutive patients with severe unilateral oculomotor nerve palsy present for at least 2

years were prospectively treated and evaluated. In all patients, a 12–16 mm recession ofthe lateral rectus muscle was performed along with the precaruncular anchoring procedure.Follow-up evaluations were performed at 1 week, and at 1, 2, and 3 months after surgery,with ongoing follow-up at 3 month intervals.

RESULTS Fourteen eyes of 14 patients with complete oculomotor nerve palsy were included in the

series. The median horizontal preoperative deviation of �90D � 4.8D reduced to �10D

� 8.3D. The vertical deviation reduced from 24D � 7.4D to 12.8D � 6.0D. Mean follow-up was 8.9 � 5.5 months (range, 6-21 months). A slight exotropic drift was observedover 4 to 6 weeks following surgery in all cases. Satisfactory alignment was observed in13 of the 14 cases (92.85%) over the duration of the follow-up period.

CONCLUSIONS Anchoring the globe to the medial orbital wall using a precaruncular approach is a viable

option in the management of complete external oculomotor nerve palsy. ( J AAPOS2009;13:578-582)

Introduction

Severe paretic strabismus in the form of complete ex-ternal third (oculomotor) nerve palsy is one of thegreatest challenges facing strabismus surgeons. This

condition often leaves the eye in fixed hypotropic and exo-tropic positions,1 and achieving even modest correction isdifficult. Various treatment options have been tried in thepast. Horizontal muscle surgery may work only in cases hav-ing residual function of the medial rectus muscle.2 In caseswith inadequate or no medial rectus muscle action, the devi-ation may recur due to unopposed lateral rectus muscleaction,3 often requiring globe fixation procedures.4 Variousapproaches to anchoring surgery have been described.4-9

The authors previously described a new technique formanaging complete external oculomotor nerve palsy.10 Inthis technique, a supramaximal recession of the lateral rec-tus muscle is combined with periosteal anchoring of theglobe to the medial orbital wall via a conjunctival incision

Prasad Centre for Ophthalmic Sciences, All India InstituteIndiaer at the 2008 World Ophthalmology Conference, Hong

0, 2009., MD, Associate Professor, Dr Rajendra Prasad Centre forew Delhi-29, India (email: rohitsaxena80@yahoo.com).erican Association for Pediatric Ophthalmology and

0.003

nasal to the caruncle. Here we evaluate the technique inone of the largest case series in the management of severeparetic strabismus as a result of complete external oculo-motor nerve palsy.

Patients and Methods

This was a prospective case series, wherein consecutive patients

with unilateral oculomotor nerve palsy with a stable ocular devia-

tion for at least 2 visits 3 months apart were included after provid-

ing written informed consent. This study was approved by the

Institutional Review Board of All India Institute of Medical Sci-

ences, New Delhi, India. All patients had severe paretic strabis-

mus. Inclusion criteria included deviation present for at least 2

years, inability to adduct the globe to the midline, and positive

forced duction testing showing a tight lateral rectus muscle. Exclu-

sion criteria included previous ptosis surgery or chemodenerva-

tion. The Krimsky method, at 6 m and 33 cm, was used to assess

the alignment. For calculation purposes, an angle of .90D was re-

corded as 90D. Absolute values were used for calculations related to

the amount of vertical misalignment.

Surgical Technique

All patients were treated with the same surgical procedure (Fig-

ure 1),10 with the exception of Case 14, described below (Figure 2).

Under peribulbar block (6 mL of 2% lidocaine and 4 mL of 0.5%

bupivacaine) or general anesthesia, forced duction testing was re-

peated to confirm the tight lateral rectus muscle. Using a limbal

conjunctival incision, a 12–16 mm lateral rectus muscle recession

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FIG 1. Surgical steps for anchoring of the globe through a precaruncular approach. A, Incision is made at the precaruncular conjunctiva; lacrimalprobes are placed to protect the canaliculi from inadvertent transaction. B, Dissection is continued medially. Fibers of the posterior medial canthaltendon are separated to reach the periosteum posterior to the posterior lacrimal crest. C, Nonabsorbable sutures are passed through the periosteumposterior to the posterior lacrimal crest. D, Medial rectus insertion is exposed using limbal conjunctival approach. E, Sutures are held with the needletips and brought out in the sub-Tenon’s space using artery forceps. F, sutures are passed on the sclera on either end of the medial rectus muscle.

Volume 13 Number 6 / December 2009 Saxena et al 579

was performed. The amount of recession was adjusted to ensure

free forced duction test for adduction intraoperatively.

The caruncular area was exposed using sutures through the

skin near the medial canthus. After identifying and dilating

the 2 puncta using a Nettleship punctum dilator, Bowman lac-

rimal probes were placed to secure the canaliculi and avoid in-

advertent damage during surgery. The caruncular area was then

injected with 0.2 to 0.5 mL of 1:1000 adrenaline with 2% lido-

caine to decrease intraoperative bleeding and postoperative

pain. A curved superficial incision (approximately 7–8 mm)

was then made at the junction of the conjunctiva and canthal

skin. Blunt dissection was performed posteriorly and nasally

to reach the periosteum posterior to the posterior lacrimal crest,

taking care to avoid the lacrimal drainage apparatus. Two dou-

ble-armed 5-0 nonabsorbable coated braided polyester sutures

(NW683, Ethibond; Johnson and Johnson Ltd, Aurangabad, In-

dia) were passed through the exposed periosteum and gently

pulled to test the strength of the tissue bite. The lacrimal probes

were then removed. Using a limbal incision, the medial rectus

muscle was hooked and cleared of all its attachments. Straight

tenotomy scissors were passed through this incision toward

the medial canthus. Once the tip of the scissors was seen

through the medial canthal incision, the intervening fibrous tis-

sue was cut using spring scissors to create a tunnel. Using the

blunt-tipped serrated forceps passed from the side of the medial

Journal of AAPOS

rectus muscle, the needles of the polyester sutures were pulled

laterally, adjacent to the medial rectus muscle. These sutures

were then anchored to the sclera on either end of the medial

rectus muscle, thus leaving the anterior ciliary vessels of the

muscle undisturbed. The sutures were tightened to leave an eso-

tropia of about 10� to 15� intraoperatively. The conjunctival in-

cisions were sutured separately using 8-0 polyglactin 910

sutures (Vicryl; Johnson and Johnson Ltd). At the conclusion

of surgery, irrigation was performed to confirm patency of the

lacrimal system.

All patients were given topical antibiotic steroid combination

drops along with oral analgesics as required. Follow-up visits

were conducted at the first week, at monthly intervals for the first

3 months, and every 3 months thereafter.

Results

A total of 14 consecutive patients (7 males) of isolated com-plete external oculomotor nerve palsy were included in thestudy (Table 1). Mean age was 28.8 � 20.9 years (range,10-64 years). The oculomotor nerve palsy was congenitalin 8 patients and posttraumatic in 6. All patients with con-genital oculomotor nerve palsy had amblyopia associatedwith ptosis: severe in 7 cases and moderate in 1 case.Two patients had aberrant regeneration. Of the 6 patients

FIG 2. Case 14 (the only patient with hypertropia) before (A) and 3 weeks after (B) surgery: note decrease in amount of hypertropia.

580 Saxena et al Volume 13 Number 6 / December 2009

with traumatic oculomotor nerve palsy, 2 had traumaticoptic neuropathy leading to poor vision, and 1 patientinjured at age 3 had severe ptosis and amblyopia. Theremaining 3 posttraumatic cases had a best-corrected visualacuity of 20/20.

The mean preoperative horizontal deviation was�87.7D

� 4.8D (range, 75D to .90D) and the median was 90D. Themean vertical deviation was 23.3D � 7.5D (range, 35D hy-pertropia to 30D hypotropia). Of the 14 patients includedin the study, 13 had varying degrees of hypotropia andonly 1 (Case 14) had hypertropia (Table 1).

At the conclusion of the surgery, all patients (exceptCase 1) were left with an esotropia of approximately10� to 15�. Exotropic drift occurred in all patients; itstabilized after a period of 4 to 6 weeks. In the firstcase there was no overcorrection and thus an exotropicdrift led to moderate residual exotropia. In all subse-quent surgeries, intraoperative overcorrection wasintended.

After a mean follow-up of 8.9 � 5.5 months (range, 6-21months), the mean postoperative horizontal deviation was�10.7D� 8.3D (range, exotropia of 30D to esotropia of 8D);

the median was 10D, and the mean correction achieved was75.9D � 7.7D. The mean postoperative vertical deviationwas 12.7D � 6.4D (range, hypotropia of 25D to hypertropiaof 10D).

Postoperative diplopia was observed in the 3 patientswith 20/20 visual acuity in the involved eye. One of thesepatients was able to ignore the second image, while theother 2 adopted a compensatory head posture. No otherpatients had described diplopia.

In Case 14 (Figure 2), both anchor sutures were passedabove the medial rectus muscle insertion to pull the globedown. This decreased but did not satisfactorily eliminatethe hypertropia.

None of the patients complained of postoperative epi-phora and there was no evidence of injury to the lacrimalsystem.

Discussion

Various procedures have been described to manage com-plete oculomotor nerve palsy. Jackson11 described transpo-sition of the superior oblique tendon by fracturing the

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Table 1. Patient characteristics and outcome of the surgery

Horizontal deviation Vertical deviation

Case Cause Associated abnormalities Pre Post Pre PostFollow-up(months) BCVA

1 C Ptosis and amblyopia . � 90 �30 24a 20a 21 2/602 C Ptosis, amblyopia, and eccentric fixation . � 90 �10 30a 25a 8 FCCF3 T Pupillary involvement, ptosis, no diplopia �90 �8 25a 12a 6 20/204 C Ptosis, amblyopia, unsteady fixation, and pupillary

involvement. � 90 �10 25a 18a 6 FCCF

5 C Ptosis and amblyopia �80 �15 20a 8a 9 1/606 T Ptosis with pupillary involvement and traumatic optic

neuropathy�90 �8 15a 12a 6 1/60

7 C Ptosis, amblyopia, aberrant regeneration (elevation of lidson attempted adduction)

�90 18 15a 10a 6 2/60

8 T Partially recovered ptosis, involvement of pupil withtraumatic optic neuropathy

. � 90 �15 24a 18a 13 1/60

9 T Partially recovered ptosis, involvement of pupil, diplopia �75 �8 10a 2a 6 20/2010 C Severe ptosis with amblyopia �90 �6 30a 14a 6 FCCF11 T Partially recovered ptosis with involvement of pupil and

diplopia. � 90 �14 14a 6a 10 20/20

12 T Ptosis and amblyopia . � 90 �5 30a 4a 6 1/6013 C Ptosis and amblyopia �85 �12 30a 14a 6 1/6014 C Partial ptosis, amblyopia, aberrant regeneration with

pupillary involvement. � 90 �18 35b 15b 15 2/60

C, congenital; T, posttraumatic; H, horizontal deviation; V, vertical deviation; BCVA, best-corrected visual acuity.aHypotropia.bHypertropia.

Volume 13 Number 6 / December 2009 Saxena et al 581

trochlea and disinserting the muscle. Scott12 modified thisprocedure by transposing the superior oblique tendonwithout fracturing the trochlea. Although superior obliquetendon transposition has been shown to yield cosmeticallyacceptable results, paradoxical ocular movements13 havebeen reported with this procedure.

Various materials have been used to anchor the globe tothe periosteum, including periosteal flaps,4 superior obli-que tendon,5 silicon bands,6,7 fascia lata,8 and 5-0 polyestersutures.1 Each of these materials has advantages and disad-vantages. While it is difficult to harvest a 12–14 mm lengthof superior oblique tendon,5 the use of silicone bands hasbeen associated with foreign-body reaction and extru-sion.6,7 Fascia lata cannot always be harvested in sufficientamounts in very young children, and its use prolongs theprocedure and adds the risk of leg wound complications.8

Creation of a periosteal flap is an extensive procedurethat requires the expertise of an orbital surgeon.4 Anchor-ing the globe with a metal screw system has the advantageof precise placement and postoperative adjustment, but aswith any other foreign body, it carries the risk of extrusion,inflammation, infection, and progressive loosening.14 Re-cently a technique of fixation of the globe at the anteriorlacrimal crest by a half tendon width of medial rectus mus-cle has been described. The procedure has the advantage ofbetter adhesion and less chance of rejection, but it is asso-ciated with persistent congestion and swelling on the nasalconjunctiva that requires conjunctival excision and flatten-ing of the medial canthal area.15

Most surgeons differ in their approach to the medial or-bital wall. A skin incision gives good exposure of structures

Journal of AAPOS

at the medial canthal area; however, the chemosis and full-ness of the medial canthal region persists postoperativelyfor months.1,9 An approach to the medial wall through anincision in the medial Tenon’s capsule has also been de-scribed.16 The precaruncular approach10 was initially de-scribed by Moe.17 The technique obviates the need forskin incision, reduces the risk of inadvertent injury to theglobe, medial canthal tendon, or angular vessels, and avoidsthe extensive dissection required to fashion periosteal flaps.This approach follows an avascular path directly to the me-dial orbital wall.10,18 It heals rapidly, with minimal postop-erative morbidity.17

In this study, all patients showed marked decrease inhorizontal as well as vertical deviation with median resid-ual deviation of 10D. Only the first patient (Case 1) inwhom the eye was placed in primary position at surgeryshowed residual exotropia of 30D, following which we de-cided to leave all eyes with 10� to 15� of esotropia intra-operatively. This intraoperative placement has beenrecommended by others.9,14-16 The modification in su-ture placement for vertical tropia as in Case 14 has alsobeen suggested in previous articles9,10; however, in ourexperience this was not sufficient to fully correct the ver-tical deviation with a single procedure. Considering thatthe vascular supply of the medial rectus muscle is left in-tact, it will be possible to perform subsequent surgery onthe vertical rectus muscles if necessary to correct for anyresidual vertical tropia.

The limitation of this surgery, as with any tethering ap-proach, is that satisfactory alignment can only be achievedin primary gaze, and patients will experience diplopia in all

582 Saxena et al Volume 13 Number 6 / December 2009

other gazes. In our study only 3 of 14 patients complainedof diplopia postoperatively, but none required occlusion orprism therapy for treatment. The other patients had eithercongenital oculomotor nerve palsy with amblyopia or post-traumatic oculomotor nerve palsy with posttraumatic opticatrophy and were able to suppress or ignore the other im-age. This may explain why diplopia has not been reportedin other studies.1,15

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3. Von Noorden GK. Binocular vision and ocular motility. St Louis(MO): Mosby;1996:422.

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14. Dalman NE, Schwarcz RM, Velez FG. Suture fixation system as globetethers in severe paralytic strabismus. JAAPOS 2006;10:371-2.

15. Yonghong J, Kanxing Z, Wei L, Xiao W, Jinghui W, Fanghua Z. Sur-gical management of large angle incomitant strabismus in patientswith oculomotor nerve palsy. JAAPOS 2008;12:49-53.

16. Mora J. An adjustable medial orbital wall suture for third nerve palsy.Clin Exp Ophthalmol 2004;32:460-61.

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