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 Treatment of Acquired

 VI Nerve Palsies

 William E. Scott, M.D.

Rebecca Parrish, B.A.Pamela Kutschke, C.O.

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Retrospective review of 

319 records with diagnosis of 

 VI nerve palsies

1970 – 2002

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Exclusion Criteria (n=137)

Improper diagnosis

Incomplete records

Refused treatment Treated elsewhere

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Included Patients (n=182)

34 Resolved within 6 months

148 Treated (Age range 1 to 87 years)

Botox only  – 

15 patients Surgery  – 133 patients

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Etiology of Resolved Cases n=34

18 Trauma

7 Vascular

3 Neoplasm 3 Viral

1 Increased Cranial Pressure (ICP)

1 MS 1 Unknown

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Etiology of Treated Cases

Botox (n=15)

 Trauma – 7

Neoplasm – 5

ICP – 1

 Vascular - 1

Surgery (n=133)

 Trauma – 65

Neoplasm – 23

 Vascular – 18

ICP – 3

 Viral – 1

CNS abnormalities – 5

Unknown - 18

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Pre-Op Considerations to Determine

 Type of Treatment

Botox

Recent onset

Small to moderate angle Chance for recovery 

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Botox Results (n=21)

2.5 to 7.5 units

Pre-op deviation

3

D

to 45

D

  Post-op deviation

10 patients +/-10D 

11 patients >10

D

  6 opted for further surgery 

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Pre-Op Considerations to Determine

 Type of Treatment

Surgery 

Stable measurements > 3 months

Size of deviation

Lateral rectus function

 Versions

Forced generation

Forced duction Saccades (n=64)

Clinical (observation)

Formal (EOG)

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Surgical Procedures

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Indications for Horizontal Muscle

Surgery

 Versions: 0 to -6

Forced duction (n=20)

1 Normal

12 Mild

3 Moderate

4 Marked

Saccades (34)

Clinical (n=7)

5 Good 2 Moderate to slow 

Formal (n=27)

2 20-40%

25 >40%

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Horizontal Muscle Surgery (n=80)

Unilateral medial rectus recession

BMR or R&R 

R&R and MRc R&R OU

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One Muscle Surgery (n=2)

Pre-op deviation

12D to 25D 

Post-op deviation

1 patient +/-10D 

1 patient >10D

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 Two Muscle Surgery (n=69)

Bilateral VI (n=22)

Pre-op deviation

14D to 70D 

Post-op deviation

17 patients +/-10D 

5 patients >10D

Unilateral VI (n=47)

Pre-op deviation

20D to 70D 

Post-op deviation

28 patients +/-10D 

19 patients >10D

 

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 Three Muscle Surgery (n=8)

Bilateral VI (n=2)

Pre-op deviation

65D to 85D 

Post-op deviation

1 patient +/-10D 

1 patient >10D

Unilateral VI (n=6)

Pre-op deviation

40D to 50D 

Post-op deviation

4 patients +/-10D 

2 patients >10D

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Four Muscle Surgery (n=1)

Pre-op deviation

75D

Post-op deviation

40D ET

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Indications for Transpositions

 Versions: -4 to -7 Forced generation (n=2)

No pull

Forced duction (n=15) 1 Normal 5 Mild 6 Moderate 3 Marked

Saccades

Clinical (n=5)

No function to slow 

Formal (n=25)

17 <20%

7 20-40%

1 >40%

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 Transposition (n=53)

38 Jensen procedures

15 Augmented full muscle transposition

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 Jensen Procedure

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 Jensen Results

Bilateral VI (n=12)

Pre-op deviation

>50D 

Post-op deviation 7 patients +/-10D 

5 patients >10D 

Unilateral VI (n=26)

Pre-op deviation

30D to >50D 

Post-op deviation 20 patients +/-10D 

6 patients >10D 

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Full Muscle Transposition(O’Connor with the Foster modification) 

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Full Muscle Transposition(O’Connor with the Foster modification) 

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Full Muscle Transposition(O’Connor with Foster modification) 

 With Botox (n=9)

Bilateral VI (n=2)

Pre-op deviation 95D to >100D 

Post-op deviation

2 patients <10D 

Unilateral VI (n=7)

Pre-op deviation 45D to 90D 

Post-op deviation

4 patients +/-10D 

3 patients >10D 

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Full Muscle Transposition(O’Connor with Foster modification) 

 Without Botox (n=6)

Bilateral VI(n=2)

Pre-op deviation 95D 

Post-op deviation

2 patients >10D 

Unilateral VI (n=4)

Pre-op deviation 35D to >50D 

Post-op deviation

3 patients +/-10D 

1 patient >10D 

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Full Muscle Transposition Results(O’Connor with Foster modification) 

(n=15)

Bilateral VI (n=4)

Pre-op deviation 95D to >100D 

Post-op deviation

2 patients +/-10D 

2 patients >10D 

Unilateral VI (n=11)

Pre-op deviation 35D to 90D 

Post-op deviation

7 patients +/-10D 

4 patients >10D

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 Transposition Complications

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Case 14 G.M. 65 ♀ 

 Trauma – bilateral VI nerve palsy 

100DET

Saccadic velocity flat OU

Forced ductions +2 abduction OU

 Treatment - BMRc 7 mm, bilateral Jensen

- Anterior segment ischemia OS –  2 o’clock –  9 o’clock  

- Resolved with oral steroids x 4 weeks

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 Transposition Complications Anterior Segment Ischemia

2 with Jensen procedure

2 with full muscle transposition (with Botoxinjection to the medial rectus)

 All resolved with systemic steroid treatmentexcept segmental iris atrophy 

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Binocular Visual Fields (BVF)

Bilateral sixth nerve palsy with >100DET

Post-op diplopia field

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Surgical Results

Horizontal (n=80)

Horizontal (n=80)

51 (64%) <10D 

29 (36%) >10D 

23 Under-corrected

6 Over-corrected

15 (50%) opted for further surgery 

5 had recurrent VI nerve palsies

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Surgical Results

 Transpositions (n=53)

 Jensen (n=38)

27 (71%) <10D 

11 (29%) >10D 

11 Under-corrected 0 Over-corrected

6 opted for further surgery 

Full Muscle (n=15)

9 (60%) <10D 

6 (40%) >10D 

5 Under-corrected 1 Over-corrected

2 opted for further surgery 

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Horizontal Abduction Deficits

(n=80)

Pre-operatively 

73 patients showed LR dysfunction on versions

 Versions: -1 to -6

Post-operatively 

48 patients improved LR function by 1 or more

 Versions: -1 to -5

20 patients showed no improvement 5 recurrent VI nerve palsies

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 Transposition Abduction Deficits

(n=53)

 Jensen (n=38)

Pre-operatively 

38 with LR dysfunction

on versions >-4 Post-operatively 

29 showed LR improvement

9 showed noimprovement

 Versions: -1.5 to -5

Full Muscle (n=15)

Pre-operatively 

15 with LR dysfunction

on versions >-4 Post-operatively 

15 showed improvement

 Versions: -1 to -5

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Summary

Determine etiology 

Ensure stability 

Choice of surgical procedure If lateral rectus function present -

horizontal muscle surgery.

Number of muscles depends on size of deviation.

If lateral rectus muscle absent or poor -transposition.

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Summary Type of Transposition

Both effective

In improving alignment

In improving abduction deficit

Both have a chance of a second procedure

Ease of procedure