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Abstract
Purpose
We present a new technique of anchoring the eyeball to the nasal periosteum with supramaximal recession of the lateral rectus muscle in one eye for exotropia management in bilateral total third nerve palsy combined with trochlear nerve palsy.
Case summary
A 38-year-old man presented with drooping of both upper lids and exodeviation of the left eye with a history of intraventricular hemorrhage 9 months previously. We noted bilateral ptosis, dilated pupils, right fixing eye, left face turn, and left exotropia over 100 prism diopters (PD) in the primary position with an inability to move both eyes together except abduction. He was diagnosed with bilateral total third nerve palsy and trochlear nerve palsy. We fixated the left globe (sclera anterior to the insertion of the medial rectus muscle) to the nasal periosteum including the medial palpebral ligament using a nonabsorbable suture. A large recession of the left lateral rectus muscle (14 mm) was also performed. Ocular alignment in the primary position was exotropia of 25PD and cosmetically satisfactory after 6 months of follow-up.
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References
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 | Figure 1.Preoperative photograph in 9 gazes shows bilateral total third nerve palsy and trochlear nerve palsy. The patient had ptosis and mid-dilated fixed pupil in both eyes and left exotropia over 100PD in the primary position. Both eyes had limitation in adduction, elevation, and depression. |
 | Figure 3.Schematic drawings. (A) The anterior lacrimal crest and the insertion of the medial palpebral ligament were exposed. (B) Double armed 5-0 Ethibond suture was passed through the medial palpebral ligament insertion at the anterior lacrimal crest including the periosteum. (Insert) Second bite was taken just lateral to the first. (C) A small buttonhole was created in the medial orbital fascia up to the exposed periosteum by blunt scissors. (D) Ends of the 5-0 Ethibond were brought out into the subtenon space (toward the conjunctival side) using artery clamps. (E) The sutures were secured to the sclera anterior to the medial rectus insertion. |
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