A Potentially Adjustable Modification of the Nishida Procedure

ABSTRACT

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.

KEYWORDS:

• Sixth nerve palsy
• abducens nerve palsy
• Nishida procedure
• adjustable suture

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/2576117X.2022.2152267

Voiceover transcript

00:01 - In this video, we discuss the surgical management of a complete sixth nerve palsy with an adjustable modification of the Nishida procedure.

00:06 - To begin, a 6-0 polyglactin traction suture is placed at the supratemporal limbus and is used to rotate the eye infranasally.

00:13 - A supratemporal radial incision is then madethrough conjunctiva and Tenon’s, exposing the sclera in the supratemporal quadrant.

00:21 - Both the superior rectus and lateral rectus areidentified and hooked using a small tenotomy hook and a Jameson muscle hook in sequential fashion. While isolated on the Jameson, the relevant margins of bothmuscles are exposed with sharp dissection.

00:48 - A caliper is used to mark a point 13 mm posterior tothe limbus, 1-2 mm superior to the superior border of the lateral rectus.

00:58 - A 6-0 polyglactin suture is passed through thesclera at this point.

01:03 - The same suture is then passed through the SR,again 13 mm posterior to the limbus, with care taken to incorporate the temporal 1/3^rd of the muscle.

01:12 - The superior rectus is transposed laterally withthe first throw of the surgeon’s knot.

01:20 - The suture is tied using a temporary bowtie technique.01:27 - The radial incision is closed anteriorly with a single 8-0 polyglactin suture.01:31 - An identical procedure is repeated for the inferior rectus.

01:34 - A radial incision is made infratemporally and boththe inferior rectus and lateral rectus are identified, hooked, and cleaned.

01:41 - A 6-0 polyglactin suture is passed through thesclera at a point 13 mm posterior to the limbus, 1- 2 mm inferior to the inferiorborder of the lateral rectus.

01:50 - The same suture is passed through the inferiorrectus, incorporating the lateral 1/3rd of the muscle.

01:55 - The muscle is transposed and tied using a temporarybowtie technique.

02:08 - The radial incision is closed anteriorly with a single 8-0 polyglactinsuture.

02:14 - The adjustable suture ends are tucked in the superior and inferiorfornix, respectively.

02:19 – Upon awaking in the PACU, this patient had single vision in primary gaze and reported no vertical or torsional diplopia. There, his sutures were tied without adjustment.

Additional information

Funding

This paper was part of an approved research in strabismus IRB at Duke University. This paper has an exception by the Duke IRB.