Traction sutures in the management of long-standing third nerve palsy

Exotropia in long-standing third nerve palsy presents a significant cosmetic problem and the management is difficult.

A retrospective review of patients with long-standing exotropia secondary to third nerve palsy between 1996 and 2006 was carried out. Patients underwent large lateral rectus recession and medial rectus resection, combined with muscle traction sutures left in situ for 6 weeks.

Thirty-three patients were treated, with a mean follow up of 16 months, ranging from 3 to 108 months; the age range was 3 to 66 years with a mean of 28.8 years. The cause of third nerve palsy was congenital in 39%, orbital or intracranial tumour 21%, trauma 15%, microvascular 9%, complication of neurosurgery 9%, and unknown in 6%. Pre-operative angle measurements ranged from 25 to 95PD exotropia, mean 60PD exotropia. After removal of the traction sutures, the eye maintained a good cosmetic position in all but 3 patients. Final angle measurement ranged from 16 to 40PD exotropia, mean: 14.5PD exotropia. Post-operative motility was extremely limited; very limited abduction was a good indicator of the final eye position. Complications included conjunctival hypertrophy, suture infection, and "cheese wiring" of sutures.

Adducting traction sutures combined with large recess-resect of the horizontal rectus muscles are safe and effective in the management of long-standing strabismus due to third nerve palsy.