Nishida procedure associated with botulinum toxin in a long-standing complete bilateral sixth cranial nerve palsy

In severe cases of abducens or sixth cranial nerve palsy, transpositions of the superior rectus and inferior rectus into the paralytic lateral rectus have been demonstrated to be useful. Numerous techniques have been described over time to carry out these transpositions, such as the Hummelsheim, O'Connor, Jensen, Foster, or Nishida technique. The first 4 techniques mentioned above have an increased risk of anterior segment ischaemia. The case is presented of a long-standing bilateral sixth cranial nerve palsy secondary to a severe cranial injury. Given the risk of ischaemia of the anterior segment, the Nishida technique was chosen in order to reduce the risk of suffering from this complication. This is combined with botulinum toxin in both middle rectus to try to resolve the muscle contracture associated with the long evolution of the case, obtaining good results at 6, and 12 months after the surgical procedure.