Management of fixed divergent squint in third nerve palsy using traction sutures

Long-standing fixed divergent squint is a difficult management problem, presenting marked cosmetic and functional symptoms in the patient, and a significant challenge for the squint surgeon to overcome.

We describe use of through-the-lid traction sutures in 24 consecutive patients with fixed divergent squint secondary to long-standing third nerve palsy. Very large recessions of the lateral rectus were combined with large resections of the medial rectus and traction sutures placed through the insertions of the superior and inferior rectus were brought out through the extreme medial fornices and skin of the upper and lower lids. Sutures were tied over tarsorrhaphy bolsters and left in situ for six weeks.

After removal of the traction sutures, the eye maintained a good cosmetic position in all but two cases. Postoperative motility was extremely limited or absent. Complications were limited to transient skin ulceration in two cases.

Supramaximal horizontal recess-resect procedure combined with adducting traction sutures left in situ for six weeks in a safe and effective procedure to restore the eye to the centre of the palpebral fissure.