Major article
Long-term outcomes after surgical management of chronic sixth nerve palsy*,**

Presented in part at the 28th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, Seattle, Washington, March 21, 2002.
https://doi.org/10.1067/mpa.2002.127917Get rights and content

Abstract

Background: In a multicenter prospective data collection study of chronic sixth cranial nerve palsy, we previously reported that the initial successful outcome rate was 39% after a single surgical intervention and 25% after surgery combined with botulinum toxin (Botox), using strict success criteria. We now report the longer term outcome of these patients. Methods: A previously described cohort of 31 patients in 18 centers who underwent strabismus surgery for a sixth nerve palsy of greater that 6 months duration was studied prospectively. Twenty-three had strabismus surgery alone and 8 surgery with Botox. Fourteen (45%) were complete palsies and 17 (55%) were incomplete. Seven (23%) were bilateral and 24 (77%) were unilateral. Outcome was classified at time of last follow-up, which was 5 weeks to 24 months postoperatively. Success was defined as no diplopia in primary position at distance fixation. Partial success was defined as no more than 10 PD esotropia despite diplopia. Results: Overall, 16 (52%) of the patients were classified as successes, 7 (23%) as partial successes, and 8 (25%) as failures. Three (43%) of the partial successes were using prism. Eight (35%) of the patients classified as successes or partial successes required 2 surgical procedures. Of all patients (10, 32%) who had a second surgery, only 2 (20%) remained failures. Conclusions: Despite our reported poor initial surgical success rate in chronic sixth nerve palsy, additional strabismus surgery, longer follow-up, and the use of prism or face turn for small residual deviations yields an overall surgical success rate of 75%. More than 1 surgical procedure and prism are often necessary in the management of chronic sixth nerve palsy. (J AAPOS 2002;6:283-8)

Section snippets

Cohort

As we have described previously,1, 6, 7 we used a prospective multicenter data collection study design. All members of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) and the North American Neuro-Ophthalmology Society (NANOS) were invited to enroll patients with chronic sixth nerve palsy during a 2-year period (between March 1998 and February 2000). Inclusion criteria were chosen to parallel those that might be used for a future randomized treatment trial (Table 1).

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Description of the cohort

Thirty-one patients with chronic sixth nerve palsy who underwent surgical intervention were enrolled in 18 centers (see acknowledgements). Ages ranged from 5 years to 83 years (median, 45 years); 55% were female and 90% were white (Table 2).Regarding etiology of the chronic sixth nerve palsy, 14 (45%) were traumatic, 9 (29%) were unknown (including presumed hypertensive), 4 (13%) were neoplastic, and 4 (13%) were other (Table 2). The other causes included 1 case of aneurysm, 1 described as

Discussion

In this prospective multicenter study of chronic sixth nerve palsy or paresis, the long-term surgical success rate was 52% using strict criteria for success and 75% if partial success with small angle strabismus is included. A total of 32% of all patients had a second procedure and 19% were using prism.

The long-term overall success rate of 75% with surgery for chronic sixth nerve palsy is clearly greater than in our first report1 of initial surgical outcome. Our long-term success rate is

Acknowledgements

The authors thank the following investigators for their participation in this study: Brian Arthur, MD, Wilkes-Barre, Pa; William Astle, MD, Calgary, Alberta, Canada; Sandra Brown, MD, Lubbock, Tex; Stephen Christiansen, MD, Minneapolis, Minn; David Coats, MD, Houston, Tex; Oscar Cruz, MD, St Louis, Mo; Sean Donahue, MD, PhD, Nashville, Tenn; Mark Dorfman, MD, Hollywood, Fla; Patrick Droste, MD, Grand Rapids, Mich; W. Keith Engel, MD, Minneapolis, Minn; Robert Enzenauer, MD, MPH, Chattanooga,

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*

Supported by National Institutes of Health grant EY11578; Research to Prevent Blindness, Inc (J.M.H. as Olga Keith Wiess Scholar and an unrestricted grant to the Mayo Clinic Department of Ophthalmology), New York, New York; and the Mayo Foundation, Rochester, Minnesota.

**

Reprint requests: Dr Jonathan M. Holmes, Department of Ophthalmology W7, Mayo Clinic, Rochester, MN 55905.

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