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A variant Nishida’s technique for surgical correction of monocular elevation deficiency syndrome
Variante de la técnica de Nishida para la corrección quirúrgica del síndrome de déficit monocular de la elevación
A. Ortuerta-Olartecoechea, J.A. Reche-Sainz
, L. de-Pablo-Gómez-de-Liaño, L. Hernández-Pereira, M. Álvarez-Fernández, M. Ferro-Osuna
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Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Madrid, Spain
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Ortuerta-Olartecoechea, J.A. Reche-Sainz, L. de-Pablo-Gómez-de-Liaño, L. Hernández-Pereira, M. Álvarez-Fernández, M. Ferro-Osuna" "autores" => array:6 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Ortuerta-Olartecoechea" ] 1 => array:4 [ "nombre" => "J.A." "apellidos" => "Reche-Sainz" "email" => array:1 [ 0 => "jalbres@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "L." "apellidos" => "de-Pablo-Gómez-de-Liaño" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Hernández-Pereira" ] 4 => array:2 [ "nombre" => "M." "apellidos" => "Álvarez-Fernández" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Ferro-Osuna" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Oftalmología, Hospital Universitario 12 de Octubre, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variante de la técnica de Nishida para la corrección quirúrgica del síndrome de déficit monocular de la elevación" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 803 "Ancho" => 1755 "Tamanyo" => 238437 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic positions of preoperative gaze. A significant limitation of the elevation of the left eye in adduction and abduction, and hypotropia and ptosis in primary gaze position can be observed.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Monocular Elevation Deficit Syndrome (MEDS) is characterized by the limitation of supraductions in one eye, both in adduction and abduction, and is frequently associated with hypotropia and ptosis (or pseudoptosis) of that same eye. Its etiopathogenesis can be paretic, restrictive or combined<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. The most common surgical correction consists of Knapp-type substitution, with transposition of the horizontal rectus tendons to the insertion of the upper rectus, to compensate for the paresis of the elevator muscles<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. This technique is sometimes preceded by recession of the ipsolateral lower rectus if restricted<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>,2. Performing both procedures at the same surgical time involves a significant risk of anterior segment ischemia<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. A case of MEDS is described in an adult patient treated with a variant of the Nishida technique with the aim of avoiding this complication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinic case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 62-year-old woman who consulted for a long-standing hypotropia of the left eye (LE), but without diplopia. Six years earlier, she had undergone surgery for left ptosis with a frontal suspension technique. She reported having low vision in the LE since childhood. She was being treated for type 2 diabetes, high blood pressure and hypothyroidism, and she was also a 10 cigarette/day smoker. The examination revealed a 3<span class="elsevierStyleHsp" style=""></span>mm ptosis of the LE while the eyelid presented a notch at the junction of the middle and outer third due to defective surgical molding. The best corrected visual acuity in the right eye (RE) was of decimal unit and in the LE of finger counting at 2<span class="elsevierStyleHsp" style=""></span>m. It was pseudo-phakic in the RE and in the LE a yellowish cataract was observed. Intraocular pressure of both eyes was in normal range and there were no pathological findings in the fundus of the RE (in LE it was not observable). Regarding extrinsic motility, in near vision it presented an exotropy of 6 prismatic diopters (PD), with RE dominance and a manifest hypotropia of 25 PD of LE, with important elevation limitation (+++), which was similar in adduction and in abduction (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">After surgical correction under general anesthesia, passive duction of the lower left rectus was found to be positive. A 4<span class="elsevierStyleHsp" style=""></span>mm recession of the left lower rectus with double scleral anchorage was performed, using a 6/0 polyglactin suture. A modified Nishida technique was then performed in the same eye. A 5/0 polyester non-absorbable suture was fixed on the upper edge of each horizontal, medial and lateral rectus at a distance of 8–10<span class="elsevierStyleHsp" style=""></span>mm from the insertion and covering one third of the muscular body. These sutures were then anchored 12<span class="elsevierStyleHsp" style=""></span>mm from the corneal limb, in the superonasal and super-temporal quadrants respectively (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> and Appendix).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Postoperatively, the LE presented an exotropia of 6 PD with a hypotropia of 3 PD. It exhibited minor ptosis and the elevation of the eye had improved, but the adduction was somewhat limited (+) and the depression especially in abduction (+) (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). This residual hypotropia remained stable after 4 months of follow-up.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">MEDS usually has a congenital origin, but is also due to acquired ischemic (thromboembolism, arteritis, high blood pressure), inflammatory (sarcoidosis), infectious (lues) causes or primary or metastatic neoplasms of the brain stem<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a>. Historically, unilateral deficit of gaze elevation had been attributed to the lack of action of the superior rectus and inferior oblique ipsolateral muscles (called "double paralysis of elevators"), which would be a disorder of supranuclear origin<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a>. However, the syndrome was extended with other subtypes responding to primary and isolated paresis of the upper rectus, or to congenital fibrosis of the lower rectus<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a>. Contracture of the lower rectus, in some cases, may also be secondary to hypoaction of the upper rectus in the context of MEDS<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinically, MEDS is characterized by the inability to elevate the affected eye, both in adduction and abduction, and there may be an associated horizontal deviation<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. In the primary gaze position (pgp), the affected eye is usually hypotrophic but, exceptionally, if this were the fixated eye, the opposite eye would be in hypertrophy<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. The eye with the elevation deficit may also exhibit ptosis due to possible adhesions of the upper rectus with the upper eyelid elevator, but in cases where it disappears with the fixation of that eye it would be a pseudoptosis2. Amblyopia would be present in deviations of long evolution (from childhood), generally with associated ptosis or anisometropia2. Vertical diplopia would be more typical of cases acquired in adulthood, sometimes accompanied by a compensatory posture of chin elevation<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Congenital cases almost always occur without diplopia, since they are associated with amblyopia and suppression phenomena<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The present patient exhibited amblyopia and palpebral ptosis as part of the MEDS, so a congenital origin was presumed. However, the elevation deficit was not detected early, since she underwent surgery first for ptosis and in adulthood.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The treatment of MEDS is mainly surgical. In children, correct refraction of the affected eye and treatment of amblyopia, if any, is essential<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>,3. The main surgical indications are significant deviation in pgp, diplopia in pgp, abnormal head position or amblyopia induced by vertical deviation<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. The surgical objectives are primarily to improve the alignment of the eye in pgp and to increase the binocular field of vision<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. In the presence of paresis of the upper rectus, the surgical technique of choice is Knapp-type muscle transposition<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. According to the series described, the average correction of hypotropia obtained is very variable and even unpredictable, since it can range from 21.1 to 38 DP<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and with a tendency to hypercorrection in time<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>. Furthermore, this procedure must be preceded by an ipsolateral rectal recession, provided that a restriction of the lower rectus is determined by means of a passive duction test. This restriction could be present in up to 70–83% of patients<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. Anterior segment ischemia is a possible complication when both procedures are performed simultaneously, but there are cases described 4 months apart<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. On the other hand, some authors recommend not exceeding 4–5<span class="elsevierStyleHsp" style=""></span>mm of lower rectal recession to avoid hypertrophy in gaze depression or lower eyelid retraction<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. Therefore, in hypotropies <15-20 PD it might be useful to combine it simultaneously with contralateral upper rectal recession for inervation purposes<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>. Our patient presented a large contracture of the lower rectus so it was retro-inserted 4<span class="elsevierStyleHsp" style=""></span>mm and, as the hypotropia was >20 PD, a technique of muscle replacement of the upper rectus had to be performed as well.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The Nishida technique<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> was originally described for the correction of endotropy caused by VI pair paresis and consists in the transposition of the temporal margins of the vertical lines by suturing them to the upper and lower sclera. In this way, a significant abductive action is obtained by displacing the temporal portion of the muscular bellies of the vertical lines, avoiding disinsertions and partitions<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. The use of this modified technique had only been reported by Murthy and Pappuru<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> for 3 children with MEDS in 2018, achieving a correction of 30 PD of hypotropia in one of the cases and 40 PD in the other 2, when it was combined with recession of the lower rectus. This variant of Nishida's technique for MEDS is easier to perform than Knapp-type substitution, since neither tenotomies nor muscle partitions are required. In our case, it proved to be effective in correcting 25 PD of vertical deviation combined with lower rectal recession and also safe in minimizing the risk of anterior segment ischemia. The patient presented here would be the first reported case of an adult patient.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Financing</span><p id="par0050" class="elsevierStylePara elsevierViewall">This work has not received any funding.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">None of the authors of this manuscript have any conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1583669" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1425297" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1583668" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1425296" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinic case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Financing" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-05-11" "fechaAceptado" => "2020-09-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1425297" "palabras" => array:5 [ 0 => "Elevation deficiency" 1 => "Nishida’s procedure" 2 => "Hypotropia" 3 => "Inferior rectus" 4 => "Ptosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1425296" "palabras" => array:5 [ 0 => "Déficit de la elevación" 1 => "Técnica de Nishida" 2 => "Hipotropia" 3 => "Recto inferior" 4 => "Ptosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Monocular elevation deficiency (MED) is characterized by unilateral limitation of supraductions, similar in adduction and abduction, in addition to hypotropia and ptosis. We describe a case of a 62-year-old woman with long-standing left ptosis who was initially operated with a frontal suspension technique. On subsequent examinations, a MED of that eye was found. The passive duction test was positive, so the inferior rectus was recessed. In addition, a modified Nishida technique was performed, consisting of the scleral anchorage of the superior edges of the rectus, medial and lateral, 12<span class="elsevierStyleHsp" style=""></span>mm from the corneal limbus in the superonasal and superotemporal quadrants, respectively. Postoperatively, the left eye presented a minimal hypotropia of 3 PD. This modified technnique used here on the horizontal rectus muscles, turned out to be effective and safe for the correction of MED.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El síndrome del déficit monocular de la elevación (SDME) se caracteriza por la limitación de las supraducciones de un ojo, tanto en aducción como en abducción, además de hipotropía y ptosis. Se describe el caso de una mujer de 62 años con ptosis izquierda de larga evolución que fue inicialmente intervenida con una técnica suspensión al frontal. En exploraciones posteriores, se le objetivó un SDME de ese ojo. La ducción pasiva fue positiva, por lo que se le realizó una recesión del recto inferior. Además, se le asoció una técnica modificada de Nishida, consistente en el anclaje escleral de los bordes superiores de los rectos, medio y lateral, a 12<span class="elsevierStyleHsp" style=""></span>mm del limbo corneal en los cuadrantes superonasal y superotemporal, respectivamente. Posoperatoriamente el ojo izquierdo presentaba una mínima hipotropía de 3 dioptrías prismáticas. Esta técnica modificada aquí empleada sobre los rectos horizontales resultó ser eficaz y segura para la corrección del SDME.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ortuerta-Olartecoechea A, Reche-Sainz JA, de-Pablo-Gómez-de-Liaño L, Hernández-Pereira L, Álvarez-Fernández M, Ferro-Osuna M. Variante de la técnica de Nishida para la corrección quirúrgica del síndrome de déficit monocular de la elevación. Arch Soc Esp Oftalmol. 2021;96:545–548.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0065" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0035" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 803 "Ancho" => 1755 "Tamanyo" => 238437 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Diagnostic positions of preoperative gaze. A significant limitation of the elevation of the left eye in adduction and abduction, and hypotropia and ptosis in primary gaze position can be observed.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1142 "Ancho" => 2500 "Tamanyo" => 107927 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diagram of the variant of the Nishida technique used. A) Non-absorbable 5/0 polyester suture on the upper edge of each horizontal rectangle at a distance of 8–10<span class="elsevierStyleHsp" style=""></span>mm from the insertion covering one third of the muscle body. Anchorage of these sutures 12<span class="elsevierStyleHsp" style=""></span>mm from the corneal limb, in the superonasal quadrant for the medial rectus and superotemporal for the lateral rectus. B) The upper edges of the horizontal lines are transposed.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">IR: inferior rectus; LR: lateral rectus; MR: middle rectus; SR; upper rectus.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 807 "Ancho" => 1755 "Tamanyo" => 263450 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Post-operative diagnostic gaze positions (at 3 months) showing improvement of hypotropia and ptosis of the left eye in the primary gaze position, as well as of elevation. Nevertheless, a slight limitation of the adduction and depression of said eye is observed.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 50809692 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical outcome in monocular elevation deficit: a retrospective interventional study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S. 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