This protocol addresses the surgical management of complete oculomotor nerve palsy in patients presenting with the full syndrome — in which the affected eye is deviated and ocular movement is severely restricted — including ptosis of the eyelid.

Clinical scenario

When the palsy is complete, the eye is fixed in abduction, in infraduction, and in intorsion, and the eyelid is ptotic. This specific constellation — large-angle exotropia combined with ptosis and loss of adduction — defines the population for which this protocol applies.

Treatment approach (partial overview)

Primary surgical repair involves targeted procedures on the extraocular muscles responsible for the large-angle deviation. The approach addresses both the horizontal misalignment and incorporates intraoperative measures aimed at sustaining alignment through the healing period. The complete step-by-step regimen is available via the link below.

Treatment goals

Eyes aligned in primary position and, where achievable, restoration of a useful field of binocular single vision.

References

DOI: 10.1016/j.jaapos.2022.11.017

When the palsy is complete, the eye is fixed in abduction, infraduction, and intorsion, and the eyelid is ptotic.
A simple option for reducing large-angle exotropia is supramaximal recession (14–16 mm) of the lateral rectus muscle (LR) and large resection (8–14 mm) of the medial rectus muscle (MR).
Traction sutures to keep the eye fully adducted during healing may prevent or at least delay recurrence of exotropia in some cases.
The aim of strabismus surgery is to align the eyes in primary position and, when possible, restore a useful field of binocular single vision.

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Treatment of Complete Oculomotor Nerve Palsy with Ptosis and Eye Fixed in Abduction