Oculomotor nerve palsy
ICD-10 H49.0 ICD-11 9C81.0

Complete Oculomotor Nerve Palsy with Ptosis: When Primary Repair Has Not Restored Alignment

Clinical Scenario

Ptosis present

In complete oculomotor nerve palsy, the eye is fixed in abduction, in infraduction, and in intorsion, and the eyelid is ptotic. This reflects total loss of CN III motor function to the extraocular and levator muscles.

Previous Treatment — Goals Not Reached

Prior line

Primary repair — supramaximal recession of the lateral rectus and large resection of the medial rectus, with traction sutures to maintain full adduction during healing — did not achieve alignment in primary position or restoration of a useful field of binocular single vision. This protocol addresses the next step after that outcome.

Next-Line Approach (partial)

The next step targets the residual abducting force of the lateral rectus through a specific surgical intervention directed at that muscle. The complete technique, selection criteria, and procedural detail are available in the full protocol.

Instant Access to Structured Evidence-Based Regimens

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.

To reduce this abducting force, Knapp described recession and fixation of the LR to the lateral orbital wall, taking care to cover the exposed LR with Tenon's fascia to prevent reattachment to the globe.

Another option is maximal resection and extirpation of the LR, which should help prevent LR reattachment to the globe.

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