Precaruncular periosteal anchor of medial rectus, a new technique in the management of complete external third nerve palsy

Management of complete external third nerve palsy is a challenge to a strabismologist; as four of six extra-ocular muscles are affected, it leaves eye in fixed hypotropic and exotropic position (Srivastava et al., 2004). Although numerous surgical procedures have been described, none has been found to be ideal for all cases. Horizontal supramaximal recession-resection procedure may work in cases having some function of medial rectus (Harley, 1980). In cases of complete external palsy, anchoring of globe to periosteum of medial orbital wall using different structures has been described (Villasenor Solares et al., 2000; Bicas, 1991; Salazar-Leon et al., 1998), as recession-resection may result in large residual deviation and/or eye drifts back to abducted position due to unopposed lateral rectus action (Von Noorder, 1996). These anchoring procedures are with associated problems of skin incision, thigh surgery or loss of superior oblique function (Villasenor Solares et al., 2000; Bicas, 1991; Salazar-Leon et al., 1998). We describe a new and safe technique for management of complete external third nerve palsy by anchoring insertion of medial rectus to medial wall periosteum, posterior to posterior lacrimal crest, along with supra maximal recession of lateral rectus.