Two Stage Surgical Correction for Bilateral Sixth Nerve Palsy with Large-angle Esotropia

Purpose: We report the postoperative results of a two stage surgical procedure for bilateral sixth nerve palsy with large-angle esotropia due to a traumatic event.Case summary: A 66-year-old female had a traffic accident and sustained a subdural hemorrhage.After the accident, the patient complained of diplopia.Using the Krimsky test, large-angle esotropia of about 90 prism diopters at the primary position, and -6 limitation of lateral gaze eye movement were observed in both eye.At 14 months after the accident, we performed medial rectus recession and augmentation of the superior rectus, and inferior rectus transposition at the lateral rectus insertion along the spiral of Tillaux in a two stage surgical correction.Two months after the second operation, the patient's eye alignments showed slight exophoria of about 2 prism diopters at the primary position on the far and near alternate prism cover test.Abduction and adduction limitations of -1 were found in both eyes and her diplopia had disappeared.Conclusions: We report a case of bilateral sixth nerve palsy with large-angle esotropia due to trauma.Although it was difficult to predict the surgical outcome, two stage surgery provided a stable surgical result, and additional sutures between the transposed muscle and the lateral rectus muscle, resulted in improvement of the abduction disorder.