Management of CNP

Q: What is the general approach in the acute phase of CNPs?

A: Observe for spontaneous recovery (3–6 months), provide symptomatic relief with prisms or occlusion, and conduct further investigations (MRI, blood tests)

Q: What is the general approach in the chronic phase of CNPs?

A: Ensure stability for 6+ months before surgery, and perform surgical correction based on residual motility

Third Nerve Palsy IIINP

• Q: What are the characteristics of complete III NP?

• A: Ptosis, eye "down and out," pupil involvement

• Q: What are the possible etiologies of III NP?

• A: Microvascular (pupil-sparing) and aneurysm (pupil-involving)

• Q: How is III NP managed in the acute phase?

• A: Occlusion for diplopia, immediate imaging if pupil involvement

• Q: What are the surgical options for complete III NP?

• A: Anchoring technique, transposition surgery

• Q: How is partial III NP surgically managed?

• A: Address specific muscle paresis (e.g., MR resection, LR recession)

Fourth Nerve Palsy (IV NP):

• Q: What are the features of IV NP?

• A: Hypertropia of affected eye (worse in adduction), diplopia with torsion, positive Bielschowsky head tilt test

• Q: What are the surgical options for unilateral IV NP?

• A: SO tuck or IO weakening

• Q: What are the surgical options for bilateral IV NP? A: Bilateral SO tuck or Harada-Ito procedure for torsion

• Q: What special considerations are there for IV NP?

• A: Classify using Knapp or Scott's classification for tailored surgery; bilateral cases often show V-eso pattern

Sixth Nerve Palsy (VI NP):

• Q: What are the features of VI NP?

• A: Esotropia worse in distance, limited abduction

• Q: What are possible etiologies of VI NP?

• A: Ischemia, trauma, false localizing sign

• Q: How is VI NP managed in the acute phase?

• A: Botulinum toxin to weaken antagonist MR, prevent contracture

• Q: What are the surgical options for VI NP?

• A: Resection-recession (LR resect, MR recess), Hummelsheim's or Jensen's transposition for complete palsy

• Q: What are the uses of Botulinum Toxin in CNPs?

• A: Temporary relief of antagonist overaction, diagnostic mimic of surgical results

• Q: What is the Hummelsheim transposition technique?

• A: Transfer part of SR/IR to LR

• Q: What is the Jensen transposition technique?

• A: Half of vertical recti split and attached to LR

• Q: What should be assessed post-operatively?

• A: Residual deviation and binocular vision (BV)

• Q: What complications should be addressed?

• A: Diplopia, torsion

• Q: What should be planned for if necessary?

• A: Further surgery