Lecture: The Nishida Procedure: A Technique to Tackle Diplopia

During this live webinar, we will review the reasons to perform a Nishida procedure and briefly review what is published in the medical literature. We will go through the technique step-by-step and watch videos and model demonstrations. We will also discuss errors to avoid. (Level: Advanced)

Lecturer: Dr. Melissa Simon, Ophthalmologist, Brown University/Lifespan Physician Group, USA


DR. SIMON: Hi, good morning, everyone. I’m gonna share my slides with you now. My name’s Melissa Simon. I’m joining you today from providence, Rhode Island. And we’re going to be talking about the Nishida Procedure for strabismus. And in this talk I’m gonna be specifically focusing on this one procedure. I know there were some questions ahead of time about diagnosing diplopia and when to do which procedure. And those are great ideas for another talk. But this talk is specifically going to be about this procedure. I just want to make sure everybody can hear me… okay. Good. Okay so, we’re going to begin with a poll question. Have you ever performed a Nishida procedure or a vertical rectus belly transposition?
And so, most of you have not. Yet. So, you’re in the right place this morning. And this procedure is my procedure of choice for six nerve policies. And I’ve actually started using it for other paralytic conditions. Okay. And one more poll question. Which of these are possible complications of vertical rectus transposition surgery? So, you’ve decided that you’re gonna do a transposition surgery with vertical rectus muscles, which are some possible complications?
And most of you said all of the above which is correct. They are all possible complications. One thing I want to point out is that anterior segment ischemia is kind of the most dreaded complication of vertical rectus transposition surgery. The vertical recti supply a large percentage of the anterior segment. And so, interrupting their vasculature really does introduce significant risk. Especially if you’re also doing a medial rectus recession at the same time because then you’ve interrupted three muscles and their ciliary vessels.
So, the Nishida Procedure was published in 2013. And it was developed to answer this concern about anterior segment ischemia. The Hummelsheim and the Jensen are effective procedures. And the Jensen was an attempt to mitigate the anterior segment ischemia risk. But still, there was that risk. And so, the group with Dr. Nishida was trying to do another type of transposition without disrupting the ciliary vessels. And so, what they did, and I’m gonna be showing you many different diagrams, drawings, and videos today to introduce the steps of the procedure. This drawing shows that what they did is they basically put a suture around the lateral one-third of the superior rectus and the lateral one-third of the inferior rectus. And tied it. But did not split the muscle. And then they measured midway between that vertical rectus muscle insertion and the lateral rectus muscle insertion, and 10 to 12 back from the limbus and then did a partial thickness through the sclera and then tied the suture — it’s a permanent suture. And what you end up with is like that figure on the right where it almost just looks like the muscles kind of spread. But you’ve taken some of those belly — mid-point belly fibers and moved them toward the lateral rectus. And they published a case series of nine patients and found that this procedure could correct 24 to 36 prism diopters without doing anything else. If you added in the medial, it corrected 50 to 60 prism diopters, no major vertical produced by this procedure in the publication, and no instances of anterior segment ischemia. This is just another drawing from a great paper published in 2023 where you can kind of see what identify what I’ve just described in more like three dimensions here.
Now, I’m gonna show you how I do the procedure. And I wanted to start by showing you my tray in the operating room. And we’ll talk about the efficacy of the procedures and some particular cases later in the talk. But first I just want to walk you through the steps. In addition to awful my hooks and other instruments, I have this one tool or instrument that I really love. It’s called the Globe Ruler. And in my OR, other people might call it different things. But it has the ability to measure back in the globe really precisely. And you’ll see me using it in the video I’m going to show you. First I’m going to show you a drawing of my incision technique because I wasn’t able to capture that on video. My video is captured by the circulating nurse in my operating room so we weren’t able to get everything because sometimes she had to do other tasks. So, we’re gonna start with just a drawing of my incision. So, you can do this with two fornix incisions around the lateral rectus if you want to, or you can join those two fornix incisions to open it up at, you know, closer to the limbus. I do it just in front of the insertion of the muscle. If you need better exposure. Fornix incisions alone will preserve even more vasculature to the anterior segment. And now this is a video of me operating on a patient. And so, what I’m doing here is I’m finding I have hooked the inferior rectus muscle. And I’m measuring it 10 millimeters back from the insertion. The procedure prescribes 8 to 10 millimeters back. And then I like using a globe ruler to identify what would be the lateral one-third. And that’s because the globe ruler accounts for the curve of the eye. I’m sorry, I it just started over again, I apologize. And so, we’re just gonna see that again.
So, I’m using the Globe ruler to identify the lateral one-third. I want to avoid any ciliary arteries. This is a close-up, you see the little millimeter tick marks on the Globe ruler. And now I’m using — sorry, that was very fast — I’m using a hook to lift the muscle posteriorly. So, that I can put my needle underneath the muscle and make a full thickness pass without age the point of the needle at the globe. It’s just a safer technique to go from back to front. And so, I have my assistant put a hook behind where I’ve marked and just lift the muscle up ever so slightly so that it can get underneath and now you’re seeing me pull my permanent suture through and double check that I have about a third. I’ve avoided the muscle. And oh, I’m sorry. I’m having some difficulties with this video. All right. So, now I’ve isolated that and I’m gonna tie the suture. And I tie it 2-1-1, I don’t want to tie it too tight. You want it to be snug, but you don’t want to strangle the tissue. The whole point of this procedure is to not cause ischemia if you can help it. Now, I’m measuring between the lateral rectus muscle and the inferior rectus insertion. And I’m going try to find the midway point between those insertions and mark it. My assistant’s marking that for me. And now I’m gonna measure 10 to 12 millimeters from the limbus. The globe ruler is so helpful because the curve of the ruler helps you get an accurate measurement. I’m measuring . back at that point. And I’m going to measure a partial thickness pass with just one needle. You don’t need a double O for this, I use a 6-0 Mersilk. That’s what we have. Our colleagues in Japan who I consulted with, they use a 6-0 proline. And I’m tying the muscle. You can see it’s moving over. But we had to take the hook out because the hook was kind of restricting my ability to get the muscle to fully move over. So, now we’re hooking the lateral rectus instead. And just tying that lateral one-third of tissue down. And finishing the tie. And then I always like to confirm correct placement before I cut. So, here I am measuring again. That’s just an extra step. It’s my personal preference. And then we do the same thing. Superiorly. So, to hook this superior rectus, I like to approach temporally. I like to measure where I think it will be. I didn’t get all the superior rectus the first time. And so, now what I’m doing is I’m trying to figure out where the rest of the superior rectus is. And it looks like it fanned temporally back a little bit and I missed a little bit. I’m going to re-hook it in a minute. But I want to see where is the superior oblique to make sure I’m not accidently hooking that. We always need to make sure of that when we do surgery on the superior rectus. Never with force, don’t to want detach it with force. But just gently strumming it to feel that like guitar string feel. now I’m identifying the lateral one-third of the superior rectus. It’s right on a vessel so I’m going to go little bit inside one-third of it. I have a second hook so I don’t impale the globe when I pass my suture. And I’m gonna go back to front with my needle. I’m using the calipers now since it’s kind of flat just to double check my measurement. And you see I went back to front avoiding the vessels and I’m tieing it. And then after this tie, that’s where the nurse I was working with had to stop videoing. So, I’m just gonna complete the procedure with you with this drawing. So, this is where we left off. I’ve tied the suture around the lateral one-third.
Now, I’m measuring halfway between the two insertions. And then 12 millimeters back from the limbus at that point and passing a needle there.
Then to close it all up, I have just a drawing of the original incision that I made. I had made two fornix incisions. In this particular patient, the conjunctiva was friable. And I just didn’t feel like I had good enough exposure or manipulation of the conjunctiva with two fornix incisions so I opened it up. And now I’m going to re-join those two corners first. And then once those two corners are approximated, I’ll sew the rest back up. Sometimes I even mark those two corners with a marking pen when I first take them down. It just helps me at the end to find my landmarks to join them. And make a nice, neat closure.
So, now let’s pause. Another poll question. Is the Nishida Procedure as effective as other transposition procedures for the same indications? So, just in terms of six nerve palsies, which is what it was originally introduced for. Is it as effect as the Hummelsheim? The Jensen? Foster?
And it is. And 78% of you thought so. And so, let’s look at what the literature says about that. And so, first of all, let’s just remember that any time we do a transposition, the point of the transposition is not to correct paralysis, right? We can’t correct paralysis. A cranial nerve that doesn’t work and doesn’t regenerate, we can’t make it work. All we can do is add static force to the eye with other muscles to almost like tether the eye more in the position that we want. And then when the antagonist muscle relaxes, the eye has the ability to move in the direction of the parallelized muscle. So, that’s an important point. There was another study in 2018, it was a case series. The biggest case series published at that time to date of ten patients. They did the Nishidas for cranial nerve six palsies and found it was effective. Similar results to the 2013 paper. Also no anterior segment ischemia. And this group did medial rectus recessions on adjustables on everyone. And they still had no anterior segment ischemia, which is great. Now I want to talk with you about a series from China. And this research group first looked at comparing what they called modified vertical rectus belly transpositions. Which is very similar to the Nishida. What they did with a slight variation was they put the muscle a little more posteriorly on the sclera beyond the 12 millimeters and a little bit closer to the lateral. And they also only took a quarter of the width of the vertical rectus muscle. But it was essentially the same procedure as the Nishida. And they compared it to an augmented superior rectus transposition.
And what they found was when they compared first the — they looked at retrospective cases, 14 cases, and they did this belly transposition which is like the Nishida, with a medial rectus recession and found that it was more effective than the augmented superior rectus transposition with a recession. So, then they did a bigger study in 2022 and they randomized patients and they double masked it. And they found similar results that the muscle belly transposition corrected about 10 prism diopters more than the rectus transposition with presentation both with medial rectus recession. The belly transposition and medial rectus recession corrected about 66 prism diopters of esotropia. And the other was 52. There was really no difference in the terms of post-op drift. And what they did notice was a trend for the belly transposition group to have a little bit more extortion — excyclotorsion, sorry — excyclotorsion and hypertropia afterwards. And advised that we could use that as surgeons to our advantage in patients who also had a cranial nerve four palsy. But also, we should monitor torsion inter-operatively. Mark the limbus and watch for torsion during surgery. Which I think is a good tip. And I do do that. Then in 2023, they published another comparison study. This was really interesting. They looked at the same belly transposition, which is like the Nishida. And then they compared it to a group where they did that belly transposition on the inferior rectus only. And then with the superior rectus, they did the full tendon dis-insertion transposition. And then both groups had medial rectus recession. And what they found was in this case, it was the opposite. The group that had the full superior rectus tendon transposition corrected more esotropia. But they both worked in a predictable fashion. And what I take away from all of this is that this belly transposition procedure works and in a predictable fashion. And so, in my opinion, why not use it? Because it does seem safer. If you wanted to get — if you want to maximize how many prism diopters you’re correcting with this 2023 study is really interesting. Because they compared different to the Nishida Procedure to show that you could maximize how many prism diopters you’re correcting. With the Nishida alone we found a correction of 29 prism diopters, it was similar to 2018 and 2019. Around 30. They did a Nishida plus a medial resection, that corrected about 63 prism diopters. Although the range was large so they recommended doing it on adjustable, the medial rectus recession. That was similar to the group from China that I had just shown you a slide before. And then they did something else. They had three patients where they did the Nishida, the medial rectus recession and Botox to that medial rectus muscle. Botox doesn’t kick in for about five days after injection. So, I think they did the adjustable, you know, post-operatively before the Botox had kicked in. And they found long-term that corrected about 95 prism diopters on average and there were no post-op complications.
So, then the next question is: Okay, the Nishida Procedure works. We’ve seen that demonstrated .
it in many ways is comparable to other transposition procedures. Is it safe? I scoured the literature and I only found a single case report of anterior segment ischemia with the Nishida Procedure. It was published in 2023. And this patient had had a traumatic six nerve palsy. Was older. Had other vasculopathic risks like hypertension and diabetes. The patient first had Botox because the cranial nerve palsy was bilateral. And the left esotropia improved from that. But the right still had a total six nerve palsy. There was just no improvement. And so, seven months after the injury, the — the surgeon went ahead with a right-sided Nishida and a medial rectus recession at the same time. And the conjunctiva was opened with a limbal peritomy that was about half of the eye. And the — and no cautery was used. So, these are things to consider in thinking about interrupting the vasculature to the anterior segment. Anterior segment ischemia was diagnosed 24 hours later in a typical fashion. The patient had poor vision, cell in the chamber, a dilated pupil. Started on topical steroids, taken out OR to reverse the procedure. The sutures were cut down and the muscles cut down to the original position. The patient did well long-term. The lesson from the case that the — that the publishing team described was that they reviewed their video. And that a ciliary artery had been incorporated into a their suture when they tied the one-third of the vessel, it was ligated. Which is counter to the surgery, we want to avoid incorporating those ciliary arteries into our suture tight. And thing maybe they pulled the muscle segments too tight in the segment, the eye was myopic and too stretched. That’s interesting and just reminds us to be really careful about the ciliary arteries.
Is it reversible? Yes. It is reservable. If you find a surprise or something like to case, you know, a complication, you can cut down the suture. You know? Within the next few days and just put everything back where it was. I don’t know if you can do that three weeks later, you know? It really — I don’t see any case reports of reserving after about three to five days with this procedure. But certainly in the immediate post-operative period you can.
Here’s another poll question. Do you need to rule out restrictive strabismus and confirm that this is a paralytic etiology before you perform a transposition? In other words, can you just perform a transposition for any esotropia or do you have to confirm that it’s a real six nerve palsy and not thyroid disease or decompensated isophoria or something like that before you do a transposition? Yeah. Everybody seems like on the — most part you do need to confirm that. This type of transposition procedure is really only for paralytic etiologies. If you have a restrictive etiology, you’ve got a fracture or something. You’ve got thyroid disease. You’ve got just an esotropia, you know, or heavy eye or some other reason for causing this — this strabismus, you don’t want to do a transposition. You only want to save your transpositions for when the muscle is paralyzed from, you know, a cranial nerve paralysis.
And/or, you know, something like any other sort of paralysis. I can’t think of what else would cause a paralysis.
So, let’s talk about some case studies. This is a patient who came to me with a long-standing cranial nerve six palsy. What’s interesting is she also had multiple sclerosis. And didn’t really want anything done about the six nerve palsy. She had so many other health issues. And her dominant eye is her left eye. So, even though it’s her left eye that’s palsied, she actually would just turn her head a lot to fixate with her left eye. And her right eye would go iso. And when I met her, she had this condition for more than 10 years. She had an esotropia of about 50 prism diopters and she had a small left hyper of about 6 prism diopters. And as we know from previous studies, our colleagues in China, sometimes this type of belly — vertical belly transposition, the Nishida Procedure might induce a little bit of hypertropia. That’s a good thing for us in this case. And we also know that Nishida alone will correct, you know, about 30 prism diopters. So, I needed to do a little bit more than just a Nishida alone. And I wanted to do something for her vertical. She didn’t have any torsion. So, you know, if she already had a lot of cyclotorsion, that would be something to consider. But she did not. And she couldn’t abduct her left eye past midlines. And this is her — her scan. And it’s really blurry. I’m sorry about the quality of it. But you can still see where that arrow pointing that her lateral rectus has really atrophied over time. And so, I did a left eye Nishida, but other stuff too. I actually plicated her lateral rectus as well. Why? None of the studies I’ve presented in the literature have anything to do with the lateral rectus. But I wanted to move her — I wanted to move her lateral rectus inferiorly to try and correct the hyper. I’m sorry, I said before that the Nishida would correct the hyper. The Nishida we could count on making the hyper a little bit worse. I’m sorry. She presented with a left hyper. And the Nishida might make the hyper a little bit worse. I wanted to counter that. I wanted to move both of her horizontal rectus muscles downwards in order to address the hyper. If I was gonna move the lateral downwards, I decided to plicate it a little bit as well. This way I didn’t need to interrupt any ciliary arteries. Again, we’re trying to protect the vasculature to the anterior segment. And then with her right medial rectus, I recessed it 4 millimeters. And I did — that’s a typo — I did an inferior transposition on that one as well. And this is her immediately post-operatively. She had a small exophoria in primary. Only two prism diopters the day after. And then three months later, she’s ortho. And what’s interesting is, when you look at her left eye, she can actually move it past midline. When she relaxes the tone of her medial rectus, even though her lateral rectus doesn’t work, right? Her sixth nerve can’t innervate her lateral rectus. But when she relaxes her medial rectus, there’s enough tone now on the left eye that she can pull that left eye over. Or it can go over. It’s not full abduction.
So, this poll question I just answered for you. Would you a transposition of any kind if the patient can move their eye well past midline? And the answer is no. Sorry. I took away the fun of the poll question. If — and if a patient can move their eye well past midline, you’re not gonna do a transposition procedure. You’re going to do — I would do a recession of the medial rectus and a plication of the lateral rectus. I love plications, they protect the vasculature and I think they work really well. And if that lateral rectus works, you can use it.
Here’s another case. You can do a Nishida on children. This is a young child. He was born full-term. He had multiple other medical issues. And he was seen first elsewhere at age 6 months for a bilateral esotropia with a right eye preference and was started on patching and with glasses. And sent to me for surgical consultation. His teller cards with both eyes together weren’t bad for a kid that age. He was patching the right eye for amblyopia on the left. I met him when he was 1 years old. At the time, looked like oblique over action as well. In the office, he measured about 75 prism diopters. It was hard to appreciate abduction at the time. But he didn’t have any globe retraction to make me think he had a bilateral Duane’s. As we know, kids with really large congenital esotropias, a lot of times they don’t abduct fully in the office for you because that medial rectus is so tight. And I assumed — falsely, we’ll see — but I assumed that was the case for this child. And so, what I did was a bilateral medial rectus recession of 6.5 millimeters which is a maximum of what I will do. I usually don’t — I wouldn’t do more than 6.5 millimeters for a medial rectus recession because then you can really cripple a deduction if you do more than that. I did bilateral oblique surgery, my procedure of choice is myectomy. I counseled the family he might need another after if I didn’t get all 75, maybe lateral rectus plications later. But let’s see where he lands after this and figure out what to do next. And so, post-op month two, he still had an esotropia, but now it was really obvious that he was having some trouble with a deduction. And his esotropia actually increased over time and the deficit became more obvious over time. He increased to about an esotropia of 30. He was already seeing genetics for his other congenital issues. I mentioned this to genetics that I think there’s at least one crane annual nerve palsy six, maybe two. And we did an MRI. We have the luxury at our hospital of being able to do a special protocol to look at the six cranial nerve. And the MRI — this is him at the time — the MRI found that the cranial nerve six on the right was intact. But on the left it was not identifiable. There was no cranial nerve six on the left. okay. So, this kind of changes my surgical planning. And so, the genetic workup was still pending but I spoke with the geneticist. They didn’t think it was Duane’s. We went back to the OR, I discussed with his mom the idea of doing a Nishida Procedure and how it works. And she wanted to go for it. So, at 18 months he had his second surgery. Because we were trying to get him orthophoric in primary gaze by 2 years of age. I did it a Nishida Procedure on the left. And post-op week two, he was ortho. And actually, he was able to move his eye pretty well. And at one month, it endured. And now he’s about six months out. And he is still ortho in primary gaze. And can move his eyes pretty well past midline now. Mom says that his playing and learning have blossomed and his motor skills blossomed since surgery. He’s a 2-year-old child, they might have just blossomed anyway. But it did seem to her in her mom intuition that after surgery things really took off.
And this is him now. And I have a little video of him moving his eyes in the office that I would like to show you. And he’s a really playful kiddo and I was trying to get him to move his eyes all the way to his left so you could see how well he can get past midline now. You could see that there. I’m just gonna show that to you again. So, if you watch, I’m trying to get him to look to the left. There he goes. All right.
And so, just in our final few minutes before I take questions, I want to talk about some other applications of the Nishida Procedure. What’s been reported in the literature for other applications of this procedure? Can it be used for also monitoring monocular elevation deficiency, vertical rectus palsies, transected or lost medial rectus muscles? All of the above?
Yeah. All of these have been reported. I’ve personally used it for monocular elevation deficiency and vertical rectus palsies using the one-third principle of the medial and lateral rectus muscle. I’ve never used this procedure for transected or lost medial rectus muscles, but it has been reported.
So, I just want to present finally one case of an adult who had a superior rectus palsy. And he had all kinds of vasculopathic risk factors and had a partial third nerve palsy of his right eye with a really large right hypotropia and ptosis. He had some torsion. But the torsion didn’t bother him that much. The issue was really how the hypotropia. He was just — he wanted to be able to have eyelid surgery and then to be able to see when the eyelid was lifted. And he used a crutch for his eyelid and he was diplopic. And you can see here, the photo quality is not great. But you can see that he can’t supraduct his right eye. And on the scan, you can see that superior rectus is really atrophic compared to the left side.
And so, what di for him was basically the same procedure, but I rotated it. So, that I used the medial rectus and the lateral rectus one-third and superior one-third and transposed them superiorly midway between their insertion and the superior rectus insertion. First, I placed suture in the superior rectus to plicate the superior rectus. Why, you might ask? Because the superior rectus does not work. Why waste time doing surgery on the superior rectus. It might have been a waste of time. But unlike a resection, I’m not interrupting any vasculature to the interior segment with the plication. Even if the plication doesn’t work long-term, it does have a forceful tethering of the eye upwards and I wanted him to have that in addition to this application of the Nishida. It may have been the same result without the plication. But I placed the sutures first and then I did the modified — I did a modification of the Nishida Procedure. It’s not really — my colleagues — our colleagues in Japan say that they don’t really want us calling it a modified Nishida Procedure. It’s just a Nishida Procedure, I just modified it for the superior rectus. And I pre-placed these sutures for the plication. But I didn’t complete it. If I had completed it, I would have tightened the eye into a supraduction, making the Nishida Procedure harder to perform. You always do your tightening procedure last. I just pre-placed those sutures. Then I did the Nishida. And then I completed the plication.
And post-operatively, he did really well. It actually overcorrected him a little bit at near. He had a small hypertropia at near. But he could often fuse through it. He still had an exotropia at near as well. But again, he could fuse through it interestingly with his reading glasses. And, you know, if at any point he fatigues from that, I can put a little prism on his reading glasses. But in primary gaze, he was just a little — a little bit of exotropia. He can fuse really well when his eyelid is lifted.
he’s right now using an eyelid crutch. And he’s sketched to have surgery with my oculoplastics colleague in June for his eyelid. This is post-op month two. And we’re almost at the 6 month mark now. And he’s been stable.
So, in summary, the Nishida Procedure is effective and seems to reduce the risk of anterior ischemia. Though did doesn’t eliminate that risk entirely. Things that can minimize that risk of anterior segment ischemia. Limbal incisions instead of conjunctival peri — sorry, I apologize. That is a typo. It’s not a limbal incision. It is a fornix incision. Botox to the medial recti. And medial rectus recession of the opposite eye can then reduce your risk of anterior segment ischemia further. And I’m just gonna share my screen with you again. Okay.
So, I just changed that fornix incisions. Botox to the medial recti or medial rectus recession of the opposite eye will further reduce your risk. And then as with any transposition, you want to monitor intra-op for organization. And watch for post-op keratitis. Because patients who have cranial nerve six palsies might also have cranial nerve five palsies so, just watch them carefully post operatively. And while the Nishida Procedure was developed to treat cranial nerve six palsies, it can be applied to other paralytic or absent muscles. Though there’s not extensive reviews or controls or reports of randomized studies in the literature. It’s a little bit beyond the scope of today’s talk anyhow. But it’s all kind of new, these additional applications. So, my final poll question for you is after this talk: Do you think you will try a Nishida Procedure? I’m curious. For a six nerve palsy.
So, 78% of you said you’re going to give a shot. 3% no, and 18% still not sure. I would be curious at what additional information might help you. You know? Make that decision if you’re not sure. So, I wanted to say thank you to colleagues really all over the world who helped me with this talk. A special thanks to Dr. Molinari, Dr. Marcon, and especially our colleagues in Japan, Dr. Nishina and Dr. Sato who were really generous with our time and, you know, over the — in walking me through Dr. Nishida’s procedure and the group’s intentions and, of course, the team at Orbis. And we have 129 different countries represented today in our audience. And I just think it’s really cool that we can all come together and learn together from each other’s experiences to help our patients. So, with that, I would like to look at some of these questions that are coming in and take some time to answer your questions.
Okay. So, the first question is I have more effect in correcting the esotropia in connecting these if I attach the muscles adjacent to the lateral rectus instead of in that midway point between the lateral and the vertical rectus insertions. And what do you think about that? Yeah, for other types of transpositions, we get more power the closer we move to the lateral insertion when we dis-insert the tendon. When you dis-insert the tendon, you can move it closer to the lateral rectus than the midway point. When we’re just working with the belly of the vertical rectus muscle as with in the Nishida and not splitting it or detaching anything, you really can’t get that muscle belly all the way over to the lateral rectus. It will be too tight. And you don’t need to. You really don’t. The midway point — I’ve done — I have been doing these procedures now for a few years. And the midway point really is sufficient to get that 30 prism diopter effect on average. Okay. Let’s see another question. Why are the transposed vertical rectus muscles inserted 12 millimeters behind the limbus instead of 7 millimeters behind the insertion of the lateral rectus muscle? Another great question. And it’s the same answer as previously. I don’t think you can get it there. You’ll tear the tissue, strangle the tissue. May get too much of an effect. I did ask our colleagues in Japan why they chose that positioning and that was also their answer. That in developing this procedure that’s what they found to give them the correction they needed for the esotropia without compromising any vertical function and without compromising the integrity of the tissue.
Okay. How big is the medial rectus recession to do with the Nishida? Great question. So, the answer is you want to do a really little medial rectus recession with a Nishida Procedure. Excuse me. Most of the time you’re gonna do something like a 3 millimeter recession. And you can put it on an adjustable. You might need to recess it back to 4. But you’re not gonna do a 6 millimeter recession off the bat with a Nishida Procedure. You’re more likely in that case to get a huge overcorrection. I mean, if you put it on an adjustable, there’s no harm in that. But I typically find that in my hands, about a 3 millimeter recession of the medial rectus works most times. Most of the published studies have done medial rectus recessions around that size. And used adjustables.
Okay. Let’s do another question. Okay. Do I have any experience with a single muscle Nishida? Like just doing the superior rectus lateral third? Instead of the superior rectus and the inferior rectus? I don’t. I don’t. That’s interesting. And I didn’t see that in the — in the literature. But that would be interesting to look at. And then the second question. Can we use the Nishida for monocular elevation deficiency? Yeah. Yeah. I have used it for monocular elevation deficiencies. I used the Nishida Procedure for a child who had myoptosis and could not supra duct his eye. And he was really young. And I did a Nishida Procedure where I took, you know, I rotated it and I took the superior one-third of his lateral and the superior one-third of his medial and I moved — I tied them, you know, with a permanent suture. And then I did a single pass in the sclera, midway point between the horizontal and vertical insertion. And then 12 millimeters back. And he did really well. He did great. I think going forward — I don’t have that many monocular elevation deficiency patients for whatever reason in my practice. I have a lot more cranial nerve six palsies and cranial nerve three palsies. But I think in the future I would probably do — for a monocular elevation deficiency, I would do the Nishida, again. But I would probably also inject 5 or 10 units of Botox into whichever vertical muscle was tight. So, if it was the ipsilateral inferior rectus, or if it was the contralateral superior rectus, I would, you know, in my — in the operating room, I would see which one is tight, usually one is, and inject that with Botox at the same time. I hope that answers your question.
Okay. The next question. Can you repeat where the muscle bite is actually taken behind the limbus? And can you repeat the names of other procedures for 6th nerve palsy? So, yeah. Absolutely. So, behind the limbus, you’re gonna measure 10 to 12 millimeters. I would recommend going for 12. If you really can’t get 12 millimeters back from the limbus for some reason, you know, 10 should still work. But I’d go for 12. I always measure 12 back. And then where in that space of 12 millimeters from the limbus you’re going to all — you’re gonna kind of make a cross and you’re gonna go 12 millimeters back from the limbus. And then you’re gonna measure midway between your lateral — sorry, between your lateral point of the insertion of the vertical rectus muscle and then that vertical point of the insertion of the lateral rectus muscle. So, if you’re doing the superior, you’re going to do the superior point of the lateral rectus insertion and the lateral point of the superior rectus insertion. You’re gonna measure that midway. So, let’s say the distance there is 8 millimeters, for example. So, you’re gonna find 4 millimeters along that line and mark it. And then that’s gonna be, you know, your horizontal cross. And then you’re gonna measure 12 from the limbus. And that’s gonna be your vertical cross. And kind of where the, you know, where they would meet is why you’re gonna pass your suture.
Okay. Oh. And the other procedures. What I mentioned before was the Hummelsheim, invented in 1964. That’s where you take the whole tendon and dis-insert it. The superior muscle tendon and the inferior muscle tendon and you move them towards the lateral rectus muscle. And that work the. And a lot of people still do it. But there’s a greater risk of anterior segment ischemia because you’re dis-inserting two rectus muscles. And then if you also do a medial rectus muscle recession in the same eye, now three muscle. The Jensen procedure was an answer to than by not dis-inserting any tendons. Just splitting these three muscles. The both superior and the lateral rectus muscle. And then this the splits tieing them all together. And that improved the risk of segment anterior ischemia, but didn’t eliminate it. Okay. Next question. So, in our center after the Nishida Procedure and medial rectus recession, we give a sub-conjunctiva injection with cortisone to diminish any risk of anterior segment ischemia. Do you think in the discussed case this might have prevented that? This is interesting. In the literature with the anterior segment ischemia, that patient did recover with steroid treatment. But also, they took down the Nishida Procedure and they released what through the was the ligated vessel. I don’t know if infra-op steroids would diminish the risk. I don’t know if I’ve ever seen a study on that. But I also haven’t looked for a study on that. So, I’m just gonna write that down. That’s very interesting.
I think that the researchers in that case felt like there were a number of opportunities to minimize the risk for anterior segment ischemia instead of doing such a large conj perimetry at the limbus, might somewhere tried two fornix incisions instead. And maybe not done a medial recession at the same time. Botox to the medial rectus, given how high that patient’s of anterior ischemia, bilateral cranial nerve palsies from head trauma, she was diabetic, she is had hypertension. Some of those things might have also reduced the risk. But interop steroids is a great suggestion.
Is there an under-correction with the Nishida? And what is the success rate of a repeat procedure? Okay. Great question. Under-corrections with the Nishida are not common. You just have to know what you’re expecting to get from it. You’re not gonna correct 50 prism diopters of esotropia with a Nishida alone. You’re gonna have to do something to a medial rectus muscle, whether it’s on the same eye or the contralateral eye in order to get more than about 30 prism diopters with the Nishida. But in general, it’s pretty predictable in getting you that approximately 30 prism diopters. If anything, the Nishida skews to overcorrection, that’s why it’s good to put the medial rectus on a movable suture. Repeated procedure, I haven’t seen that reported and I have known done any. I can’t answer that question. I think where — what the Nishida has been used for is if patients already had a medial rectus recession and lateral rectus resection for a palsy and that didn’t work, then Nishida is a great option because it’s safer. Because now you’ve — you have a patient who has had two muscles where the tendon has been dis-inserted. Then your next step wouldn’t dis-insert any tendons further.
Okay. If the patient needs multiple priors, do you prefer to do recession and then transposition? Do you mean during the same — I think what you mean is during the same surgery. So, during the same surgery, the order doesn’t really matter if you do the Nishida first or the medial rectus recession first. Because the Nishida is gonna pull the eye laterally and that will give you great exposure for your medial rectus recession. And if you do the medial rectus recession first, you have loosened everything up and you can rotate the eye however you need to for the Nishida. But what I would say is if you’re talking about separated procedures in time, you’re gonna want to do your transposition first. If you’re sure that you have a cranial nerve palsy, the patient is not abducting past midline, you’re gonna want to do your transposition first if you’re planning to separate them in time. And then, you know, you can see if you need a medial rectus recession later. Let’s say you’ve got a patient with 35 prism diopters of esotropia. You might want to just do the Nishida and maybe Botox to the medial rectus and kind of see where you’re at.
Counsel the patient you might need to do a medial rectus recession. Might a medial rectus recession alone is not going to treat a palsy. In your second case, the child after the medial recession only had about 15 prism diopters. Since with the Nishida you correct about 30, weren’t you afraid of overcorrection? Great question. So, here’s the thing about this kiddo. He immediately post-op was 15 prism diopters. But because he couldn’t AB-duct, he actually went many and more atropic every time I saw him. By three months post operatively, he had that. And at that point I had confirmation that the lateral rectus on the left side would never work because my radiologist told me, yeah, there’s no 6th nerve on the left side. I knew they needed to do a transposition procedure or the esotropia would just keep coming back. In that case, I wasn’t afraid to overcorrect him because I knew where he was headed without a 6th nerve. If I didn’t tether something and transpose something to hold the eye out laterally out towards the ear, that he was just going to keep going in. Okay. So, this question is in Spanish. I do speak some Spanish. But be patient with me please for a minute while I try and translate it — [Reading in Spanish] —
How long do you wait before you transpose a muscle with cranial nerve palsies to minimize the strabismus and to minimize secondary reinnervation? So, great question. I typically wait a standard six months-ish. I mean, I don’t take someone to the operating room before six months. Often that ends up being surgeries happening at 7 or 8 months. And, you know, you can do it later. You can do it any time. If you do Botox first in that first six month period, you have to wait for the Botox to wash out before you take them to the operating room. So, let’s say I did Botox it, you know, four months. Because that’s when I met the patient and they were desperate for Botox right away and to see if it would work. Then I would wait another three months before planning surgery. Because I would want to measure their strabismus after their Botox had worn out. I wouldn’t plan surgery until we’re at a six month park and I’m sure that eye is not moving past midline. And if I do Botox, I would have to wait more, depending on the timing of it. Okay. I just got an FYI. Let me just see something here.
Oh, I got a translation. Yeah. Okay. Good. Looks like I nailed it with the translation. That’s exciting. You — so, the next question is, why can you not do it for Duane syndrome? You can do it for Duane syndrome. You can. It’s just that it’s been shown for reasons that are not entirely clear to me at this time that with Duane’s syndrome it just may not work as well. I think because of some of the tightness and retraction that you get in a type one in the lateral rectus. You — you know — you may — you may want to also make sure that you’re recessing or even like doing a Y-split if you have an offshoot. But yeah. You can do it for Duane’s. You just have to make sure that you’re addressing all of the issues for Duane’s, especially if they have an upshoot. So, the next question is what are the indications of Nishida Procedure? So, the indications are paralysis of the muscle that you want to transpose towards. Long-standing for at least six months. And the patient cannot move their eye past midline or they can barely move it past midline. That would be the indications of the Nishida Procedure. And the other two muscles that you’re transposing ideally would be working also. But even if they’re not working, say you have multiple cranial nerve palsies, you can still get tethering effect from that transposition. So, you know, a patient with multiple palsies I would still consider doing it. Especially if they have multiple palsies because then you’re introducing less risk of anterior segment ischemia like if they had a trauma or a vasculature event. Is this surgery applicable for children? Definitely. This surgery is definitely applicable for children. The case that I showed you of that 2-year-old, he’s doing great with this procedure. When I spoke with his mother to get her consent for her to use her child’s whole face and video in this talk, she was thrilled because she felt like this procedure really helped her kid. And if it could help another kid worldwide, she wanted me to share her son’s information. Yeah. So, if you have like congenital cranial nerve palsies or children with like hypoxic ischemic events, perinatal, I think this is a good procedure. Next question. Does the functional reserve of cranial nerve six palsy matter? Yes. Yeah. So, if you have a lot of reserve function of your sixth nerve, like it works. Just not as perfectly as you want it to. That’s where it’s not so black and white. But if you have function of your sixth nerve, you probably are gonna want to try before you do a transposition to just do two horizontal muscle surgery. In my case, I do a medial rectus recession. And a lateral rectus plication. I don’t resect the lateral rectus muscle. I plicate it. One, in my hands, it works. I really like plications, I did a talk last summer, I really like them. I have only disrupted the ciliary arteries to one muscle, the medial rectus. That way later if I need to go back and do a transposition, I haven’t — I haven’t already interrupted the ciliary arteries in two muscles because any transposition I did now, it’s gonna be — if I — if anything happens to a vertical ciliary artery, now I’ve interrupted vessels in three muscles. But yeah. Patients who have already had a resection and a recession, the Nishida is perfect for them if they still need a transposition because it’s much safer than intentionally interrupting the vasculature to a vertical rectus muscle.
Okay. The next question is how do you ensure vessel sparing with plication. That’s a good question. You do your best. You visualize the ciliary arteries which run, you know, on the surface of the muscle and try to avoid them. If you have an assistant who can take a small hook without a sharp edge, they can kind of gently nudge the vessel without breaking it away from your needle. You can have your assistant put a hook behind the muscle to lift it up so you can like really see, you know, multiple angles of the muscle. And you just do your best to visualize them and avoid them.
You can take thinner bites if you need to in order to avoid the vessels. The next question — have I done a Nishida for a patient with Moebius syndrome. Great question. I haven’t. But I would. I think that would be a great case report if you are gonna do one. I think we would all really enjoy reading that. Okay. Next question. Do you prefer any transposition at two stages? One transposition and other stage recession on adjustables or one stage? Yeah. Great question. I love doing stage procedures in adults. With kids under age 4, I try to minimize multiple procedures if I can. Although sometimes it’s just necessary as in the case I presented. That child had to have two procedures. And that’s because of the risk of anesthesia. I just try to reduce the risk of anesthesia to kids. But with adults, a lot of times I can do their procedures under local. And even so, you know, their risk from repeat anesthesia, you know, isn’t the same as for a developing child and so, with adults, a lot of times I will do a transposition first and let them recover and see where things end up. Or a transposition with Botox. Let them recover, let the Botox wash out after a few months and re-evaluate them. And then if they still need an additional procedure, then do the recession. That way we’re minimizing how much surgery we’re doing and we don’t risk overdoing it with the surgery and overcorrecting them or unnecessarily interrupting the vessels of a muscle.
Okay. Next question. How can I diagnosis early an tear your segment ischemia in the presence of conjunctival edema? That’s a good question. Most post operative patients are gonna have conjunctival edema the day after surgery. Most anterior segment ischemia presents almost immediately after surgery. You know, the classic presentation is 24 hours later, next day in the office. The patient has more pain than you would expect for the first day after surgery. Their vision is really blurry and you look at them in a slit lamp. The cornea is cloudy. The cornea is edematous, you shouldn’t have corneal edema after a strabismus surgery. Corneal edema is concerning if you have this hazy cornea. And usually you can find a spot that’s clear to look in the anterior chamber. And in that post-op day one visit you see anterior chamber cells. And the pupil is often dilated. The other thing is, patients have trouble accommodating sometimes too. I hope that answers the question. Anterior segment ischemia would be a good separate talk. So, the next question is: Waiting rehabilitation period between brain insult and surgery? Great question. At least six months. At least six months. If there’s no recovery in the first six months, then I would go ahead and start planning surgery if the patient’s neurologically stable for surgery. If in the first six months the patient demonstrates some recovery, then I would wait longer to see how much they’re going to recover. So, this is true for any cranial nerve palsy. If in the first six months there’s know recovery, I wait longer until they stop recovering. And then I see where they’re at and if we should proceed with surgery. If in the first six months there’s no recovery, then we can just go ahead and plan surgery at month seven or eight.
Okay. Next question. How can you plicate a muscle and at the same time transpose it? Oh, well. You can. So, what you do is you put your sutures in for the plication the same as you would for an ordinary plication. But instead of taking your partial thickness scleral bites right in front of your original insertion, you just transpose your scleral bites. If you want to transpose the muscle up, you would put your — let’s say you have a horizontal muscle and you’re trying to transpose it superiorly. You talk your inferior pull and you would put it, you know, maybe in the middle of the — of the — in front of the original insertion. And that would be a half tendon with transposition. And then your other superior suture you would move up the same number of millimeters. And the muscle ends up looking like there’s this little oblique like strand. But it ends up working in creating that vertical transposition effect. It’s just the bump of the plication looks a little funny. But it works just the same as if you had resected the muscle and just shifted where you put your sutures back in for a transposition.
Okay. Next question. We have ten to go. And I am gonna try and get to them all before I have to leave. On case one, why do you prefer to do the Nishida Procedure in the left eye for a case with a right abducens nerve palsy? Oh, let me clarify, she did not have a right abducens nerve palsy, she had a left abducens nerve palsy. She had a dominant left eye so she was fixating with her palsied eye. She had a huge head turn and was fixating with her palsy eye. And her other eye became isotropic, and that medial rectus muscle became really tight. But actually the palsied eye was the left eye. I did the Nishida on the left eye. And repositioned the medial rectus, it had the secondary — and it was really fight. Is there an age restriction for the Nishida Procedure? No, not that I’m aware of. I’ve done it on very young kids and very elderly adults. They do very well. Because you’re not — excuse me — because you’re not dis-inserting the muscle, you know, there isn’t a ton of bleeding and so for adults on Coumadin or, you know, any sort of blood thinner, it’s a great choice. And the children I’ve done the procedure on have done great. Good morning. In case of a residual deviation, would you reinforce the Nishida and how? Yeah, if I had a residual deviation after a Nishida, I might inspect the Nishida to make sure that my sutures didn’t break. It’s possible, you know, that it just has to be redone. It may be that the suture broke and the muscle segment is back where it started and you might need to repeat it. But if everything is in the place where I left it, I probably wouldn’t revise the Nishida. At that point, I would probably work with my medial recti on adjustables to try and get more effect. And you always could consider doing it a different type of transposition. Although the Nishida is, you know, on par with efficacy to other transposition procedures.
I’ve carried out a Nishida on a superior rectus in a re-op vasculopathic patient with an associated hypotropia with helped with abduction and hypotropia and corrected 18 and 10 of the affected eye. Thank you for sharing. Dr. Fourier said that in a patient who was vasculopathic and needed a re-operation for a hypotropia from a palsied superior rectus — no, no. For a six nerve palsy with an associated hypotropia, they did the Nishida just with the superior rectus. And that corrected 18 prism diopters of esotropia with just the superior belly alone and corrected ten hypotropia. That was a good — there was another question whether you could just do one vertical belly. I think if you’re interested, you should write up that case. It would be a very interesting case report.
Okay. Next question. Do you think that adding the lateral rectus plication in the Nishida will help increase the field of binocular in these patients? I might. I sometimes do it if I want a little extra oomph. The creators of this procedure didn’t think that doing anything to the lateral rectus was necessary. Actually, doing anything to the lateral rectus is my own personal revision or modification. Everything that’s published on this procedure suggests just leaving the lateral rectus alone. And I’ve used it in certain circumstances. Like when I need to transpose the eye up or down. And I want to just transpose both of the horizontal rectus muscles. Sometimes I plicate just to give a little extra tethering. I haven’t — I don’t have enough cases of this to look at data to see if it would be just as effective to leave the lateral rectus alone. The field of binocular single vision does improve with just the Nishida and no horizontal rectus surgery.
Okay. Next question. Can you inject Botox into chronic 6th nerve palsy if the medial rectus is tight and fibrosed? Definitely. Yeah. And it’s a great indication for Botox. I have found disappointing results in fibrosed muscles from thyroid disease. I still try it every once in a while. But it doesn’t really do much for me. But in a fibrous tight musculoskeletal from a 6th nerve palsy, Botox tends to help a lot in a lot of patients. I think it’s worth giving it a try and just seeing where you’re at. Just be aware that then any future surgery you want to make sure that — that it’s all kind of washed out from the patient’s system before you start doing your pre-op measurements. Because otherwise you’re gonna have an inaccurate surgical result. Okay. Is the Nishida Procedure only for nerve palsy or can we apply it for mechanical as well? I would not apply it to mechanical strabismus. No. The — any sort of transposition procedure is really reserved for paralytic etiologies. And one thing I’ve noticed from the questions coming in and preparing for this talk is there are a lot of questions about who to use which type of procedure. And I think that would be a great future talk. What to use for paralytic strabismus, what to use for mechanical, what to use for, you know, various different types. But these transpositions are really only for paralytic cases.
Okay. For the 12 millimeter back for the scleral attachment, is that measured from the limbus or the from spiral of Tillaux? Great question. It’s measured from the limbus.
Does the effect of the Nishida Procedure last over several years? Great question. So, in my patients I have been doing this procedure now for three or four years in my patients. It has lasted. I haven’t seen any unraveling of the procedure. I didn’t see any publication, any research published on the long-term effect of the procedure. Remember that the Nishida group published for the first time their procedure in 2013. So, we’re only 11 years out from its first — from its first larger case series presentation. I think they started doing it in 2005. So, they might have almost 20-year data. I don’t know if they’re planning to publish that. That would be something interesting to know.
Why do I work on the medial rectus of the other eye? Great question. So, sometimes that’s the muscle that’s tight. I work typically on whichever medial rectus is tighter. Often it is the medial rectus of the same eye in the palsied eye. But what I have found is sometimes the medial rectus of the other eye is tighter. And here’s why. When you have a palsied 6th nerve. So, let’s say my right eye cannot abduct. It’s not like my brain isn’t trying to AB-duct, right? Like I’m still walking around the world and seeing things over to my right and wanting to see things over to my right. And I will — my brain will always try to AB duct my right eye. It just can’t. My body just can’t, right? So, when that’s happening, because of the equal innervation signal that is sent to both eyes, the medial rectus of my left eye is getting all kinds of signalings to just keep abducting and keep going and try to go to the right. It’s trying so hard to look to the right and it can’t. So, this eye, the medial rectus is just powering and powering and powering to look to the right also because it’s getting equal innervation. And so, over time, sometimes that medial rectus muscle becomes really, really tight. Especially like in the case of the patient I presented she was — she was fixating with her paralytic eye. And so — and so, this other eye was getting all of this secondary deviation. And so, this eye was isotropic all the time. And that medial rectus just became very, very tight.
Okay. So, I answered all the questions. Thank you all so much for participating today. And I hope to see you again.

Last Updated: April 19, 2024

3 thoughts on “Lecture: The Nishida Procedure: A Technique to Tackle Diplopia”

    • Hi Riyad Abdinaasir Ahmed,

      Thank you for your comment.

      Please note that Cybersight is not a university. We offer free programs and services for eye-care professionals.

      Cybersight is an online training and mentorship service for eye health professionals in developing countries.

      You can create a free account here: https://consult.cybersight.org/en/web/guest/create-account

      With your Cybersight account, we offer two services: (A) Online courses only and (B) Online courses and expert advice (i.e., Consult).

      More information regarding Cybersight Consult can be found here: https://cybersight.org/consultation/

      Cybersight Consult is only available for ophthalmic clinicians in the countries that we serve (https://cybersight.org/where-we-work/) and require you to submit a copy of your medical ID/registration. Please wait 48-72 hours for your application to be approved if you select this service.

      In addition to these services, we broadcast free, live webinars about once a week with ophthalmic topics that may interest you. More information can be found here: https://cybersight.org/lectures/

      Our free, online courses can be found here: https://cybersight.org/online-learning/

      Lastly, our Cybersight Library offers an extensive number of free, online resources where you can explore our recordings of previous Cybersight Live Webinars, surgical videos, Test Your Knowledge quizzes, textbooks and manuals, and simulation resources. More information can be found here: https://cybersight.org/library/

      Do alert us with any further questions by emailing us at [email protected].


Leave a Comment