Multiple different procedures have been proposed to treat complete sixth nerve palsy with an associated severe abduction deficit. In this study, we report a modification of the Hummelsheim procedure. It is simple muscle pulley transposition that obviates the need for tenotomy or muscle splitting. In the literature, there is one report of this procedure by Muraki and Nishida in 2013.

Patients with large angle esotropia and abduction limitation of minus four or greater were enrolled. The surgery involved insertion of a 5-0 polyester monofilament fiber suture through the temporal muscular margin of each vertical rectus muscle at approximately one-third of the width from the edge at 10 mm behind the muscle insertion in a locking fashion. We tried to insert sutures away from the vessels of vertical muscles. Then the vertical muscles were transposed without any tenotomy or splitting and the sutures were secured to the sclera 10 mm behind the lateral rectus insertion.

A total of ten patients were included, all of them had an esotropia with profound abduction deficit (_4 or more). The mean age of patients was 44.6±11 years( 28- 57). The mean preoperative deviation was 45.7 ± 5.3 prism diopters(PD). The mean preoperative abduction limitation was -5.1±0.8. The patients were followed for at least 12 months. Postoperative deviation ranged from orthotropia to 12 PD of esotropia and all the patients obtained abduction at least beyond the midline. No major vertical ductional disturbances or deviation were developed. Anterior segment ischemia did not occur in any patients.

This procedure is comparable to traditional procedures with the advantages of no need to tenotomy or splitting and can be a good alternative to conventional Hummelsheim procedure .