Esotropic Duane Retraction Syndrome Research Articles

Superior Rectus Transposition Surgery: Safety, Efficacy, and Place in Therapy.

Abduction limitation in esotropic Duane retraction syndrome (DRS), esotropic Mobius syndrome, and sixth nerve palsy is one of the difficult-to-manage problems in strabismus surgery. The procedure of superior rectus transposition (SRT) was introduced by Johnston et al. In this procedure, the superior rectus (SR) muscle is disinserted and sutured adjacent to the insertion of lateral rectus (LR) muscle. The purpose of this review is to explore literature about efficacy and safety of SRT and its usage in strabismus surgery.

Bilateral augmented superior rectus transposition with medial rectus recession for bilateral esotropic Duane retraction syndrome

Superior rectus transposition with medial rectus recession is commonly performed for unilateral esotropic Duane syndrome. For bilateral esotropic Duane syndrome, bilateral medial rectus recession is the most frequently performed surgery and usually provides satisfactory alignment in primary position; however, there is limited improvement in abduction. We report the outcomes of bilateral augmented superior rectus transposition and medial rectus recession in 4 patients with bilateral esotropic Duane syndrome. Postoperatively, abduction was improved in all patients; 3 were orthotropic in the primary position, and 1 had residual esotropia.

Augmented superior rectus muscle transposition in management of defective ocular abduction

BackgroundSuperior rectus muscle transposition (SRT) is one of the proposed transposition techniques in the management of defective ocular abduction secondary to chronic sixth nerve palsy and esotropic Duane retraction syndrome (Eso-DRS). The aim of the current study is to report the outcomes of augmented SRT in treatment of Eso-DRS and chronic sixth nerve palsy.Methodsa retrospective review of medical records of patients with Eso-DRS and complete chronic sixth nerve palsy who were treated by augmented full tendon SRT combined with medial rectus recession (MRc) when intraoperative forced duction test yielded a significant contracture. Effect on primary position esotropia (ET), abnormal head posture (AHP), limitation of ocular ductions as well as complications were reported and analyzed.Resultsa total of 21 patients were identified: 10 patients with 6th nerve palsy and 11 patients with Eso-DRS. In both groups, SRT was combined with ipsilateral MRc in 18 cases. ET, AHP and limited abduction were improved by means of 33.8PD, 26.5°, and 2.6 units in 6th nerve palsy group and by 31.1PD, 28.6°, and 2 units in Eso-DRS group respectively. Surgical success which was defined as within 10 PD of horizontal orthotropia and within 4 PD of vertical orthotropia was achieved in 15 cases (71.4%). Significant induced hypertropia of more than 4 PD was reported in 3 patients (30%) and in 2 patients (18%) in both groups, respectively.Conclusionaugmented SRT with or without MRc is an effective tool for management of ET, AHP and limited abduction secondary to sixth nerve palsy and Eso-DRS. However, this form of augmented superior rectus muscle transposition could result in high rates of induced vertical deviation.

Hummelsheim procedure combined with medial rectus recession in complete sixth nerve palsy and esotropic Duane Retraction Syndrome.

To evaluate the effect of half tendon vertical rectus muscle transposition (HVRT) combined with medial rectus muscle recession (MRrec) in complete sixth nerve palsy (CSNP) and esotropic Duane Retraction Syndrome (eDRS). A retrospective study of patients with unilateral CSNP or eDRS who underwent HVRT combined with medial rectus recession over the course of 18 years. The patients with previous strabismus surgery and follow up less than 3 months were excluded. Overcorrection was defined as any amount of exotropia, and undercorrection was defined as residual esotropia of ⩾10 prism diopter (PD). A total of 39 patients were enrolled including 22 CSNP and 17 eDRS patients. Esotropia improved from 45.8 ± 22 and 22.5 ± 6.4 PD to 0.8 ± 2.5 and 0.3 ± 1 PD in CSNP group and eDRS group respectively. The angle of face turn improved from 34.3 ± 8.4° and 26.5 ± 9° to 0.6 ± 2.4° and 0.8 ± 1.6° in the CSNP group and eDRS group respectively. Abduction limitation improved from -4.5 ± 0.5 and -4 ± 0 units to -2.9 ± 0.5 and -2.7 ± 0.5 units in CSNP group and eDRS group respectively. No patient developed a new vertical deviation. An overcorrection occurred in one patient of the eDRS group who improved after botulinum toxin injection in the ipsilateral lateral rectus muscle. Undercorrection was seen in two patients. HVRT combined with MRrec is an effective procedure to improve esotropia, face turn, and abduction limitation in CSNP and eDRS.

Outcomes of symmetric bilateral medial rectus recession in large-angle esotropic Duane syndrome.

To evaluate the efficacy of symmetric bilateral medial rectus recession in large-angle esotropic Duane retraction syndrome (DRS) with moderate to severe globe retraction. In a retrospective study, medical reports of 30 patients with esotropia of equal or more than 20 prism diopters (pd) and moderate to serve globe retraction due to unilateral DRS who underwent symmetric bilateral medial rectus recession were reviewed. Age, gender, laterality, amblyopia, length of follow-up, pre- and postoperative measurements of primary position deviation, ocular ductions and severity of globe retraction and abnormal head posture were evaluated. A successful result was defined as decreasing esotropia to equal or less than 8 pd or equal or less than 8 pd of consecutive exotropia. The mean age of patients at surgery was 13.7 ± 8.5 years old (range: 3-38). The mean preoperative esotropia measured 28.9 ± 9.1 pd in distance and 25.7 ± 7.2 pd in near, which decreased to 4.9 ± 6.1 pd in distance and 3.9 ± 8.8 pd in near postoperatively. The mean bilateral medial rectus recession was 4.9 ± 0.9 mm (range: 3-6 mm). The mean abnormal head posture improved from 19.1 ± 6.9 degrees (range: 10-30 degrees) to 3.3 ± 4.7 degrees (range: 0-15 degrees) postoperatively. At the last follow-up visit, 23 patients (76.7%) had a successful outcome. In the large-angle esotropic DRS patients with moderate to severe globe retraction, symmetric bilateral medial rectus recession, can be conducted to successfully resolve primary position deviation and abnormal head posture.

Superior Rectus Transposition With Medial Rectus Recession Versus Medial Rectus Recession in Esotropic Duane Retraction Syndrome.

To compare the results of augmented superior rectus transposition (with or without medial rectus recession) with simple medial rectus recession in the treatment of patients with esotropic Duane retraction syndrome. This was a prospective, randomized, and interventional comparative study of 20 patients with esotropic type 1 Duane retraction syndrome. Patients were randomly divided into two groups. In the first group (superior rectus transposition group), superior rectus transposition with or without medial rectus recession was performed. In the second group (non-superior rectus transposition group), unilateral medial rectus recession was performed. Each group included 10 patients. Esotropia improved from 20.4 prism diopters (PD) preoperatively to 0.6 PD postoperatively in the superior rectus transposition group and from 22.5 PD preoperatively to 0.9 PD postoperatively in the non-superior rectus transposition group. Face turn improved from 11.5° preoperatively to 0.5° postoperatively in the superior rectus transposition group and from 12° preoperatively to 1.5° postoperatively in the non-superior rectus transposition group. Abduction improved in the superior rectus transposition group from -3.9 preoperatively to -3.1 postoperatively and from -3.9 preoperatively to -3.6 postoperatively in the non-superior rectus transposition group. Vertical deviation developed in two cases in the superior rectus transposition group. Both superior rectus transposition and medial rectus recession are effective in the elimination of esotropia and face turn in patients with esotropic Duane retraction syndrome. Superior rectus transposition is more effective in improving abduction, but it can be complicated by vertical deviation. [J Pediatr Ophthalmol Strabismus. 2020;57(5):309-318.].

Reoperation in esotropic Duane retraction syndrome: Long-term motor outcome of superior rectus transposition.

The aim was to evaluate the long-term motor outcome of superior rectus transposition procedure in patients affected by unilateral esotropic Duane retraction syndrome with residual esotropia and anomalous head position. A retrospective analysis of medical records of patients affected by esotropic Duane retraction syndrome who underwent superior rectus transposition procedure as reoperation for residual esotropia and/or residual anomalous head position. Amount of deviation, anomalous head position, duction limitation, globe retraction, presence of upshoot/downshoot, and vertical deviation were analyzed before and after superior rectus transposition procedure. Twenty patients were selected. All patients underwent unilateral medial rectus recession or bilateral medial rectus recession, for unilateral esotropic Duane retraction syndrome at least 2 years before superior rectus transposition reoperation. Mean age at surgery (superior rectus transposition) was 12 ± 6.8 years, and the follow-up period was 2.7 ± 0.6. Mean deviations at distance and near before surgery were 19.5 ± 5.7 and 15.2 ± 6.8, respectively. Two patients showed upshoot. Head turn was 11.4 ± 5.1°; abduction limitation was -2.6 ± 0.9. After superior rectus transposition, all patients showed an improvement of esotropia at distance and near (8.1 ± 5.7 and 5.1 ± 5.6, respectively; p < 0.05), anomalous head position (5.6 ± 3.9°; p < 0.05), and abduction limitation (-2.3 ± 0.8; p < 0.05). No statistically significant changes occurred in globe retraction. No adduction limitation, vertical deviation, and upshoot/downshoot were present after superior rectus transposition procedure. Results were stable during follow-up. Superior rectus transposition procedure is an effective procedure in esotropic Duane retraction syndrome patients who previously undergone unilateral/bilateral medial rectus recession, with residual esotropia and anomalous head position. It allows improvement of esotropia, head turn, and partial recovery of abduction in a significant percentage of patients (30%) with no vertical complications.

Botulinum toxin-A injection in esotropic Duane syndrome patients up to 2 years of age

To evaluate the role of botulinum toxin-A (BTX) injection as the primary treatment for patients with esotropic Duane retraction syndrome ≤2 years of age. The medical records of patients with esotropic Duane syndrome who underwent unilateral or bilateral BTX injection to the medial rectus muscle at or before 2 years of age were reviewed retrospectively. The following data were extracted from the record: laterality, age at the time of injection, primary position deviation, duction deficit, anomalous head posture, globe retraction before and after injection, further surgeries, and complications. Success was defined as permanent resolution of esotropia and head turn in primary position at final follow-up. A total of 15 patients (14 unilateral, 1 bilateral) were included. Before BTX injection the mean primary esotropia at near with full cycloplegic refraction was 29.3Δ ± 14.4Δ; the mean head turn, 23° ± 11°. Mean duration of follow-up was 37±29months (range, 7-96months). Orthotropia and resolution of head turn was achieved in 7 patients (46.7%). In subgroup analysis, success rate gradually decreased from 100% in patients ≤7months of age to 33.3% in patients 8-12months of age, and 20% in patients >12months of age. Seven patients (46.7%) required surgery (medial rectus recession and/or superior rectus transposition) because of residual head turn and esodeviation following BTX. In this patient cohort, orthotropia in primary position and correction of head turn were achieved with a single BTX injection in about half of the patients ≤2 years of age and all patients ≤7months of age. BTX injection early in infancy can obviate the need for surgery in esotropic Duane syndrome.

Management of duane retraction syndrome

Background Duane retraction syndrome (DRS) is a congenital ocular motility disorder most commonly characterized by the inability of the eye to abduct, sometimes limitation of adduction, and globe retraction with palpebral fissure narrowing on adduction. Aim To study the clinical features, management, and outcome of DRS. Patients and methods A prospective, nonrandomized study was carried out on patients attending the Outpatient Clinic of Ophthalmology in Menoufia University Hospital during the period of study from June 2017 to July 2019. This study was conducted on 51 patients with DRS. Ocular and systemic features were studied. Surgery was done when indicated to eliminate upshoot or downshoot, face turn with a horizontal deviation, and globe retraction. Preoperative and postoperative ocular deviation, angle of head turn, and severity of limitation in abduction and adduction were detected and analyzed. Results Type I DRS was more common (70.6%), with female preponderance (52.9%) and a predilection for the left eye (70.6%). Twenty-one (41.2%) cases were operated, by recessing MR and/or lateral rectus (LR) muscles and/or Y-splitting and acceptable improvement was detected. Mean esotropic DRS improved from 18±4.02 to 3±2.8 (P Conclusion Proper diagnosis of patients with DRS and proper plan for surgical management can reduce several complications with satisfactory postoperative outcomes.

Comparison of augmented superior rectus transposition with medial rectus recession for surgical management of esotropic Duane retraction syndrome

Medial rectus recession (MRc) and vertical rectus transpositions are procedures used to treat esotropic Duane retraction syndrome. Recently superior rectus transposition (SRT) combined with MRc has also been shown to improve primary alignment and abduction. The purpose of this study is to compare the results of augmented (ie, with scleral fixation) SRT with or without MRc with either unilateral or bilateral MRc for treatment of esotropic Duane syndrome. The medical records of patients who underwent surgery for esotropic Duane syndrome between May 2007 and February 2013 were retrospectively reviewed. Success was defined as alignment within 8(Δ) of orthotropia and abnormal head posture of <5°. There were 8 patients in the SRT group (6 of whom had additional ipsilateral MRc) and 13 in the MRc group (6 unilateral and 7 bilateral). In the SRT group, the mean preoperative deviation was 20(Δ) of esotropia; the mean postoperative deviation, 3(Δ). In the MRc group, the mean preoperative deviation was 24(Δ) of esotropia; the mean postoperative deviation, 4(Δ). The success rate was 87% in the SRT group; 77%, in MRc group (P = 0.98). Mean abduction limitation improved from -3.6 to -2.4 units in the SRT group and from -3.6 to -3.3 units in the MRc group (P = 0.003). Induced vertical deviation or subjective torsion was not seen. Three patients in each group developed adduction limitation postoperatively. Although both the procedures successfully correct esotropia in Duane syndrome, SRT with or without MRc has the additional advantage of improving abduction.

Respond to: Management of exotropic Duane retraction syndrome

Dear Editor, We thank the authors for showing interest in our article Sharma et al.[1] For clinical management purpose, we have followed Jampolsky's classification,[2] which would mostly comprise the Type II of Huber[3] and not Type III, herein considered as just exotropic Duane retraction syndrome (DRS). The esotropic DRS and Ortho DRS have to be tackled differently. One needs to clearly understand that the primary problem in all cases of DRS is paradoxic innervation of the lateral rectus (LR) during the adduction, and this cannot be eliminated by any procedure other than total extirpation or periosteal fixation of LR. In exotropic DRS, it is a good strategy to sacrifice the aberrant LR and convert the DRS into LR palsy and improve the abduction by transposition of the vertical recti. The adduction limitation in DRS is due to the co-contraction of LR and medial rectus (MR) in adduction and improves on periosteal fixation of LR. No surgery on the ipsilateral MR is usually required. The MR is usually normal and should be confirmed by passive ductions, which are of paramount importance and have been mentioned as the first step in operative procedure in the methodology. Adduction improvement was not full in Group B due to the resting tone of partial vertical rectus transpositioning (pVRT) providing some resistance. The improved abduction, however, is minimal and is mainly due to the relaxed MR action during abduction. Following pVRT, the vertical vectors start working in synergy to aid the abduction tone with the inhibition of the tone of MR helps in abduction. The case A6 shown in picture had no improvement in abduction as shown in Table 1. However, it has been highlighted by Jampolsky, one should not be mistaking the degree of exodeviation as good abduction in exotropic DRS. Fig. 2 clearly demonstrates improved abduction. Statistical tests have not been claimed by us due to small numbers in this pilot study. Use of VRT in esotropic DRS with abnormal LR innervation can worsen retraction and upshoots and downshoots in adduction. In exotropic DRS, rather than graded recession of the aberrant LR, pVRT done as an adjustable procedure, along with the periosteal fixation seems to be better alternative and will be published soon. This study clearly establishes the role of periosteal fixation of LR to solve the paradoxic innervation and of the partial VRT to correct the esotropia thus created and also improves abduction as shown by the two groups. This strategy corrects the anomalous head posture, the deviation in the primary position, the retraction, narrowing of palpebral aperture and upshoots or downshoots in adduction, as well as improves the adduction and convergence, a vital function, as also improves the fields of binocular single vision. The improvement in abduction is minimal but a good value addition.

Hypermetropia, accommodative and decompensated/partially accommodative esotropia and esotropic Duane′s retraction syndrome in infants: Words impact understanding

Dear Editor, We read with interest the article by Kekunnaya et al.[1] and would like to make certain observations. The purpose, to study partially accommodative esotropia (ET) in esotropic Duane's retraction syndrome (DRS), is skewed to say the least. Partially accommodative ET is that part which is left after full correction of the accommodative component, implying that partially accommodative component and eso DRS could be the same. Authors have not clarified as to how they have segregated the two, thereby congealing the entire study and attendant inferences. Terms hypermetropia and accommodative ET are not synonymous, certain criteria have to be met for the latter. By preoperative data, only cases 1, 3 and 6 fall in accommodative category, only case 1 had vertical rectus transposition (VRT), other two did not. Both cases (2 and 4) that ended up with exotropia (XT) lacked a proven accommodative component, so also case 5 with VRT. Accordingly, it is misleading to use the term partially accommodative ET in such cases as the deviation was ostensibly due to eso DRS. We don’t know how many were refractive/nonrefractive accommodative, high/low AC/A ratio, how many went in for deteriorated/decompensated accommodative ET, were decompensated monofixational esotropes, developed intermittent XT with accommodative component or simply passed from eso DRS to exo DRS due to long variable follow-up.[12] Hypermetropia does not increase with the passage of time, it may only decrease due to the process of emmetropization. It is not clear why, at last follow-up, accommodative component worsened de novo after VRT surgery in cases 3 and 5. Refraction at last follow-up and change vis-a-vis preoperative values is not known to draw any logical conclusions regarding induced (non) refractive accommodative component. Most patients are 1-year old, one being just 6 months; ocular deviation, motility cannot be assessed reliably, including the effect of glasses on the deviation. Most patients with DRS achieve alignment and fusion with abnormal head posture (AHP) and develop good binocularity. Moderate AHP in a 1-year old with fusion does not call for surgical intervention, larger AHP in an older child with symptoms like neck pain/cosmetic blemish may earn it. Operating on DRS without clear indications is not in order as a lot of negative planning is involved. Full muscle VRT with Foster augmentation as an alternative to lateral rectus/medial rectus recessions for eso DRS in 1-year olds may raise ethical issues. VRT may only add to globe retraction[3] (which was core criterion to diagnose DRS in this study), induce a vertical deviation (case 2), and limit adduction. The study does not address these issues, neither documents improvement in abduction if any. There is absolutely no controversy that correction of refractive errors is a prerequisite before other surgical/nonsurgical measures are contemplated in treatment of strabismus, neither that ortho DRS may adopt AHP if deviation is induced by other concurrent factors. However, reasons for AHP in DRS are legion. XT after years could be due to diverse factors as stated above, words hypermetropia and accommodative ET have been used interchangeably, partially accommodative ET and ET due to DRS have not been pigeonholed, accordingly inferences drawn lack legitimacy.

Medial rectus tendon elongation with bovine pericardium for type 1 Duane's retraction syndrome

Some patients with esotropic Duane's retraction syndrome (type 1) adopt a head turn to gain binocular vision. For some patients recession of the ipsilateral medial rectus muscle is not sufficient to eliminate head turn and squint angle. Surgery with tendon elongation allows the correction of larger angles and maintains a sufficient arc of contact. We report our results and experience. We retrospectively reviewed the medical records of 10 patients with unilateral, esotropic Duane syndrome type 1 who had tendon elongation with bovine pericardium to correct a head turn or squint angle. Two patients had primary surgery with tendon elongation due to preoperative excessive angles, eight patients had tendon elongations as secondary procedures. Nine of the patients had their follow-up examination at least six weeks after surgery. The median preoperative angle of squint in primary position was + 27.5 pdpt, the median postoperative angle + 0 pdpt. The median dose effect relation for secondary interventions was 2.4 pdpt reduction of squint angle/mm surgery, for one patient with primary surgery and long-term follow-up 2.75 pdpt/mm. The median, preoperative head turn of seven patients with preoperative binocular functions was 20°. Postoperatively, six patients with long-term follow-up showed a median head turn of 0°. The median dose-effect relation was 3.3° reduction of head turn/mm surgery. All nine patients with long-term follow-up had a maximal head turn of 10°, six of the patients had no persisting head turn. Binocular functions were stable or better than preoperatively. For patients with retraction syndrome type 1, tendon elongation of the medial rectus muscle using Tutopatch® is a good option for secondary interventions or excessive preoperative squint angle or head turn.

Superior rectus transposition versus medial rectus recession for esotropic Duane retraction syndrome (DRS)

Medial rectus recession (MRc)1 or vertical rectus transpositions (VRT)2 are the commonly described procedures for esotropic DRS. Recently superior rectus transposition (SRT) and MR recession3 have been shown to align the eyes and improve abduction. The purpose of this study was to compare the results of SRT (with or without MRc) with MRc alone for treatment of esotropic DRS.

Outcomes in patients with esotropic duane retraction syndrome and a partially accommodative component

Background:The management of Duane retraction syndrome (DRS) is challenging and may become more difficult if an associated accommodative component due to high hyperopia is present. The purpose of this study is to review clinical features and outcomes in patients with partially accommodative esotropia and DRS.Setting and Design:Retrospective, non-comparative case series.Materials and Methods:Six cases of DRS with high hyperopia were reviewed.Results:Of the patients studied, the mean age of presentation was 1.3 years (range: 0.5-2.5 years). The mean amount of hyperopia was + 5D (range: 3.50-8.50) in both eyes. The mean follow up period was 7 years (range: 4 months-12 years). Five cases were unilateral while one was bilateral. Four cases underwent vertical rectus muscle transposition (VRT) and one had medial rectus recession prior to presentation; all were given optical correction. Two (50%) of the four patients who underwent vertical rectus transposition cases developed consecutive exotropia, one of whom did not have spectacles prescribed pre-operatively. All other cases (four) had minimal residual esotropia and face turn at the last follow-up with spectacle correction.Conclusion:Patients with Duane syndrome can have an accommodative component to their esotropia, which is crucial to detect and correct prior to surgery to decrease the risk of long-term over-correction. Occasionally, torticollis in Duane syndrome can be satisfactorily corrected with spectacles alone.

Risk factors for consecutive exotropia after vertical rectus transposition for esotropic Duane retraction syndrome

To define risk factors for postoperative exotropia after vertical rectus transposition (VRT) for Duane syndrome. The records of patients with Duane syndrome who underwent augmented VRT were retrospectively reviewed; those with postoperative exotropia (study group) were compared with those with postoperative esotropia/orthotropia (controls). A total of 51 patients were included, of whom 14 were exotropic postoperatively. Of the 14, 6 became exotropic after augmented VRT, and 8 who were initially esotropic became exotropic after subsequent medial rectus muscle (MR) recession. Study subjects were significantly younger (2 ± 2 years vs 6 ± 10 years, P = 0.04) and demonstrated less restriction on intraoperative forced duction testing than control subjects. Subjects who became exotropic after MR muscle recession had significantly less esotropia at near (5.2(Δ) ± 6.5(Δ) vs 18.4 (Δ) ± 7.9(Δ) esotropia, respectively; P = 0.005) and in adduction (1(Δ) ± 2(Δ) exotropia vs 3(Δ) ± 4(Δ) esotropia, respectively; P = 0.02) than control patients who also underwent VRT and MR muscle recession. Forced duction testing was also significantly different among these groups (P = 0.03). Risk factors for exotropia after augmented VRT include younger age and less restriction on forced duction testing. Additional risk factors for exotropia after VRT and subsequent MR muscle recession include preoperative exotropia in adduction and smaller deviation at near. These factors may be useful in distinguishing patients at risk, allowing for consideration of less powerful procedures.

Medial rectus recession following vertical rectus transposition in esotropic Duane's retraction syndrome

Introduction: Augmented vertical rectus transposition surgery (VRT) improves esotropia, torticollis, and abduction in esotropic Duane syndrome. The length-tension curve shows an increased stiffness in the ipsilateral medial rectus muscle in Duanes. Some Duanes patients require medial rectus recession (MRc) following VRT to improve alignment. We aim to characterize these patients, and their post-operative results.

Outcomes of surgery for bilateral esotropic Duane retraction syndrome

Introduction: Indications for surgery in patients with bilateral esotropic Duane's retraction syndrome (DRS) are strabismus, globe retraction, abnormal head posture and/or overshoots. Limited previous studies of bilateral esotropic DRS showed mixed outcomes with bilateral medial rectus recession with high incidence of consecutive exodeviation and adduction lag. In this series, we describe outcomes of bilateral medial rectus recessions for bilateral Esotropic DRS.

Consecutive exotropia after vertical rectus transposition for esotropic Duane retraction syndrome

Consecutive exotropia after vertical rectus transposition for esotropic Duane retraction syndrome