Exotropic Duane Retraction Syndrome Research Articles

Duane Retraction Syndrome: The Role of Botulinum Toxin A Injection in Adults and Its Impact on Quality of Life in an Indian Population.

To evaluate the role of botulinum toxin A in the treatment of adults with Duane retraction syndrome and its impact on quality of life. A total of 25 adults with unilateral Duane retraction syndrome were selected for this interventional case series. Botulinum toxin was injected in the appropriate horizontal recti. The parameters assessed were ocular deviation (▵), overshoots, and abnormal head posture. Patients were followed up at 1 day, 10 days, and 3 months after the injection. The outcome was categorized on the basis of deviation/abnormal head posture/overshoots as: (1) significant improvement (< 8 prism diopters [PD]/< 5 degrees/≤ grade 1); (2) partial improvement (8 to 20 PD/5 to 15 degrees/≤ grade 2); and (3) no improvement (> 20 PD/> 15 degrees/≥ grade 3). Patients with partial/significant improvement were considered to have a favorable outcome. The impact on quality of life was assessed using the Adult Strabismus-20 Questionnaire scores 10 days after injection. There was a significant reduction in ocular deviation in esotropic and exotropic Duane retraction syndrome at 10 days (P = .001) and 3 months (P = .04) after botulinum toxin injection. The abnormal head posture improved from 11.58 ± 7.43 to 7.86 ± 6.25 degrees at 10 days. Botulinum toxin had a positive impact on the Adult Strabismus-20 Questionnaire scores, which significantly improved (P < .05) at 10 days. A favorable outcome was noted in 21 patients at 10 days but only 4 patients at 3 months. Three patients developed ptosis and 1 patient with orthotropic Duane retraction syndrome developed transient exotropia. In adults with Duane retraction syndrome, botulinum toxin can have a useful diagnostic role by providing insight to patients and setting realistic expectations. It can identify patients likely to benefit from further treatment and also has a positive impact on quality of life. [J Pediatr Ophthalmol Strabismus. 2023;60(1):46-51.].

Assessment of periosteal fixation of partial VRT and lateral rectus in subjects of exotropic duane retraction syndrome

Owing to the ability of the lateral rectus to contract during adduction is regained, the surgical procedures only partly relieve the problem. Complete relief is seen only when the innervation to the lateral rectus, which is misdirected, is managed effectively. The present study was conducted to prospectively evaluate the efficacy of periosteal fixation of the lateral rectus muscle and periosteal fixation along with the partial VRT in subjects with Exo-DRS. 15 subjects with Exo-DRS were randomly divided into two groups, where Group I (n=7) subjects were treated with periosteal fixation of the lateral rectus muscle and Group II (n=8) subjects were treated using periosteal fixation of the lateral rectus muscle with split VRT. At 1 week, 1 month, and 3 months postoperatively, exophthalmometry, binocular single visual field, abduction and adduction range, and prism bar cover test was assessed. Adduction changed postoperatively from -1.7 to -0.5 in subjects of Group I and from -1.3 to -0.5 in subjects of Group II. TBSF (Total binocular single visual field) was 14.5 in subjects of Group I preoperatively and was 11.6 in subjects of Group II postoperatively. This change postoperatively was significant in both groups. In Group I.

Refractive Profile in Duane Retraction Syndrome

Aim: To study the refractive error profile of patients with Duane retraction syndrome (DRS). Methods: We conducted a retrospective analysis of patients diagnosed with DRS between January 2015 and December 2018 at a tertiary eye center. All case files of patients diagnosed with DRS were retrieved and analyzed. Following parameters were collected from the records: demographic data, laterality of involvement, type of DRS, type of refractive error, presence of anisometropia, and presence of amblyopia, if any. Type of refractive error was correlated with type of DRS. Results: Seventy-seven eyes of 74 patients were included with age range of 2 to 65 years. There were 42 female patients and 32 male patients. Exotropic DRS with unilateral presentation was the commonest pattern. Left eye was predominantly involved in unilateral DRS. Hyperopia (58.1%) was the most common refractive error in both esotropic and exotropic DRS. Anisometropia was present in 16% cases, with anisoastigmatism being the most common refractive error in them. Amblyopia was reported in only three cases with anisometropia being the cause. Abnormal head posture was reported in most of the patients (81%). Upshoots and downshoots were common in exotropic DRS. Conclusion: Hyperopia was the most common refractive error in both esotropic and exotropic DRS. Amblyopia was reported in a few cases and was due to anisometropia. This underscores the importance of proper evaluation of refractive error in patients with DRS.

A rare case of racemose ocular myocysticercosis masquerading as exotropic Duane's retraction syndrome

A 13-year-old girl presented with recent onset diplopia. At presentation, she had an ocular motility deficit resembling left eye exotropic-Duane's retraction syndrome. On imaging, her left eye lateral rectus was grossly swollen, with the presence of an elongated cystic lesion in its belly. The latter was a rare presentation of racemose cysticercosis, an uncommon variant of neurocysticercosis, hitherto unreported in an extraocular muscle. The child was medically managed with oral steroids and albendazole. There was a partial resolution of ocular motility deficit and complete regression of the intramuscular cysticercus lesion.

Surgical Outcomes of Exotropic Duane Retraction Syndrome From a Tertiary Eye Care Center.

To report surgical outcomes of patients with exotropic Duane retraction syndrome. A retrospective review of the medical records from patients with exotropic Duane retraction syndrome who underwent strabismus surgery and had at least 2 months of postoperative follow-up was conducted. Surgical success was defined as a postoperative horizontal deviation within 8 prism diopters (PD), abnormal head posture (AHP) less than 5 degrees, and a two-step decrease in overshoots. Seventy-three patients with exotropic Duane retraction syndrome (38, 52% male, mean age 14 ± 7.9 years) met the study criteria. Unilateral type 3 Duane retraction syndrome was seen in 56 (77%) patients and type 1 in 14 (19%) patients. The mean follow-up period was 22 weeks (range: 8 to 209 weeks). Unilateral and bilateral lateral rectus recession were performed in 48 (65%) and 25 (34%) patients, respectively. In addition to recession, a lateral rectus Y-splitting was performed in 42 (56%) patients. Five patients underwent differential medial rectus and (larger) lateral rectus recession to alleviate severe globe retraction. The mean primary position reduced from 23 PD (CI: 19.6 to 26 PD) preoperatively to 9 PD (CI: 7.02 to 11.02 PD) postoperatively (P < .0001). Postoperatively 50% of patients were orthotropic in the primary position. Surgical success for primary position deviation, AHP, and overshoots were achieved in 74%, 81%, and 71% of patients, respectively. In the current study, type 3 Duane retraction syndrome was the most common subtype necessitating surgery for exotropic Duane retraction syndrome. Good surgical outcomes were obtained for various indications. Unilateral or bilateral lateral rectus recession was successful in improving motor alignment and AHP. The addition of lateral rectus Y-splitting corrected overshoots greater than grade 2 in most patients with exotropic Duane retraction syndrome. [J Pediatr Ophthalmol Strabismus. 2021;58(1):9-16.].

Surgical outcome of patients with unilateral exotropic Duane retraction syndrome

To describe the clinical features and surgical outcomes of patients with unilateral exotropic Duane retraction syndrome (DRS). The medical records of patients with unilateral exotropic DRS who underwent surgery between March 2015 and February 2018 were reviewed retrospectively. A total of 40 patients (mean age, 18.75±12.54years; 21 males [53%]) were included. In 28 patients (70%) the left eye was involved. All patients had globe retraction and head turn toward the opposite side of the affected eye. Remarkable upshoot/downshoot movement was detectable in 11 patients (28%). The mean deviation for near and distance improved from 24.37Δ ± 12.34Δ (range, 6Δ-77Δ) and 19.67Δ±10.76Δ (range, 4Δ-60Δ) to 4.25Δ±8.61Δ (range, 0Δ-50Δ) and 2.62Δ±6.15Δ (range, 0Δ-35Δ) after the first surgery (P <0.001 for near and far deviation). Mean postoperative follow-up was 7.82±9.45months. Two patients required reoperation. Different types of surgeries, including lateral rectus recession (with or without Y-splitting), lateral and medial rectus recession (with or without Y-splitting of the lateral rectus muscle), bilateral lateral rectus recession, and lateral rectus recession with vertical rectus nasal transposition were performed. Twenty-four patients (60%) were successfully treated with only a single recession of the ipsilateral lateral rectus muscle. The mean lateral rectus recession was 7.45±0.73mm (range, 6-8.5mm), and the mean dose-response for lateral rectus recession was 2.79Δ±0.64Δ/mm for near and 2.45Δ±0.67Δ/mm for distance. Simple lateral rectus recession (with or without Y-splitting), even in the presence of significant deviation (through 35Δ), seems to be a successful procedure for management of patients with unilateral exotropic DRS.

Combined surgical strategy for management of unilateral exotropic Duane retraction syndrome associated with limitation of abduction

To report the effect of asymmetrical bilateral lateral rectus recession combined with augmented partial vertical rectus transposition (VRT) in the management of exotropia, head turn, limited abduction, and anomalous vertical movements associated with unilateral exotropic Duane retraction syndrome (XT-DRS). The medical records of all patients with unilateral XT-DRS associated with limitation of abduction who underwent surgery during a 5-year period from 2013 to 2018 with at least 6months' follow-up were reviewed retrospectively. Outcome measures were changes in head turn, primary position distance and near exodeviation, degree of limited abduction, and anomalous vertical movements on adduction. A total of 11 patients (6 males) were included. Mean patient age was 16.3years (range, 6-29). Exodeviation at distance and near fixation were corrected by means of 26.4Δ and 24.8Δ, respectively. Head turn was improved by a mean of 17.3°. Limited abduction and anomalous vertical movements were corrected by means of 1.6 and 1.5 units, respectively. No patients developed symptomatic induced vertical deviation or anterior segment ischemia. In our study cohort, the combined strategy of asymmetrical bilateral lateral rectus recession with unilateral augmented partial VRT yielded satisfactory results in the management of unilateral XT-DRS associated with limited abduction with no recorded intra- or postoperative complications.

A modified technique for attaching the lateral rectus muscle to the orbital periosteum through a skin incision over the lateral orbital rim

The traditional approach for periosteal fixation of the lateral rectus muscle involves securing the muscle using nonabsorbable sutures by exposing the orbital periosteum 5mm to the inside of the orbital margin. We present a simplified approach that exposes the orbital periosteum through a skin incision, providing more room and avoiding extraconal fat manipulation. We used our technique to expose the lateral orbital periosteum and suture the lateral rectus muscle to the periosteum using nonabsorbable sutures in 2 patients with exotropic Duane retraction syndrome and 1 patient with congenital oculomotor nerve palsy. All 3 patients had satisfactory postoperative alignment, with abduction limitation of 3-. Adduction improved in all patients. The patient with oculomotor nerve palsy had a small overcorrection in primary position that remained stable during follow-up of 18months. There were no intraoperative complications. This modified approach to extraocular muscle periosteal fixation may be simpler thanthestandard approach. Further evaluation in a larger series of patients is warranted.

The Efficacy of Bilateral Lateral Rectus Recession According to Secondary Deviation Measurements in Unilateral Exotropic Duane Retraction Syndrome.

To evaluate the surgical results of asymmetric bilateral lateral rectus recession in exotropic Duane retraction syndrome with abnormal face turn toward the opposite side according to secondary deviation measurements. Retrospective chart review. Seven cases of unilateral exotropic Duane retraction syndrome were reviewed. All cases had globe retraction on adduction and exotropia with limited adduction, five of which also had mild limitation of abduction. Four cases had upshoot/downshoot on adduction and all patients had face turn. Exotropia was measured in forced primary position. The average lateral rectus recession was 6.36 mm (range: 5.5 to 7.5 mm) in the affected eye and 7.36 mm (range: 6.5 to 8.5 mm) in the healthy eye. The mean follow-up period was 282 days. Mean exotropia in the forced primary position improved from 27.9 ± 5.7 prism diopters (PD) preoperatively to 7.9 ± 16.8 PD postoperatively (P = .025). Head position resolved completely in all but one case (P =.031). There were no significant changes in ductions. The results suggest that asymmetric bilateral lateral rectus recession in exotropic Duane retraction syndrome with abnormal head turn posture successfully eliminates abnormal head turn posture and exotropia in most cases. [J Pediatr Ophthalmol Strabismus. 2018;55(1):47-52.].

Y-Split Recession vs Isolated Recession of the Lateral Rectus Muscle in the Treatment of Vertical Shooting in Exotropic Duane Retraction Syndrome

To compare the results of 2 surgical procedures in the management of vertical shooting in exotropic Duane retraction syndrome (XT-DRS). This was a prospective, interventional study of consecutive patients with XT-DRS with vertical shooting on adduction operated on from August 2012 to January 2015. A total of 25 patients were identified and were divided into 2 groups: the Y-split (Y) group, which included 12 patients, who underwent Y-splitting with recession of the lateral rectus muscle (LR); and the isolated recession (R) group, which included 13 patients, who underwent isolated LR recession. Surgical outcomes in both groups were compared in terms of improvements in vertical shoots, ocular deviation, and face turn. Upshoot, downshoot, XT, and face turn showed significant postoperative improvement in both groups (p&lt;0.001). When comparing the groups, the difference in the average correction of the upshoot and downshoot was statistically significant (p = 0.0004 and 0.0174, respectively) in benefit of the Y-group. One case of horizontal overcorrection (consecutive esotropia) with another case of horizontal undercorrection (persistent XT) were reported postoperatively in the Y-group. In our series, both procedures achieved comparable results in the correction of XT and face turn. The combined Y-split recession procedure attained a more significant improvement of upshoot and downshoot but with higher incidence of postoperative complications.

Unilateral large lateral rectus recession in treatment of unilateral exotropic duane retraction syndrome

Purpose The purpose of this study was to determine the effect of unilateral large lateral rectus (LR) recession on head turn and horizontal ocular deviation in patients with unilateral exotropic Duane retraction syndrome. Patients and methods This was a prospective, interventional study of 10 consecutive patients with unilateral exotropic Duane retraction syndrome associated with contralateral head turn. All patients underwent large (8.5–10 mm) unilateral LR recession on the affected eye. All patients were followed up for at least 6 months. Preoperative and postoperative ocular deviation, angle of head turn, stereoacuity, and severity of limitation in abduction and adduction were recorded and analyzed. Results Mean head turn decreased from 30.5±9.56° (range, 15°–40°) to 6.5±4.74° (range, 0°–15°) (P Conclusion Unilateral large LR recession abolishes or ameliorates the wide scale of head turn and exotropia in unilateral exotropic Duane retraction syndrome with noticeable improvement of defective adduction.

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.

Isolated lateral rectus recession with Y splitting versus anchoring of the lateral rectus muscle in patients with exotropic Duane syndrome

To compare the outcome of two surgical procedures used to treat up- and downshoots in Duane retraction syndrome associated with exotropia. The medical records of patients with exotropic Duane retraction syndrome seen at a single tertiary care facility from 2009 to 2012 were retrospectively reviewed. Patients were divided into two groups, one comprising patients treated with Y splitting and recession of the lateral rectus muscle; the other, patients treated with anchoring of the lateral rectus muscle to the lateral palpebral ligament. Surgical outcomes were compared in terms of deviation, head turn, up- and downshoot, and duration of surgery. A total of 15 patients were included, 7 treated by Y splitting and recession and 8 by anchoring of the lateral rectus muscle. Both groups were comparable in terms of age, sex, laterality, best-corrected visual acuity, mean deviation in primary position, and preoperative head turn to the affected side. Torticollis decreased from 27.9° ± 6.4° to 2.6° ± 4.4° in the Y-split group and from 22.5° ± 5.9° to 1.6° ± 3.1° in the anchoring group (P < 0.001 [95% CI]). Exotropia decreased from 26.4(Δ) ± 5.6(Δ) to 2.28(Δ) ± 4.07(Δ) in the Y-split group and 26.9(Δ) ± 5.3(Δ) to 1.5(Δ) ± 6.88(Δ) in the anchoring group (P < 0.001 [95% CI]). The up- and downshoots decreased markedly in the both groups (P = 0.7 for upshoots and P = 1 for downshoots). The mean operating time was 15.3 ± 2.0 minutes for Y splitting plus recession and was 8.3 ± 1.8 minutes for anchoring. In our patient cohort, the two procedures yielded comparable results in terms of the correction of the horizontal position deviation, head posture, and up- and downshoots.

Evaluation of periosteal fixation of lateral rectus and partial VRT for cases of exotropic Duane retraction syndrome

Purpose:The purpose of this study is to evaluate the lateral rectus periosteal fixation and partial vertical rectus transpositioning (VRT) as treatment modalities to correct exotropic Duane retraction syndrome (Exo-DRS).Materials and Methods:Prospective interventional case study of cases of Exo-DRS with limitation of adduction. A total of 13 patients were subdivided into two groups. Six patients underwent only lateral rectus periosteal fixation (group A) and seven patients also underwent partial VRT (group B). Assessment involved prism bar cover test, abduction and adduction range, extent of binocular single visual field and exophthalmometry. These tests were repeated at 1 week, 1 month and 3 months post-operatively and data analyzed.Results:The pre-operative mean values and ranges were 26.2Δ (22-35) exotropia for group A and −21.3Δ (14-30) exotropia for group B. The post-operative mean and range was +0.6Δ esotropia (+20 to −8) for group A and 8Δ (−2 to −20) exotropia for group B. Mean grade of limitation of abduction changed from −3.8 to −3.6 versus −3.6 to −2.8 and mean grade of limitation of adduction changed from −1.9 to −0.7 versus −1.5 to −0.5 in the groups A and B respectively. Mean binocular single visual field changed from 14.7° to 23.3° in group A and 11.8° to 26.4° in the group B respectively.Conclusion:Lateral rectus periosteal fixation is an effective surgery to correct the exodeviation, anomalous head posture and improving adduction in Exo-DRS and partial VRT in addition is effective in improving abduction and binocular single visual fields.

Contralateral lateral rectus muscle recession in patients with Duane retraction syndrome type 3.

The aim of this study was to evaluate the motor, sensory, functional, and head posture results of recession of the lateral rectus muscle contralateral to the involved eye in patients with exotropic Duane retraction syndrome (DRS) type 3. This was a retrospective, longitudinal, observational study of a consecutive clinical case series. Of the 11 patients with DRS type 3 operated on at a tertiary medical center from 1977 to 2012, 8 underwent recession of the lateral rectus muscle contralateral to the involved eye (with combined Y-splitting of ipsilateral lateral rectus muscle in 3 of them). Full ophthalmic, orthoptic, and neurological examination was performed before and after surgery. Main outcome measures included intragroup changes in motor misalignment, abnormal head turn, ocular upshoot, and stereopsis. Mean patient age was 8.75±3.1 years at surgery. Mean exodeviation for distance was -17.3±3.5 prism diopters (PD) preoperatively and -4.0±6.1 PD postoperatively; corresponding values for near were -23.1±7.2 PD and -5.9±8.7 PD. Motor deviation improved by 77% for distance (P=0.017) and 74.5% for near (P=0.01). In 7/8 patients, the postoperative residual exodeviation (distance and near) was <8.0 PD. There was an 80% improvement in head turn, from 15.3±4° before surgery to 3.1±5.0° after (P=0.01). Stereopsis improved significantly in 6/8 patients. Findings remained stable during follow-up (mean duration 35.9±50.8 months, range 5-132 months). Contralateral lateral rectus muscle recession appears to be a promising technique for the treatment of moderate unilateral DRS type 3, with patients showing significant motor and functional improvement and a decrease in head turn.

Surgical and functional outcomes in bilateral exotropic Duane's retraction syndrome

AimsTo evaluate the outcomes following surgery on patients with bilateral Duane's Retraction Syndrome (DRS) associated with exotropia or exophoria.MethodsEleven consecutive patients with exotropic DRS were identified in a 10-year period....