Journal of Pediatric Ophthalmology and Strabismus

Original Article 

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

Mohamed E. I. Abdallah, MSc; Elsayed M. Eltoukhi, MD; Ahmed R. Awadein, MD; Rasha H. Zedan, MD

Abstract

Purpose:

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.

Methods:

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.

Results:

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.

Conclusions:

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.]

Abstract

Purpose:

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.

Methods:

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.

Results:

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.

Conclusions:

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.]

Introduction

Duane retraction syndrome is the most common form of congenital cranial dysinnervation disorder.1 It has been described as the consequence of a congenital anomaly of the sixth cranial nerve nuclei with aberrant innervations supplied from the third cranial nerve.2 In 1905, Duane published his landmark study of 54 cases that included the unique features of the syndrome, of which the most prominent feature was globe retraction.3 Huber classified Duane retraction syndrome into three types. In type I there is a limitation or total absence of abduction and normal or slightly altered function of adduction. Type I is the most frequent form and usually associated with primary position esotropia. Most patients have good binocular vision by acquiring ipsilateral face turn toward the field of action of the deficient muscle.4

The major indications for surgical intervention are an abnormal head posture and/or a significant ocular deviation in primary position. Several surgical options have been described in the literature. These include ipsilateral rectus muscle recession, vertical rectus muscle transposition, lateral posterior fixation sutures, simultaneous medial and lateral rectus recessions, and surgery on the normal eye.5

The goals of treatment are primarily to eliminate the deviation in primary position and abnormal head posture, as well as to center the diplopia-free field and reduce upshoots and downshoots. The secondary goals are to reduce globe retraction, improve ductions, and enlarge the field of single binocular vision.6

In 1974, for the first time, Gobin used the vertical rectus muscle transposition laterally along the spiral of Tillaux with recession of the medial rectus muscle of the affected eye for the treatment of patients with esotropic Duane retraction syndrome.7 The main complications of vertical rectus muscle transposition are anterior segment ischemia (especially if associated with medial rectus recession), undercorrection, overcorrection, vertical deviation, and limitation of adduction.8–11

A posterior fixation or augmentation suture at approximately 14 to 16 mm from the limbus with nonabsorbable suture was proposed by Foster in 1997 to increase the tone and elastic stress in the direction of the paralyzed muscle and the rotation of the eye in that direction, which increases the diplopia-free field of vision. Augmentation suture placement may enhance the effect of a previously performed vertical rectus muscle transposition when added later.14,15

In 2006, Johnston et al16 described superior rectus transposition, a procedure in which only the superior rectus muscle is transposed temporally.

The aim of this study was to compare the safety and efficacy of augmented superior rectus transposition with or without medial rectus recession versus medial rectus recession alone in the treatment of patients with esotropic Duane retraction syndrome.

Patients and Methods

This study was approved by the Cairo University Research Ethics Committee. The study and data collection conformed to all local laws and were compliant with the principles of the Declaration of Helsinki. A prospective, randomized, and interventional comparative study was conducted on patients with esotropic Duane retraction syndrome. The patients were recruited from the pediatric ophthalmology clinic at Abu Elrish Cairo University Hospital and Research Institute of Ophthalmology.

The study included 20 patients with esotropic type 1 Duane retraction syndrome with ipsilateral face turn. Patients with marked globe retraction or overshoots on attempted adduction were excluded. Patients younger than 1 year or with a history of previous extraocular muscle surgery were also excluded.

The patients were randomly divided into two groups with 10 patients in each group. In the first group (superior rectus transposition group), augmented superior rectus transposition was performed in all patients accompanied by medial rectus recession in 8 patients. Two patients in the superior rectus transposition group had superior rectus transposition only. In the second group (non-superior rectus transposition group), only ipsilateral medial rectus recession was performed.

In the superior rectus transposition group, a fornix-based superotemporal conjunctival incisional was made and the superior rectus muscle was hooked and secured using a double-armed 6-0 polyglactin 910 suture after careful dissection from the levator palpebrae superioris and the superior oblique tendon. After disinsertion, the superior rectus muscle was attached to sclera adjacent to the superior border of the lateral rectus muscle along the spiral of Tillaux. Thereafter, an augmentation suture (5-0 polyester) was passed 8 mm behind the lateral rectus muscle insertion incorporating one-quarter thickness of each of the superior and lateral rectus muscles and passing through the underlying sclera.

The medial rectus muscle was approached via a fornix-based inferomedial conjunctival incision and then secured using a 6-0 polyglactin 910 suture. Following its disinsertion, the muscle was recessed to the desired amount and sutured to the sclera at the new insertion site.

In the transposition group, 8 patients underwent augmented superior rectus transposition with ipsilateral medial rectus recession. The remaining 2 patients underwent superior rectus transposition only. The average amount of medial rectus recession in the 8 patients who underwent medial rectus resection was 3.562 ± 0.417 mm (range: 3 to 4 mm). In the non-transposition group, the average amount of recession was 4.7 ± 0.258 mm (range: 4.5 to 5 mm).

Preoperative and postoperative patient evaluations included a complete ophthalmic evaluation. Deviation in the primary position in prism diopters (PD), amount of face turn in degrees, and degree of duction limitation on a scale from 0 to −4 (with 0 indicating no limitation and −4 indicating inability to cross the midline) were tabulated. Assessment of abnormal head posture was measured using double prism bars (one bar before each eye and the base with the face turn), the power of the prisms before both eyes was gradually increased symmetrically until centralization of the corneal light reflection and neutralization of the face turn. The patients were followed up 1 day, 1 week, and 1, 3, and 6 months following surgery.

Data were statistically described in terms of mean ± standard deviation, median and range (minimum and maximum), or frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables was done using the t test. P values less than .05 were considered statistically significant. All statistical calculations were done with Microsoft Excel 2010 for Microsoft Windows software (Microsoft Corporation).

Results

The superior rectus transposition group included 10 patients (5 males and 5 females) with a mean age of 13.65 ± 7.7 years (range: 1.6 to 22 years). The non-superior rectus transposition group included 10 patients (3 males and 7 females) with the mean age of 8.7 ± 6.325 years (range: 1 to 24 years). The left eye was affected in 8 patients (80%) in the superior rectus transposition group and 7 patients (70%) in the non-transposition group.

Postoperatively in the transposition group, 9 patients (90%) were horizontally orthotropic and 1 patient (10%) had 6 PD residual esotropia. Two of the patients with horizontal orthotropia developed hypertropia. In the non-transposition group, 8 patients (80%) were orthotropic and 2 patients (20%) had residual esotropia of 4 and 5 PD.

No patients developed overcorrection (consecutive exotropia), postoperative fundus torsion, or anterior segment ischemia.

The mean preoperative deviation decreased from 20.4 ± 2.756 PD (range: 16 to 25 PD) and 22.5 ± 2.635 PD (range: 20 to 25 PD) of esotropia to 0.6 ± 1.897 PD (range: 0 to 6 PD) and 0.9 ± 1.911 PD (range: 0 to 5 PD) of residual esotropia in the transposition and non-transposition groups, respectively. The mean improvement of esotropia in the transposition group was 19.8 ± 3.425 PD (range: 14 to 25 PD) and 21.6 ± 2.366 PD (range: 20 to 25 PD) in the non-transposition group. No statistically significant difference was found between the two groups (P = .72878) (Figure 1).

Preoperative and postoperative esotropia in the superior rectus transposition (SRT) group and the non-SRT group.

Figure 1.

Preoperative and postoperative esotropia in the superior rectus transposition (SRT) group and the non-SRT group.

The mean preoperative face turn in the transposition group was 11.5° ± 2.415° (range: 10° to 15°), which decreased to 0.5° ± 1.58° (range: 0° to 5°) of residual ipsilateral face turn with a mean improvement of the face turn of 11° ± 2.108° (range: 10° to 15°). Only one patient (10%) had 5° of residual ipsilateral face turn. In the non-transposition group, the mean preoperative face turn of 12° ± 2.581° (10° to 15°) improved to 1.5° ± 2.415° (range: 0° to 5°) of residual ipsilateral face turn postoperatively with a mean improvement of the face turn of 10.5° ± 2.838° (range: 5° to 15°). Three patients (30%) had residual ipsilateral face turn. There was no statistically significant difference between groups (P = .28776) (Figure 2). Figures 34 show examples of correction in face turn in both groups.

Preoperative and postoperative face turn in the superior rectus transposition (SRT) group and non-SRT group.

Figure 2.

Preoperative and postoperative face turn in the superior rectus transposition (SRT) group and non-SRT group.

Complete correction of face turn with straight head in patient 1 of the superior rectus transposition group.

Figure 3.

Complete correction of face turn with straight head in patient 1 of the superior rectus transposition group.

Complete correction of face turn with straight head in patient 9 of non-transposition group.

Figure 4.

Complete correction of face turn with straight head in patient 9 of non-transposition group.

The mean grade of preoperative abduction limitation was −3.9 ± 0.307 grade in both the transposition and non-transposition groups, ranging from −3 to −4 grade without a statistically significant difference (P = 1.00). Postoperatively, the abduction improved to a mean of −3.1 ± 0.6567 grade (range: −2 to −4) in the transposition group and −3.6 ± 0.459 grade (range: −3 to −4) in the non-transposition group, with a statistically significant difference (P = .044). Postoperatively, the average grade of abduction limitation was smaller in the transposition group compared with the non-transposition group.

Abduction improved by at least one unit in 8 patients (80%) in the transposition group and in 2 patients (20%) in the non-transposition group. The mean improvement of abduction was 0.8 ± 0.4216 grade (range: 0 to 1) in the transposition group and 0.3 ± 0.4216 grade (range: 0 to 1) in the non-transposition group. There was a statistically significant difference between both groups (P = .0162). The average of abduction improvement was greater in the transposition group compared with the non-transposition group (Figures 59).

Preoperative and postoperative abduction limitation in the superior rectus transposition (SRT) group and non-SRT group.

Figure 5.

Preoperative and postoperative abduction limitation in the superior rectus transposition (SRT) group and non-SRT group.

Preoperative (upper row) and postoperative (middle and lower row) abduction limitation in patient 1 in the superior rectus transposition group.

Figure 6.

Preoperative (upper row) and postoperative (middle and lower row) abduction limitation in patient 1 in the superior rectus transposition group.

Preoperative (upper row) and postoperative (lower row) abduction limitation in patient 2 in the superior rectus transposition group.

Figure 7.

Preoperative (upper row) and postoperative (lower row) abduction limitation in patient 2 in the superior rectus transposition group.

Preoperative (upper row) and postoperative (lower row) abduction limitation in patient 3 in the superior recus transposition group.

Figure 8.

Preoperative (upper row) and postoperative (lower row) abduction limitation in patient 3 in the superior recus transposition group.

Preoperative (upper row) and postoperative (middle and lower row) abduction limitation in patient 9 of the non-transposition group.

Figure 9.

Preoperative (upper row) and postoperative (middle and lower row) abduction limitation in patient 9 of the non-transposition group.

Preoperatively, there was no limitation of adduction in both groups. Postoperatively, adduction was normal in 16 patients (80%) without any limitation, whereas 4 patients (20%) developed limited adduction. Two of the patients were in the transposition group and two were in the non-transposition group. The mean grade of adduction limitation was −0.15 ± 0.337 (range: 0 to −1) in the transposition group and −0.10 ± 0.210 (range: 0 to −0.5) in the non-transposition group. No statistically significant difference was found between groups (P = .69577).

Two patients (20%) in the transposition group developed ipsilateral hypertropia. Both patients were horizontally orthotropic.

The first patient with hypertropia was a boy who was 1 year and 6 months old and had right type 1 Duane retraction syndrome. He had esotropia of 20 PD in the primary position, right face turn of 10°, and his abduction limitation was graded as −4. He underwent right augmented superior rectus transposition toward the lateral rectus muscle with right medial rectus recession of 3.5 mm. Postoperatively, he was orthotropic both horizontally and vertically with improvement of his abduction limitation to −3. Three months postoperatively, he developed right hypertropia. The augmentation suture was removed first but did not correct the hypertropia. The superior rectus muscle was returned to its original insertion site with 2 mm recession, but the hypertropia persisted (Figure 10).

Right hypertropia in patient 4 of the superior rectus transposition group.

Figure 10.

Right hypertropia in patient 4 of the superior rectus transposition group.

The second patient with vertical tropia was a 5-year-old girl with left type 1 Duane retraction syndrome. She had esotropia of 20 PD in the primary position, left face turn of 10°, and her abduction limitation was −4. She underwent left augmented superior rectus transposition toward the lateral rectus muscle. Postoperatively, she was horizontally orthotropic but had 20 PD of left hypertropia for which the superior rectus muscle was returned to its original insertion site and recessed 4.5 mm with mild improvement of her vertical deviation (Figure 11).

Left hypertropia in patient 7 of the superior rectus transposition group.

Figure 11.

Left hypertropia in patient 7 of the superior rectus transposition group.

Discussion

When planning surgery for Duane retraction syndrome, we should take into account the amount of ocular deviation in primary gaze, abnormal head position, the extent of duction limitations, the degree of globe retraction, the presence of upshoot and down-shoot, and the results of forced duction testing.18 Surgeries for management of primary position deviation and abnormal head position in patients with esotropic Duane retraction syndrome can be classified into three categories: horizontal rectus muscle surgery, vertical rectus muscle surgery, and a combination of both.19

Horizontal muscle recession was first proposed by Duane in 1905 and it has been used considerably with success. Recession of the tight and overacting muscle is a simple and effective operation with few complications. Although simple recession does not normalize the motility of the eye, recession of the appropriate horizontal rectus muscle normalizes head posture, reduces globe retraction, relieves overshoots without causing vertical tropias, and rarely overcorrects.20

For patients with esotropic Duane retraction syndrome, unilateral or bilateral medial rectus recession are common procedures with satisfactory results for correcting alignment in primary gaze and reducing the face turn.5,21 Simple medial rectus recession does not significantly improve the abduction limitation. A slight improvement was noted in 28% to 30% of cases.22–24

Barbe et al5 documented improved abduction (range: 0.5 to 2 units) in 69% of patients with unilateral Duane retraction syndrome undergoing unilateral or bilateral medial rectus recession. However, an equal number of patients in their study developed an adduction limitation of 1 to 3 units. The average medial rectus recession per eye performed in their patients was 5.8 mm, with 16 of 22 patients undergoing 6 mm or more of medial rectus recession in the affected eye. Pressman et al25 reported similar results. Increasing the amount of medial rectus recession may improve abduction, but at the cost of decreased adduction.25 A large medial rectus recession may also cause difficulty with convergence and exotropia in the contralateral gaze.26,27

To improve abduction without limiting adduction in patients with Duane retraction syndrome, a variety of transposition procedures have been used, including transposition of both vertical recti muscles. In 1997, Foster suggested that vertical rectus transposition alone may achieve good results when augmented with posterior fixation sutures.14 However, subsequent medial rectus recession or botulinum toxin injection may be required in some patients, especially when the medial rectus muscle is found to be tight during intraoperative forced duction testing.12,13,15

In 2004, Rosenbaum28 reviewed the results of vertical recti muscles with posterior fixation, orbital fixation, and partial vertical recti muscles in patients with sixth nerve palsy and Duane retraction syndrome. His study showed a marked improvement in the field of binocular single vision of patients who had undergone vertical recti muscle surgery with posterior fixation. Rosenbaum also reported that moving the vertical recti muscles temporally has a greater chance of inducing a vertical deviation and that the tightening effect of augmentation sutures may contribute to this vertical deviation.

In 2006, Johnston et al16 proposed the innovative technique of superior rectus transposition, a method in which only the superior rectus muscle is transposed temporally along the spiral of Tillaux toward the lateral rectus insertion, thus reducing the number muscles operated and the postulated risk of anterior segment ischemia.

In 2012, Mehendale et al17 published results of their retrospective study on 17 patients who had superior rectus transposition: 10 patients had esotropic Duane retraction syndrome and the other 7 patients had sixth nerve palsy. All patients with Duane retraction syndrome underwent ipsilateral superior rectus transposition with or without augmentation and short-tag noose adjustable medial rectus recession. Isolated superior rectus transposition allows the surgeon to relieve medial rectus restriction while also expanding the field of binocular vision by improving abduction of the eye. The procedure resulted in good postoperative alignment and improved abduction without inducing vertical deviations or significant torsion in cases of Duane retraction syndrome. A new primary position vertical deviation was observed in two patients with complex sixth nerve palsy. No patients described torsional diplopia.17

In 2014, Yang et al24 also published their retrospective study on 36 patients with esotropic Duane retraction syndrome who had either superior rectus transposition with or without medial rectus recession (superior rectus transposition group) or medial rectus recession whether unilateral or bilateral (non-superior rectus transposition group). They found that the combination of superior rectus transposition and medial rectus recession was more effective than unilateral or bilateral medial rectus recession at improving abduction while allowing for a smaller recession to align the eyes and eliminate a compensatory head posture. No vertical or torsional complications were reported in their patients. Patients treated with superior rectus transposition in their study appeared to have a reduced likelihood of long-term undercorrection.24

In 2015, Tibrewal et al30 published their retrospective study in which they compared the results of augmented superior rectus transposition with or without medial rectus recession with unilateral or bilateral medial rectus resection alone for treatment of 21 patients with esotropic Duane retraction syndrome. Their study population were also divided into two groups: 8 patients (3 males) in the superior rectus transposition group and 13 patients (6 males) in the medial rectus recession group. They concluded that both procedures successfully correct esotropia in Duane retraction syndrome but superior rectus transposition with or without medial rectus recession has the additional advantage of improving abduction.30

In 2018, Agarwal et al31 published their retrospective study to assess the effect of superior rectus transposition in patients with esotropic Duane retraction syndrome (9 patients, 10 eyes) and abducens nerve palsy (10 patients). They concluded that superior rectus transposition is effective in esotropia reduction and improvement of abduction.31

The current study was conducted to compare the safety and efficacy of augmented superior rectus transposition with or without medial rectus recession versus medial rectus recession alone in the treatment of Duane retraction syndrome. Regarding the correction of esotropia and face turn, the results were comparable in both groups in the current study without a statistically significant difference, but the improvement in abduction was greater in the transposition group when compared with the non-transposition group (Table 1).

Results of the Current Study vs Tibrewal et al's Study

Table 1:

Results of the Current Study vs Tibrewal et al's Study

The results of the current study are comparable to the results of the study performed by Tibrewal et al30 (Table 1). In their superior rectus transposition group, the mean preoperative deviation was 20 PD of esotropia and the mean postoperative deviation was 3 PD. In their medial rectus recession group, the mean preoperative deviation was 24 PD of esotropia and the mean postoperative deviation was 4 PD. Their success rate was 87% in the superior rectus transposition group and 77% in the medial rectus recession group (P = .98).30

In contrast to the previous reports by other authors that superior rectus transposition is not associated with a new onset vertical deviation except the two cases of sixth nerve palsy in the Mehendale et al study mentioned above, in our study there were two cases (20%) of hypertropia in the transposition group. Both patients were horizontally orthotropic.

The average amount of medial rectus recession was smaller in the transposition group of the current study with a mean of 3.6 mm/eye (3 to 4 mm) if compared with the non-transposition group in which the mean of medial rectus recession was 4.7 mm/eye (4.5 to 5 mm). This is due to the abduction effect of the transposed superior rectus muscle, which should not be associated with more than 3 to 4 mm of medial rectus recession guarded by the amount of esotropia and the degree of medial rectus muscle contracture.

In the current study, augmented superior rectus transposition improved abduction by at least one grade in 8 patients (80%) in the transposition group. The mean improvement in abduction was 0.8 ± 0.4216 grade, ranging from zero or no improvement to one grade of abduction improvement. The degree of improvement in abduction was comparable to that achieved with both vertical rectus transposition and superior rectus transposition, as seen in related studies (Table 2). Compared to vertical rectus transposition, superior rectus transposition is unlikely to increase the risk of anterior segment ischemia. In the non-transposition group, abduction improved in two patients (20%). The mean improvement in abduction was 0.3 ± 0.4216 grade, ranging from zero or no improvement to one grade of abduction improvement. This is comparable to the results of the previous studies mentioned above.22–24

Improvement in Abduction Following Vertical Rectus Transposition

Table 2:

Improvement in Abduction Following Vertical Rectus Transposition

Adduction was not markedly limited in any of the patients postoperatively. In the transposition group, 8 patients (80%) had normal adduction and 2 patients (20%) had limited adduction. These 2 patients had −0.5 and −1 worsening of their adduction. In the non-transposition group, 8 patients (80%) had normal adduction. The remaining 2 patients (20%) had −0.5 worsening of their adduction. This reflects the smaller amount of medial rectus recession performed on the patients of the current study.

Superior rectus transposition is a novel surgical option in the treatment of patients with esotropic Duane retraction syndrome. It can be used in conjunction with medial rectus recession in the correction of primary position deviation and in straightening of the head in these cases. The amount of medial rectus recession should be smaller than usual if performed in conjunction with superior rectus transposition. Superior rectus transposition is superior to simple medial rectus recession in the improvement of abduction limitation, but it can be complicated by vertical deviation, which should be evaluated in further studies.

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Results of the Current Study vs Tibrewal et al's Study

StudyTransposition GroupNon-transposition GroupSuccess Rate


ParameterPreoperativePostoperativeSuccess RatePreoperativePostoperative
Tibrewal et al30 (2015)Esotropia (PD)20.4 PD (8 to 45 PD)3 PD (6 PD of residual esotropia, 6 PD of consecutive exotropia)87%24.2 PD (10 to 45 PD)4 PD of residual esotropia (0 to 20 PD)77%
Amount of MRc (mm)5 mm/eye (3.5 to 6 mm)5 mm/eye (3.5 to 7 mm)
Face turn (degree)13.5°(8°to 20°)2°(0 to 7°)87%17.8°(5 to 30°)3°(0°to 20°)77%
Abduction limitation (grade)−3.6 (−2 to −4)−2.4 (−2 to −3) (1.2 grade of improvement)87.5 %−3.6 (−2 to −4)−3.3 (−1 to −4) (0.3 grade of improvement)23.1%
Current studyEsotropia (PD)20.4 PD (16 to 25 PD)0.6 ± 1.897 PD (0 to 6 PD of residual esotropia)90%22.5 PD (20 to 25 PD)0.9 PD of residual esotropia (0 to 5 PD)80%
Amount of MRc (mm)3.6 mm/eye (3 to 4 mm)4.7 mm/eye (4.5 to 5 mm)
Face turn (degree)11.5°(10°to 15°) of ipsilateral face turn0.5°(0°to 5°of residual ipsilateral face turn)90%12°(10°to 15°) of ipsilateral face turn1.5°(0°to 5°) of residual ipsilateral face turn70%
Abduction limitation (grade)−3.9 (−3 to −4)−3.1 (−2 to −4) (0.8 grade of improvement)80%−3.9 (−3 to −4)−3.6 (−3 to −4) (0.3 grade of improvement)20%

Improvement in Abduction Following Vertical Rectus Transposition

StudyType of VRTNo. of PatientsMean Abduction LimitationAverage Improvement in Abduction

PreoperativePostoperative
Molarte & Rosenbaum12 (1990)Non-augmented VRT13−3.8−2.31.5
Foster14 (1997)Augmented VRT5−4−3.40.6
Velez et al15 (2001)Augmented VRT32−3.9 ±0.22.9 ±0.61
Velez et al15 (2001)Non-augmented VRT22−3.7 ±0.4−2.7 ±0.71
Britt et al32 (2003)Augmented partial VRT following prior non-transposition surgery5−3.8−3.10.7
Britt et al33 (2005)VRT ± augmentation in bilateral Duane syndrome11−3.75−2.681
Yazdian et al34 (2010)Augmented VRT38−4.00 ± 0.23−2.11 ±0.481.89
Mehendale et al17 (2012)Augmented SRT with MRc10−4−22
Yang et al24 (2014)Augmented SRT ± MRc1979% of patients showed 1 unit improvement in abduction
Tibrewal et al30 (2015)Augmented SRT ±MRc8−3.6−2.41.2
Current studyAugmented SRT ±MRc10−3.9−3.10.8
Authors

From the Department of Ophthalmology, Abo El Reesh Pediatric Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Rasha H. Zedan, MD, 3D Garrana Community, Alexandria Desert Road, P.O. Box 230, Pyramids, Giza, Egypt. Email: rhhzedan@gmail.com

Received: February 13, 2020
Accepted: April 14, 2020

10.3928/01913913-20200506-02

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