FP1625 : Surgical Outcome of Single Muscle Surgery in Duane’sDuanes Retraction Syndrome (DRS)

Dr. Gaurav Agarwal, A19237, Dr. K. Sai Rani, Dr. Mahathi Vankireddi

Agarwal Gaurav,K sairani,V Mahathi

ABSTRACT

Purpose:

To assess the surgical outcome of single muscle recession with or without Y splitting in DRS(Duane’s Retraction Syndrome).

Methodology:

Retrospective analysis of 14 patients with DRS who underwent medialrectus recession for type1 DRS, Lateralrectus recession for type 2 DRS, and with Y spilt if there is upshoot/downshoot. The criteria for assessing the outcome are correction abnormal head posture, correction of narrowing of palpebral fissure, reduction of deviation.

Results:

Among 14 patients, 8 had DRS type 1, 6 had DRS type 2. In type1 DRS patients 1 had bilateral DRS who underwent both MR recession of 5mm, remaining underwent one eye MR recession (5.0mm). In type 2 DRS patients 3 underwent LR recession(avg 7.6mm), 3 underwent LR recession with Y spilt. Thirteen patient out of 14 patients abnormal head posture and narrowing of palpebral fissure was corrected. Two patient out of 14  had consecutive exotropia(≥30PD) who needed a second surgery

Conclusion:Single muscle recession surgery is a very effective and simple procedure to treat DRS.

 

INTRODUCTION

Duanes retraction syndrome(DRS) is a congenital disease in which theoculomotor nerve to medial rectus supplies to lateral rectus muscle, this leads to narrowing of palpebral fissure and retraction of the globe and limitation of adduction or abduction or both.DRS has been categorized in 3 types.Type 1(limitation of abduction),type 2 (limitation of adduction) and in type 3 (limitation in both).Out of 3 types; type 1 is most common and in type 1 girls are most common and left eye is also common.

METHODOLOGY:

In the present study we looked at the data of diagnosedcases of Duane’s retraction syndrome in Sankara eye hospital,Guntur.The subjects who were diagnosed with Dunae’s syndrome and had follow up period of minimum 3 months.  Any history of previous surgeryand unable to follow was the exclusion criteria.Surgery was done by single senior surgeon by recession method with limbal approach.Then patientswere evaluated after post operative day 1,at1month and at3 months.

RESULT:

In our study total 6 are male and 8 are female out of 14 subjects.Mean age was 16.91 year(no SD),ranging from 8 to 32 year.Out of 14 subjects,  8 patient had type 1 and 6 subjects  had type2.Out of 14 patient, 12 eyes were left and one eye was right and one case was bilateral.

Among 14 patients, 8 had DRS type 1, 6 had DRS type 2. In type1 DRS patients 1 had bilateral DRS who underwent both MR recession of 5mm, remaining underwent one eye MR recession (5.0mm). The 14 patients with DRS underwent medial rectus recession for type1 DRS, Lateralrectus recession for type 2 DRS, and with Y spilt if there is upshoot/downshoot. The criteria for  assessing the outcome are correction abnormal head posture, correction of narrowing of palpebral fissure, reduction of deviation.

In type 2 DRS patients 3 underwent LR recession(avg 7.6mm), 3 underwent LR recession with Y spilt. 13 subjects out of 14 had corrected abnormal head posture and  narrowing of palpebral fissure.2 subjects out of 14 did not correct the deviation,resurgery was performed and both get corrected.

Table1: Distribution of study subjects.

TYPE	DRS TYPE1	DRS  TYPE 2
	U/L B/L 7 1	U/L B/L 6 0

Table 2: Characteristics of study subjects.

	Subject	Eye	Type	Type of surgery performed	Post operative amount of  deviation	Face Turn	Narrowing of palpebral fissure
1	11/M	LE	2 with downshoot	OU LR resc OD 8.5 OS 7.5 with Y splitting	30PD exotropia	corrected
2	20/F	LE	2	OS LR Recession 9mm	Ortho	corrected
3	9/F	LE	1	MR recession 5mm	Ortho	corrected
4	10/F	LE	1	MR recession 5mm	Ortho	corrected
5	18/F	LE	1	MR recession 5mm	Ortho	corrected
6	8/F	RE	1	MR recession 5mm	Ortho	corrected
7	26/M	LE	2 with upshoot	LR recession with Y splitting	Ortho	corrected
8	32/F	LE	2	LR recession 7mm	Ortho	corrected
9	7/F	LE	1	MR recession 5mm	Ortho	corrected
10	18/M	LE	2	LR recession 7mm	Ortho Diplopia+	corrected
11	12/M	BE	1	OD MR recession 11mm OS MR recession 10.5mm	30PD exotropia after 1 year followup Resurgery done OU LR recession 7mm 2 month post op ortho	Not corrected After resurgery AHP corrected
12	32/M	LE	2 with dowshoot	LR recession with Y splitting	Ortho	corrected
13	28/F	LE	1	MRrecession 5 mm	Ortho	corrected
14	22/F	LE	1	MR recession 5 mm	Ortho	corrected

Table-3 Study subjects in type1&2 DRSgroups.

Type of   DRS	Distribution according to sex	Distribution according to   Laterality
Type 1 Type 2 8subjects 6 subjects	Male Female 6 8	RE LE BE 1 12 1

Post operative  refraction after 3 month months all patient who had unilateral DRS achieved  BCVA 6/9 or better than 6/9.

DISCUSSION

Surgical success of DRS depends on correction of face turn,amount of deviation correctedand correction of narrowing of palpebral fissure. Various approaches have been recommended Rosenbaum(1) recommended transposition of vertical recti towards  lateral recti so that after increasing the abduction eye ball can be align in primary position. But in 15% patient require second surgery in which they did medial rectus recession but it increases post operative increased risk of anterior segment ischemia syndrome.According to Foster (2)after primary transposition medial rectus recession procedure should be avoided because of post chances of  over correction.He proposed vertical muscle transposition with lateral posterior fixation suturealthough small vertical deviation found in 20% of patient that were corrected by botulinum toxin injection.

Post  operative period  always residual muscle restriction was present.Abnormal head position is compensatory phenomenon to maintain binocular single vision in case of deviation. That’s why no patient in our study had a complaint of diplopia  because of compensatory mechanism fusion was present.In our study, AHP was corrected in 13 patients.In cases of bilateral DRS,bilateral medial rectus and/or lateral rectus recession is recommended.In our study, we found only one patient of type 1 in which we did bilateral MR recession but post operative AHP was not corrected.  The deviation was more than 30PD (Esotropia or exotropia?) after one yearwe again did resurgery bilateral lateral rectus recession after 2 month  post operative period AHP was corrected and deviation also.

CONCLUSION

In DRS, single horizontal muscle recession  is simple and effective .

REFERENCES

1 Molarte AB, Rosenbaum AL. Vertical rectus muscle transposition surgery for

Duane’s syndrome. J Pediatr Ophthalmol Strabismus 1990;27:171–7.

2 Foster RS. Vertical muscle transposition augmented with lateral fixation.

J AAPOS 1997;1:20–30