Superior Rectus Transposition vs Medial Rectus Recession for Treatment of Esotropic Duane Syndrome

Abstract

Superior rectus transposition (SRT) with or without medial rectus recession (MRc) has been introduced as an alternative to MRc alone for treatment of esotropic Duane syndrome; however, the effectiveness of these procedures has not been compared previously.OBJECTIVE To compare the safety and efficacy of MRc and SRT in treatment of Duane syndrome. DESIGN, SETTING, AND PARTICIPANTSRetrospective medical record review of all patients with esotropic Duane syndrome who underwent surgical treatment from January 1, 2006, through December 31, 2012, in a multispecialty, hospital-based pediatric ophthalmology/adult strabismus practice at Boston Children's Hospital. Patients in the SRT group underwent SRT with or without MRc; those in the non-SRT group underwent unilateral or bilateral MRc.EXPOSURES Surgical treatment of esotropic Duane syndrome.MAIN OUTCOMES AND MEASURES Binocular alignment, ocular ductions, head position, stereopsis, and fundus torsion were recorded before surgery and at the 2-month and final postoperative visits. We also evaluated postoperative drift. RESULTSThe medical record review identified 36 patients who underwent 37 procedures, including 19 in the SRT group (13 SRT + MRc and 6 SRT alone) and 18 in the non-SRT group (11 unilateral MRc and 7 bilateral medial rectus resession). Mean MRc was smaller when performed with SRT (3.3 vs 5.3 mm; P = .004). Although the initial deviation was larger in the SRT group, both groups had a similar improvement in esotropia and head turn. Abduction improved by at least 1 unit in 15 of 19 patients in the SRT group (79%) vs 5 of 18 in the non-SRT group (28%). In 24 patients followed up for more than 6 months, mean esotropia decreased from 8.2 to 6.1 prism diopters (Δ) in the SRT group (n = 12) but increased from 7.2 to 10.9Δ in the non-SRT group (n = 12). CONCLUSIONS AND RELEVANCEThe combination of SRT and MRc was more effective than MRc or bilateral medial rectus resession at improving abduction while allowing for a smaller recession to align the eyes and eliminate a compensatory head posture. Although any surgery on the vertical rectus muscles should in theory increase the risk for vertical or torsional complications, to date this theory has not been borne out in our patients. Patients treated with SRT appear to have a reduced likelihood of long-term undercorrection. We therefore recommend SRT with adjustable MRc for treatment of Duane syndrome in patients with larger amounts of esotropia.

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

“…Similar to our study, previous studies report around 28% to 30% of improvement in abduction in patients undergoing unilateral or bilateral medial rectus recessions. [12][13][14] Barbe and colleauges 8 documented improved abduction (range, 0.5-2 units) in 69% of cases with unilateral Duane syndrome undergoing unilateral or bilateral MRc. However, an equal number of patients in their study developed an adduction limitation of 1-3 units.…”

“…[6][7][8][9][10][11] It effectively corrects the deviation and abnormal head posture; there may also be a small improvement in abduction in 28%-30% of patients. [12][13][14] To improve abduction effectively, vertical rectus transposition to the lateral rectus muscle has been suggested and performed by various authors. [15][16][17] However, it may be associated with consecutive vertical deviations in 13%-30% of cases.…”

Assessment of torsion after superior rectus transposition with or without medial rectus recession for Duane syndrome and abducens nerve palsy

“…A recent study by Yang and colleagues 6 compares the superior rectus transposition procedure to medial rectus recession for the treatment of Duane syndrome. The authors comment on torsional changes after surgery, stating that 8 of the 9 patients with torsional measurements had no change postoperatively, and 1 patient had asymptomatic intorsion with a “+1” shift in fundus torsion.…”

Inferior Rectus Transposition: A Novel Procedure for Abducens Palsy

“…4 Recent interest in the SRT has led to several published studies evaluating the efficacy of this procedure in improving ocular alignment, head posture, and abduction. 4–6 However, other authors have discussed the potential of inducing intorsion or hypertropia with the use of SRT in certain patients. 6,7 …”

“…4–6 However, other authors have discussed the potential of inducing intorsion or hypertropia with the use of SRT in certain patients. 6,7 …”