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David G. Hunter - One of the best experts on this subject based on the ideXlab platform.
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incidence of symptomatic vertical and torsional diplopia after superior rectus transposition for esotropic Duane Syndrome and abducens nerve palsy
Journal of Aapos, 2020Co-Authors: Anna G Escuder, Linda R Dagi, David G. Hunter, Melanie Kazlas, Gena Heidary, David ZurakowskiAbstract:Purpose To report the incidence of symptomatic vertical and torsional diplopia after superior rectus transposition (SRT) for esotropic Duane Syndrome and abducens nerve palsy. Methods The medical records of patients with esotropic Duane Syndrome or abducens nerve palsy seen at Boston Children's Hospital (2006-2018) and treated with unilateral SRT with or without augmentation was performed. The primary outcome was incidence of postoperative vertical or torsional diplopia in primary position. The secondary outcome was induced vertical deviation in affected side gaze. Results A total of 69 patients met inclusion criteria: 32 with abducens nerve palsy and 37 with esotropic Duane Syndrome. Vertical alignment changed in both hyper- and hypotropic directions. Median pre- and postoperative vertical deviation in primary gaze was 1.1Δ (10th-90th percentile, 0Δ-6Δ hypertropia) and 0.4Δ (10th-90th percentile, 6Δ hypotropia to 8 Δ hypertropia), respectively. Postoperative vertical diplopia occurred in 7%, including 4 of 49 treated with loop myopexy (8%), 1 of 13 without augmentation (8%), and 0 of 7 treated with sclera-fixated augmentation. All but one was successfully treated with prism or secondary surgery. Intorsional change predominated, but no patient had torsional diplopia post adjustment. Vertical misalignment in affected side gaze increased from 19% to 45% after SRT (P = 0.01). Conclusions In this largest-to-date review of patients treated with SRT, with or without MR recession, no patient developed persistent torsional diplopia, while 7% developed symptomatic vertical diplopia in primary position, similar to the reported incidence after balanced vertical rectus transposition. Vertical misalignment in affected side gaze increased, however fusion is already limited by unresolved esotropia in this field.
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transposition procedures in Duane retraction Syndrome
Journal of Aapos, 2019Co-Authors: Jefferson J Doyle, David G. HunterAbstract:Duane retraction Syndrome, or Duane Syndrome (DS), is one of several congenital cranial dysinnervation disorders. Patients present with limited horizontal eye movement(s) and globe retraction with eyelid fissure narrowing on attempted adduction due to co-contraction of the lateral and medial rectus muscles in one or both eyes. Various surgical approaches have been proposed to improve binocular alignment, reduce head turn, and minimize undesirable up- or downshoots in DS. Transposition procedures are one such approach, and a number of techniques have been described. These may involve one or both vertical rectus muscles and may or may not include full or partial disinsertion of the rectus muscle(s) from the insertion. Options involving both vertical rectus muscles include full vertical rectus transposition (VRT), partial VRT, rectus muscle union, and other modifications to be discussed. Options involving one vertical rectus muscle include superior rectus transposition (SRT) and inferior rectus transposition (IRT). The effectiveness of any transposition procedure may be enhanced with augmentation (posterior fixation) sutures, resection of the transposed muscle(s), and/or simultaneous weakening of the ipsilateral medial rectus muscle. This review discusses the indications, strengths, weaknesses, and other considerations of these approaches within the context of DS. Since the majority of DS cases are unilateral and most have the esotropic form, this will be the main focus of the review, although other forms will also be discussed.
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anomalous vertical deviations in attempted abduction occur in the majority of patients with esotropic Duane Syndrome
American Journal of Ophthalmology, 2018Co-Authors: Soolienah Rhiu, David G. Hunter, Suzanne M Michalak, Warachaya PhanphrukAbstract:Purpose To describe a phenomenon, depression in attempted abduction, not previously recognized as a feature of Duane Syndrome (DS). Design Retrospective, observational case series. Methods Setting : Institutional practice. Patient Population : Patients diagnosed with esotropic DS at Boston Children's Hospital from 2002 to 2015. Patients with clinical photographs documenting horizontal gaze were included. Patients with prior strabismus surgery were excluded. Observation Procedures : Patients were classified into 3 groups according to their vertical eye position in attempted abduction: midline group, depression group, and elevation group. Group assignment was performed by 3 independent ophthalmologists. Baseline characteristics, eye movement, and ocular deviation were compared among the 3 groups. Main Outcome Measures : Horizontal and vertical deviation on attempted abduction in the DS eye. Results Depression in attempted abduction was present in 74 of 113 unilateral patients (66%) and 18 of 42 gradable eyes (43%) of bilateral patients. Abduction limitation was significantly less severe in the midline group (median: -3.0) than in the depression group (median: -4.0) (P = .01). Vertical deviation in attempted abduction was more severe in the elevation group than in the depression group (P = .003). Conclusions Depression of the eye in attempted abduction has not been widely described, yet it is present in the majority of DS patients. It is more likely to occur with more severe abduction limitation. This phenomenon is likely another form of dysinnervation in DS, the result either of anomalous vertical rectus muscle activation or asymmetric lateral rectus muscle innervation during attempted abduction. Awareness of vertical deviation in attempted abduction may facilitate surgical planning in affected patients.
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Duane Syndrome with prominent oculo auricular phenomenon
Journal of Aapos, 2017Co-Authors: David G. Hunter, Aubrey L GilbertAbstract:Duane Syndrome is a congenital cranial dysinnervation disorder involving absent or anomalous innervation of the lateral and medial rectus muscles that is sometimes associated with other manifestations of dysinnervation. We describe a patient with right esotropic Duane Syndrome with a long-standing retroauricular tugging sensation in right gaze who was noted to have prominent ipsilateral oculo-auricular phenomenon, representing either abnormal enhancement of existing innervation or an uncommon dysinnervation. After successful strabismus surgery the tugging sensation improved but the phenomenon could still be elicited.
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superior rectus transposition vs medial rectus recession for treatment of esotropic Duane Syndrome
JAMA Ophthalmology, 2014Co-Authors: Shiqiang Yang, Linda R Dagi, David G. Hunter, Sarah MackinnonAbstract:Importance 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 Participants Retrospective 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. Results The 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 Relevance The 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.
Federico G. Velez - One of the best experts on this subject based on the ideXlab platform.
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pathologic study of supernumerary orbital band in type i Duane Syndrome
Ocular Oncology and Pathology, 2019Co-Authors: Muhammad Hassaan Ali, Federico G. Velez, Stacy L Pineles, Anika Tandon, Ben J GlasgowAbstract:Background/aims Accessory orbital bands are relatively rare and very few reports detail histopathology. Cases in the literature describe the composition of the bands as muscular and/or fibrous. The composition of the supernumerary band lying deep in the medial rectus muscle in a patient with type I Duane Syndrome was investigated. Methods Histochemical stains were used in conjunction with polarized light for differentiating compressed collagen from muscle. Immunohistochemistry was used for verification of the presence of muscle. Results Compressed collagen appeared red using Masson trichrome staining. Collagen was positively identified by illumination with polarized light on several stains including the underutilized Sirius red dye. Conclusions The findings of dense collagen fibers in the fibrotic band with focal striated muscle correlated with the restrictive strabismus. In concert with other cases in the literature, it is proposed that the fibrous bands are generally associated with restrictive strabismus. Bands that are muscular may or may not be associated with strabismus. Special techniques are needed to positively identify compressed collagen.
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Management of surgical overcorrections following surgery for Duane Syndrome with esotropia in primary position
Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 2018Co-Authors: Federico G. Velez, Stacy L PinelesAbstract:Summary Surgery for esotropic Duane Syndrome may result in overcorrections. Managing these overcorrections can be challenging. We describe the most common over-correction scenarios and recommendations for their surgical management.
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accessory fibrotic lateral rectus muscles in exotropic Duane Syndrome with severe retraction and upshoot
Journal of Aapos, 2015Co-Authors: Stacy L Pineles, Federico G. VelezAbstract:FIGURE 1. Final position of lateral rectus (LR) and accessory bands. A 3.5-year-old boy presented at the University of California Los Angeles–Olive View Hospital with abnormal eye movements present since birth. His parents noticed that his left eye always appeared smaller than his right eye and that he had a right head turn. On examination, the patient demonstrated a 5 right head turn. In forced primary position, he had an exotropia of 6. He had 2 limitation to adduction and abduction and13 overelevation in adduction (upshoot) in the left eye. The decision was made to perform surgery consisting of a lateral rectus recession with Y-splitting for presumed exotropic Duane Syndrome with a significant upshoot. Preoperative forced duction testing revealed moderate restriction to adduction and no restriction to abduction. The surgical video demonstrates the presence of 2 accessory bands posterior to the lateral rectus muscle. All 3 structures (the lateral rectus and the 2 accessory bands) were recessed to 17 mm from the limbus in a V-shaped configuration (Figures 1 and 2). At postoperative month 1, the patient was orthotropic in primary position, and his upshoot had resolved. His adduction improved to 1 but his abduction worsened to 3. First reported in 1893 by Nussbaum, accessory muscles have been well described in disorders such as Duane Syndrome and congenital fibrosis of the extraocular muscles. They should be suspected in patients with atypical patterns of restrictive strabismus, globe retraction in directions other than adduction, or in patients with severe upor downshoots. Lueder described 3 types of accessory bands in his 2002 review: (1) structures arising from extraocular muscles and inserting in abnormal locations, (2) fibrous
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assessment of torsion after superior rectus transposition with or without medial rectus recession for Duane Syndrome and abducens nerve palsy
Journal of Aapos, 2014Co-Authors: Federico G. Velez, Erica Oltra, Sherwin J Isenberg, Stacy L PinelesAbstract:Background Superior rectus transposition with or without medial rectus recession has been advocated for the treatment of abducens nerve palsy and esotropic Duane Syndrome. Early reports have focused mainly on postoperative ocular alignment, but there is concern that superior rectus transposition may induce torsional misalignment. The purpose of this study was to evaluate torsional outcomes after superior rectus transposition surgery using prospective preoperative and postoperative torsional assessments. Methods Prospective measurements were performed on all patients undergoing superior rectus transposition. Preverbal infants were assessed using fundus torsion evaluating the position of the fovea relative to the optic nerve; older children/adults underwent double Maddox rod (DMR) assessment of torsion. Results A total of 11 subjects met the study inclusion criteria. The etiology of strabismus was an abducens nerve palsy (n = 7) or Duane Syndrome (n = 4). For the subjects evaluated by fundus torsion (n = 4), there was no significant change in torsion for 3 (75%). For those subjects undergoing DMR (n = 7), there was a significant change in subjective torsion (4.7 ± 3.8°excyclotorsion vs 0.0° ± 5.0° excyclotorsion; P = 0.004). Esotropic deviation improved significantly for all subjects (39 Δ ± 23 Δ vs 6.5 Δ ± 13 Δ ; P = 0.001) and no significant mean vertical deviation postoperatively, although 1 patient had a clinically significant postoperative hypertropia measuring 14 Δ . Abduction also improved significantly (−4.2 ± 0.9 vs −2.8 ± 1, P = 0.0001). Conclusions In this patient series, superior rectus transposition with medial rectus recession did not have clinically significant induction of torsional diplopia as a result of the procedure.
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adjustable augmented rectus muscle transposition surgery with or without ciliary vessel sparing for abduction deficiencies
Strabismus, 2014Co-Authors: Karen Hendler, Joseph L Demer, Stacy L Pineles, Dawn Yang, Federico G. VelezAbstract:AbstractBackground: Vertical rectus transposition (VRT) is useful in abduction deficiencies. Posterior fixation sutures enhance the effect of VRT, but usually preclude the use of adjustable sutures. Augmentation of VRT by resection of the transposed muscles allows for an adjustable technique that can reduce induced vertical deviations and overcorrections.Methods: We retrospectively reviewed the records of all patients undergoing adjustable partial or full tendon VRT augmented by resection of the transposed muscles. Ciliary vessels were preserved in most of the patients by either splitting the transposed muscle or by dragging the transposed muscle without disrupting the muscle insertion.Results: Seven patients with abducens palsy and one with esotropic Duane Syndrome were included. Both vertical rectus muscles were symmetrically resected by 3–5 mm. Preoperative central gaze esotropia of 30.6 ± 12.9Δ (range, 17–50Δ) decreased to 10.6 ± 8.8Δ (range, 0–25Δ) at the final visit (p = 0.003). Three patients requi...
Stacy L Pineles - One of the best experts on this subject based on the ideXlab platform.
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pathologic study of supernumerary orbital band in type i Duane Syndrome
Ocular Oncology and Pathology, 2019Co-Authors: Muhammad Hassaan Ali, Federico G. Velez, Stacy L Pineles, Anika Tandon, Ben J GlasgowAbstract:Background/aims Accessory orbital bands are relatively rare and very few reports detail histopathology. Cases in the literature describe the composition of the bands as muscular and/or fibrous. The composition of the supernumerary band lying deep in the medial rectus muscle in a patient with type I Duane Syndrome was investigated. Methods Histochemical stains were used in conjunction with polarized light for differentiating compressed collagen from muscle. Immunohistochemistry was used for verification of the presence of muscle. Results Compressed collagen appeared red using Masson trichrome staining. Collagen was positively identified by illumination with polarized light on several stains including the underutilized Sirius red dye. Conclusions The findings of dense collagen fibers in the fibrotic band with focal striated muscle correlated with the restrictive strabismus. In concert with other cases in the literature, it is proposed that the fibrous bands are generally associated with restrictive strabismus. Bands that are muscular may or may not be associated with strabismus. Special techniques are needed to positively identify compressed collagen.
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Management of surgical overcorrections following surgery for Duane Syndrome with esotropia in primary position
Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus, 2018Co-Authors: Federico G. Velez, Stacy L PinelesAbstract:Summary Surgery for esotropic Duane Syndrome may result in overcorrections. Managing these overcorrections can be challenging. We describe the most common over-correction scenarios and recommendations for their surgical management.
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accessory fibrotic lateral rectus muscles in exotropic Duane Syndrome with severe retraction and upshoot
Journal of Aapos, 2015Co-Authors: Stacy L Pineles, Federico G. VelezAbstract:FIGURE 1. Final position of lateral rectus (LR) and accessory bands. A 3.5-year-old boy presented at the University of California Los Angeles–Olive View Hospital with abnormal eye movements present since birth. His parents noticed that his left eye always appeared smaller than his right eye and that he had a right head turn. On examination, the patient demonstrated a 5 right head turn. In forced primary position, he had an exotropia of 6. He had 2 limitation to adduction and abduction and13 overelevation in adduction (upshoot) in the left eye. The decision was made to perform surgery consisting of a lateral rectus recession with Y-splitting for presumed exotropic Duane Syndrome with a significant upshoot. Preoperative forced duction testing revealed moderate restriction to adduction and no restriction to abduction. The surgical video demonstrates the presence of 2 accessory bands posterior to the lateral rectus muscle. All 3 structures (the lateral rectus and the 2 accessory bands) were recessed to 17 mm from the limbus in a V-shaped configuration (Figures 1 and 2). At postoperative month 1, the patient was orthotropic in primary position, and his upshoot had resolved. His adduction improved to 1 but his abduction worsened to 3. First reported in 1893 by Nussbaum, accessory muscles have been well described in disorders such as Duane Syndrome and congenital fibrosis of the extraocular muscles. They should be suspected in patients with atypical patterns of restrictive strabismus, globe retraction in directions other than adduction, or in patients with severe upor downshoots. Lueder described 3 types of accessory bands in his 2002 review: (1) structures arising from extraocular muscles and inserting in abnormal locations, (2) fibrous
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assessment of torsion after superior rectus transposition with or without medial rectus recession for Duane Syndrome and abducens nerve palsy
Journal of Aapos, 2014Co-Authors: Federico G. Velez, Erica Oltra, Sherwin J Isenberg, Stacy L PinelesAbstract:Background Superior rectus transposition with or without medial rectus recession has been advocated for the treatment of abducens nerve palsy and esotropic Duane Syndrome. Early reports have focused mainly on postoperative ocular alignment, but there is concern that superior rectus transposition may induce torsional misalignment. The purpose of this study was to evaluate torsional outcomes after superior rectus transposition surgery using prospective preoperative and postoperative torsional assessments. Methods Prospective measurements were performed on all patients undergoing superior rectus transposition. Preverbal infants were assessed using fundus torsion evaluating the position of the fovea relative to the optic nerve; older children/adults underwent double Maddox rod (DMR) assessment of torsion. Results A total of 11 subjects met the study inclusion criteria. The etiology of strabismus was an abducens nerve palsy (n = 7) or Duane Syndrome (n = 4). For the subjects evaluated by fundus torsion (n = 4), there was no significant change in torsion for 3 (75%). For those subjects undergoing DMR (n = 7), there was a significant change in subjective torsion (4.7 ± 3.8°excyclotorsion vs 0.0° ± 5.0° excyclotorsion; P = 0.004). Esotropic deviation improved significantly for all subjects (39 Δ ± 23 Δ vs 6.5 Δ ± 13 Δ ; P = 0.001) and no significant mean vertical deviation postoperatively, although 1 patient had a clinically significant postoperative hypertropia measuring 14 Δ . Abduction also improved significantly (−4.2 ± 0.9 vs −2.8 ± 1, P = 0.0001). Conclusions In this patient series, superior rectus transposition with medial rectus recession did not have clinically significant induction of torsional diplopia as a result of the procedure.
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adjustable augmented rectus muscle transposition surgery with or without ciliary vessel sparing for abduction deficiencies
Strabismus, 2014Co-Authors: Karen Hendler, Joseph L Demer, Stacy L Pineles, Dawn Yang, Federico G. VelezAbstract:AbstractBackground: Vertical rectus transposition (VRT) is useful in abduction deficiencies. Posterior fixation sutures enhance the effect of VRT, but usually preclude the use of adjustable sutures. Augmentation of VRT by resection of the transposed muscles allows for an adjustable technique that can reduce induced vertical deviations and overcorrections.Methods: We retrospectively reviewed the records of all patients undergoing adjustable partial or full tendon VRT augmented by resection of the transposed muscles. Ciliary vessels were preserved in most of the patients by either splitting the transposed muscle or by dragging the transposed muscle without disrupting the muscle insertion.Results: Seven patients with abducens palsy and one with esotropic Duane Syndrome were included. Both vertical rectus muscles were symmetrically resected by 3–5 mm. Preoperative central gaze esotropia of 30.6 ± 12.9Δ (range, 17–50Δ) decreased to 10.6 ± 8.8Δ (range, 0–25Δ) at the final visit (p = 0.003). Three patients requi...
Linda R Dagi - One of the best experts on this subject based on the ideXlab platform.
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incidence of symptomatic vertical and torsional diplopia after superior rectus transposition for esotropic Duane Syndrome and abducens nerve palsy
Journal of Aapos, 2020Co-Authors: Anna G Escuder, Linda R Dagi, David G. Hunter, Melanie Kazlas, Gena Heidary, David ZurakowskiAbstract:Purpose To report the incidence of symptomatic vertical and torsional diplopia after superior rectus transposition (SRT) for esotropic Duane Syndrome and abducens nerve palsy. Methods The medical records of patients with esotropic Duane Syndrome or abducens nerve palsy seen at Boston Children's Hospital (2006-2018) and treated with unilateral SRT with or without augmentation was performed. The primary outcome was incidence of postoperative vertical or torsional diplopia in primary position. The secondary outcome was induced vertical deviation in affected side gaze. Results A total of 69 patients met inclusion criteria: 32 with abducens nerve palsy and 37 with esotropic Duane Syndrome. Vertical alignment changed in both hyper- and hypotropic directions. Median pre- and postoperative vertical deviation in primary gaze was 1.1Δ (10th-90th percentile, 0Δ-6Δ hypertropia) and 0.4Δ (10th-90th percentile, 6Δ hypotropia to 8 Δ hypertropia), respectively. Postoperative vertical diplopia occurred in 7%, including 4 of 49 treated with loop myopexy (8%), 1 of 13 without augmentation (8%), and 0 of 7 treated with sclera-fixated augmentation. All but one was successfully treated with prism or secondary surgery. Intorsional change predominated, but no patient had torsional diplopia post adjustment. Vertical misalignment in affected side gaze increased from 19% to 45% after SRT (P = 0.01). Conclusions In this largest-to-date review of patients treated with SRT, with or without MR recession, no patient developed persistent torsional diplopia, while 7% developed symptomatic vertical diplopia in primary position, similar to the reported incidence after balanced vertical rectus transposition. Vertical misalignment in affected side gaze increased, however fusion is already limited by unresolved esotropia in this field.
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adjustable graded augmentation of superior rectus transposition for treatment of abducens nerve palsy and Duane Syndrome
Journal of Aapos, 2020Co-Authors: Linda R Dagi, Abdelrahman M ElhusseinyAbstract:Purpose To report the results of adjustable graded augmentation of superior rectus transposition, a novel modification of superior rectus transposition (SRT) designed to reduce postoperative vertical or torsional diplopia. Methods The medical records of patients who underwent adjustable graded augmentation of SRT with or without adjustable medial rectus recession (MRc) from February 2017 to December 2019 were reviewed retrospectively. A Mendez ring was used to monitor torsional change after transposition of the superior rectus muscle to the lateral rectus muscle and after sequential placement of 2 or 3 augmentation sutures by superior rectus–lateral rectus loop myopexy. If excessive mechanical intorsion was induced, the responsible augmentation suture was severed intraoperatively. If torsional or vertical diplopia was noted after recovery, the distal-most augmentation suture was cut. Exotropia was managed by severing the distal-most augmentation suture or by medial rectus adjustment. Results A total of 8 patients who underwent adjustable graded augmentation of SRT were included (6 using the 3-suture technique): 3 for esotropic Duane Syndrome, 2 for abducens nerve palsy, 1 for Moebius Syndrome, and 2 for combined trochlear and abducens nerve palsies. Of the 8 patients, 4 had prior strabismus surgery, and 1 patient had previously undergone treatment with botulinum toxin. Severing one augmentation suture in 3 cases resolved vertical (n = 2) or torsional (n = 1) diplopia and consecutive exotropia (n = 2), resulting in excellent alignment and reduction of torticollis to ≤4° in 7 cases. The technique proved insufficient in 1 patient, who had undergone 3 prior strabismus procedures. Conclusions In this study cohort, adjustable graded augmentation of SRT effectively managed the risk of postoperative vertical or torsional diplopia.
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superior rectus transposition vs medial rectus recession for treatment of esotropic Duane Syndrome
JAMA Ophthalmology, 2014Co-Authors: Shiqiang Yang, Linda R Dagi, David G. Hunter, Sarah MackinnonAbstract:Importance 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 Participants Retrospective 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. Results The 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 Relevance The 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.
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superior rectus transposition and medial rectus recession for Duane Syndrome and sixth nerve palsy
Archives of Ophthalmology, 2012Co-Authors: Reshma A Mehendale, Suzanne Johnston, Linda R Dagi, Carolyn Wu, Danielle Ledoux, David G. HunterAbstract:Objective To describe our results using augmented temporal superior rectus transposition (SRT) with adjustable medial rectus muscle recession (MRc) for treatment of Duane Syndrome and sixth nerve palsy. Methods Retrospective surgical case review of patients undergoing SRT. Preoperative and postoperative orthoptic measurements were recorded. Minimum follow-up was 6 weeks. Main outcome measures included the angle of esotropia in the primary position and the angle of head turn. Secondary outcomes included duction limitation, stereopsis, and new vertical deviations. Results The review identified 17 patients: 10 with Duane Syndrome and 7 with sixth nerve palsy. Combining SRT with MRc improved esotropia from 44 to 10 prism diopters (P Conclusions Superior rectus transposition allows for the option of simultaneous MRc in patients with severe abduction imitation who require transposition surgery. Combining SRT and MRc improved esotropia, head position, abduction limitation, and stereopsis without inducing torsional diplopia.
Arthur L. Rosenbaum - One of the best experts on this subject based on the ideXlab platform.
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medial rectus recession after vertical rectus transposition in patients with esotropic Duane Syndrome
Archives of Ophthalmology, 2011Co-Authors: Stacy L Pineles, Arthur L. Rosenbaum, Ramesh Kekunnaya, Federico G. VelezAbstract:Objective To describe preoperative characteristics and postoperative results among patients with esotropic Duane Syndrome who underwent vertical rectus transposition with vs without subsequent medial rectus recession (MRR). Methods Clinical records were compared of patients with esotropic Duane Syndrome who underwent vertical rectus transposition with (study group) vs without (control group) subsequent MRR. Results Twenty-three study group members and 26 control group members were identified. Preoperative characteristics that differed between groups were the mean (SD) primary position deviation (20 [7] prism diopters of esotropia [ΔET] for the study group vs 15 [9] ΔET for the control group, P = .002) and the mean (SD) adduction deviation (1.4 [4.0] ΔET for the study group vs 2.5 [4.0] Δ exotropia for the control group, P = .04). Forced duction testing (FDT) revealed greater restriction to abduction (17 [7]° for the study group vs 23 [6]° for the control group, P = .002). After vertical rectus transposition, study group members had significantly greater mean (SD) ET (16 [7] ΔET vs 0.4 [0.6] ΔET for the control group, P Conclusions Risk factors for requiring MRR after vertical rectus transposition include greater ET in the primary position and in the adducting field of gaze, as well as greater restriction to abduction on intraoperative FDT. Postoperative results of patients who required MRR were similar to those of patients who did not require MRR.
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Vertical rectus muscle transposition for bilateral Duane Syndrome.
Journal of American Association for Pediatric Ophthalmology and Strabismus, 2005Co-Authors: Michelle T. Britt, Federico G. Velez, Guillermo Velez, Arthur L. RosenbaumAbstract:Background: Augmented transposition of the superior and inferior rectus muscles to the lateral rectus muscle is effective surgical treatment for esotropia in unilateral Duane Syndrome. Medial rectus muscle recession in bilateral Duane Syndrome may increase the risk of consecutive exotropia and cause limitation to adduction postoperatively. Vertical rectus muscle transposition may be useful in bilateral Duane Syndrome with esotropia. Methods: We undertook a retrospective review of 11 patients with bilateral Duane Syndrome and esotropia in primary position. All patients had vertical rectus muscle transpositions. Six patients had unilateral vertical rectus transpositions (2 eyes with and 4 without suture augmentation). Twelve eyes from 7 children (2 unilateral and 5 bilateral) had transpositions augmented with posterior fixation sutures. Posterior fixation suture were added to large deviations in patients without prior medial rectus recessions. Results: The preoperative esotropia at distance was 22.8 ± 6.3 prism diopters (PD). It reduced to 2.0 ± 6.7 PD postoperatively. ( P P Conclusion: Vertical rectus muscle transposition in patients with bilateral Duane Syndrome and esotropia is an effective procedure to improve ocular alignment and motility while preserving adduction.
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surgical management of severe cocontraction globe retraction and pseudo ptosis in Duane Syndrome
Journal of Aapos, 2004Co-Authors: Michelle T. Britt, Scott R Foster, Federico G. Velez, Neepa Thacker, Deborah Alcorn, Arthur L. RosenbaumAbstract:Abstract Background Correction of severe cocontraction and pseudo-ptosis present unique surgical challenges in patients with Duane Syndrome. Methods We report four Duane Syndrome patients with esotropia in primary position, poor abduction, and severe cocontraction causing limitation to adduction, globe retraction, and pseudo-ptosis. All were treated with partial tendon transposition of the vertical rectus muscles augmented with Foster fixation sutures and surgical weakening of the ipsilateral lateral rectus muscle. One patient had a large recession of the lateral rectus muscle, and in three patients, the lateral rectus muscle was inactivated by removing from the globe and attaching its insertion to the lateral orbital wall. Results Postoperatively, all patients were aligned within eight prisms diopters of orthotropia, had no face turn, and improved adduction and abduction. The two patients who had restriction to abduction on intraoperative forced ductions also had residual esotropia in primary position and underwent recession of the ipsilateral medial rectus muscle as a second procedure. Postoperative binocular single visual field was enlarged by 56 to 500% in the three patients who were tested preoperatively and postoperatively. Globe retraction and cocontraction were markedly relieved. Palpebral fissure widened 1.0 and 6.0 mm in two patients who had preoperative and postoperative measurements. Conclusion In Duane Syndrome patients, severe cocontraction, globe retraction, and limitation to adduction may improve if the lateral rectus muscle is maximally recessed or its insertion is inactivated from the globe. Partial transposition of the vertical rectus muscles augmented with Foster sutures improved the angle of esotropia in primary position and abduction. Medial rectus muscle recession is indicated when the passive forced duction test reveals moderate-to-severe restriction to abduction.
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The efficacy of rectus muscle transposition surgery in esotropic Duane Syndrome and VI nerve palsy
Journal of American Association for Pediatric Ophthalmology and Strabismus, 2004Co-Authors: Arthur L. RosenbaumAbstract:Background: Partial tendon transposition was first described by Hummelshein in 1907. Full tendon transposition was reported by Schillinger in 1959. Recently, full tendon transposition with posterior augmentation was reported by Foster in 1997. I will review current thinking concerning the anatomy and physiology of rectus muscle transposition and present our current clinical experience with this procedure in Duane Syndrome. Methods: A retrospective review of vertical rectus muscle transposition procedures in patients with VI Nerve palsy was performed comparing the postoperative field of single binocular vision, amount of improved abduction, and change in the primary esotropic angle. In addition, a consecutive series of vertical rectus muscle transposition cases for the treatment of esotropic Duane Syndrome is presented, evaluating the improvement and head position, abduction, and reduction of the primary position esotropia. Results: In VI Nerve palsy patients, vertical rectus transposition surgery produces 41° to 71° of binocular visual field with 10° to 21° of binocular field in abduction. In esotropic Duane Syndrome the surgical procedure produces 42° to 66° of binocular field and a correction of approximately 15° of face turn. Variability in the efficacy of the procedure is related to the degree of ipsilateral medial rectus contracture. Conclusion: Vertical rectus transposition with posterior fixation can create a binocular diplopia-free field of 40 to 70 degrees in patients with VI Nerve palsy and about 40 to 65 degrees in patients with Duane Syndrome. Partial rectus muscle transposition is an effective procedure in cases where surgery on multiple rectus muscles has been or will be required. Orbital wall fixation of the lateral rectus muscle is an effective and reversible method to inactivate a lateral rectus muscle and may be useful in cases of Duane Syndrome with marked anomalous innervation and severe cocontraction.
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vertical rectus muscle augmented transposition in Duane Syndrome
Journal of Aapos, 2001Co-Authors: Federico G. Velez, Scott R Foster, Arthur L. RosenbaumAbstract:Abstract Introduction: Reduction or elimination of face turn and esotropia in the primary position while maintaining the largest possible diplopia-free field are the major surgical goals in Duane Syndrome with esotropia. Unsatisfactory postoperative results may occur because of limitation in adduction, poor abduction, or induced vertical deviations. Recent reports have shown enhanced results from rectus muscle transposition techniques when a lateral posterior augmentation fixation is placed. Methods: Preoperative and postoperative data of 2 groups of subjects who had Duane Syndrome with esotropia in primary position and markedly reduced abduction were comparatively analyzed. Group A consisted of subjects who had transposition of both vertical rectus muscles to the lateral rectus muscle with a posterior lateral augmentation suture placed in each transposed muscle. Group B subjects had transposition of both vertical rectus muscles to the lateral rectus muscle without the posterior lateral augmentation suture. Results: A total of 32 subjects in group A and 22 subjects in group B were analyzed. In group A, anomalous head position improved 19.1° ± 10.3° compared with group B subjects who improved 10.6° ± 5.8° ( P P Conclusions: Subjects with Duane Syndrome and esotropia in primary position who had undergone augmented transposition of the vertical rectus muscles obtained improved head position and better alignment in primary position and had a reduction in the incidence of reoperation for undercorrection when compared with similar patients who had undergone vertical rectus muscle transposition without posterior lateral augmentation sutures. (J AAPOS 2001;5:105-13)
