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Duane Syndrome Treatment · 2016-10-19 · Duane Syndrome Treatment The surgery aims to : •...
Transcript of Duane Syndrome Treatment · 2016-10-19 · Duane Syndrome Treatment The surgery aims to : •...
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Ioannis C. Asproudis
Associate Professor of Ophthalmology
University of Ioannina
Duane
Syndrome Treatment
HAPOS Thessaloniki, 7th Nov. 2015
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Duane Syndrome Treatment
• Refractive error correction
• Amblyopia treatment
• Accommodative component
• Surgery
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Duane Syndrome Treatment
The surgery aims to :
• Reduce the compensatory head posture
• Reduce the angle of an esotropia (or less commonly an
exotropia) in the primary position
• Eliminate any upshoots or downshoots
• Reduce the retraction of the globe
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Duane Syndrome Treatment
Preoperative assessment
• Is fusion present, and if so where ?
• Does the patient fix with the Duane or non-Duane eye?
• Perform cover testing (with and without a
compensatory head posture) in the primary position,
elevation, depression and lateral gaze
• Examine ocular rotations
• Degree of abduction
• Increase of abduction in elevation or depression
• Cocontraction of lateral rectus on attempted adduction
• Upshoot or downshoot in adduction
• Y-pattern
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Unilateral Esotropic Duane
• Unilateral medial rectus recession
• Bilateral medial rectus recession
• Unilateral recession and resection
• Vertical rectus muscle transposition
• Superior rectus muscle transposition ± MRc
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Unilateral Esotropic Duane
Unilateral MR recession
• Deviation ≤ 20∆ (primary position)
• Forced duction test (FDT) Contraction MR recession
• MR recession ≤ 6mm
• Iatrogenic adduction limitation
• diplopia
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Unilateral Esotropic Duane
Bilateral MR recession
( Symmetric or asymmetric)
• Large angle esotropia
• Severe globe retraction
• Contracture of the affected MR muscle
(create the fixation duress)
• Sachdeva V et al JAAPOS 2012
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Unilateral Esotropic Duane
Unilateral recession – resection
• Esotropia in primary gaze at least 15∆
• Mild globe retraction in adduction (<33% narrowing)
• Clinically normal adduction
• Substantial limitation of abduction
• Minimal or no upshoot or downshoot phenomena
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Unilateral Esotropic Duane
Vertical muscle transposition augmented with lateral fixation
• Cobin MH. Br J Ophthalmol 1974
• Molarte AB, Rosenbaum AL. J Ped Ophthalmol Strabismus 1990
• Foster RS JAAPOS 1997
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Reoperations following vertical rectus
muscle transposition
Residual esotropia
• Lack of abducting rector force
and/or
• Excess tonus or contracture of the
ipsilateral medial rectus muscle
(length –tension curve)
• Large angle esotropia
• Greater restriction to abduction on
intraoperative FDT
Exotropia (diplopia)
• Excess tension or restriction
• Weak ipsilateral medial rectus
• Ipsilateral lateral rectus stiffness
In cases of VRT + MRC
• Preop less esotropia or exotropia
in adduction
• Unrecognized accommodative
component
• Slipped MR muscle
• Morad Y et al JAAPOS 2001
• Velez FG et al JAAPOS 2012
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Reoperations following VRT
Induced vertical deviation
(13-30%)
(full tendon transposition)
• Intraoperative monitoring
of torsion
• Holmes J. et al JAAPOS 2012
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Superior rectus transposition (± MR Recession)
• Profound abduction limitation
• Simultaneous contraction of MR
• Johnston SC et al. I0VS 2006
• Mehendale RA et al. Arch Ophthalmol 2012
• Yang S et al Jama Ophthalmol 2014
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Unilateral Esotropic Duane
Plication augmentation of the modified Hummelsheim
procedure
• Correction of very large
esotropias
• Better preservation of the
blood supply to the anterior
segment
• Kinori M. et al. JAAPOS 2015
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Unilateral Exotropic Duane
Associated with type II or III
(Tightness of the lateral rectus muscle)
• Ipsilateral lateral rectus recession (8mm) for
deviation ≤ 20∆
• Bilateral lateral rectus recession for deviation > 20∆
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Surgical treatment of globe retraction
Recession of both horizontal muscles
• Orthotropia in primary position
recess equally
• Esotropia in primary position
recess MR more
• Exotropia on primary position
recces LR more only
• Sprunger D. JAAPOS 1997
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Surgical treatment of upshoot and downshoot
on adduction
• Y-splitting of the lateral rectus with or
without recession
• Attachment of the lateral rectus
muscle to lateral canthal tendon or
fixation to the periosteum of the
lateral orbital wall
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Bilateral Duane Syndrome
Preffered surgical options
• Bilateral esotropic Duane (15%)
bilateral medial rectus recessions
• Bilateral exotropic Duane
unilateral or bilateral lateral rectus recession
• Y-splitting may be necessary
• Bilateral vertical rectus transposition
• Sachdeva V. et al JAAPOS 2012
• Theodorou N. et al Eye 2013
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………“ The surgical approach to patient with
Duane syndrome must be individualized based
on the amount of ocular deviation, abnormal
head position, associated globe retraction and
overshoots ”……….
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Thank You