alexa <p>Inferior Oblique Anterior Transposition in the Treatment of Upshoot in Duane Syndrome</p> | OMICS International
ISSN: 2155-9570
Journal of Clinical & Experimental Ophthalmology

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Inferior Oblique Anterior Transposition in the Treatment of Upshoot in Duane Syndrome

Chunhua Sun1 and Ze Wang2*

1Tianjin Eye Hospital, Clinical College of Ophthalmology, Tianjin Medical University, Tianjin Key Lab of Ophthalmology and Visual Science, Tianjin Eye Institute, Tianjin 300020, P. R. China

2Department of Strabismus and Pediatric Ophthalmology, Nanjing South East Eye Hospital, Nanjing 210007, P. R. China

*Corresponding Author:
Ze Wang
Department of Strabismus and Pediatric Ophthalmology
Nanjing South East Eye Hospital, Nanjing 210007, P. R. China
Tel: +8613905173656
E-mail: [email protected]

Received Date: Apr 06, 2016; Accepted Date: June 24, 2016; Published Date: June 27, 2016

Citation: Sun C, Wang Z (2016) Inferior Oblique Anterior Transposition in the Treatment of Upshoot in Duane Syndrome. J Clin Exp Ophthalmol 7:567. doi: 10.4172/2155-9570.1000567

Copyright: © 2016 Sun C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Purpose: We report the procedure of inferior oblique anterior transposition (IOAT) in the treatment of upshoot in patients with Duane retraction syndrome (DRS). Methods: Two patients with DRS underwent surgery for severe up-shoot. For both patients, the inferior oblique (IO) was transposed to the temporal border of IO insertion. Approximately 64 months of periodic follow-ups for Case 1 and 7 months of periodic follow-ups for Case 2 were conducted. Results: After surgery, both patients showed a marked decrease in upshoot without noticeable anti-elevation syndrome. Conclusions: IOAT is an effective procedure in the treatment of significant upshoot in DRS

Introduction

The classical Duane retraction syndrome (DRS) is characterized by limitation of abduction, defective adduction, narrowing of the palpebral fissure and retraction on adduction, widening of the palpebral fissure on attempted abduction, and sometimes retraction accompanied by upshoot or downshoot. Symptoms indicating the need for surgery to treat DRS include significant deviation in the primary position, unacceptable abnormal head position, significant globe retraction, noticeable narrowing of the palpebral fissure, and significant upshoot or downshoot [1-5]. In the present study, we report two cases with upshoot, but no significant deviation was observed in the primary position or the abnormal head posture. We employed the procedure called inferior oblique anterior transposition (IOAT) to treat the upshoot in DRS.

Case 1

The parents of a19-year-old male patient noted that, since his birth, his left eye ran upward when looking to the right. He had no other health problems.

The visual acuity for both his eyes was 20/20. Anterior segments and fundi were normal. Both eyes were basic orthotropic in the primary position. The limitation of left eye abduction was−3 grade, whereas the limitation of adduction was −2 grade. The left eye upshot with adduction and fell behind on right downgaze.

The palpebral fissure and eyeball retraction narrowed on adduction. The palpebral fissure widened on attempted abduction in the left eye. The diagnosis was DRS with upshoot in the left eye (Figures 1 and 2).

clinical-experimental-ophthalmology-alignments-before-surgery

Figure 1: Eye alignments before surgery in Case 1. The left eye upshot as the eyes shifted from the primary position to the right gaze and to the right upgaze.

clinical-experimental-ophthalmology-alignments-after-surgery

Figure 2: Eye alignments after surgery in Case 1. The upshoot on the right disappeared.

The IOAT operation was performed on December 25, 1991. A conjunctival incision was made 8 mm away from the limbus in the inferotemporal region. Inferior oblique (IO) was identified and isolated to the insertion under direct visualization. The tendon was totally clipped with an artery clip, and a 6-0 polyglactin suture was passed through the front border of the muscle temporal to the clip. IO was cut from its attachment point. Then, the anterior border of the cut IO was reattached to the temporal insertion of the inferior rectus. Then, the posterior border was fixed 3mm lateral to its anterior border.

When the patient sat up for inspection at the operation bed, the upshoot was noticeably improved. After 64 months of follow-up appointments, his ocular movement was stable without evident upshoot. The patient was satisfied (Tables 1 and 2).

Left ET22
LHT
  XT16
LHT20
Right
ET25
LHT2
XT8
LHT3
XT16
LHT14
ET20
LHT2
REF XT18
LHT8

Table 1: The deviation (prism diopter, PD) for case 1 before surgery.

Left ET25
LHT2
  XT16
LHT5
Right
ET16
LHT2
XT6 XT18
LHT2
ET20
LHT1
REF XT18
LHT1

Table 2: The deviation (prism diopter, PD) for case 1 after surgery.

Case 2

A 23-year-old female sought treatment for an intermittent upward deviation of her left eye, which had existed since birth. She had no prior strabismus surgery. She denied any eye injury and she was otherwise in good health (Tables 3 and 4).

Left ET20
LHT6
  XT26
LHT24
Right
ET20
LHT6
XT10
LHT8
XT18
LHT2
ET20
LHT6
REF XT26
LHT16

Table 3: The deviation (prism diopter, PD) for case 2 before surgery.

Left ET20
LHT2
  XT20
LHT8
Right
ET20
LHT2
XT8
LHT2
XT18
LHT2
ET20
LHT2
REF XT22
LHT2

Table 4: The deviation (prism diopter, PD) for case 2 after surgery.

The best corrected vision was 20/20 in the right eye and 20/25 in the left eye. Anterior segments and fundi were normal. The left eye upshot on the right gaze and was limited on both adduction (−4 grade) and abduction (−3 grade). The palpebral fissure widened on attempted abduction but narrowed on adduction with eye retracted in the left eye. The head posture was unremarkable. She was diagnosed with DRS with upshoot in the left eye (Figure 3).

clinical-experimental-ophthalmology-hypertropia

Figure 3: Eye alignments before surgery. The left eye has hypertropia in the primary position and upshoot on right gaze.

The operation was performed on July 9, 2010. IO was disinserted from its attachment point. The anterior border of the unattached IO was also reattached to the temporal insertion of the inferior rectus, and the posterior border of the muscle was fixed 3mm temporal to its anterior border, same as that in Case 1. When the procedure was finished in the operating room, the ocular movement was tested to verify that the upshoot was gone. After 7 months of follow-up appointments, upshoot was remarkably improved (Figure 4). The patient was satisfied.

clinical-experimental-ophthalmology-upshoot

Figure 4: Eye alignments after surgery. The upshoot was noticeably improved. No significant deviation in the primary position.

Discussion

On the basis of the clinical characteristics described by Kraft [6], upshoots and downshoots in DRS were classified as mechanical, innervational, or both. The mechanical type showed abrupt upshoot and downshoot, and minimal hypertropia in the primary position. The innervational type showed only gradual upshoot or downshoot and greater hypertropia in the primary position. Thus, both patients in this case study had innervational upshoot.

In many cases of DRS, upshoot is associated with globe retraction and narrowing of the palpebral fissure on attempted abduction. Ysplitting of the lateral rectus muscle and recession of the horizontal rectus muscles are extremely effective in the treatment of significant upshoot and primary strabismus associated with globe retraction in DRS [6,7]. However, in our cases, the patients had no significant horizontal deviation in the primary position. We planned recessing both horizontal rectus muscles and Y-splitting of the lateral rectus if IOAT had no effect on the upshoot. However, transposition inspection during operation showed that the upshoot was markedly improved, which indicated that IO played a role in upshoot. At the same time, weakening the IO has only a slight effect on the horizontal deviation in the primary position [8], as observed in these two patients.

Anterior and nasal transposition (ANT) [9] of IO was reported to be effective in treating upshoot in DRS. In ANT, the IO was transposed to the nasal and posterior to the nasal border of IR to avoid anti-elevation syndrome. However, for one case with downshoot, ANT made downshoot worse [9]. Anti-elevation syndrome is a recognized risk of IO anteriorization [9]. Kushner concluded that elevation during abduction might be limited if the anteriorization is more than 1 mm away from the inferior rectus insertion and if the new insertion spreads out laterally [9]. This limitation occurs less frequently if the IO muscle is reinserted close to the temporal border of the insertion of the inferior rectus [10,11]. We transposed the IO just to the temporal of the inferior rectus insertion, placing the anterior and posterior borders 3 mm apart, and did not find limitation of elevation. However, the follow up period of case 2 was only 7 months. A longer term still is needed for the evaluation. By transposing the IO temporal to the inferior rectus insertion and placing the anterior and posterior borders 3 mm apart, the depressor effect of the IO in the primary position may be reduced. However, the follow-up time of Case 2 was only 7 months. A longer term is still needed for the evaluation. As a result, after the operation, no hypotropia in the primary position nor significant deficiency in ipsilateral elevation is observed [12,13]. The IO was reattached in the same location for both patients in our report and they did not show downshoot, primary position hypotropia, or noticeable anti-elevation syndrome after surgery.

In summary, we described how IOAT can treat the DRS with upshoot in patients without evident horizontal deviation in the primary position. A larger sample with longer follow-up period can be designed in the future to observe the benefits of the procedure.

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  1. Connor
    Posted on Jul 18 2016 at 6:14 pm
    The article discussed a new treatment: IO anterior transposition for upshoot in Duane syndrome. The authors report a significant decrease in upshoot in two patients, after undergoing IOAT surgery. The article promotes clinical application of inferior oblique anterior transposition (IOAT) in the treatment of severe upshoot in patients suffering from Duane syndrome.
 

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