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Original Investigation |

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

Shiqiang Yang, MD1,2; Sarah MacKinnon, MSc, OC(C)1; Linda R. Dagi, MD1,3; David G. Hunter, MD, PhD1,3
[+] Author Affiliations
1Department of Ophthalmology, Boston Children’s Hospital, Boston, Massachusetts
2now with Department of Strabismus and Pediatric Ophthalmology, Tianjin Eye Hospital, Tianjin Eye Institute, Clinical College of Ophthalmology, Tianjin, China
3Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
JAMA Ophthalmol. 2014;132(6):669-675. doi:10.1001/jamaophthalmol.2014.358.
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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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Figure 1.
Comparison of Surgical Results of Deviation Angle and Head Turn

A, Deviation angle before surgery and at final follow-up in the superior rectus transposition (SRT) and non-SRT surgical groups. Positive values represent esotropia; error bars, SEM. B, Box-and-whiskers plot of postoperative change of the deviation angle in both surgical groups. C, Box-and-whiskers plot of postoperative change of deviation angle in each surgical subgroup. D, Head turn before and after surgery in the SRT and non-SRT groups. Positive values represent improvement in head turn (in degrees); error bars, SEM. E, Box-and-whiskers plot of postoperative change in head turn in both surgical groups. F, Box-and-whiskers plot of postoperative change of head turn in each surgical subgroup. Unless otherwise indicated, positive values represent the difference between preoperative and final values. In the box-and-whiskers plots, the bottom and top of each box represent the 25th and 75th percentiles (the lower and upper quartiles, respectively); the band near the middle of the box, the 50th percentile (the median). The ends of the whiskers represent the minimum and maximum of all the data. BMR indicates bilateral medial rectus resession; MRc, medial rectus recession; and Δ, prism diopter.aP < .001.bP < .05.cP < .01.

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Figure 2.
Comparison of Limitation of Abduction and Adduction Before and After Surgery

Duction grades range from 0 (full duction) through −4 (eye was able to move to the midline) and −5 (eye approached but was unable to reach the midline). A, Limitation of abduction preoperatively and at final follow-up in the superior rectus transposition (SRT) and non-SRT surgical groups. B, Postoperative improvement of abduction in each surgical subgroup; clinically significant improvement of at least 1.0 units was observed in 15 of 19 SRT patients (79%) and 5 of 18 non-SRT patients (28%). C, Limitation of adduction preoperatively and at final follow-up in the SRT and non-SRT surgical groups. D, Postoperative improvement of adduction in each surgical subgroup. BMR indicates bilateral medial rectus resession; MRc, medial rectus recession; error bars, SEM; markers, individual patients; and bands near the middle, the 50th percentile.aP < .001.bP < .01.

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Figure 3.
Changes in Abduction in Elevation vs Depression

A, Preoperative images of a 6-year-old boy with Duane syndrome of the right eye. Improved abduction of the right eye is observed in elevation (top panel) compared with vertical midline or depression. B, Preoperative images of a 2-year-old girl with Duane syndrome of the left eye. Improved abduction of the left eye is observed in depression. C, Maximal abduction in the affected eye in elevation and depression before surgery. D, Maximal improvement of abduction in elevation and depression.

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Figure 4.
Postoperative Drift of Surgical Results of Deviation, Head Turn, and Ductions in the Superior Rectus Transposition (SRT) and Non-SRT Surgical Groups

A, Postoperative drift of deviation (given in prism diopters [Δ]). Positive values represent the angle of deviation in straight-ahead gaze. B, Postoperative drift of head turn. Positive values represent the angle of head turn. C, Postoperative drift of limitation of abduction. D, Postoperative drift of limitation of adduction. Duction grades range from 0 (full duction) through −4 (eye was able to move to the midline) and −5 (eye approached but was unable to reach the midline). Negative values represent the limitation of abduction and adduction. Error bars represent SEM.aP < .05.

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