Duane Retraction Syndrome

1. Duane’s Retraction Syndrome Dr Sunayana Bhat Consultant Paediatric ophthalmology , Strabismus and Neuro ophthalmology Vasan eye care , Mangalore Ph : 9611102754 chanyn9@gmail.com

2. Historical Background • Duane syndrome is a rare, congenital disorder of eye movement • Stilling and Turk : described it first • Duane popularised it Classic features Limitation of abduction Slight limitation of adduction Retraction of globe on adduction Adduction narrowing of palpebral fissure Upshoot / downshoot of eye in adduction

3. Pathophysiology “ Musculo Fascial Innervational Anomaly ” Fibrosis of LR/MR Fibrous bands Co contraction – paradoxical innervation

4. Duane’s Syndrome Type I: OS -limited abduction -retraction in adduction

5. Duane’s Syndrome Type II: OS -limited adduction -retraction in adduction

6. Duane’s Syndrome Type III: OS -limited adduction and abduction -retraction in adduction/abduction

7. History • Squinting • Head tilt • Loss of binocular vision • Reduced ocular movement • Facial asymmetry • Picture of paralytic squint

8. Epidemiology • 1% of all cases of strabismus • Sporadic • Unilateral 60% • Left eye • Female preponderance

9. Clinical Picture • AHP • Strabismus ( 77% of cases) • Globe retraction • Palpebral fissure narrowing • Anisometropia /amblyopia • Sensory adaptation with excellent binocular functions -directions of gaze where visual axes are aligned -suppression without diplopia in gaze of abnormal muscle

10. Associated Anomalies • Skeletal • Auricular • Ocular -dysplasia of the iris stroma, -pupillary anomalies -cataracts - heterochromia - Marcus Gunn jaw-winking -coloboma - crocodile tears -microphthalmos. • Neural

11. Syndromes • Okihiro syndrome • Wildervanck syndrome • Holt-Oram syndrome • morning-glory syndrome • Goldenhar syndrome. • congenital labyrinthine deafness. Klippel-Feil anomaly

12. Variants • Bilateral DRS

13. Inverse DRS

14. Differentials DRS Sixth N palsy • ET small angle • Narrowing • Saccadic velocities • ET large angle • -ve • Slow in abduction only

15. Differentials • Mobius syndrome

16. Treatment • Treat refractive error /amblyopia • Conservative : Age 5-6 yrs

17. Indications for surgery • Anomalous head posture • Strabismus in primary gaze • Significant upshoot or downshoot in adduction • Cosmetically significant palpebral fissure narrowing in adduction. “ Limited Goals ”

18. Made simple … Eso DRS Small angle <15 PD Single MR recession Larger angle Bilateral MR recession Asymmetric

19. Exo DRS Small angle <15 PD Single LR recession Larger angle Bilateral LR recession Symmetric

20. Upshoots Downshoots Globe retraction Recession of MR and LR Y split Posterior fixation suture to LR

21. Duction Improvement Transposition of SR /IR FOSTER’S modification

22. Carry home message • Diagnosis often elusive SO LOOK for it ! • Treat Ref Error , amblyopia • Risk benefit ratio of surgery to be well understood by patients and surgeon • Tailor made surgery required for every case

23. Thank u

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