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

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

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

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

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

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

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

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

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

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

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

Variants Bilateral DRS

Inverse DRS

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

Differentials Mobius syndrome

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

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 ”

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

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

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

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

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

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