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Expert Commentary
Comments of Albert W. Biglan, M.D.
Cranberry Township, Pennsylvania
This is a mild form of Duane's retraction syndrome. There is a mild face turn with fusion.
If the parents would accept some loss of adduction of the left eye in exchange for improvement of the face turn, a large recession of the left medial rectus muscle could be considered. In my hands, I would perform a 6 mm recession of the left medial rectus muscle.
I have not found great success in working on the "good eye" to improve abduction of the affected "Duane eye".
Comments of Arthur L. Rosenbaum, M.D.
Chief, Division Pediatric Ophthalmology and Strabismus;Vice Chairman, Dept. Ophthalmology, UCLA School of Medicine; Los Angeles, California
This child has a fairly typical esotropic Duane Syndrome. The left hypotropia is somewhat unusual, especially since it seems to increase in left gaze. I would suggest a full transposition of the vertical rectus muscles to the lateral rectus insertion with posterior fixation of each muscle at the time of transposition. At the time of transposition, I would look carefully at the lateral rectus. If it is displaced or slanted downward, I would try and reposition the body of the muscle to a more normal anterior-posterior orientation with several fixation sutures. It is possible that abnormal inferior direction of the lateral rectus (LR) is causing the hypotropia and the "downshoot" of the left eye in abduction. Left medial rectus recession may be required 4-6 months later if it is tight and causing a forced duction restriction to abduction. If this is required, do a small amount so that the child does not develop a significant exotropia in right gaze.
Comments of Thomas D. France, M.D.
University of Wisconsin School of Medicine
A 3-year-old girl with left Duane syndrome. She has good vision in each eye and prefers an abnormal head position to allow her to be binocular. In the primary position she is said to have a "small esotropia with right hypertropia" and a left hypotropia in straight upgaze. She has no significant refractive error. (+0.50 OD, +0.75 OS)
My indications for treatment of patients with Duane Syndrome are: 1. Amblyopia, 2. Constant angle of strabismus, 3. A significant Abnormal Head Position (AHP), 4. Significant Up or Down Shoots, and 5. Significant enophthalmos due to the co-contraction of the horizontal muscles.
This patient does not have problem's 1, 2, 4 or 5. So the question is, "Is the AHP severe enough to warrant intervention?" I usually do not intervene if the AHP is less than 15 degrees. We are not told what the AHP measures but it is appears to be probably close to 10 to 15 degrees.
She could be treated with glasses and a prism to allow her to have a straight head position. However, since she sees well without the need for glasses, she will probably not tolerate them well.
My favorite approach to the AHP in Type 1 Duane syndrome, is to release the "tight" medial rectus muscle. (We are told this patient has a mild adduction deficit OS, which might make me want to weaken the contralateral medial rectus (MR), but the photos show that the "underaction" of the MR may be due to incomplete gaze to the right as the OD is not fully in abduction, either.) I am not worried about the small vertical, since she clearly is able to fuse with only a horizontal AHP. I usually plan the amount of MR recession based on how tight the muscle is at the time of surgery. With only a small AHP I would probably recess the MR in the range of 4-5 mm.
Editor's Comments
The management of Duane syndrome is likely to demonstrate differences in treatment philosophy as it has with these three experts. While there is agreement regarding indications for surgery including anomalous head posture, primary position deviation, limited ductions, and up and downshoots, the preferred surgical solution varies among experienced surgeons. The need for weakening the medial rectus of the involved eye, either at the first surgery or later if it limits forced abduction after transfer, is agreed upon. Full tendon transfer shifting the vertical recti to the lateral rectus is preferred by one expert who also directs attention to the position of a possibly offending lateral rectus in the involved eye. Weakening of the opposite medial rectus by recession (or posterior fixation -- Ed.) is also an option to be considered in Duane mentioned by two experts.
Eugene M. Helveston, M.D. | 
