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Superior Rectus Transposition and Medial Rectus Recession for Duane Syndrome and Sixth Nerve Palsy

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Superior Rectus Transposition and Medial Rectus Recession for Duane Syndrome and Sixth Nerve Palsy CLINICAL SCIENCES Superior Rectus Transposition and Medial Rectus Recession for Duane Syndrome and Sixth Nerve Palsy Reshma A. Mehendale, MD; Linda R. Dagi, MD; Carolyn Wu, MD; Danielle Ledoux, MD; Suzanne Johnston, MD; David G. Hunter, MD, PhD Objective: To describe our results using augmented tem- from −4.3 to −2.7 (PϽ.001), and improved compensa- poral superior rectus transposition (SRT) with adjust- tory head posture from 28° to 4° (PϽ.001). Stereopsis able medial rectus muscle recession (MRc) for treat- was recovered in 8 patients (P=.03). Three patients re- ment of Duane syndrome and sixth nerve palsy. quired a reoperation: 1 for overcorrection and 2 for un- dercorrection. A new primary position vertical devia- Methods: Retrospective surgical case review of pa- tion was observed in 2 patients with complex sixth tients undergoing SRT. Preoperative and postoperative nerve palsy and none with Duane syndrome. No patient orthoptic measurements were recorded. Minimum fol- described torsional diplopia. low-up was 6 weeks. Main outcome measures included the angle of esotropia in the primary position and the angle Conclusions: Superior rectus transposition allows for of head turn. Secondary outcomes included duction limi- the option of simultaneous MRc in patients with severe tation, stereopsis, and new vertical deviations. abduction imitation who require transposition surgery. Combining SRT and MRc improved esotropia, head po- Results: The review identified 17 patients: 10 with sition, abduction limitation, and stereopsis without in- Duane syndrome and 7 with sixth nerve palsy. Combin- ducing torsional diplopia. ing SRT with MRc improved esotropia from 44 to 10 prism diopters (PϽ.001), reduced abduction limitation Arch Ophthalmol. 2012;130(2):195-201 ATIENTS WITH DUANE SYN- (SRTϩMRc).7 The purpose of this study drome and sixth nerve palsy was to report and evaluate the results of have moderate to severe limi- SRTϩMRc to correct the esotropia and tation of abduction, often head turn in patients with Duane syn- leading to primary position drome or sixth nerve palsy. Pesotropia that is associated with a com- pensatory head posture, reduced stereop- METHODS sis, and diplopia. Various approaches to improving eye position have been pro- posed, including partial and full vertical This retrospective study was approved by the rectus muscle transposition (VRT) to in- institutional review board of Children’s Hos- crease the abduction of the eye. Full VRT pital Boston. We reviewed the medical rec- ords of patients treated in the Department of procedures are among the most effective Ophthalmology at Children’s Hospital Boston for treatment of the abduction deficit; how- from January 1, 2006, through October 31, ever, new vertical deviations have been de- 2010. Patients treated with SRT, with or with- scribed in 6% to 30% of patients.1-3 There out augmentation suture,8 were included. Ex- is also the concern of anterior segment is- clusion criteria consisted of being younger than chemia with this procedure, especially 1 year, having had prior transposition sur- when a medial rectus muscle recession gery, or having follow-up of less than 4 weeks. (MRc) is also required.4,5 Information obtained included preoperative and Johnston et al6 introduced a modifica- postoperative head turn, esotropia and hyper- tion of the VRT in which only the supe- tropia in all gaze positions, ductions, and ste- reopsis. Postoperative complications were also Author Affiliations: rior rectus muscle is transposed. Since monitored, including the development of a new Department of Ophthalmology, then, we have adopted this superior rec- vertical misalignment or torsion, impairment Children’s Hospital Boston and tus transposition (SRT) technique for ap- of adduction, and the need for reoperation or Harvard Medical School, propriate patients, usually combining an a revision procedure to improve ocular align- Boston, Massachusetts. augmented SRT with an adjustable MRc ment (excluding postoperative adjustment of ARCH OPHTHALMOL / VOL 130 (NO. 2), FEB 2012 WWW.ARCHOPHTHALMOL.COM 195 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 A B Augmentation suture MRc with adjustable suture SRT along spiral of Tillaux 8-12 mm posterior to insertion Figure 1. Diagram representation of the superior rectus transposition (SRT) plus medial rectus recession (MRc) procedure. A, The MRc procedure with adjustable sutures. B, The SRT technique with augmentation suture. The amount of muscle included in the augmentation suture appears in the rendering to be less than one-quarter of the muscle width after tying the knot. adjustable sutures). Alignment was recorded from the orthop- with no scleral pass (specific exceptions are noted in para- tic evaluation results. Ductions were graded on a scale from 0 graph 3 of the “Results” section) (Figure 1B). (indicating full ductions) through −4 (indicating an eye that Patients underwent assessment in the recovery room 1 to 3 was able to move to the midline) and −5 (indicating an eye that hours after the procedure to check alignment and perform su- approached but was unable to reach the midline) to a maxi- ture adjustment if required. The short tag noose approach al- mum of −8 (indicating a rare case where the eye was fixed in lowed for a second suture adjustment to be performed (if re- an extreme adducted position). Head turn measurements (re- quired) within 10 days of the procedure. The postoperative corded at distance fixation) were taken from patient records follow-up visit was scheduled for 6 to 12 weeks after surgery. or, for 2 patients, measured by estimation using preoperative and postoperative photographs. STATISTICAL ANALYSIS SURGICAL TECHNIQUE The paired t test was used to analyze the preoperative and post- After a “short tag noose” adjustable MRc (described by Niha- operative results on head turn, esotropia in primary position, lani et al7 and Hunter et al9) was performed (Figure 1A), a and limitation of abduction. Stereopsis data were compared using superotemporal incision was made and the superior rectus the McNemar test. A P value of less than .05 was considered muscle was isolated. The muscle was then cleared of surround- statistically significant. ing attachments, with extra care taken to separate the superior rectus muscle from the levator muscle (best achieved by re- RESULTS moving the lid speculum and using a handheld retractor for exposure) and the superior oblique tendon. The muscle was then secured with a double-armed, 6-0 polyglactin 910 suture The medical record review identified 17 patients treated and detached from the globe. The posterior surface of the muscle with SRT during the study period, all of whom had si- was inspected for remaining attachments to the superior oblique multaneous MRc. Patient characteristics and severity grad- tendon or the frenulum. The temporal pole of the muscle was ing of all patients are summarized in Table 1. The av- reattached adjacent to the superior pole of the lateral rectus erage postoperative follow-up was 8 (range, 2-32) months, muscle, and the nasal pole was reattached adjacent to the tem- with 9 patients followed up for 6 months or longer. poral pole of the superior rectus muscle insertion following the Patients with Duane syndrome were younger than spiral of Tillaux (Figure 1B). In most cases, a double-armed 6-0 those with sixth nerve palsy. The average abduction defi- polyester augmentation suture was then placed by passing one needle through the lateral one-quarter of the superior rectus cit was greater in the sixth nerve palsy group. All pa- muscle and the other needle through the superior one-quarter tients had a compensatory head turn of more than 20°. of the lateral rectus muscle, positioning this suture 8 to 12 mm The mean MRc was 5 mm. Postoperative adjustment posterior to the insertion of the 2 muscles.2,10,11 The suture was was performed in 7 of 17 patients. The final amount of then tied to pull the 2 muscles together as a loop myopexy,12 recession ranged from 0 to 8 mm after adjustment, but ARCH OPHTHALMOL / VOL 130 (NO. 2), FEB 2012 WWW.ARCHOPHTHALMOL.COM 196 ©2012 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 only 1 patient had a recession of more than 6 mm. In 6 cases, there were minor variations from the surgical tech- Table 1. Patient Demographics and Distribution nique noted in the “Methods” section. One patient, the first in the series, did not have an augmentation suture Patient Groups placed. In 3 patients, the polyester augmentation suture Duane Sixth Nerve was secured to the sclera; 1 of these patients also under- Syndrome Palsy went a simultaneous 9-mm recession of the lateral rec- (n = 10) (n=7) tus muscle to correct globe retraction. Three patients, all Age range, mo 1 to 33 6 to 60 with a primary position esotropia of at least 50 prism di- Sex, No. of patients opters (⌬), had a simultaneous or a subsequent reces- Male 6 1 sion of the contralateral medial rectus muscle. Female 4 6 Follow-up, mo 2 to 32 2 to 16 Mean (SD) esotropia in the primary position im- ⌬ ⌬ ⌬ ⌬ Abduction deficit, U −3 to −5 −4 to −5 proved from 44 (16 ) preoperatively to 10 (9 ) post- Head turn Ͼ20°, No. (%)a 10/10 (100) 7/7 (100) operatively (Figure 2A; PϽ.001). Five patients be- Stereopsis, No. (%)b came orthophoric at distance in the primary position Preoperative 4/9 (44) 1/6 (17) without spectacle correction. There was also a mean 21° Postoperative 8/9 (89) 5/6 (83) improvement in head turn (from 28° to 4°, Figure 2B; Ͻ a Patients used a head turn for fusion or for fixation. P .001) and a 1.6-unit improvement in abduction (from b Data were not included for 1 patient with Duane syndrome (not recorded) −4.3 to −2.7, Figure 3A; PϽ.001), with a 0.6-U reduc- and 1 patient with sixth nerve palsy (blind in 1 eye).
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