Recession of Both Horizontal Recti Muscles in Duane's Retraction Syndrome With Elevation and Depression of the Adducted Eye Gunter K. v o n N o o r d e n , M . D .
Upshoot and downshoot of the adducted eye in Duane's retraction syndrome is thought to be caused by a bridle effect of the co-contracting horizontal recti muscles. A recession of both of these muscles transposes their insertions posteriorly in relation to the center of rotation of the globe, which reduces the bridle effect and decreases the upshoot and downshoot. An 11-year-old girl had Duane's retraction syndrome type III and upshoot and downshoot of the left eye. The left lateral rectus muscle was recessed 8 mm and the left medial rectus muscle 6 mm. At last examination IOV2 months postoperatively, the upshoot and downshoot on attempted adduction was no longer present.
T H E MECHANISM of elevation and depression of the adducted eye in Duane's retraction syn drome has undergone much clarification in re cent years. This phenomenon is thought to be caused by a vertical bridle effect of the cocontracting horizontal recti muscles1"4 or by a paradoxical co-contraction of the cyclovertical muscles in combination with co-contraction of the horizontal recti muscles. 5 7 The concept of a bridle effect has been confirmed by data ob tained in normal subjects with modern imaging techniques, which show that there is little, if any, vertical movement of the horizontal recti muscles in relationship to the orbital walls as the eye is elevated or depressed. 8,9 For the mus cle plane to stabilize, the globe must slip be neath the muscles when the eye elevates or
Accepted for publication June 4, 1992. From the Cullen Eye Institute, Baylor College of Medi cine, and the Department of Ophthalmology, Texas Children's Hospital, Houston, Texas. Reprint requests to Gunter K. von Noorden, M.D., Department of Ophthalmology, Texas Children's Hospi tal, Houston, TX 77030.
depresses. Because of this movement of the globe, the muscle planes of the horizontal recti muscles change their position in reference to the center of rotation. This adds a vertical function to the horizontal action of these mus cles during their paradoxical co-contraction on adduction and causes upshoot and downshoot of the eye. Previously, we have shown that retroequatorial posterior fixation of both horizontal recti muscles reduced this vertical effect in five pa tients. 4 However, severe mechanical restric tions of horizontal ocular motility may exist in Duane's syndrome, especially in the type III. Such restrictions may limit the surgeon's ability to suture the muscles retroequatorially. In this situation, I found recession of both horizontal recti muscles 13 to be equally effective and have used this approach with good results.
Case Report A 5-year-old girl was not able to move her left eye at initial examination. Her uncorrected vis ual acuity was 20/20 in each eye and her refractive error was insignificant. She preferred her right eye for fixation. A face turn to the right, estimated to be about 10 degrees, was noted. When the head was passively straighten ed and in primary position, she had an exotropia of 5 prism diopters at 33-cm fixation dis tance and of 16 prism diopters at 6-m fixation distance. In right gaze, the exotropia increased to 50 prism diopters and in left gaze an esotro pia of 25 prism diopters was present. In the left eye, adduction was markedly limited and ab duction was moderately limited, with retrac tion of the globe and narrowing of the palpebrai fissure on attempted adduction and widening of the palpebrai fissure on abduction. Upshoot and downshoot of the left eye was noted on
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Fig. 1 (von Noorden). Preoperative auctions and versions in Duane's retraction syndrome type III with severe limitation of adduction, narrowing of eyelid fissure on attempted adduction, and moderate limitation of abduction. Note upshoot and downshoot of the left eye on attempted adduction when it was slightly elevated or depressed (bridle effect), but not when it adducted from primary position. attempted adduction when the eye was slightly elevated or depressed from the primary po sition (Fig. 1). The remaining results of the eye examination were normal. Duane's retrac-
September, 1992
Fig. 2 (von Noorden). Postoperative ductions and versions after recession of both horizontal recti mus cles. Upshoot and downshoot are no longer present. tion syndrome type HI of the left eye was diagnosed, and the patient was followed up at irregular intervals without treatment until she was 11 years old. At that time, an examination showed the same findings as were recorded on the first visit, except that she had developed variable exotropia of up to 12 prism diopters at near fixation. Her head turn was unchanged. The patient had become embarrassed about
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Duane's Retraction Syndrome
the upshoot and downshoot and her parents requested surgical correction. A posterior fixa tion of the left medial and lateral recti muscles was scheduled. However, a forced-duction test performed with the patient under general anes thesia showed severe restriction on attempts to move the left eye into adduction and abduction. Because a posterior fixation was technically impossible to perform under these conditions, we recessed the left lateral rectus muscle 8 mm and recessed the left medial rectus muscle 6 mm. More surgical correction was performed on the lateral than on the medial rectus muscle to counteract the small exotropia in the primary position that caused the head turn. The postop erative course was uncomplicated. The head turn was diminished and the upshoot and downshoot of the left eye on attempted adduc tion was no longer present (Fig. 2). The im provement persisted at last examination, 10V2 months postoperatively.
Discussion Recession of both horizontal recti muscles is a viable alternative to retroequatorial scierai fixation in controlling cosmetically unaccepta ble elevation and depression of the adducted eye in Duane's retraction syndrome. Because of the ease with which this procedure is per formed compared with posterior fixation and its equal effectiveness in controlling the upshoot and downshoot, we no longer use posterior fixation of the horizontal recti muscles in this condition. Both operations work similarly by transposing the effective insertion of the mus cles posteriorly in relation to the center of rotation and thus reducing the vertical bridle
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effect when these muscles co-contract paradox ically in adduction.
References 1. Scott, A. B.: Strabismus-muscle forces and in nervations. In Lennerstrand, G., and Bach-y-Rita, P. (eds.): Basic Mechanisms of Ocular Motility and Their Clinical Implications. Oxford, Pergamon Press, 1975, p. 181. 2. Souza-Diaz, C: Additional Consequences of Muscle Co-contraction in Duane's Syndrome. Guariya, Brazil. Fifth Congress of Conselho LatinoAmericano de Estrasismo, October 1976, p. 93. 3. Jampolsky, A.: Surgical leashes and reverse leashes. Trans. New Orleans Acad. Ophthalmol. 244, 1978. 4. von Noorden, G. K., and Murray, E.: Up- and downshoot in Duane's retraction syndrome. J. Pediatr. Ophthalmol. Strabismus 23:121, 1986. 5. Scott, A. B., and Wong, G. Y.: Duane's syn drome. An electromyographic study. Arch. Ophthal mol. 87:140, 1972. 6. Moore, L. D., Feldon, S. E., and Liu, S. K.: Infra red oculography of Duane's refraction syndrome (type 1). Arch. Ophthalmol. 106:943, 1988. 7. Miller, J. M., Demer, J. L., and Rosenbaum, A.: Two mechanisms of up-shoots and down-shoots in Duane's syndrome revealed by a new MRI technique. In Campos, E. C. (ed.): Strabismus and Motility Disorders. Proceedings of the Sixth Meeting of the International Strabismological Association. London, Macmillan Press, 1990, p. 229. 8. Simonsz, H. J.: Investigations of Ocular Counterrolling Bielschowsky Head-tilt Test, Stiffness in Passive Ocular Rolling and Displacement of Recti Eye Muscles. Amsterdam, The Netherlands, University of Amsterdam, 1984. Thesis. 9. Bloom, J. N., Graviss, E. R., and Mardelle, P. G.: A magnetic resonance imaging study of the upshoot-downshoot phenomenon of Duane's retrac tion syndrome. Am. J. Ophthalmol. 111:548, 1991.
Upshoot and downshoot of the adducted eye in Duane's retraction syndrome is thought to be caused by a bridle effect of the co-contracting horizontal recti muscles. A recession of both of these muscles transposes their insertions posteriorly in relation to the center of rotation of the globe, which reduces the bridle effect and decreases the upshoot and downshoot. An 11-year-old girl had Duane's retraction syndrome type III and upshoot and downshoot of the left eye. The left lateral rectus muscle was recessed 8 mm and the left medial rectus muscle 6 mm. At last examination IOV2 months postoperatively, the upshoot and downshoot on attempted adduction was no longer present.
T H E MECHANISM of elevation and depression of the adducted eye in Duane's retraction syn drome has undergone much clarification in re cent years. This phenomenon is thought to be caused by a vertical bridle effect of the cocontracting horizontal recti muscles1"4 or by a paradoxical co-contraction of the cyclovertical muscles in combination with co-contraction of the horizontal recti muscles. 5 7 The concept of a bridle effect has been confirmed by data ob tained in normal subjects with modern imaging techniques, which show that there is little, if any, vertical movement of the horizontal recti muscles in relationship to the orbital walls as the eye is elevated or depressed. 8,9 For the mus cle plane to stabilize, the globe must slip be neath the muscles when the eye elevates or
Accepted for publication June 4, 1992. From the Cullen Eye Institute, Baylor College of Medi cine, and the Department of Ophthalmology, Texas Children's Hospital, Houston, Texas. Reprint requests to Gunter K. von Noorden, M.D., Department of Ophthalmology, Texas Children's Hospi tal, Houston, TX 77030.
depresses. Because of this movement of the globe, the muscle planes of the horizontal recti muscles change their position in reference to the center of rotation. This adds a vertical function to the horizontal action of these mus cles during their paradoxical co-contraction on adduction and causes upshoot and downshoot of the eye. Previously, we have shown that retroequatorial posterior fixation of both horizontal recti muscles reduced this vertical effect in five pa tients. 4 However, severe mechanical restric tions of horizontal ocular motility may exist in Duane's syndrome, especially in the type III. Such restrictions may limit the surgeon's ability to suture the muscles retroequatorially. In this situation, I found recession of both horizontal recti muscles 13 to be equally effective and have used this approach with good results.
Case Report A 5-year-old girl was not able to move her left eye at initial examination. Her uncorrected vis ual acuity was 20/20 in each eye and her refractive error was insignificant. She preferred her right eye for fixation. A face turn to the right, estimated to be about 10 degrees, was noted. When the head was passively straighten ed and in primary position, she had an exotropia of 5 prism diopters at 33-cm fixation dis tance and of 16 prism diopters at 6-m fixation distance. In right gaze, the exotropia increased to 50 prism diopters and in left gaze an esotro pia of 25 prism diopters was present. In the left eye, adduction was markedly limited and ab duction was moderately limited, with retrac tion of the globe and narrowing of the palpebrai fissure on attempted adduction and widening of the palpebrai fissure on abduction. Upshoot and downshoot of the left eye was noted on
©AMERICAN JOURNAL OF OPHTHALMOLOGY 114:311-313, SEPTEMBER, 1992
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AMERICAN JOURNAL OF OPHTHALMOLOGY
Fig. 1 (von Noorden). Preoperative auctions and versions in Duane's retraction syndrome type III with severe limitation of adduction, narrowing of eyelid fissure on attempted adduction, and moderate limitation of abduction. Note upshoot and downshoot of the left eye on attempted adduction when it was slightly elevated or depressed (bridle effect), but not when it adducted from primary position. attempted adduction when the eye was slightly elevated or depressed from the primary po sition (Fig. 1). The remaining results of the eye examination were normal. Duane's retrac-
September, 1992
Fig. 2 (von Noorden). Postoperative ductions and versions after recession of both horizontal recti mus cles. Upshoot and downshoot are no longer present. tion syndrome type HI of the left eye was diagnosed, and the patient was followed up at irregular intervals without treatment until she was 11 years old. At that time, an examination showed the same findings as were recorded on the first visit, except that she had developed variable exotropia of up to 12 prism diopters at near fixation. Her head turn was unchanged. The patient had become embarrassed about
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Duane's Retraction Syndrome
the upshoot and downshoot and her parents requested surgical correction. A posterior fixa tion of the left medial and lateral recti muscles was scheduled. However, a forced-duction test performed with the patient under general anes thesia showed severe restriction on attempts to move the left eye into adduction and abduction. Because a posterior fixation was technically impossible to perform under these conditions, we recessed the left lateral rectus muscle 8 mm and recessed the left medial rectus muscle 6 mm. More surgical correction was performed on the lateral than on the medial rectus muscle to counteract the small exotropia in the primary position that caused the head turn. The postop erative course was uncomplicated. The head turn was diminished and the upshoot and downshoot of the left eye on attempted adduc tion was no longer present (Fig. 2). The im provement persisted at last examination, 10V2 months postoperatively.
Discussion Recession of both horizontal recti muscles is a viable alternative to retroequatorial scierai fixation in controlling cosmetically unaccepta ble elevation and depression of the adducted eye in Duane's retraction syndrome. Because of the ease with which this procedure is per formed compared with posterior fixation and its equal effectiveness in controlling the upshoot and downshoot, we no longer use posterior fixation of the horizontal recti muscles in this condition. Both operations work similarly by transposing the effective insertion of the mus cles posteriorly in relation to the center of rotation and thus reducing the vertical bridle
313
effect when these muscles co-contract paradox ically in adduction.
References 1. Scott, A. B.: Strabismus-muscle forces and in nervations. In Lennerstrand, G., and Bach-y-Rita, P. (eds.): Basic Mechanisms of Ocular Motility and Their Clinical Implications. Oxford, Pergamon Press, 1975, p. 181. 2. Souza-Diaz, C: Additional Consequences of Muscle Co-contraction in Duane's Syndrome. Guariya, Brazil. Fifth Congress of Conselho LatinoAmericano de Estrasismo, October 1976, p. 93. 3. Jampolsky, A.: Surgical leashes and reverse leashes. Trans. New Orleans Acad. Ophthalmol. 244, 1978. 4. von Noorden, G. K., and Murray, E.: Up- and downshoot in Duane's retraction syndrome. J. Pediatr. Ophthalmol. Strabismus 23:121, 1986. 5. Scott, A. B., and Wong, G. Y.: Duane's syn drome. An electromyographic study. Arch. Ophthal mol. 87:140, 1972. 6. Moore, L. D., Feldon, S. E., and Liu, S. K.: Infra red oculography of Duane's refraction syndrome (type 1). Arch. Ophthalmol. 106:943, 1988. 7. Miller, J. M., Demer, J. L., and Rosenbaum, A.: Two mechanisms of up-shoots and down-shoots in Duane's syndrome revealed by a new MRI technique. In Campos, E. C. (ed.): Strabismus and Motility Disorders. Proceedings of the Sixth Meeting of the International Strabismological Association. London, Macmillan Press, 1990, p. 229. 8. Simonsz, H. J.: Investigations of Ocular Counterrolling Bielschowsky Head-tilt Test, Stiffness in Passive Ocular Rolling and Displacement of Recti Eye Muscles. Amsterdam, The Netherlands, University of Amsterdam, 1984. Thesis. 9. Bloom, J. N., Graviss, E. R., and Mardelle, P. G.: A magnetic resonance imaging study of the upshoot-downshoot phenomenon of Duane's retrac tion syndrome. Am. J. Ophthalmol. 111:548, 1991.
