Paradoxical eyelid movement in trisomy 2p

Paradoxical eyelid movement was reported in a 12-year-old female with 46,XX,dup(2)(p25.3p22.2). Alternating seesaw-like movement of the eyelids during lateral gazing had been observed at 5 months of age when she was first referred to our neuropediatric outpatient department, and the abnormal lid movement persisted without any change for 11 years. The differentiation of the features of the paradoxical lid movements in our patient from those of Duane syndrome were discussed, and a possible pathogenesis is discussed as well. Besides ophthalmologic abnormalities, the patient demonstrated severe psychomotor retardation, marked growth failure, symptomatic generalized epilepsy, and multiple anomalies. The dysmorphism consisted of a cleft lip, a narrow high-arched palate, malalignment, lowset ears, and kyphoscoliosis caused by fused thoracic vertebrae.

Bilateral Duane syndrome with bilateral congenital glaucoma

Multiple ocular associations with Duane syndrome have been reported as summarized by DeRespinis et al. The most frequently noted include nystagmus, anisocoria, ptosis, optic nerve colobomas, and epibulbar dermoids. Less encountered abnormalities are optic nerve hypoplasia, heterochromia, and congenital cataract. To our knowledge, no reports of associated congenital glaucoma exist in the literature. We report a 10-year-old patient with bilateral Duane syndrome and bilateral congenital glaucoma who we have monitored for 7 months after birth.

Duane retraction syndrome

Duane retraction syndrome (DRS) consists of deficient horizontal eye movements, eyelid retraction, palpebral fissure narrowing, and abnormal vertical eye movements. Most cases are sporadic and unilateral (usually left side) with a slight female predominance. Several associated ocular and systemic conditions have been described in DRS patients. In most cases, the abducens nucleus and nerve are absent or hypoplastic, and the lateral rectus muscle is innervated by a branch of the oculomotor nerve. However, there may be contributing mechanical abnormalities. Type I DRS (primary gaze position esotropia with limitation of abduction) comprises the majority of cases. Approximately 50% of type I DRS patients are orthophoric in primary gaze. Esotropia is the most common type of strabismus encountered, and characteristic up shoots and down shoots occur in adduction. Surgical intervention has gradually become more popular in order to improve the primary gaze alignment and mitigate some of the associated abnormalities in ocular motility. However, patients are rarely rendered clinically normal, and limited expectations are appropriate.

Characteristics of Okihiro syndrome

PURPOSE

To describe Okihiro syndrome, a syndrome consisting of Duane's syndrome, radial ray anomaly, and sensorineural deafness.

METHODS

The incidence of anomalies in 41 individuals from 9 affected families was assessed by literature review and patient examination, and the frequency of the characteristics occurring together was determined.

RESULTS

Of all the individuals with at least one of the above characteristics, only 12% had all three characteristics. However, 44% had both Duane's syndrome and radial ray anomaly, whereas sensorineural deafness alone occurred in only 17% of patients.

CONCLUSION

Okihiro syndrome is consistent with autosomal dominance with variable penetrance, manifesting primarily with Duane's syndrome and radial ray anomaly, and less frequently, sensorineural deafness.

[Duane's retraction syndrome--overview and diagnosis of clinical types]

The author presents a postgraduate review of the problem. In the introduction he reviews typical features of Duane's retraction syndrome (DS) and its main symptoms and reminds of the main approaches to classification: (1) Malbrane s (Duane I, II and III), (2) Huber's which is based on EMG findings in ZOS and (3) Kaufman's which classifies DS according to the enforced position of the head. The author maintains that even according to the above many atypical rare pictures cannot be classified or explained pathogenetically. Some are mentioned: (1) "Inverse" DS, which was recorded and documented by Chytilová-Divisová (1949) in a girl with congenital paralysis of abduction on both eyes retraction of the bulbus developed and narrowing of the palpebral aperture when attempting abduction (1) of the eye, (2) Bilateral acquired DS in a female patient with a tumour of the brain stem confirmed by EMG records of both horizontal muscles. (3) Unilateral DS in a child from a family with familial incidence of congenital ZOS fibrosis with an obscure ratio of the neurogenic and myogenic and fibrous component of the two pictures. In another member of this family the Marcus Gunn phenomenon was present. The latter findings support the idea that in the development of the fairly uniform picture of DS a combination of neurogenic, myogenic and connective tissue changes participate.

[Duane's retraction syndrome--surgical treatment]

The author presents possible surgical approaches in Duane's syndrome I. The weakening operation of the medial rectus muscle by means of marginal myotomy is recommended in case of striking ocular torticolis. The bifurcation recession of the lateral rectus muscle is recommended in case of change of palpebral fissure. The author documents the indications and the after-surgery results.

Duane's syndrome with compressive denervation of the lateral rectus muscle

PURPOSE

To describe an unusual case of Duane's syndrome.

METHODS

Individual case report.

RESULTS

A skull base meningioma was discovered in a woman with Duane's syndrome who presented with recurrent, large-angle esotropia and uncharacteristic atrophy of the lateral rectus muscle on magnetic resonance image (MRI) scan.

CONCLUSION

Neuroimaging may be useful in unusual cases of Duane's syndrome.

Duane's retraction syndrome: literature review

BACKGROUND

Duane's retraction syndrome (DRS), also known as Stilling-Turk-Duane syndrome, is defined as a congenital miswiring of the lateral and medial recti muscles, resulting in an impaired ocular motility syndrome that includes palpebral fissure narrowing. The incidence of DRS is approximately 1% of the total cases of strabismus. Eighty percent of cases are unilateral and characterized by either limited abduction, limited adduction, or both.

CASE REPORT

A 21-year-old man came to the clinic for a routine ocular examination without symptoms. A review of the history uncovered the presence of congenital, type I Duane's retraction syndrome. The examination demonstrated orthophoria in primary gaze, an abduction deficit O.S., and left globe retraction with palpebral fissure narrowing on right gaze O.S.

MANAGEMENT

In most cases of DRS the eyes are straight in primary position and there is no amblyopia. Amblyopia, when present, is usually the result of anisometropia and not strabismus. Because our patient had no symptoms of diplopia in primary gaze (orthophoria) or in attempted right gaze (due to suppression of the left eye with abduction), prismatic and/or surgical management were not indicated, since the patient was free from binocular and cosmetic abnormalities.

CONCLUSION

DRS is characterized by abnormal development of the cells in the abducens nucleus (CN VI), resulting in restricted or absent abduction and erroneous innervation of the lateral rectus by branches emanating from oculomotor nuclei (CN III). Management may include orthoptics, surgery, or monitoring.

A patient with de Morsier and Duane syndromes

de Morsier syndrome, or septo-optic dysplasia, is a developmental malformation complex characterized by optic nerve hypoplasia, dysgenesis of the septum pellucidum, and hypothalamic-pituitary dysfunction. (1,2) In Duane retraction syndrome, there is absence of the sixth nerve nucleus with congenital retraction of the globe and narrowing of the lid fissure in adduction, frequent abduction deficiency, and variable limitation to adduction of the affected eye. (3) The purpose of this report is to present a patient with the uncommon and previously unreported concurrence of both of these congenital malformation complexes, presumably because of a common disturbance of neuronal development.

[Clinical features of 201 cases with Duane's retraction syndrome]

OBJECTIVE

To summarize the clinical features of 201 cases with Duane's retraction syndrome (DRS) and discuss its differential diagnosis.

METHODS

The 201 cases in 1979 similar 1996 were retrospectively summarized. The clinical features including chief complaints, sex distribution, age at first visit, laterality, type of presentation, ocular deviation in the primary position, refractive errors, amblyopia, globe retraction, change of the palpebral fissure, upshoot and downshoot in adduction, binocular single vision, and its associated ocular and non-ocular anomalies were analyzed.

RESULTS

There were 99 males and 102 females with a female-to-male ratio of 1:1.65.88% of DRS cases had left eye involvement with two-to-one predilection for the left eye. The most common form of the syndrome was type 1 (184 patients, 91.54%). Exotropia was the most common deviation in the primary gaze (72 patients, 35.82%). Among 118 patients, most had abduction deficits, globe retraction in adduction, and face-turn for maintaining single binocular vision. Crocodile tears (26 patients, 12.93%) were the most frequently encountered ocular abnormality.

CONCLUSIONS

Diagnosis of DRS in a typical case is not difficult, however, children with bilateral abduction deficits which may mimic DRS must be differentiated from the following four motility disorders, namely, abducens nerve palsy, Moebius' syndrome, congenital oculomotor apraxia, and congenital or infantile esotropia.

[Clinical features of 31 cases with bilateral Duane's retraction syndrome]

OBJECTIVES

To summarize the clinical features of 31 cases with bilateral Duane's retraction syndrome (DRS) and discuss its differential diagnosis.

METHODS

We retrospectively summarized 31 cases with bilateral DRS from 1979 to 1996. Its clinical features including chief complaints, age and sex distribution, types of presentation, defects in abduction and adduction, retraction of the globe, upshots and downshots in abduction, etc. were analyzed.

RESULTS

There were 14 males and 17 females with a female-to-male ratio 1 : 0.8. The chief complaints comprised 14 cases (45%) with ocular motility disorders and 10 cases (32%) with ocular deviations. The most common form of the syndrome was type 1 (29 cases, 94%), the remaining 2 cases (6%) with type III. Its clinical features consisted of retraction of the globe with narrowing of the palpebral fissure in attempted adduction, limitation in abduction with variable extent also in adduction, and upshot and/or downshot of the affected eye during adduction.

CONCLUSIONS

In atypical cases, the retraction of the globe in adduction was not obvious and the diagnosis of DRS must be differentiated from the following ocular motility disorders, namely, abducens nerve palsy, Möebius syndrome, congenital oculomotor apraxia and congenital or infantile esotropia.

[Wildervanck or cervico-oculo-acoustic syndrome]

In 1952, Wildervanck described the first case of what he called the Cervico-Oculo-Acoustic (COA) syndrome, which comprises Klippel-Fetl anomalad (congenitally fused cervical vertebrae), congenital deafness and Duane's retraction syndrome (abducen's paralysis and retraction on adduction). Since the first case was reported, there have been more reports describing this triad, either completely or incompletely. A further case of this syndrome with CSF leakage is reported here and exploratory tympanotomy was performed. Abnormalities of both inner and middle ear were found. In addition, MRI and CT scan of the head revealed an abnormal cerebellum which is the second case reported in the world. And a review of literature concerning this syndrome is also presented here.

Clinical features of 201 cases with Duane's retraction syndrome

OBJECTIVE

To summarize the clinical features of 201 cases with Duane's retraction syndrome (DRS) and discuss its differential diagnosis.

METHODS

We retrospectively summarized the 201 cases from 1979 to 1996. The clinical features including chief complaints, sexual distribution, age at first visit, laterality, type of presentation, ocular deviation in the primary position, refractive errors, amblyopia, globe retraction, change of the palpebral fissure, upshoot and downshoot in adduction, binocular single vision, and its associated ocular and non-ocular anomalies were analysed.

RESULTS

There were 99 males and 102 females with a female-to-male ratio 1:1. The 65.88% of DRS cases had left eye involvement with two-to-one predilection for the left eye. The most common form of the syndrome was type I (184 patients, 91.54%). Exotropia was the most common deviation in the primary gaze (72 patients, 35.8%). Among 118 patients, most had abduction deficits, globe retraction in adduction, and faceturn as to maintaining single binocular vision. Crocodial tears (26 patients, 11.93%) was the most frequently encounted ocular abnormalities.

CONCLUSIONS

Diagnosis of DRS in a typical case is not difficult, however, children with bilateral abduction deficits which may mimic DRS must be differentiated from the following four motility disorders, namely, abducens nerve palsy, Moebius syndrome, congenital oculomotor apraxia, and congenital or infantile esotropia.

[Stilling-Duane retraction syndrome; surgical options]

BACKGROUND

The Stilling-Duane's retraction syndrome is a congenital abnormality of ocular movements. In order to maintain simple binocular vision, most patients adopt an abnormal head posture; this can be corrected by surgery.

MATERIALS AND METHODS

We carried out a retrospective study of the clinical files of 56 patients who presented with Duane's syndrome and had been examined at the Strabological Department of the Lausanne Eye Clinic between 1974 and 1993.

RESULTS

Our group study is comparable to that found in the literature as regards the distribution according to sex (45% of males, 55% of females), laterality (75% of the cases with disease predominance in the left eye, 18% in the right eye, and 7% with bilateral, symmetrical disease), and associated anisometropia (18%) or amblyopia (12.5%). Approximately 1 of 5 patients sought medical advice only after 20 years of age. A compensating head turn (towards the ill side in patients with esotropia and towards the healthy side in patients with exotropia) was found in 71% of the cases. Our surgery (10 patients with a mean follow-up of 8 months) resulted in a decreased head turn in 7 cases.

CONCLUSIONS

The purpose of this surgery is to improve the head turn without worsening retraction. This can be achieved with simple muscle recessions.

[Congenital syndromes of oculomotor disturbances--diagnosis and results of surgical treatment]

During the period of 30 years (1964-1994), 363 children with different congenital syndromes of oculomotor disturbances were treated: 300 with Duane's retraction syndrome, 29 with Moebius syndrome, 34 with the superior oblique tendon sheath syndrome of Brown. Symptoms of these syndromes are presented. The choice of appropriate therapy of oculomotor disturbances are described. For aesthetic indications surgical treatment was carried out in 142 (47.3%) patients with retraction syndrome, in 20 (68.7%) with Moebius syndrome and in 23 (67.75%) with Brown's syndrome. Marked reduction of deviation in primary position and reduction of anomalous head posture were obtained.

[Diagnosis and surgical treatment of bilateral paralysis of the superior oblique muscle]

BACKGROUND

Typically, bilateral superior oblique palsies manifest with small vertical deviation in primary position, reversing in lateral gaze, with a positive headtilt test on both sides, a V pattern, and a chin-down head position. In primary position, excyclotropia often exceeds 10 degrees and markedly increases in inferior gaze.

PATIENTS AND METHODS

Retrospective study of 21 patients with bilateral SO palsy who underwent operations including various surgical techniques such as SO tucking, inferior oblique recessions and inferior rectus weakering procedures (recession, posterior fixation). Preoperative symptoms of this group of patients was compared to those of 60 patients with unilateral SO palsy.

RESULTS

No significant difference was found between cases operated with complete SO tucking and cases operated with specific surgery on the anterior part of the tendon when pre- and postoperative excyclotropia was compared. Severe excyclotropia in primary gaze, markedly increasing in downgaze, was found to be statistically significantly associated with bilateral lesions (p = 0.001).

CONCLUSION

Bilateral SO palsy, even when highly asymetrical, can be surely diagnosed by carefully measuring excyclotorsion in both primary and downgaze by using dissociating devices. To avoid iatrogenic postoperative Brown syndrome it is recommended to adjust the amount of bilateral superior oblique tucking peroperatively, according to the degree of tendon extensibility. In cases of very severe excyclotorsion such a procedure can be completed by mild bilateral simultaneous inferior oblique recessions.

[The Stilling-Türk-Duane retraction syndrome]

The typical symptoms of Retraction syndrome (Stilling-Türk-Duane) are severe limitation of abduction, slight limitation of adduction and convergence, which are always accompanied by retraction of the globe, narrowing of the palpebral fissure, vertical deviation and elevated intraocular pressure, and a remarkable motility of the globe in the orbital axis. All symptoms are explicable by the cocontraction of the horizontal rectus muscles. In cases of single binocular vision, surgery is indicated only when the head posture is intolerable. We restrict surgery to recession of horizontal rectus muscles according to the head posture and the deviation. The surgical results of this procedure are satisfactory concerning the horizontal and the vertical deviation and the head posture.

Duane's retraction syndrome

Duane's retraction syndrome (DRS) has been a recognized clinical entity for nearly a century. It is a clinically well described ocular disorder consisting of retraction of the globe with narrowing of the lid fissure in attempted adduction, frequent abduction deficiency with variable limitation to adduction, and upshoot and/or downshoot of the affected eye on adduction. Among strabismus patients the incidence of DRS is probably not more than 5%. Most cases are sporadic, but familial cases have been estimated at 10% by most authors. Numerous theories concerning the etiology and pathogenesis of DRS have been proposed, including agenesis of the abducens nucleus, but the majority of investigators concur that the characteristic findings are best explained by a paradoxical innervation of the lateral rectus muscle, which subsequently causes a cocontraction of the horizontal rectus muscles. The frequent association of DRS with other congenital anomalies suggests a teratogenic event occurring between the fourth to eighth week of gestation as an etiological factor. In this review historical aspects and theories of the syndrome are studied and statistical data are compiled and analyzed. Clinical features, differential diagnoses and variants of the syndrome are examined. Testing and treatment objectives are discussed.

Duane retraction syndrome associated with Chiari I malformation

A 13-year-old girl who had Duane retraction syndrome associated with Chiari I malformation is reported. Neuro-ophthalmologic examination revealed severe limitation of abduction of the left eye, as well as narrowing of the palpebral fissure and retraction of the globe on adduction. Electro-oculography of the affected eye revealed decreased saccadic velocity on attempted abduction and adduction. Midsagittal magnetic resonance imaging demonstrated cerebellar tonsillar herniation to 6 mm below a line from the basion to opisthion. Taking into consideration the relative rarity of the two disorders, the association may not be coincidental. Magnetic resonance imaging of the posterior fossa is recommended in Duane retraction syndrome.