Synoptometer analysis of vertical shoot in Duane's retraction syndrome

Contralateral lateral rectus muscle recession in patients with Duane retraction syndrome type 3

AIMS

The aim of this study was to evaluate the motor, sensory, functional, and head posture results of recession of the lateral rectus muscle contralateral to the involved eye in patients with exotropic Duane retraction syndrome (DRS) type 3.

METHODS

This was a retrospective, longitudinal, observational study of a consecutive clinical case series. Of the 11 patients with DRS type 3 operated on at a tertiary medical center from 1977 to 2012, 8 underwent recession of the lateral rectus muscle contralateral to the involved eye (with combined Y-splitting of ipsilateral lateral rectus muscle in 3 of them). Full ophthalmic, orthoptic, and neurological examination was performed before and after surgery. Main outcome measures included intragroup changes in motor misalignment, abnormal head turn, ocular upshoot, and stereopsis.

RESULTS

Mean patient age was 8.75±3.1 years at surgery. Mean exodeviation for distance was -17.3±3.5 prism diopters (PD) preoperatively and -4.0±6.1 PD postoperatively; corresponding values for near were -23.1±7.2 PD and -5.9±8.7 PD. Motor deviation improved by 77% for distance (P=0.017) and 74.5% for near (P=0.01). In 7/8 patients, the postoperative residual exodeviation (distance and near) was <8.0 PD. There was an 80% improvement in head turn, from 15.3±4° before surgery to 3.1±5.0° after (P=0.01). Stereopsis improved significantly in 6/8 patients. Findings remained stable during follow-up (mean duration 35.9±50.8 months, range 5-132 months).

CONCLUSIONS

Contralateral lateral rectus muscle recession appears to be a promising technique for the treatment of moderate unilateral DRS type 3, with patients showing significant motor and functional improvement and a decrease in head turn.

Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall in exotropic Duane syndrome: a case report

INTRODUCTION

The surgical correction of anomalous movement such as upshoot in Duane syndrome is challenging. Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall is a new approach used to minimize or eliminate the effects of co-contraction including globe retraction, palpebral fissure narrowing and anomalous vertical movement.

CASE PRESENTATION

We report a case of a 7-year-old boy who underwent this procedure for severe upshoot, globe retraction and exotropia in the left eye due to Duane syndrome. The patient achieved satisfactory ocular alignment following surgery. Upshoot and globe retraction were substantially improved.

CONCLUSION

Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall is a safe and effective procedure for weakening of the anomalous lateral rectus muscle in Exotropic Duane Syndrome.

Tc-99m labeled red blood cells scintigraphy: a diagnostic method for orbital cavernous hemangioma

PURPOSE

To evaluate Tc-99m labeled red blood cells scintigraphy (Tc-99m RBC scintigraphy) as a diagnostic method for orbital cavernous hemangioma.

PATIENTS AND METHODS

Retrospective analysis of the medical records of all patients who were diagnosed as suffering from orbital cavernous hemangioma over the last 16 years.

RESULTS

Medical records of 12 patients with orbital cavernous hemangioma were identified. In all twelve patients, the tentative diagnosis of orbital cavernous hemangioma was made by CT scan. In all of them, the diagnosis was established by Tc-99m RBC scintigraphy, demonstrating a typical picture of "perfusion blood- pool mismatch" (This is normal radionuclide angiography, followed by a variable radionuclide uptake during the early blood-pool study and an intensive radionuclide uptake during the delayed blood-pool study). The tumor was surgically removed in all 12 patients. This diagnostic method was found to be reliable as no single case was recorded in which the preoperative diagnosis was not confirmed pathologically after surgical removal of the tumor.

CONCLUSIONS

Tc-99m RBC scintigraphy is a reliable method for diagnosing orbital cavernous hemangioma. It should be included in our arsenal of diagnostic techniques, particularly for cases which are otherwise difficult to diagnose.

Congenital ocular aberrant innervation--new concepts

BACKGROUND

We have the impression that congenital aberrant innervations are more common than previously reported. Many varieties exist and typically involve the sixth nerve. The most common ocular miswirings are Duane's syndrome and Marcus Gunn jaw-winking ptosis. The second most common miswiring involves lateral rectus activation in upgaze causing a "Y" pattern exotropia (pseudo inferior oblique overaction). This commonly is confused with inferior oblique overaction but surgery on the obliques does not cure the condition. Lateral rectus recession and elevation are required.

METHODS

We selected demonstrative cases from our practices to illustrate a variety of congenital aberrant innervations. A literature search for previous reported cases of aberrant innervations was performed. This report is an eclectic collection of observations of individual selected cases.

RESULTS

We found aberrant innervations of unusual varieties. These miswirings involve simultaneous firing of the lateral rectus with other muscles, including: the ipsilateral superior rectus, causing "pseudo inferior oblique overaction"; the contralateral lateral rectus, causing synergistic divergence; the ipsilateral superior rectus, in upward saccades only; and the masticatory muscles, causing exotropia with sucking. The third nerve by itself rarely is involved in congenital miswirings, but commonly shows aberrant regeneration after traumatic injuries. We know of no cases of aberrant innervation involving the fourth nerve.

SUMMARY

We present cases describing these congenital aberrant innervations and discuss a unifying hypothesis as to their typical involvement of the sixth nerve.