Two cases of Duane retraction syndrome with abnormal orbital structures

Duane retraction syndrome (DRS) is a rare congenital nonprogressive restrictive strabismus. The absence/hypoplasia of the abducens nerve and the aberrant innervation of the lateral rectus muscle by the oculomotor nerve have been hypothesized as causes of DRS, although the phenomenon of globe retraction can also occur in the setting of mechanical factors, such as congenital abnormal orbital structures or orbital trauma. We present the cases of 2 DRS patients with absent abducens nerve and abnormal muscular bands connecting the superior rectus and inferior rectus muscles on the temporal side of the optic nerve.

Magnetic Resonance Imaging Findings in Patients With Duane Retraction Syndrome

BACKGROUND

Duane retraction syndrome (DRS) is known to relate to the absence of the abducens nucleus, with abnormal innervation of the lateral rectus (LR) muscle by branchesof the oculomotor nerve (CN III). The purposes of this study were to investigate the morphological characteristics of the oculomotor nerve (CN III), the abducens nerve (CN VI), and the extraocular muscles in patients with clinically diagnosed Duane retraction syndrome (DRS) using MRI. In addition, we assessed the association between ocular motility, horizontal rectus muscle volumes, and CN III/VI in patients with Duane retraction syndrome (DRS).

METHODS

The study comprised 20 orthotropic control subjects (40 eyes) and 42 patients with Duane syndrome (48 eyes), including 20 patients with DRS Type I (24 eyes), 5 patients with DRS Type II (6 eyes), and 17 patients with DRS Type III (18 eyes). Three-dimensional (3D) T1/2 images of the brainstem and orbit were obtained to visualize the cranial nerves, especially the abducens (VI) and oculomotor (III) nerves, as well as extraocular muscles.

RESULTS

Based on the clinical classification, among 42 patients, MRI showed that the abducens nerves (CN VI) on the affected side were absent in 24 of 24 eyes (100%; 20 patients) with Type I DRS and in 16 of 18 eyes (88%; 16 patients) with Type III DRS. However, CN VI was observed in 6 of 6 eyes (100%; 5 patients) with Type II DRS and in 2 of 18 eyes (11%) with Type III DRS. CN III was observed in all patients. The oculomotor nerves on the affected side were thicker than those on the nonaffected contralateral side in DRS Type I ( P < 0.05) and Type III ( P < 0.05), but not in DRS Type II. Smaller LR and larger MR volumes were shown in the affected eye than that in the nonaffected eye in DRS Types I and III. Based on the presence or absence of CN VI, there was a tendency for thicker oculomotor nerves in the affected eye than in the nonaffected eye in the absence groups ( P < 0.05). However, no significant difference was found in the present group. In the CN VI absence groups, similar results were found in the affected eyes than in the nonaffected eyes as in DRS Types I and III. In addition, the presence of CN VI was correlated with better abduction ( P = 0.008). The LR and MR volumes have positive correlations with the oculomotor nerve diameter in the affected eye. However, there was no correlation between the range of adduction/abduction and the LR/MR ratio in patients with or without an abducens nerve.

CONCLUSIONS

Different types of DRS have different characteristic appearances of CN VI and CN III on MRI. Horizontal rectus muscles have morphological changes to adapt to dysinnervation of CN VI and aberrant innervation of CN III. Thus, these neuroimaging findings may provide a new diagnostic criterion for the classification of DRS, improving the comprehension of the physiopathogenics of this disease.

Orbital leiomyoma presenting as inverse globe retraction syndrome: a unique presentation of a rare disease

Inverse globe retraction syndrome is a rare ocular motility disorder characterized by limited abduction, with globe retraction and up- or downshoots on attempted abduction, differentiating it from globe retraction due to Duane retraction syndrome, seen on attempted adduction. It can be congenital or acquired. We report the case of a 3-year-old girl who presented with classical features of inverse globe retraction syndrome secondary to an underlying orbital tumor involving the medial rectus muscle. Incisional biopsy confirmed the diagnosis of a leiomyoma. At 10 months' follow-up, vision, ocular alignment, and ocular motility had improved.

Expanding the Phenotype of the FAM149B1-Related Ciliopathy and Identification of Three Neurogenetic Disorders in a Single Family

Biallelic truncating FAM149B1 variants result in cilia dysfunction and have been reported in four infants with Joubert syndrome and orofaciodigital syndrome type VI, respectively. We report here on three adult siblings, 18 to 40 years of age, homozygous for the known FAM149B1 c.354_357delinsCACTC (p.Gln118Hisfs*20) variant. Detailed clinical examinations were performed including ocular and gait analyses, skeletal- and neuroimaging. All three patients presented with neurological and oculomotor symptoms since birth and mild skeletal dysplasia in infancy resulting in characteristic gait abnormalities. We document mild skeletal dysplasia, abnormal gait with increased hip rotation and increased external foot rotation, ataxia, variable polydactyly, ocular Duane syndrome, progressive ophthalmoplegia, nystagmus, situs inversus of the retinal vessels, olfactory bulb aplasia, and corpus callosal dysgenesis as novel features in FAM149B1-ciliopathy. We show that intellectual disability is mild to moderate and retinal, renal and liver function is normal in these affected adults. Our study thus expands the FAM149B1-related Joubert syndrome to a mainly neurological and skeletal ciliopathy phenotype with predominant oculomotor dysfunction but otherwise stable outcome in adults. Diagnosis of FAM149B1-related disorder was impeded by segregation of multiple neurogenetic disorders in the same family, highlighting the importance of extended clinical and genetic studies in families with complex phenotypes.

Anomalous Vertical Deviations in Attempted Abduction Occur in the Majority of Patients With Esotropic Duane Syndrome

PURPOSE

To describe a phenomenon, depression in attempted abduction, not previously recognized as a feature of Duane syndrome (DS).

DESIGN

Retrospective, observational case series.

METHODS

Setting: Institutional practice.

PATIENT POPULATION

Patients diagnosed with esotropic DS at Boston Children's Hospital from 2002 to 2015. Patients with clinical photographs documenting horizontal gaze were included. Patients with prior strabismus surgery were excluded.

OBSERVATION PROCEDURES

Patients were classified into 3 groups according to their vertical eye position in attempted abduction: midline group, depression group, and elevation group. Group assignment was performed by 3 independent ophthalmologists. Baseline characteristics, eye movement, and ocular deviation were compared among the 3 groups.

MAIN OUTCOME MEASURES

Horizontal and vertical deviation on attempted abduction in the DS eye.

RESULTS

Depression in attempted abduction was present in 74 of 113 unilateral patients (66%) and 18 of 42 gradable eyes (43%) of bilateral patients. Abduction limitation was significantly less severe in the midline group (median: -3.0) than in the depression group (median: -4.0) (P = .01). Vertical deviation in attempted abduction was more severe in the elevation group than in the depression group (P = .003).

CONCLUSIONS

Depression of the eye in attempted abduction has not been widely described, yet it is present in the majority of DS patients. It is more likely to occur with more severe abduction limitation. This phenomenon is likely another form of dysinnervation in DS, the result either of anomalous vertical rectus muscle activation or asymmetric lateral rectus muscle innervation during attempted abduction. Awareness of vertical deviation in attempted abduction may facilitate surgical planning in affected patients.

Understanding the Relationship Between Teacher Behavior and Motivation in Students with Acquired Deafblindness

Because little is known about teacher-student relationships that involve students with acquired deafblindness, the authors performed a multiple case study with a multiple-method design to investigate the relationship between need-supportive teaching behaviors and student engagement. Using self-determination theory (Deci & Ryan, 2000), they analyzed video observations of interactions. It was found that teachers' provision of structure, autonomy support, and involvement often cooccurs with higher levels of student engagement. Moreover, varying degrees of need support over time seem to result in varying levels of student engagement. Examples are provided of need-supportive teaching behaviors that can be used to foster the motivation of students with acquired deafblindness.

Duane retraction syndrome type 1 with Usher syndrome type 2: an unreported association

Duane retraction syndrome is characterized by globe retraction and palpebral fissure narrowing on adduction, with restriction of abduction, adduction, or both. Usher syndrome type 2 consists of congenital bilateral sensorineural hearing loss and retinitis pigmentosa. The authors present a case with a yet unreported association between Duane retraction syndrome type 1 and Usher syndrome type 2.

Severe scoliosis, torticollis and short stature in a woman with Wildervanck Syndrome (WS)

Wildervanck syndrome (WS) combines features of Klippel-Feil syndrome (KFS), sixth nerve palsy, and deafness. This is a case of a 23 year old woman, diagnosed with KFS (a triad of short neck, low posterior hairline and restricted neck movements) at the age of 20 days. The manifestations of the WS in this patient are severe: she has torticollis, and an extremely severe scoliosis. In addition, she is short (-3 SD; parental target height + 0.8SD) and has mixed sensorineural and conductive deafness. She also has ptosis, strabismus and a high myopia. Radiologically, there are multiple coalitions of cervical vertebrae. Intelligence is unaffected (IQ 95), but deafness, strabismus and high myopia forced her early out of school. Karyotype is 46, XX. In brief, this is a patient with severe WS and additional anomalies. Short and/or reduced parental target height is a part of WS.

Cervico-Oculo-Acoustic Syndrome in a Male with Consanguineous Parents

Background:

The cervico-oculo-acoustic syndrome comprises Klippel-Feil anomaly, sensorineural deafness and Duane's retraction syndrome. Polygenic, autosomal dominant, and X-linked inheritance have been hypothesized. The disorder has rarely been reported in males.

Case Report:

A 42-year-old male, born of consanguineous parents, presented with Duane's syndrome, mixed hearing loss, C2-C3 fusion, neck stiffness, and right facial palsy. A variety of cardiac, neurological and urogenital anomalies occurred in his relatives. The electro-oculographic studies showed impaired abduction and adduction of the right eye and impaired abduction of the left eye. Vergence, vertical eye movements and peripheral vestibular responses were normal. Somatosensory evoked potentials showed absence of the N13 peak and brainstem auditory evoked potentials bilateral delay of the I-III interpeak latencies.

Conclusions:

Consanguinity of the patient's parents, not previously reported, suggests autosomal recessive inheritance, but autosomal dominant inheritance is indicated by the family history. The pattern of the oculomotor deficit is consistent with bilateral dysplasia of the abducens nuclei with preserved internuclear neurons in the right abducens nucleus. Neurophysiological investigations revealed lower brainstem and cervical cord involvement.

Duane retraction syndrome in a Nigerian child

We report a case of a four year old Nigerian girl who presented to the paediatric unit of our eye clinic with complaints of a squint on looking to the right side and reduction in the size of the right eye when looking to the left. On examination, she had right exotropia in the primary position of gaze. There was limitation of abduction and widening of the palpebral fissure of the right eye on right gaze. On left gaze there was narrowing of the palpebral fissure of the right eye with marked limitation of adduction and an upshoot, or occasionally a downshoot, of the eyeball. This report demonstrates that Duane's syndrome occurs in West Africa. Therefore, detailed examination of all patients with squints is important to ensure accurate diagnosis and appropriate management of the patient's condition.

Functional Amblyopia and Deficient Binocular Vision as Initial Clinical Features in Duane's Syndrome

PURPOSE

To investigate and report the clinical characteristics at initial presentation in patients who had Duane Syndrome, especially binocular vision and functional amblyopia.

METHODS

The medical files of patients with Duane's syndrome were reviewed. The main outcome measures of the study were the initial clinical characteristics including amblyopia and associated risk factors including deficiences of binocular vision.

RESULTS

The review identified 99 patients with Duane Syndrome. The median age of patients was 6 years. The frequency of amblyopia at initial presentation was 23 percent. Forty-five patients had measurable stereopsis and 58 patients had binocular vision fusion.

CONCLUSIONS

Amblyopia and altered binocular function are important among the clinical features of Duane Syndrome which should be highlighted at initial examination.

Vertical deviation and A pattern of type III Duane retraction syndrome

BACKGROUND

Researches in ocular electromyography (EMG) and Magnetic resonance imaging (MRI) of patients with Duane retraction syndrome (DRS) suggest that there may be additional abnormalities such as paradoxical innervation between horizontal rectus muscles and vertical rectus muscles, hypoplasia of vertical rectus muscle and that oblique muscles may also contribute to the heterogeneity of the clinical manifestation of DRS. This paper reports the results of superior rectus recession for vertical deviation and A pattern in DRS Type III and discusses the pathogenesis of the disease.

METHODS

Superior and lateral rectus recession were performed in 5 cases of Huber type III DRS to treat vertical deviation and A pattern strabismus. Before operation, MRI of the brain, brainstem, cavernous sinus, and orbits were performed.

RESULTS

All subjects had unilateral limitation of both abduction and adduction, with palpebral fissure narrowing and globe retraction in adduction. Three cases had A pattern of strabismus, three cases had hypertropia. The abducens nerves (CN6) were either absent or hypoplasitic in the brainstem in all patients. Two eyes had larger oculomotor foramen. Two eyes had hypoplasia of the superior rectus and the inferior rectus. There was presumably a branch of the third cranial nerve (CN3) innervating the lateral rectus (LR) in one eye. While in another eye, two branches of CN3 sent into medial rectus were revealed. After surgery, vertical deviation in the primary position was reduced in all patients and A pattern was eliminated in 3 patients. One patient developed 10Δ consecutive esotropia postoperatively.

CONCLUSION

The results suggest that structural abnormalities of vertical muscle and abnormal orbital innervation may be related to vertical deviation and the presence of A pattern in DRS type III. Recession of the superior rectus muscle seems to be a safe and effective treatment for vertical deviation and A pattern strabismus in DRS Type III.

Duplication of 8q12 encompassing CHD7 is associated with a distinct phenotype but without duane anomaly

Interstitial duplications of 8q12 encompassing CHD7 have recently been described as a new microduplication syndrome. Three 8q12 duplications have been reported with shared recognizable phenotype: Duane anomaly, developmental delay and dysmorphic facial features. We identified a 2.7 Mb duplication on chromosome 8q12 with SNP-array in a patient with growth delay, congenital heart defects, ear anomalies and torticollis. To our knowledge, this is the smallest duplication reported to date. Our findings support the notion that increased copy number of CHD7 may underlie the phenotype of the 8q12 duplication. Our study together with previous studies suggest that the 8q12 duplication could be defined as a novel syndrome.

Goldenhar syndrome in association with Duane syndrome

Goldenhar syndrome (GHS) is also known as Oculo-Auriculo-Vertebral (OAV) syndrome or Branchial arch syndrome. Duane retraction syndrome (DRS) is a congenital disorder of ocular motility characterized by limited abduction, adduction or both. It is unilateral in 80% of cases. The important and interesting part of this eight months old child is presence of GHS with DRS. She has bilateral invol-vement, which is seen in only 5-8% of GHS, as compared to high incidence of unilateral involve-ment. This child also had refractive error of + 6.00/ - 1.5 * 180. At four year of age her vision with glass was 6/9. Children with GHS and DRS should have early eye examination done to treat the problem of refractive error.

[Retrospective study on clinical characteristics and surgical treatment of bilateral DRS]

OBJECTIVE

To investigate the clinical characteristics and surgical treatment of bilateral Duane retraction syndrome.

METHODS

To collect 24 cases with bilateral DRS among 123 cases with DRS from hospital data during 2005.7 to 2009.11. Retrospective study included the clinical types, characteristics, plus diseases and surgical treatments.

RESULTS

Fourteen male cases (58.3%) and 10 female cases (41.7%), aging 2 to 23-year-old. 16 cases were type I (66.7%), 1 case was type II (4.2%). 7 cases were type III (29.1%), in which patients with esotropia or exotropia were 3 and 4 cases respectively. 11 cases had up- or down-shoot pre-operation, which disappeared or improved post-operation in 8 cases (73%). 15 cases had abnormal head posture (AHP) and AHP disappeared or improved in all. Seven cases (29%) were associated with other congenital ocular or systemic anomalies. For horizontal deviation, unilateral medial or lateral rectus weakening procedures were performed in 13 cases and bilateral procedures in 11 cases. Post-operation, horizontal deviation was less than ± 10(Δ) in 21 patients (91%), 1 case was under-corrected and 2 cases were overcorrected. Simultaneously, the restriction of ocular motility and global retraction were improved in all the patients. Additional vertical or oblique muscle procedures were performed in 4 patients among 7 with vertical deviation more than 10(Δ) and up- or down-shoot.

CONCLUSIONS

Bilateral DRS has more frequency in male, obviously horizontal deviation in primary position and more cases with vertical deviation which is related with up- or down-shoot phenomenon. The key point for successful surgery are forced duction test pre- and during operation to conform to relieve the mechanical factor and estimating abnormal innervation in horizontal and vertical rectus.

Imaging findings in congenital cranial dysinnervation disorders

In 2002, the term congenital cranial dysinnervation disorders (CCDDs) was proposed to group heterogeneous syndromes with congenital abnormalities of ocular muscle and facial innervations. The concept of neurogenic etiology has been supported by discovery of genes that are essential to the normal development of brainstem, cranial nerves, and their axonal connections. The CCDDs include Duane retraction syndrome, congenital fibrosis of the extraocular muscles, Möbius syndrome, horizontal gaze palsy with progressive scoliosis, the human homeobox-related disorders, pontine cap tegmental dysplasia, and an expanding list. The purpose of this review was to update the imaging features, as well as clinical and genetic information, regarding cases of CCDDs.

[Vertical retraction syndrome caused by anomalous orbital structures]

OBJECTIVE

To described the clinical feature and MRI imaging of six children with vertical retraction syndrome.

METHODS

Six children with unilateral vertical retraction syndrome between 15 months and 8 years of age, mean age was (5.01 ± 1.27) years old. Strabismus examination included diopter, prism diopters, eye movement examination, binocular vision and fundus examination. Imaging of the ocular motor nerves at the brainstem was performed in 0.8 mm thickness image planes using 3D-FIESTA sequence, the orbits were imaged with FSE T1, T2WI using surface coils, and within 2.0 mm thick planes.

RESULTS

Four children showed hypertropia, characterized by limited depression, a light retraction of the globe during downward gaze and eyelid lag. The MRI imaging showed anomalous orbital structure in the superonasal quadrant that between medial rectus and superior rectus or adjacent to the superior rectus. Two children showed intermittent exotropia, characterized by limited elevation, retraction of the globe and narrowing of the palpebral fissure during upward gaze. The MRI imaging showed anomalous orbital structure was present in the inferotemporal quadrant, one originate in inferior rectus and another close to the lateral rectus.

CONCLUSION

Anomalous orbital structures are a main cause of vertical retraction syndrome. The presence of specific unusual eye movement and MRI imaging may assist in diagnosis. When the eyelid lag was found since the early age, anomalous orbital structures were implied.

[An unusual case of non-traumatic enophthalmos]

An extensive spectrum of differential diagnoses has to be considered when a patient presents with enophthalmos. The most common causes of this presentation include orbital trauma or contraction and atrophy of the orbital contents secondary to scleroderma or radiotherapy. However radiologists also have to consider less common causes of enophthalmos, such as the imploding antrum syndrome or the ethmoid silent sinus syndrome. The latter involves the ethmoidal cells and results in medial orbital wall implosion. Along with the case presentation the pathogenesis, incidence and differential diagnoses of ethmoid silent sinus syndrome are elucidated. In particular the differentiation from normal anatomical variants, such as dehiscent lamina papyracea is discussed.

Splitting of the extraocular horizontal rectus muscle in congenital cranial dysinnervation disorders

PURPOSE

To analyze the horizontal rectus extraocular muscles (EOMs) by orbital magnetic resonance imaging (MRI) in patients with congenital cranial dysinnervation disorders that arises from abnormal development of cranial nerve nuclei or their axonal connections.

DESIGN

Case series, retrospective analysis.

METHODS

The morphology of the horizontal rectus EOMs was analyzed in orbital MRI on 4 patients with congenital oculomotor palsy, 26 with congenital superior oblique palsy, and five with Duane syndrome. Orbital imaging was performed by 1.5 tesla (T) and 3T MRI, and quasi-coronal and sagittal images perpendicular and parallel to the long axis of the orbit were obtained at slice thicknesses of 3 and 2 mm.

RESULTS

The horizontal rectus EOMs were split in 4 of the 35 patients (11%). Splitting was observed in 2 of the five patients (40%) with Duane syndrome, one of the 26 patients (4%) with congenital superior oblique palsy, and 1 of the 4 patients (25%) with oculomotor palsy, but in none of the 6 normal subjects and 12 patients with acquired cranial nerve palsy.

CONCLUSION

Since splitting of the horizontal rectus EOMs was noted in patients with congenital dysinnervation disorders, including Duane syndrome, Sevel's theory that the horizontal rectus EOMs develop from the superior and inferior mesodermal complexes is considered to be reasonable.

Auditory brainstem response and otoacoustic emissions in Duane retraction syndrome

OBJECTIVE

We aimed to investigate the origin of hearing loss with relevance to auditory brainstem responses and otoacoustic emissions in patients with Duane's retraction syndrome (DRS).

MATERIALS AND METHODS

17 patients with DRS were included in the study. 14 patients were diagnosed as DRS type 1 and the remaining three as type 3. The control group consisted of nine healthy subjects. Pure tone audiogram, auditory brainstem response, as well as distortion product otoacoustic emissions were recorded in all the patients and the controls.

RESULTS

Among the 17 patients with DRS, 15 demonstrated normal hearing according to pure tone audiogram. One patient with DRS had profound sensorineural hearing loss with a pure tone average of 110 dB, and one patient had moderate sensorineural hearing loss with a pure tone average of 60 dB. Auditory brainstem response latencies of the waves I, III and V, and interwave latencies were calculated in 15 patients with DRS and were compared with the control group. There was statistically significant increase in wave I latency of left ear in the DRS group compared to the controls (P<0.05). Amplitudes of distortion product otoacoustic emissions were also recorded at frequencies of 2, 3, 4, 6, and 8 kHz in both groups and the comparison of the DRS patients and controls revealed no statistically significant difference.

CONCLUSIONS

We recommend auditory examinations be undertaken in patients with DRS by auditory brainstem response tests, as well as distortion product otoacoustic emissions, whereas all patients with normal results should be followed-up for future hearing loss.

Congenital aberrant tearing: a re-look

PURPOSE

Congenital aberrant tearing is characterized by tearing when eating ("crocodile tears"), lack of emotional tearing, or both. Most reported cases are associated with Duane syndrome. In our previous studies we observed aberrant tearing in individuals with thalidomide embryopathy and Möbius sequence. This report summarizes the literature on the subject and adds 3 new studies that give information on this unusual condition.

METHODS

Twenty-eight individuals with Möbius sequence were interviewed about tearing symptoms at a support group meeting in Italy. In Sweden 30 adults primarily from the original thalidomide series were reexamined. In this latter study, a Schirmer test was done at baseline and repeated 5 minutes after eating. Twenty families in Brazil who have children with Möbius sequence were questioned about tearing symptoms and exposure to misoprostol during pregnancy.

RESULTS

In the 28 Italian individuals, either "crocodile tears" or lack of emotional tearing was noted in 7 cases. In the thalidomide study, 10 of 30 patients had tearing when eating and 7 had no emotional tearing. Low Schirmer scores or increased tearing after eating was noted in a few asymptomatic individuals. Among the 20 Brazilian children with Möbius sequence, 10 had some tearing abnormality.

CONCLUSION

Congenital anomalous lacrimation is rare but usually associated with Duane syndrome or abduction deficits, as in Möbius sequence and, less frequently, facial nerve palsy. Studies implicate an early insult in development at 4 to 6 weeks. At that time the facial nerve, sixth nerve, and lacrimal nucleus are in close proximity in the embryo.

Duane's retraction syndrome, a case series from Iran

PURPOSE

To determine the relative prevalence of Duane's retraction syndrome (DRS) in a population of Iranian strabismus cases and to describe the clinical features.

METHODS

Retrospectively, a population of 7,349 strabismus cases visited during 2000-2003 were evaluated for the diagnosis of DRS. Data regarding onset (noticed age), type, head turn, primary position deviation, narrowing of the palpebral fissure, leash phenomenon, refractive error, amblyopia, and history of surgery were collected. Chi-square test and Student's t-test were used.

RESULTS

About 125 DRS cases were diagnosed (prevalence: 1.7%). The noticed age of the syndrome was at birth in 35.6%, during infancy in 25.4%, or childhood in 39.0%; the age at referral ranged from 3.5 months to 65.0 (median: 10.0) years. The female/male and left/right eye involvement ratios were 3:2 and 3.5:1, respectively. The syndrome was of type I in 87.0%, II in 6.5%, and III in 5.7%; 7.2% were bilateral. Horizontal deviations existed in 76.0% and vertical deviations in 12.8%. 26.8% had different degrees of amblyopia. Leash phenomenon was detected in 37.6% of cases. Head turn, primary position deviation (without turn), and orthophoria were observed in 71.2%, 13.6%, and 15.2%. Surgery had been performed in 71.2% of the cases. Vertical deviations and leash phenomenon were more common in types II and III and hypermetropia in type I (P values: 0.036, <0.001, and 0.025, respectively).

CONCLUSION

Basic features of our series seem to be comparable with previous reports. The incidences of bilateral involvement and type III syndrome were lower. The proportion of cases with head turn was higher and surgery was performed more frequently.

Bilateral incyclotorsion, absent facial nerve, and anotia: fellow travelers in Möbius sequence or oculoauriculovertebral spectrum?

We report a patient with bilateral incyclotorsion, asymmetric facial palsy, monocular depression deficiency, and unilateral Type 3 Duane syndrome, along with contralateral anotia and a midline cleft palate. A dysplastic middle ear cavity and unilateral absence of the facial nerve were noted on magnetic resonance imaging scanning. The differential diagnosis includes Möbius sequence, oculoauriculovertebral spectrum, and a congenital cranial dysinnervation disorder.

Atypical association of Duane retraction syndrome and Bardet Biedl syndrome

Duane's retraction syndrome (DRS) includes changes in palpebral fissure width along with restriction of ocular motility. Bardet Biedl syndrome (BBS) includes presence of retinitis pigmentosa (RP) with obesity, mental retardation, polydactyly and renal abnormalities. We report a case of rare association of DRS with BBS in a seven-year-old child. The ocular motility examination revealed left DRS with esotropia. Fundus examination revealed findings characteristic of an atypical retinitis pigmentosa. The electro-retinogram waveforms were extinguished both for rods and cones. He was diagnosed as a case of BBS on the basis of the ophthalmological findings plus association with the systemic features of obesity, polydactyly, hypogonadism, mental retardation and renal abnormalities. This case gives further evidence of the fact that BBS may be associated with abnormalities of eye movements.

Magnetic resonance imaging evidence for widespread orbital dysinnervation in dominant Duane's retraction syndrome linked to the DURS2 locus

PURPOSE

High-resolution, multipositional magnetic resonance imaging (MRI) was used to demonstrate extraocular muscles (EOMs) and associated motor nerves in Duane retraction syndrome (DRS) linked to the DURS2 locus on chromosome 2.

METHODS

Five male and three female affected members of two autosomal dominant DURS2 pedigrees were enrolled in the study. Coronal T(1)-weighted MRI of the orbits was obtained in multiple gaze positions, as well as with heavy T(2) weighting in the plane of the cranial nerves. MRI findings were correlated with motility.

RESULTS

All subjects had unilateral or bilateral limitation of abduction, or of both abduction and adduction, with palpebral fissure narrowing and globe retraction in adduction. Orbital motor nerves were typically small, with the abducens nerve (cranial nerve [CN]6) often nondetectable. Lateral rectus (LR) muscles were structurally abnormal in seven subjects, with structural and motility evidence of oculomotor nerve (CN3) innervation from vertical rectus EOMs leading to A or V patterns of strabismus in three cases. Four cases had superior oblique, two cases superior rectus, and one case levator EOM hypoplasia. Only the medial and inferior rectus and inferior oblique EOMs were spared. Two cases had small CN3s.

CONCLUSIONS

DRS linked to the DURS2 locus is associated with bilateral abnormalities of many orbital motor nerves, and structural abnormalities of all EOMs except those innervated by the inferior division of CN3. The LR may be coinnervated by CN3 branches normally destined for any other rectus EOMs. Therefore, DURS2-linked DRS is a diffuse congenital cranial dysinnervation disorder involving but not limited to CN6.

Interstitial deletion of 1q42.13-q43 with Duane retraction syndrome

Duane retraction syndrome is a congenital eye movement disorder characterized by failure of the sixth cranial nerve or nucleus to develop properly, resulting in restriction of abduction, narrowing of the palpebral fissure, and retraction of the globe on attempted adduction and/or restricted adduction. The gene loci of Duane syndrome have been mapped on 8q and 2q, indicating a heterogeneity. We report here a patient with interstitial deletion of 1q with Duane syndrome. The karyotype of our patient suggests another possible locus of the Duane syndrome, and the mapped genes around the deleted region, 1q42.13-43, contain possible candidate genes such as a homeobox gene. However, further clinical descriptions of patients with Duane syndrome and genetic investigations of the deleted regions are needed for a more accurate delineation.

Comparison of orbital magnetic resonance imaging in duane syndrome and abducens palsy

PURPOSE

To help resolve the clinical ambiguity between Duane syndrome with severe abduction deficit and abducens palsy, we performed orbital magnetic resonance imaging (MRI) to qualify abnormalities of the lateral rectus (LR) muscle in these entities.

DESIGN

Prospective observational case series.

METHODS

Orbital MRI was performed in 13 subjects with Duane syndrome (19 eyes), 10 subjects with chronic abducens palsy (10 eyes), and 10 orthotropic control subjects (18 eyes). High-resolution, surface coil, T(1)-weighted MRI was used to obtain contiguous, 2-mm thick quasi-coronal images of the orbits in central gaze. Digital image analysis was used to quantify cross-sectional area of the ipsilesional and contralesional LR to provide comparison with control measurements.

RESULTS

Mean maximum LR cross-sectional area in Duane syndrome was statistically similar to control (P = .454) and contralesional LR cross-sectional area (P = .227). However, in chronic abducens palsy, mean maximum ipsilesional LR cross-sectional area was markedly smaller than contralesional (P = .003) and control cross-sectional areas (P < .0001), as well as smaller than the LR in Duane syndrome (P= .0017).

CONCLUSIONS

The LR muscle in abducens palsy exhibits profound atrophy. The sparing of the LR in Duane syndrome from denervation atrophy despite absence of normal abducens innervation suggests existence of alternative LR innervation. High-resolution MRI can noninvasively demonstrate LR muscle size and distinguish Duane syndrome from chronic abducens palsy in uncertain cases.

Clinical characteristics of bilateral Duane syndrome

PURPOSE

To describe the clinical characteristics of bilateral Duane syndrome.

METHODS

Retrospective medical record review (1982 to 2003) for patients with a diagnosis of Duane syndrome (examined by a pediatric ophthalmologist) who were bilaterally affected and had no prior ocular surgery. Data collected included type of Duane syndrome, gender, family history for strabismus, abnormal head position, versions, strabismus measurements, associated ocular and/or nonocular abnormalities, and amblyopia status.

RESULTS

Of 270 patients with the diagnosis of Duane syndrome, 37 (14%) were bilaterally affected. None had ocular surgery prior to referral. Twenty-two (59%) were male, 35 (95%) had the same Duane syndrome type in both eyes, 29 (78%) had strabismus in primary position, 9 (24%) had ocular and nonocular congenital abnormalities, 6 (16%) had amblyopia, and 8 (22%) had a recorded strabismus family history.

CONCLUSIONS

Unlike unilateral Duane syndrome, bilateral Duane syndrome may be more common in males and associated with a higher prevalence of strabismus in primary gaze position. The prevalences of amblyopia, positive strabismus family history, and associated congenital abnormalities in this series of bilateral cases is similar to the reported prevalence.

[Surgical options in retraction syndrome]

BACKGROUND

A causative therapy for Duane's retraction syndrome, which is the most prominent example of connatal ocular misinnervation, does not exist. Eye muscle surgery is indicated in cases with manifest strabismus in primary position and an annoying compensatory head posture to maintain binocular single vision. Different surgical approaches to the different types of Duane's retraction syndrome, mostly on the affected eye but also on the fellow eye, are described in the literature.

METHOD

We retrospectively analyzed the pre- and postoperative findings of 55 patients in whom we performed surgery because of Duane's retraction syndrome during the years 1999 to 2004. The type of retraction syndrome, the angle reduction in primary position and the reduction of head posture were evaluated in regard to the surgical procedure chosen.

RESULTS

In 37 cases surgery was primary. In 25 cases a single recession of the medial rectus (16 cases) or the lateral rectus (9 cases) muscle of the affected eye was performed. For a dose-response relationship of the one-muscle recessions, the mean angle reduction in the primary position was 2 pdpt (cm/m) per mm recession. The mean reduction of head posture was 1.5 degrees per mm recession. In 10 cases combined surgery on the affected eye was performed. The correlation between the mean angle reduction and the recession was 3 pdpt (cm/m) per 1 mm.

CONCLUSION

Depending on the type of retraction syndrome, the angle in primary position, the head posture and the globe retraction, different surgical options exist which aim at rehabilitation of the patient suffering from Duane's retraction syndrome.

Association of Duane retraction syndrome and Brown syndrome

Brown syndrome and esotropic Duane syndrome are common forms of noncomitant strabismus. We report the unusual coexistence of these two eye movement abnormalities in a 5-year-old boy. Strabismus surgery for both conditions was required to improve the head posture.

Presence of the abducens nerve according to the type of Duane's retraction syndrome

OBJECTIVE

To analyze whether the presence of the abducens nerve might depend upon the type of Duane's retraction syndrome (DRS).

DESIGN

Observational case series.

PARTICIPANTS

Sixteen patients with type 1 DRS, 2 patients with type 2 DRS, and 5 patients with type 3 DRS.

METHODS

Ophthalmologic examination and thin-sectioned magnetic resonance imaging (MRI) at the brain stem level were performed in 23 DRS patients. To confirm the accuracy of the procedure, we compared the results obtained with those of a control group of 30 individuals using the same technique.

MAIN OUTCOME MEASURES

Examination of ductions and versions and the presence of the abducens nerve on MRI.

RESULTS

The abducens nerve on the affected side could not be observed using MRI in 18 (100%) of 18 eyes (16 patients) with type 1 DRS and in 3 of 5 eyes with type 3 DRS. Conversely, the abducens nerve was observed in 2 of 2 eyes with type 2 DRS and 2 of 5 eyes with type 3 DRS. The abducens nerve was observed in 60 (100%) of 60 eyes screened as controls.

CONCLUSIONS

The abducens nerve on the affected side was absent in type 1 DRS patients and some type 3 DRS patients, but present in type 2 DRS patients as well as in some type 3 DRS patients. In terms of the presence or absence of the abducens nerve, type 1 and type 2 DRS were homogenous, and type 3 DRS was heterogenous.

Are Duane syndrome and infantile esotropia allelic?

PURPOSE

To evaluate the clinical overlap of families with Duane syndrome and infantile esotropia to determine whether the identification of genes for Duane syndrome may explain some cases of infantile esotropia.

METHODS

Three separate groups of patients were evaluated. 1) Families with features of infantile esotropia were identified through the Strabismus Inheritance Study Tasmania (SIST). Clinical details of participants and their families were reviewed for any cases of Duane syndrome. 2) Cases of Duane syndrome were identified through the clinical diagnostic database at the Royal Children's Hospital, Melbourne, and private ophthalmology clinics in Melbourne and Tasmania. Previous medical notes were reviewed and family history of strabismus noted. All affected individuals were invited for re-examination in cases where a positive family history of strabismus was reported; siblings, parents, and other family members, where appropriate, were invited to be examined for signs of Duane syndrome or infantile esotropia. 3) Cases of mosaic trisomy 8, which has been associated with Duane syndrome and infantile esotropia, were reviewed for signs of strabismus.

RESULTS

A total of 133 families from the SIST were reviewed, but no 'pure' families of Duane syndrome were identified. Two families with infantile esotropia had several members affected with Duane syndrome. Of the 40 index cases with Duane syndrome whose families agreed to be involved in the study, 21 had a family history of ocular motility disorders, but only two of these families had multiple cases of Duane syndrome. From 24 cases with mosaic trisomy 8, one individual case had Duane syndrome and another had mild congenital cataracts and infantile esotropia.

CONCLUSIONS

There is clinical overlap in families with Duane syndrome and infantile esotropia. We confirmed the previous association of mosaic trisomy 8 with both Duane syndrome and infantile esotropia. These data suggest that the two conditions may be allelic and may be due to a gene on chromosome 8.

Management of Duane retraction syndrome

BACKGROUND

Duane retraction syndrome is the most common cause of congenital aberrant ocular innervation. We report referral practices, clinical characteristics and complications, prevalence of congenital and familial anomalies, and management outcomes from a clinic-based series.

METHODS

Retrospective clinic-based study of 65 patients with Duane retraction syndrome seen between January 1994 and March 2004.

RESULTS

The majority of patients were girls with type I Duane retraction syndrome associated with esotropia in primary gaze. Twenty percent of cases were complicated by absent binocular stereoacuity and 16.9% had amblyopia. Family history of any ocular disorder was reported in 38.5% of cases, while an associated congenital abnormality was found in 46% of patients. There was a significant delay between the age when ocular abnormalities were first noticed and the age when patients presented at our tertiary referral center (P < .001). Twenty-two percent of patients underwent surgical correction at a mean age of 6 years. Most procedures were unilateral or bilateral medial or lateral rectus recessions. Postoperative ocular alignment < or = 15 prism diopters (PD) was achieved in 86% of cases, with 50% of cases having < or = 5 PD.

CONCLUSIONS

Amblyopia and absent binocular stereo vision affected one in five patients with Duane retraction syndrome. There was significant delay between identification of an abnormality and presentation at the eye clinic.

[Duane's syndrome--etiopathogenesis, clinical features and diagnosis]

Duane syndrome is a congenital disease also known as congenital retraction syndrome or Stilling-Turk-Duane retraction syndrome. There are three types of Duane syndrome; their variability is given by the aberrant innervation of the lateral rectus muscle. The symptoms of the disease were described and they are all known, but the etiology and the pathology remain unclear. Although Duane syndrome was considered as a pure local myogenic phenomenon (the lateral rectus muscle fibrosis), the modern theory is the absence of the abducens nuclei. Various theories have been put forward on the basis of data collected from surgical, autopsy and electromyography studies. The most frequent and terrifying differential diagnosis is the VI nerve palsy and the symptoms of Duane syndrome suggest an intracranial disease, so we understand the parents and patient fear. That's why is very important to explain them the causes and the consequences of the disease and to educate the patients to obtain the optimal functional and mental comfort. Finally, we have in mind one, at least subjective, question: why is the abducens nerve nucleus affected and how?

A report of canine tooth syndrome

The authors describe the case of a 5-year-old girl traumatized from a dog bite to the superior aspect of the orbit in the right eye. The dog's canine tooth penetrated deep into the posterior orbit and severed the attachment of the superior oblique muscle from the globe posterior to the trochlea. The management and clinical course of the patient are described and photographs documenting the initial ocular damage and postoperative course are provided. In addition, the entity known as 'canine tooth syndrome' is reviewed.

[Clinical and molecular genetic findings in isolated sporadic Duane syndrome]

BACKGROUND

Duane retraction syndrome (DURS) accounts for 1 - 4 % of all cases of strabismus. Approximately 90 % of the cases are sporadic with a preponderance for females and the left eye. Many associated ocular and systemic findings have been described. Recently, mutations of SALL4 have been found in patients with autosomal-dominantly inherited Okihiro syndrome (DURS associated with forearm malformations). The aim of this study was the clinical examination of patients with isolated sporadic DURS and the molecular genetic analysis of SALL4 in these patients.

SUBJECTS AND METHODS

Twenty-five patients with non-familial DURS (aged 1 - 75 years, 16 female, 9male) were examined clinically and were interviewed concerning associated pathologies. DNA was prepared from peripheral lymphocytes, and the complete coding region of SALL4 was sequenced.

RESULTS

In 18 patients DURS affected the left eye, in four the right eye, and was bilateral in three patients. One patient had fused vertebrae, one had a cone-rod-dystrophy. No hearing impairments or malformation of the upper limbs were observed. No mutation in the coding region of SALL4 could be detected.

DISCUSSION

Associated conditions in DURS patients most commonly involve the ear, the spinal column, the kidneys and the heart and the upper limbs. No mutations in SALL4 could be detected in patients with isolated sporadic DURS as opposed to findings in familial Okihiro syndrome. However, Okihiro syndrome shows marked intra- and interfamilial variability, suggesting that in rare cases of isolated DURS a causative SALL4 mutation may be found.

[Treatment modalities in Duane syndrome]

Stilling-Türk-Duane syndrome is a restrictive syndrome caused by an abnormal innervation of the lateral rectus muscle, which is the result of nerve VI agenesia. One of the most important feature is represented by "co-contraction phenomenon" which means the simultaneous contraction of lateral and medial muscles in adduction. The treatment is individualised and most patients may benefit of surgical procedures. The goals of surgical treatment is: improved head posture, elimination of vertical deviation, reduced of enophthalmos and normal ocular alignment. This issue represent the surgical management and the postoperative results in 3 cases of Stilling-Türk-Duane syndrome treated in Eye Clinic, Iasi.

[Familial congenital bilateral Duane's retraction syndrome (Stilling-Turk-Duane syndrome). A case report]

The authors describe a case of Duane's Retraction Syndrome, which is an unfrequent cause of eye movement disturbances. The classic syndrome is characterized by a disability for horizontal eyes movements without concurrent diplopia. It is a multi-etiological, congenital or acquired syndrome.

Magnetic resonance imaging in Duane's retraction syndrome

PURPOSE

The aim of this study was to visualize the subarachnoid portion of the nervus abducens by magnetic resonance imaging and to analyze whether aplasia of the nervus abducens is an etiologic factor in Duane's retraction syndrome.

METHODS

We performed thin-sectioned magnetic resonance imaging across the brainstem level in 8 cases (11 eyes) that were clinically diagnosed as Duane's retraction syndrome. The same test was applied to 8 healthy control subjects to verify the accuracy of this technique.

RESULTS

The nervus abducens on the affected side could not be observed in 6 (54.5%) of 11 eyes (8 cases) that were clinically diagnosed as having Duane's retraction syndrome. The nervus abducens was observed in 15 (94%) of 16 eyes that were screened as the control group.

CONCLUSIONS

The results showed that aplasia of the nervus abducens, although an important etiologic factor, is not the only factor responsible for the diagnosis of Duane's retraction syndrome.