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Profound weakening of the lateral rectus muscle with attachment to lateral canthal tendon for treatment of exotropic Duane syndrome
Short Reports Profound weakening of the lateral rectus muscle with attachment to lateral canthal tendon for treatment of exotropic Duane syndrome Jaspreet Sukhija, MD, Manpreet Singh, MD, and Usha Singh, MD
An 8-year-old girl with exotropic Duane syndrome presented with upshoot, downshoot, and globe retraction in attempted adduction. To correct the alignment and treat the secondary aberrant movements, we weakened the lateral rectus muscle using a new surgical technique. In this approach, the lateral rectus muscle of the involved eye was disinserted and then attached to the lateral canthal tendon using nonabsorbable sutures. At the 3-week return visit, the patient was orthotropic in straight-ahead gaze with slightly improved adduction and negligible upshoot, downshoot, and globe retraction.
was passed through the tendon 2 mm from its insertion in Whitnall’s tubercle (Figure 3). The lateral rectus muscle was thus anchored to the lateral palpebral ligament. Conjunctiva and Tenon’s capsule were closed in separate layers with 8-0 polyglactin 910 suture. The patient was orthotropic 3 weeks postoperatively, and there was no head turn (Figure 1B). Downshoot and upshoot were negligible and narrowing of the palpebral fissure was no longer in evidence (Figure 2B). There was also improvement in adduction.
Case Report
Discussion
A
Various surgical procedures are recommended for correction of strabismus and cocontraction in Duane syndrome, including supramaximal recession of the lateral rectus muscle,1 rectus muscle transposition,2 and Y splitting and recession of the lateral rectus muscle.3 For treatment of esotropic Duane syndrome with severe globe retraction, transposition of the lateral half of the vertical rectus muscles to the lateral rectus insertion was combined with fixation of the lateral rectus muscle to the periosteum of the lateral orbital wall.4-7 Although the outcome of periosteal fixation of the lateral rectus muscle may be excellent, exposing the adjacent periosteum and passing the needle through it is technically difficult.5 In our procedure, the lateral rectus muscle is instead attached to the lateral canthal tendon. This structure can easily be identified by its appearance and relatively superficial location because it inserts at Whitnall’s tubercle. This anatomic landmark is easily identifiable 1.5 mm behind the orbital rim and 9.7 mm inferior to the frontozygomatic suture. The lateral canthal tendon can thus be reached using a temporal incision through tendon and conjunctiva. A small pocket of fat can be identified posterior to the orbital septum and anterior to the lateral canthal tendon.8 The approach, like other orbital wall fixation procedures, has the additional advantage of being potentially reversible.
n 8-year-old girl presented to the strabismus clinic Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, with a chief symptom of outward deviation of the right eye since birth. Past medical history and family history were unremarkable, with no history of trauma or neurological disease. On examination, best-corrected visual acuity was 6/6 in the right eye and 6/9 in the left eye. The patient had a left head turn of 25 (Figure 1A). Motility testing was notable for limitation of both adduction and abduction of the right eye, with narrowing of the palpebral fissure and upshoot and downshoot of the eye in attempted adduction (Figure 2A). Prism and cover testing in straight-ahead gaze revealed an exotropia of 30D. The patient was diagnosed with exotropic Duane syndrome in the right eye. A right lateral rectus weakening procedure was planned. At surgery, the lateral rectus muscle was identified and secured with a double armed 5-0 polyester suture using a double-armed needle and disinserted from the globe. The lateral orbital rim was then palpated and a conjunctival opening was placed 3–4 mm posterior to the orbital rim. The lateral canthal tendon was identified by its bright white color and the surrounding orbital fat. The suture
Author affiliation: Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India Submitted May 24, 2011. Revision accepted January 3, 2012. Correspondence: Jaspreet Sukhija, MD, Assistant Professor, Advanced Eye Centre, PGIMER, Sec 12, Chandigarh, India (email: [email protected]). J AAPOS 2012;16:298-300. Copyright Ó 2012 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 doi:10.1016/j.jaapos.2012.01.013
298
Journal of AAPOS
Volume 16 Number 3 / June 2012
Sukhija, Singh, and Singh
299
FIG 1. External photographs of an 8-year-old girl with exotropic Duane syndrome. A, Head turn to left of 25 . B, Postoperative photograph showing resolution of abnormal head posture.
FIG 2. Ocular motility before and after weakening of the lateral rectus muscle. A, Preoperative photograph showing exotropia and limitation of movement of the right eye in dextroversion and levoversion along with globe retraction and upshooot/downshoot. B, At the 3-week postoperative visit, the patient is orthotropic in primary gaze with minimal upshoot and retraction of the right eye in adduction.
Journal of AAPOS
300
Sukhija, Singh, and Singh
Volume 16 Number 3 / June 2012
FIG 3. A, Schematic diagram showing double-armed 5-0 polyester suture anchoring the disinserted lateral rectus muscle to the lateral canthal tendon. Surgical procedure (surgeon’s view from head of patient). B, Intraoperative photograph showing disinserted lateral rectus muscle with polyester suture. C, Lateral canthal tendon held with forceps at the origin (broad arrow) and belly (thin arrow), where lateral rectus would be anchored. D, Passage of suture needle through the lateral canthal tendon (arrow). References 1. Freedman HL, Kushner BJ. Congenital ocular aberrant innervation— new concepts. J Pediatr Ophthalmol Strabismus 1997;34:10-16. 2. Carlson MR, Jampolsky A. An adjustable transposition procedure for abduction deficiencies. Am J Ophthalmol 1979;87:382-7. 3. Rao VB, Helveston EM, Sahare P. Treatment of upshoot and downshoot in Duane syndrome by recession and Y-splitting of the lateral rectus muscle. JAAPOS 2003;7:389-95. 4. Britt MT, Velez FG, Thacker N, Alcorn D, Foster RS, Rosenbaum AL. Surgical management of severe cocontraction, globe retraction, and pseudo-ptosis in Duane syndrome. JAAPOS 2004;8:362-7.
5. Velez FG, Thacker N, Britt MT, Alcorn D, Foster RS, Rosenbaum AL. Rectus muscle orbital wall fixation: A reversible profound weakening procedure. JAAPOS 2004;8:473-80. 6. Andalib D, Javadzadeh A. Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall in exotropic Duane syndrome: A case report. J Med Case Reports 2008;2:253-5. 7. Morad Y, Kowal L, Scott AB. Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall. Br J Ophthalmol 2005;89: 983-5. 8. Gioia VM, Linberg JV, McCormick SA. The anatomy of the lateral canthal tendon. Arch Ophthalmol 1987;105:529-32.
Journal of AAPOS
An 8-year-old girl with exotropic Duane syndrome presented with upshoot, downshoot, and globe retraction in attempted adduction. To correct the alignment and treat the secondary aberrant movements, we weakened the lateral rectus muscle using a new surgical technique. In this approach, the lateral rectus muscle of the involved eye was disinserted and then attached to the lateral canthal tendon using nonabsorbable sutures. At the 3-week return visit, the patient was orthotropic in straight-ahead gaze with slightly improved adduction and negligible upshoot, downshoot, and globe retraction.
was passed through the tendon 2 mm from its insertion in Whitnall’s tubercle (Figure 3). The lateral rectus muscle was thus anchored to the lateral palpebral ligament. Conjunctiva and Tenon’s capsule were closed in separate layers with 8-0 polyglactin 910 suture. The patient was orthotropic 3 weeks postoperatively, and there was no head turn (Figure 1B). Downshoot and upshoot were negligible and narrowing of the palpebral fissure was no longer in evidence (Figure 2B). There was also improvement in adduction.
Case Report
Discussion
A
Various surgical procedures are recommended for correction of strabismus and cocontraction in Duane syndrome, including supramaximal recession of the lateral rectus muscle,1 rectus muscle transposition,2 and Y splitting and recession of the lateral rectus muscle.3 For treatment of esotropic Duane syndrome with severe globe retraction, transposition of the lateral half of the vertical rectus muscles to the lateral rectus insertion was combined with fixation of the lateral rectus muscle to the periosteum of the lateral orbital wall.4-7 Although the outcome of periosteal fixation of the lateral rectus muscle may be excellent, exposing the adjacent periosteum and passing the needle through it is technically difficult.5 In our procedure, the lateral rectus muscle is instead attached to the lateral canthal tendon. This structure can easily be identified by its appearance and relatively superficial location because it inserts at Whitnall’s tubercle. This anatomic landmark is easily identifiable 1.5 mm behind the orbital rim and 9.7 mm inferior to the frontozygomatic suture. The lateral canthal tendon can thus be reached using a temporal incision through tendon and conjunctiva. A small pocket of fat can be identified posterior to the orbital septum and anterior to the lateral canthal tendon.8 The approach, like other orbital wall fixation procedures, has the additional advantage of being potentially reversible.
n 8-year-old girl presented to the strabismus clinic Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, with a chief symptom of outward deviation of the right eye since birth. Past medical history and family history were unremarkable, with no history of trauma or neurological disease. On examination, best-corrected visual acuity was 6/6 in the right eye and 6/9 in the left eye. The patient had a left head turn of 25 (Figure 1A). Motility testing was notable for limitation of both adduction and abduction of the right eye, with narrowing of the palpebral fissure and upshoot and downshoot of the eye in attempted adduction (Figure 2A). Prism and cover testing in straight-ahead gaze revealed an exotropia of 30D. The patient was diagnosed with exotropic Duane syndrome in the right eye. A right lateral rectus weakening procedure was planned. At surgery, the lateral rectus muscle was identified and secured with a double armed 5-0 polyester suture using a double-armed needle and disinserted from the globe. The lateral orbital rim was then palpated and a conjunctival opening was placed 3–4 mm posterior to the orbital rim. The lateral canthal tendon was identified by its bright white color and the surrounding orbital fat. The suture
Author affiliation: Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India Submitted May 24, 2011. Revision accepted January 3, 2012. Correspondence: Jaspreet Sukhija, MD, Assistant Professor, Advanced Eye Centre, PGIMER, Sec 12, Chandigarh, India (email: [email protected]). J AAPOS 2012;16:298-300. Copyright Ó 2012 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 doi:10.1016/j.jaapos.2012.01.013
298
Journal of AAPOS
Volume 16 Number 3 / June 2012
Sukhija, Singh, and Singh
299
FIG 1. External photographs of an 8-year-old girl with exotropic Duane syndrome. A, Head turn to left of 25 . B, Postoperative photograph showing resolution of abnormal head posture.
FIG 2. Ocular motility before and after weakening of the lateral rectus muscle. A, Preoperative photograph showing exotropia and limitation of movement of the right eye in dextroversion and levoversion along with globe retraction and upshooot/downshoot. B, At the 3-week postoperative visit, the patient is orthotropic in primary gaze with minimal upshoot and retraction of the right eye in adduction.
Journal of AAPOS
300
Sukhija, Singh, and Singh
Volume 16 Number 3 / June 2012
FIG 3. A, Schematic diagram showing double-armed 5-0 polyester suture anchoring the disinserted lateral rectus muscle to the lateral canthal tendon. Surgical procedure (surgeon’s view from head of patient). B, Intraoperative photograph showing disinserted lateral rectus muscle with polyester suture. C, Lateral canthal tendon held with forceps at the origin (broad arrow) and belly (thin arrow), where lateral rectus would be anchored. D, Passage of suture needle through the lateral canthal tendon (arrow). References 1. Freedman HL, Kushner BJ. Congenital ocular aberrant innervation— new concepts. J Pediatr Ophthalmol Strabismus 1997;34:10-16. 2. Carlson MR, Jampolsky A. An adjustable transposition procedure for abduction deficiencies. Am J Ophthalmol 1979;87:382-7. 3. Rao VB, Helveston EM, Sahare P. Treatment of upshoot and downshoot in Duane syndrome by recession and Y-splitting of the lateral rectus muscle. JAAPOS 2003;7:389-95. 4. Britt MT, Velez FG, Thacker N, Alcorn D, Foster RS, Rosenbaum AL. Surgical management of severe cocontraction, globe retraction, and pseudo-ptosis in Duane syndrome. JAAPOS 2004;8:362-7.
5. Velez FG, Thacker N, Britt MT, Alcorn D, Foster RS, Rosenbaum AL. Rectus muscle orbital wall fixation: A reversible profound weakening procedure. JAAPOS 2004;8:473-80. 6. Andalib D, Javadzadeh A. Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall in exotropic Duane syndrome: A case report. J Med Case Reports 2008;2:253-5. 7. Morad Y, Kowal L, Scott AB. Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall. Br J Ophthalmol 2005;89: 983-5. 8. Gioia VM, Linberg JV, McCormick SA. The anatomy of the lateral canthal tendon. Arch Ophthalmol 1987;105:529-32.
Journal of AAPOS