Superior Rectus Transposition in the Management of Duane Retraction Syndrome: Current Insights

Figures & data

Table 1 Indications and Contra-Indications for SRT in DRS

Indications

1. Primary surgery (+/- with MR recession) for uni/bilateral esotropic DRS without significant co-contraction (grade 2 or better)

2. To treat residual esotropia or residual AHP after MR recession

3. In cases where abduction limitation is more severe in upgaze than downgaze

4. Following LR inactivation for severe co-contraction

5. Nasal SRT in exotropic DRS

Contraindications:

Absolute:

1. Esotropic DRS with exotropia in adduction

2. Esotropic DRS with larger eso-deviation for near

3. In cases where abduction limitation is more severe in downgaze than upgaze

Relative:

1. Patients with significant co-contraction & overshoots (grade 3 or worse)

2. Patients with marked globe retraction & enophthalmos (grade 3 or worse)

3. Patients with significant hypertropia or intorsion

4. Patients with pre-existing hypotropia in attempted abduction

Abbreviations: SRT, Superior rectus transposition; DRS, Duane retraction syndrome; MR, Medial rectus; AHP, abnormal head posture; LR, Lateral rectus.

Table 2 Novel Grading Method for Retraction and Overshoot in DRS

Grading for globe retraction:
With the involved eye in the maximum adducted position, the palpebral aperture height in the centre of the palpebral fissure is compared with that of the fellow eye in abduction.	Grade 0 No narrowing
	Grade 1 <25%
	Grade 2 25% to <50%
	Grade 3 50% to <75%
	Grade 4 >= 75%
Grading for overshoots:
With the involved eye in adducted position, a straight line is drawn from the pupillary centre of the fellow eye, parallel to the intermedial canthal line.	Grade 0 Line bisects the pupil of the involved eye
	Grade 1 Line lies between pupillary centre and pupillary margin
	Grade 2 Line lies between pupillary margin and limbus
	Grade 3 Line lies at limbus or over sclera
	Grade 4 Cornea disappearing below the lid (pumpkin seed sign)

Notes: Data from Kekunnaya R, Moharana R, Tibrewal S, Chhablani PP, Sachdeva V.¹⁹Abbreviation: DRS, Duane retraction syndrome.

Figure 1 Figure showing the role of meticulous dissection to separate the superior rectus muscle from the underlying superior oblique muscle. This helps to minimize the risk of induced post-operative vertical deviations and ptosis.

Table 3 Various Strategies for Augmenting the Superior Rectus Transposition (SRT)

1. Posterior fixation suture

2. Suture myopexy

3. Multiple augmentation sutures

4. Resection of the superior rectus before transposition

5. Weakening of the medial rectus

6. Resection of the lateral rectus

Figure 2 Various approaches for augmenting the superior rectus transposition (SRT). (A) Posterior fixation suture. (B) Suture myopexy. (C) Multiple augmentation sutures. (D) Resection of the superior rectus before transposition. (E) Weakening of the medial rectus. (F) Resection of the lateral rectus.

Table 4 Table Outlining Results of Previous Studies Analysing Outcomes of SRT and MR Recession in Esotropic DRS

Study, Year	Eso DRS - Number of Patients	Surgical Intervention (Number of Patients)	Mean Change				Significant Complications (Number of Patients)
			ET (PD)	AHP (Degrees)	Abduction Deficiency (Units of Improvement)	Adduction deficit (unit)
Mehendale,^Citation8 2012	10	SRT with or without augmentation+ MRc	27	21	2	0.6	Consecutive exotropia 1
Yang et al,^Citation17 2014	37	Augmented SRT ± MRc (19)	26	20	1.5	NA	Hypotropia 2
		Uni/Bilateral MRc (18)	10	16	0.5	0.7
Velez,^Citation45 2014	4	Augmented SRT ± MRc (4)	26	9.3	1.4	NA	Hypertropia 1, Hypotropia 3
Tibrewal,^Citation32 2015	21	Augmented SRT ± MRc (8)	17	12	1.2	1.1	–
		Uni/Bilateral MRc (13)	20	15	0.3	1.5	–
Akbari,^Citation39 2018	11	Augmented SRT (11)	7.8	5.9	0.8	NA	Hypotropia 3
Agarwal,^Citation40 2018	9	SRT ± MRc (9)	23.9	16	2	1	Residual esotropia 1
Abdallah,^Citation28 2020	20	Augmented SRT ± MRc (10)	19.8	11	0.8	0.15	Hypertropia 2
		Unilateral MRc (10)	21.6	10.5	0.3	0.10
Farid,^Citation41 2021	11	Augmented SRT ± MRc (11)	31.3	28.6	2	0.4	Hypertropia 2

Abbreviations: SRT, Superior rectus transposition; MR, Medial rectus; Eso, Esotropic; DRS, Duane retraction syndrome; MRc, Medial rectus recession.

Figure 3 Surgical outcome of superior rectus transposition (SRT) in Duane retraction syndrome (DRS). (A) Pre-operative image showing primary position esotropia and −4 abduction limitation in the left eye in a case of esotropic Duane retraction syndrome. (B) Post-operative image showing improvement in both, primary position deviation and abduction limitation to −3 following SRT with medial rectus recession in the left eye.

Table 5 Table Summarizing Post-Operative Complications of SRT and Preventive and Management Strategies

Complication	Prevention	Treatment
1. Induced vertical deviations (hypodeviation more common than hyperdeviation)	● Meticulous dissection to isolate SR, proper positioning and anchoring to sclera along the Spiral of Tillaux, placement of augmentation, and consistent surgical technique ● Adjustable posterior fixation myopexy ● Adjustable graded augmentation of SRT	● Observation for asymptomatic cases ● Prism glasses ● Revision of SRT +_ removal of augmentation suture
2. Induced incyclotorsion	● Adjustable posterior fixation myopexy or graded augmentation of SRT	● Most often clinically insignificant ● May need surgical revision of SRT in severe and symptomatic cases
3. Consecutive exotropia	● Identify at risk cases pre-operatively (infants, exotropia in adduction, smaller esotropia at near)	● Surgical revision of SRT if SR-LR complex is tight on FDT ● If not, MR advancement could be planned
4. Adduction limitation	● Perform smaller MR recession when combining with SRT ● Not exceed 5.5 mm of MR recession
5. Hypotropia in attempted abduction	● Identifying this finding pre-operatively to consider IRT instead of SRT	● Observation mostly (as it is usually present pre-operatively due to dysinnervation)

Abbreviations: SR, Superior rectus; LR, Lateral rectus; MR, Medial rectus; SRT, Superior rectus transposition; IRT, Inferior rectus transposition.

Kekunnaya R, Moharana R, Tibrewal S, Chhablani PP, Sachdeva V. A simple and novel grading method for retraction and overshoot in Duane retraction syndrome. Br J Ophthalmol. 2016;100(11):1451–1454. doi:10.1136/bjophthalmol-2016-309194

 PubMed Web of Science ®Google Scholar

Mehendale RA. Superior rectus transposition and medial rectus recession for Duane syndrome and sixth nerve palsy. Arch Ophthalmol. 2012;130(2):195–201. doi:10.1001/archophthalmol.2011.384

 PubMedGoogle Scholar

Yang S, MacKinnon S, Dagi LR, Hunter DG. Superior rectus trans- position vs medial rectus recession for treatment of esotropic Duane syndrome. JAMA Ophthalmol. 2014;132:669–675. doi:10.1001/jamaophthalmol.2014.358

 PubMed Web of Science ®Google Scholar

Velez FG, Oltra E, Isenberg SJ, Pineles SL. Assessment of torsion after superior rectus transposition with or without medial rectus recession for Duane syndrome and abducens nerve palsy. J AAPOS. 2014;18(5):457–460. doi:10.1016/j.jaapos.2014.06.008

 PubMed Web of Science ®Google Scholar

Tibrewal S, Sachdeva V, Hasnat Ali M, Kekunnaya R. Comparison of augmented superior rectus transposition with medial rectus recession for surgical management of esotropic Duane retraction syndrome. J AAPOS. 2015;19:199–205. doi:10.1016/j.jaapos.2015.02.006

 PubMed Web of Science ®Google Scholar

Akbari M, Shomali S, Mirmohammadsadeghi A, Aghsaei Fard M. Augmented superior rectus transposition procedure in Duane retraction syndrome compared with sixth nerve palsy. Graefes Arch Clin Exp Ophthalmol. 2018;256:983–987. doi:10.1007/s00417-017-3885-5

 PubMed Web of Science ®Google Scholar

Agarwal R, Sharma M, Saxena R, Sharma P. Surgical outcome of superior rectus transposition in esotropic Duane syndrome and abducens nerve palsy. J AAPOS. 2018;22:12–16. doi:10.1016/j.jaapos.2017.10.004

 PubMed Web of Science ®Google Scholar

Abdallah MEI, Eltoukhi EM, Awadein AR, Zedan RH. Superior rectus transposition with medial rectus recession versus medial rectus recession in esotropic Duane retraction syndrome. J Pediatr Ophthalmol Strabismus. 2020;57(5):309–318. doi:10.3928/01913913-20200506-02

 PubMed Web of Science ®Google Scholar

Farid MF, Daifalla AEM, Awwad MA. Augmented superior rectus muscle transposition in management of defective ocular abduction. BMC Ophthalmol. 2021;21(1):50. doi:10.1186/s12886-020-01779-1

 PubMed Web of Science ®Google Scholar