DUANES CLINICAL OPHTHALMOLOGY PDF

adminComment(0)

Edition/Format: eBook: Document: English: Rev. ed. View all editions New and Revised Chapters: Duane's Clinical Ophthalmology -- New and Revised. Table of Contents > Duane's Foundations of Clinical Ophthalmology > Volume . When viewed anteriorly in the living eye, the adult human cornea is somewhat. Clinical and Experimental Optometry Duane's Ophthalmology must rank as the present most comprehensive and authoritative repository of.


Duanes Clinical Ophthalmology Pdf

Author:CHARMAIN THEODORE
Language:English, Dutch, Hindi
Country:Ireland
Genre:Lifestyle
Pages:732
Published (Last):08.11.2015
ISBN:413-3-49153-159-1
ePub File Size:20.38 MB
PDF File Size:15.11 MB
Distribution:Free* [*Sign up for free]
Downloads:27399
Uploaded by: MELODIE

This comprehensive and well-illustrated book provides a reasoned approach to the everyday practice of ophthalmology. This new edition has been updated to. Abstract: Duane retraction syndrome (DRS) is a congenital eye movement anomaly . Common reasons for seeking medical attention in DRS include an abnormal head position of the child, one of Download Article [PDF]. Duane's Clinical Ophthalmology. [-] Volume 1. [+] Ocular Motility and. Strabismus. [+] Refraction and Clinical. Optics. Print Preview. Updated Chapter.

Patients with sporadic DRS have also been found to have associated congenital malformations. Pfaffenbach and Cross 35 studied these anomalies which were skeletal, auricular, ocular or neural in presentation.

Duane retraction syndrome: causes, effects and management strategies

Generally, the crucial time for development of these congenital malformations was found to be around the fourth to eighth week of gestation. Similarly, patients with thalidomide embryopathy having DRS were also found to be associated with maternal exposure around a similar time period. These findings suggested that there could be a critical period during embryogenesis, in which an insult could result in various congenital malformations including DRS. Understanding these mechanisms can help understand the pathogenesis of the presenting features of this syndrome.

Globe retraction in adduction, which is a characteristic feature of DRS, is found to be due to tight fibrotic muscles, sometimes with anomalous insertions. Usually, these changes have been observed in the horizontal rectus muscles, as is often noted while operating such patients. These have been noted commonly in the LR and very rarely in the MR.

Unless these muscle slips are released, the tightness on forced ductions remains. Second, paradoxical innervation leading to co-contraction of MR along with LR, as described by Scott, was found to contribute to globe retraction in attempted adduction. These mechanical upshoots and downshoots in DRS are characterized by a sudden abrupt movement following a small vertical movement in adduction and usually do not have primary gaze vertical tropia. Figure 1 Demonstrating an upshoot A and downshoot B on attempted adduction.

In contrast to this, another type of vertical movement is noted in DRS, wherein there is a gradual vertical movement elevation or depression of the eye as it turns from abduction to adduction. This type of eye movement has been found to be due to anomalous paradoxical innervations of the LR by the oculomotor nerve. Such cases may even have vertical tropia in the primary position, and these are termed as innervational upshoots and downshoots. Depending upon the alignment in primary gaze, each Huber type was divided into A, B and C, indicating esotropia, exotropia and orthophoria, respectively, thus making it even more relevant clinically and surgically.

Some bilateral cases have been reported to have type I in one eye and type II in the other. Bilateral DRS, on the other hand, may be seen more often in males, but no predilection is noted. This along with right to left shunt causes more embolic phenomena that affect the left carotid artery, causing dysregulated apoptosis followed by misinnervation and ocular malformations.

These individuals may show extraocular muscle paresis other than LR or minimal palpebral fissure size changes during horizontal ductions. Miyake et al, 57 in their study, analyzed a family with c. Apart from DRS in two members, other phenotypes included vertical strabismus with elevation deficits. Thus, CHN1 mutations may have varied presentation and should be considered in the differential diagnosis of patients with elevation deficits, even in the absence of DRS.

Clinical presentation Common reasons for seeking medical attention in DRS include an abnormal head position of the child, one of the eyes appearing smaller than the other due to globe retraction, pseudoptosis in adduction or abnormal eye movements.

Though DRS is present at birth, in the early stages, it may appear only as an abduction deficit. As LR inelasticity and tightness develops with time, globe retraction and limitation of motility may be more pronounced.

Clinical features Age — Despite being a congenital anomaly, patients may not always report to the clinics early. Age at presentation is variable and has been found to be younger in type I DRS, possibly due to earlier presentation to the pediatrician or pediatric ophthalmologist.

The variations in literature are probably due to variable age of presentation in the clinics. These cases, especially with high hyperopia, may have an associated accommodative component, which must be taken into account despite not being directly linked to the underlying etiology of DRS. Myopia, simple myopic astigmatism and emmetropia are less common and are found to be almost equally distributed.

Less frequently, stimulus deprivation and mixed mechanisms of amblyopia have been seen. Also, esotropia is found to be the most common primary position deviation, followed by orthotropia, though some studies report otherwise.

Usually, patients with unilateral type I Duane syndrome have esotropia more frequently than exotropia, those with type II have exotropia and those with type III have esotropia, exotropia and orthotropia occurring equally common. Motor evaluation of strabismus Motility — One of the most notable features of DRS is the abduction limitation. The abduction deficit in DRS accompanies a disproportionately smaller primary position deviation.

This helps to distinguish it from a sixth nerve palsy, where the primary deviation and the abduction limitation are in proportion to each other.

This adduction deficit is evident from the fact that DRS patients have a remote near point of convergence. Also, these patients can be shown to have exotropia in the gaze opposite to the affected eye due to this adduction deficit. Deviations — As discussed earlier, esotropia is the most common deviation in primary position in DRS. Measuring the deviation accurately requires the head to be in forced primary position while performing the cover test, as these patients have a strong tendency for abnormal head postures which may be very small as well.

In this position, the secondary deviation is greater than the primary deviation in DRS. Also, one must remember to measure the deviations in the lateral and vertical gazes due to varying amounts of esotropia and exotropia in the lateral gazes caused by the motility deficits.

Clinical Ophthalmology

In case the abduction and adduction limitations are almost equal to each other, there may be orthotropia in the primary gaze; otherwise, the predominant deficiency will determine the type of DRS and primary gaze measurement. Management of bilateral exotropic DRS needs to be planned depending upon the presenting type in either eye.

Theodorou and Burke treated 11 patients with bilateral exotropic DRS. Unilateral LR recession 3—18 mm recessions for deviations ranging from 12 to 60 PD with conjunctival recession was the commonest surgery done, and cases with significant globe retraction also underwent additional small MR recession. In the experience of the senior author, symmetrical or asymmetrical bilateral LR recessions with or without Y splitting are more effectual for treating bilateral exotropic DRS.

Synergistic divergence, which is an extreme form of exotropic DRS, is very challenging to treat, and no definite surgical procedure has been found with satisfactory outcomes. As discussed in the previous section, globe retraction can be corrected with recessions of the co-contracting muscles.

MR recession ranging from 5 to 6. It has been suggested that adults may need larger recessions than pediatric patients due to long-standing globe retraction causing orbital tissue changes, and retraction may recur due to continued co-contraction of the muscles.

Upshoots and downshoots in DRS may be due to the mechanical effect caused by tight muscles or due to innervational anomalies. Rogers and Bremmer have described Y splitting of the LR with or without its recession to treat overshoots caused by this mechanical leash effect. With Y split, each muscle half balances the other; thus, when the eye elevates in adduction, the lower arm contracts and prevents the globe from suddenly slipping up and vice versa in depression.

Awadein studied the role of inferior oblique IO weakening in all types of DRS which presented with a slow upshoot in which the movement was similar to IO overaction. He found that IO myectomy with or without horizontal rectus recession improved upshoot in this set of patients without inducing any vertical deviations or IO underaction.

The above review emphasizes the need to extend patient evaluation in cases of DRS beyond the routine clinical examination by a strabismologist to genetic analysis, systemic workup and neuroimaging.

The understanding of DRS as a part of CCDD spectrum has evolved over time with identification of various genetic mutations as the underlying cause of these disorders.

Also, phenotypic variability has been established among individuals with heterozygous CHN1 mutations, even with vertical deviations in the absence of DRS. Hence, patients with bilateral DRS with associated vertical anomalies and those with familial vertical deviations should undergo a detailed pedigree assessment and genetic screening for CHN1 mutations.

Members of families with DRS as an autosomal dominant trait should be screened for mutations in the CHN1 gene, enhancing genetic counseling and permitting earlier diagnosis. Mutations such as SALL4, SALL1 and those involving chromosomes 8 and 22 are often associated with syndromic DRS; hence, a complete systemic evaluation including X-ray spine, renal function tests and audiometry is mandated, if these mutations are tested positive. Especially, the presence of neck anomalies should warn the clinician of underlying hearing loss to be likely due to Wildervanck syndrome, and an auditory evaluation should be done.

Though they found abnormal abducens nerve or LR muscle most commonly, superior oblique hypoplasia was noted in half of the tested individuals, suggesting involvement of the fourth cranial nerve in these cases. The only muscles that were not affected were those supplied by the inferior division of the oculomotor nerve: DRS consists of a complex set of ocular and systemic anomalies, which may have myriad presentations.

It is caused by mechanical, innervational, genetic, embryologic and central nervous system anomalies occurring together or as an independent etiology. Management of DRS is a challenge, and the surgical approach to such a patient must be individualized based on the amount of ocular deviation, abnormal head position, associated globe retraction and overshoots.

The parents or guardians of the patients gave consent for their images to be used in this paper. Author contributions. Both authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work. National Center for Biotechnology Information , U.

Journal List Clin Ophthalmol v. Clin Ophthalmol. Published online Oct Ramesh Kekunnaya and Mithila Negalur. Author information Copyright and License information Disclaimer. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https: By accessing the work you hereby accept the Terms.

Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

This article has been cited by other articles in PMC. Abstract Duane retraction syndrome DRS is a congenital eye movement anomaly characterized by variable horizontal duction deficits, with narrowing of the palpebral fissure and globe retraction on attempted adduction, occasionally accompanied by upshoot or down-shoot. Duane syndrome, strabismus surgery, esotropia, overshoots. Introduction Duane retraction syndrome DRS , also known as Stilling—Turk—Duane syndrome, is a congenital eye movement anomaly characterized by variable horizontal duction deficits, with narrowing of the palpebral fissure and globe retraction on attempted adduction, occasionally accompanied by upshoot or downshoot.

Innervational anomalies Possibility of an underlying innervational etiology came into light when Breinin 12 studied the electric potentials generated by muscles in various positions of gaze in DRS. Central nervous system anomalies Understanding muscle electrophysiology in DRS made it evident that the causative etiology was absent normal sixth nerve innervation to the LR, either nuclear eg, anomalous innervation by the oculomotor nerve or supranuclear eg, brainstem abnormality in origin.

Newer concepts It was in that Parsa et al 22 demonstrated the absence of left sixth nerve in a case of unilateral DRS using high-resolution T1-weighted images on magnetic resonance imaging MRI.

Pathogenesis The preceding discussion shows that DRS is a group of entities linked by dysinnervation leading to limited horizontal gaze and globe retraction in attempted adduction. Open in a separate window. Figure 1. Table 1 Classification of DRS. Classification system Basis of classification Papst 41 — 43 Abnormal co-contraction 1. MR and LR 2. Superior rectus and LR 3. Inferior rectus and LR 4. Palsy of abduction Type II: Palsy of adduction Type III: Limitation of depression and elevation without impairment of horizontal movements Lyle and Bridgeman 45 Motility Type A: Abduction more deficient than adduction, but both are deficient.

Adduction causes globe retraction and palpebral fissure narrowing Type B: Abduction is deficient, but not adduction Type C: Abduction less deficient than adduction, but both are deficient.

Marked limitation of abduction with minimally defective or normal adduction, globe retraction and palpebral fissure narrowing in adduction, widening in abduction EMG recordings showed paradoxical innervations of the LR with maximum impulses on adduction and defective impulses in attempted abduction. Limitation or complete absence of adduction and abduction with globe retraction and palpebral fissure narrowing in attempted adduction EMG showed simultaneous innervation of LR and MR muscles in primary gaze, adduction and abduction Huber also went on to describe the alphabet patterns of strabismus, which are also seen in DRS, suggesting that there are groups of patients wherein the vertical rectus has this synergistic innervation.

Clinical presentation Common reasons for seeking medical attention in DRS include an abnormal head position of the child, one of the eyes appearing smaller than the other due to globe retraction, pseudoptosis in adduction or abnormal eye movements.

Log in to Wiley Online Library

Clinical features Age — Despite being a congenital anomaly, patients may not always report to the clinics early. Motor evaluation of strabismus Motility — One of the most notable features of DRS is the abduction limitation. Figure 2. Clinical grading system for globe retraction and overshoots. Table 2 Ocular and systemic associations of DRS. Table 3 Acquired retraction syndrome mechanical causes. Mechanical causes Trauma 82 and orbital fracture 83 medial wall Bony orbital metastasis 84 Orbital inflammation 85 Orbital surgery 86 Thyroid myopathy Conjunctival surgery causing scarring 87 Neurogenic causes Head injury Intracranial surgery 88 Brainstem tumors such as glioma and skull base meningioma 89 — Other functions Although intelligence is usually normal in DRS, intellectual disability has been reported in a few cases of DRS with borderline intelligence and cases of autism spectrum disorder associated with fetal thalidomide exposure or HOXA1-related syndromes.

In general, the surgical plan and aim of strabismus surgery in DRS is usually based on the following: Esotropic DRS In cases of esotropic DRS, various surgical procedures may be considered, but any coexisting accommodative component must be first corrected by prescribing spectacles preoperatively to avoid consecutive exotropia. Figure 3. Globe retraction As discussed in the previous section, globe retraction can be corrected with recessions of the co-contracting muscles.

Overshoots Upshoots and downshoots in DRS may be due to the mechanical effect caused by tight muscles or due to innervational anomalies. Approach to the patient: Conclusion DRS consists of a complex set of ocular and systemic anomalies, which may have myriad presentations.

Footnotes Author contributions Both authors contributed toward data analysis, drafting and critically revising the paper and agree to be accountable for all aspects of the work. Disclosure The authors report no conflicts of interest in this work.

References 1. Duane A. Congenital deficiency of abduction associated with impairment of adduction, retraction movements, contraction of the palpebral fissure and oblique movements of the eye. Arch Ophthalmol. Surv Ophthalmol. Heuck G. Uber angeborenene vererbten Beweglichkeitsdefect der Augen. Klin Monatsbl Augenkeilkd.

Sinclair WW. Abnormal associated movements of the eyelids. Ophthalmol Rev. Bahr K. Ges Opthalmol. Stilling J, Bergmann JF, editors. Untersuchungen uber die Entstehung der Kurzsichtigkeit. Wiesbaden, Germany: Turk S. Bemerkungen zu einem Falle von Retraction des Auges.

Cbl Pract Augenheilk. Wolff J. The occurrences of retraction movements of the eyeball together with congenital defects in the external ocular muscles.

Gallus E. Sinddiesog angeborener: Retraktionsberegungen des Auges die Folge einer Gebutsverletzurg. Arch Augenheilkd. Axenfeld TH, Schurenberg E. Angeborene Retractionsbewegungen. Klin Monats. Breinin GM. In discussion of: Observations on the retraction syndrome of Duane. An electromyographic evaluation of the retraction syndrome. Am J Ophthalmol. Sato S. Electromyographic study on retraction syndrome. Jpn J Ophthalmol. Br J Ophthalmol. Metz HS.

The diagnosis and treatment of abduction deficiencies. Ann Ophthalmol. Hoyt WF, Nachtigaller H. Anomalies of ocular motor nerves. Ramsay J, Taylor D. Congenital crocodile tears: Schmidt D. Congenitale Augenmuskelparesen. Albrech v Graefes Arch Ophthalmol. Absence of the abducens nerve in Duane syndrome verified by magnetic resonance imaging.

Assaf AA. Gutowski NJ, Ellard S. Nat Genet. Homozygous HOXA1 mutations disrupt human brainstem, inner ear, cardiovascular and cognitive development. Mutations in a human ROBO gene disrupt hindbrain axon pathway crossing and morphogenesis.

Recent progress in understanding congenital cranial dysinnervation disorders. J Neuroophthal. Localization of a gene for Duane retraction syndrome to chromosome 2q Am J Hum Genet.

Okihiro syndrome is caused by SALL4 mutations. Hum Mol Genet. Mutations at the SALL4 locus on chromosome 20 result in a range of clinically overlapping phenotypes, including Okihiro syndrome, Holt-Oram syndrome, acro-renalocular syndrome, and patients previously reported to represent thalidomide embryopathy. J Med Genet. Mehdorn E, Kommerell G. Mirror-like localization of oculomotor disturbances in monozygotic twins.

J Pediatr Ophthalmol Strabismus. What can we learn from the thalidomide experience: Curr Opin Ophthalmol. Gobin MH. Jampolsky A. Surgical leashes and reverse leashes in strabismus surgical management; Symposium on Strabismus. CV Mosby; Papst W. Klin Monbl Augenheilkd Augenarztl Fortbild.

References

Papst W, Esslen E. Symptomatology and therapy of ocular motility disturbances. Paralytischer Strabismus infolge paradoxer innervation.

Ber Dstch Ophthalmol Ges. Malbran J. Clinica y terapeutua Buenos Anes, Editorial Oftalmologia. Estrabismos y paralysis; p. Bailliere Tindall and Cox; Huber A. Electrophysiology of the retraction syndromes. Acta Ophthalmologica. Kirkham TH. Moster M. Yanoff M, Duker JS, editors. Philadelphia, PA: Mosby; Duane retraction syndrome: Differences in epidemiological and clinical characteristics between various types of Duane retraction syndrome in patients.

Clinical characteristics of bilateral Duane syndrome. Duane retraction syndrome on the Arabian peninsula. Thromboembolism and congenital malformations: JAMA Ophthalmol. Expansion of the CHN1 strabismus phenotype. Invest Ophthalmol Vis Sci. Souza-Diaz C. Hering E. Die Lehre vom Binoculren Sehen.

Leipzig, Germany: Wilhelm Englemann; Outcomes in patients with esotropic duane retraction syndrome and a partially accommodative component. Indian J Ophthalmol. Hugonnier R, Clayette-Huggonier S. Strabismus, heterophoria, ocular motor paralysis. Veronnean-Troutman S, editor. Clinical Ocular Muscle Imbalance. St Louis, MO: Isenberg S, Urist MJ. Can J Ophthalmol. A simple and novel grading method for retraction and overshoot in Duane retraction syndrome.

Raab EL. Distinctive clinical features of bilateral Duane retraction syndrome. Duane Syndrome. Saunders; Wildervanck LS. Een geval van aandoening van Klippel-Feil Gecombineerd met Abducensparalyse, retractio bulbi en Doofstomheid. Ned T Geneesk. Congenital adduction palsy and synergistic divergence. Duane retraction syndrome with posterior microphthalmos: Cibis GW.

Congenital familial external ophthalmoplegia with co-contraction. Ophthalmic Paediatr Genetics. Collins ET. Br Med J. Diversified clinical presentations associated with a novel sal-like 4 gene mutation in a Chinese pedigree with Duane retraction syndrome. Mol Vis. The genetic basis of incomitant strabismus: Semin Ophthalmol. Trans Am Ophthalmol Soc. Medial orbital wall blow-out fracture producing an acquired retraction syndrome. J Clin Neuroophthalmol.

Acquired Retraction syndrome associated with orbital metastasis. Acquired retraction of the eye as the first sign of myositis. Eye Ear Nose Throat Mon. Khan AO. Inverse globe retraction syndrome complicating recurrent pterygium. Smith JL, Damast M. Acquired retraction syndrome after sixth nerve palsy. Neuro Ophthalmol Japan. Review of the major findings about Duane retraction syndrome DRS leading to an updated form of classification.

Vision Res. Silverberg M, Demer J. Bilateral type-I duane syndrome with multiple anamolies: J Clin Diagn Res. Autism Spectrum Disorders. Oxford; Oxford University Press; Kraft SP. Am Orthoptic J. Single medial rectus recession in unilateral Duane syndrome type I. A surgical approach for Duane syndrome. Resecting the lateral rectus in unilateral Duane syndrome with esotropia and limited abduction.

Binoc Vis Strab Q. Surgical management of bilateral esotropic Duane syndrome. Rosenbaum AL. Costenbader Lecture. The efficacy of rectus muscle transposition surgery in esotropic Duane syndrome and VI nerve palsy. Management of vertical deviations after vertical rectus transposition surgery.

Intraoperative monitoring of torsion to prevent vertical deviations during augmented vertical rectus transposition surgery.

Superior rectus transposition and medial rectus recession for Duane syndrome and sixth nerve palsy.Only book and journal titles were counted. The hurdles one must overcome to read this text are so daunting that I surrendered to its ineptitude and simply recorded the problems encountered. Angeborene Retractionsbewegungen. The second group was selected from one volume each of five separate journal titles covering approximately the same year.

Curr Opin Ophthalmol. Duane retraction syndrome:

SHIN from Portland
Look over my other posts. One of my hobbies is killer. I do relish studying docunments sometimes .
>