We had a recent journal club that focused on the treatment of esotropic Duane Syndrome.  The traditional treatment in our program at the University of Iowa has been to recess the medial rectus muscle on the affected side.  Dr. Bill Scott has published extensively on this treatment option.  We reviewed the data presented in his British Journal of Ophthalmology article published in 2004.  Although this is quite successful in improving esotropia and correcting the head turn, there have been objections to this approach, especially because it tends to create adduction deficits.

The late Dr. Rosenbaum and others had promoted a full tendon transposition procedure to try to improve esotropic Duane syndrome.  This procedure seemed to cause less adduction deficit but more patients needed a second treatment, particularly a medial rectus recession! There is improvement in esotropia and head turn with this procedure.  More so when posterior fixation sutures were used. We reviewed the study that compared adding a posterior fixation suture to the transposed muscles.

Several authors have recently published data on a superior rectus transposition (SRT) to help improve the medial rectus recession while leaving out the inferior rectus transposition.  We reviewed one article from the Boston group and one from the UCLA group.  There seems to be a small induced vertical deviation and some induced incyclotorsion in the small number of cases reported when the authors looked for it.  The data also suggests that adduction deficits appear with this procedure as well.  Apparently most patients don’t complain of these problems.  It appears that this procedure is not strong enough in and of itself to leave out the medial rectus recession so virtually all cases also had a medial rectus recessed.

None of these procedures has been studied in a head-to-head prospective trial.  It appears that because the treatment effects are quite similar between the different procedures that it would take a very large number of patients in a randomized controlled trial to establish which procedure is the best.  Some surgeons in our group like the SRT procedure.  Others are concerned that there isn’t enough justification for operating on vertical rectus muscles when the medial rectus recession procedure works so well and seems to be very well tolerated by patients with very few re-operations.