Strabismus - Fundamentals of Clinical Ophthalmology.pdf

THERAPY OF STRABISMUS
posterior fixation along the lateral rectus muscle
has been suggested, as has a recession of medial
rectus with recession of the lateral rectus of the
involved eye. Recession of the lateral rectus in
Type I Duane syndrome does not affect the
position of the eye in the primary position. Such
recession of the lateral rectus seems to also
reduce the pseudoptosis sometimes seen in
Duane’s.
Surgical techniques for Duane syndrome
Most often, the best management of Duane
syndrome is not to interfere if there is binocular
vision and the patient does not have a marked
head posture. Complications of surgery include
inducing a cosmetically undesirable exotropia,
and still failing to facilitate the patient’s ability
to abduct the eye. There are children and adults
who have enough of a head turn or enophthalmic
appearance as to warrant a strabismus repair. In
these cases, judicious horizontal muscle surgery
may be indicated. In some cases, upshoots and
downshoots of the eye occur on adduction.
These upshoots and downshoots may be difficult
to manage.
Although the aetiology of this problem is
debated, most experts would now agree that a
tight lateral rectus muscle slips over the globe
occasionally when stretched during adduction
and slips the eye either up or down, depending
on the individual patient. 3,4 When surgery
is indicated, a lateral rectus recession or
bifurcation of the lateral rectus with superior half
transposition up and inferior transposition down
may be helpful. 5 It is not due to dysfunction of
the superior or inferior oblique muscles. 6
Posterior horizontal fixation procedures will also
abolish the upshoots. 7 Amblyopia is rare;
however, where Duane’s is associated with a
marked convergent squint and amblyopia, we
have had two cases where an excellent cosmetic
result has been obtained with recession of the
medial rectus with transposition of the lateral
half of the vertical recti and suture beneath the
(a)
(b)
Figure 7.6 The Carlson–Jampolsky procedure
shown involves the separation of the temporal halves
of the vertical recti muscles. Joining these two muscle
segments, balancing the opposing tone to them and
then suturing them together beneath the lateral rectus
muscle near its insertion (a) corrected the deviation
(as represented in Fig. 7.7). Note the postoperative
result (b)
lateral rectus balancing the tone as described in
the Carlson–Jampolsky procedure.
Brown syndrome
This is caused by a short, tight superior
oblique tendon sheath which prevents the eye
from moving upwards in adduction. A forced
duction test would distinguish it from an
isolated inferior oblique palsy. The majority of
patients are straight in primary position and on
downgaze for reading.
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