DUANE’S SYNDROME

NV 4024 KLINIK OPTOMETRI PRIMER III

STUDENTS:1. ANIS SUZANA MOHAMAD A1233692. SHAZ’ AIN RAZAK A123368

LECTURER: PROF. SHARANJEET KAUR

DUANE’S SYNDROMEaka Duane’s retraction syndromea congenital eye movement disorder due to

misdirection of the nerve fibre on eye musclecausing some eye muscle to contract when

they shouldn’t, vice versacan be unilateral or bilateral

INTRODUCTION

Aetiology:1. Mechanical factors

fibrosed LR abnormally insertion of MR binding of MR sheath to wall

2. Embryonic factors Disturbance in normal embryonic

development during 2nd month of gestation Development of 3rd, 4th, and 6th cranial nerve occur

3. Paradoxical innervation Increase innervation to both MR & LR during

ADD and relaxation of both MR & LR during ABD

4. Trauma

Clinical features:

limitation of abduction with or without limitation of adduction

attempt adduction: retraction of the globe with narrowing of fissure

Protrusion & widening of the palpebral fissure on abduction

May or may not have AHPStrabismusAmblyopia

PATIENT: MALE/10/MALAY

FILE NO: 0377 Date: 28th February 2012

CHIEF COMPLAINT-complaint of blur when seeing distance, want to make spectacles-has problem in writing ; words become shuffle since kindergarten

OCULAR HISTORY-Father claimed has lazy eye since 2-3 years old, has follow up at Hosp. Terengganu-easily fall when young, suspect due to lazy eye-wear spect at very young age but refused to wear till now

GENERAL -Asthma, eczema, use homeopathy

FAMILY HISTORY-Mother has DM, HPT since 8mo ago

CASE STUDY

RE LE

VA *with marked AHP: face turn R

6/24 PH: 6/18+2N5 @ 15cm

6/12 PH: 6/9+N5 @ 15cm

PRIMARY GAZE

6/24 Not able to read Snellen on primary gaze

COVERTEST

AHP D moderate XPN

PRIMARY GAZE

D large L XT N

HIRSCHBERG central Reflex at nasal

AA 13,13,13 13,13,13 *not reliable

NPC 11cm LE deviates out

STREOPSIS 240 arc (TNO)

CLINICAL FINDINGS

Ocular Motility Testing

1. LE Exotropia on primary gaze

2. V pattern

3. LE has no problem when attempt on abduction (towards temporal)

Abduction on elevation: normal Abduction on depression: normal

4. LE has limitation on adduction (towards nasal)

Down shooting of LE on adduction Also limitation of adduction on elevation & adduction on depression LE presents narrow palpebral fissure, and globe retraction on adduction

1. Limitation of ADDUCTION of LE

2. Down shoot of LE

*classic presentation of Duane’s Type 2

RE LE

RE LE

KERATOMETRY 40.82@18044.67@90 CA: -3.75x180

40.82@18043.82@90 CA: -3.00x180

RETINOSCOPY PL/-4.00X15 6/12-2 -1.25/-0.75X170 6/12

SUBJ. RX -0.50/-3.00X10 6/9 -0.50/-1.75X170 6/9

OPHTHALMOSCOPY cd ratio: 0.5A/V: 2/3

cd ratio: 0.6A/V: 2/3

DIAGNOSIS1. Low myope moderate astig2. L Duane’s syndrome

MANAGEMENT3. Prescribe Rx4. Write referral letter to Hosp. Terengganu5. Refer pt to BV clinic for further assessment -

9 Apr 20126. KIV AA with Rx

The major complaint that pt has is blur at distance

More specific- since when? is it sudden or gradually blur?

Father claimed has lazy eye since young, should wear glasses but refuse could be related to chief complaint : blur- possible

uncorrected refractive errorThe reason of failure wear glasses?Ask more about symptoms of amblyopia. Any eye

turning in? Eye rubbing? See at very close distance?

DISCUSSION: HISTORY TAKING:

DISCUSSION: CLINICAL FINDINGS

1. Reduction in vision BE Improvement with pinhole: reduction of vision can

be corrected with spectacles However vision is taken with marked AHP Visual acuity with head straight shows further

decrement in vision on LE

2. Marked AHP- face turn R Visual acuity is better on LE however marked large exo-deviation on LE in

primary position face turn R (non deviating side) is significant as

to obtain fusion.

AHP• Left exotropia. As face turn to right (non

affected side), it will compensate the deviation.

• To improve visual acuity• To decrease deviation, hence strengthen BSV.

Cover test shows moderate XP with AHP compared to primary gaze

PRIMARY GAZE

FACE TURN RIGHT

FACE TURN RIGHT

4. Refractive error Unaided VA RE 6/24 is correlate with

refraction finding -0.50/-3.00DCx10 (estimated astigmatism ~±3.00DC).

Unaided VA LE 6/12 is correlate with refraction finding -0.50/-1.75X170 (estimated astigmatism ~±1.25DC).

Most astigmatism power comes from corneal astigmatism.

BE develop meridional amblyopia (6/9 BE) due to uncorrected astigmatism.

1. Diagnosis 1: low myope with moderate astig Uncorrected moderate amount of astig

presenting with reduce of vision Should suggest meridional amblyopia? Management: prescribe Rx to provide optimum

correction & prevent moderate amblyopia

2. Diagnosis 2: Left Duane’s syndrome Limitation of adduction on LE On attempt of adduction, affected eye appear

smaller (palpebral fissure narrowing, globe retraction), and down shoot. Classic sign on Duane’s Type 2.

There is 4 types of Duane’s syndrome Management: refer to Hospital and BV clinic

DISCUSSION: DIAGNOSIS & MANAGEMENT

Refer to BV: patient came on 2nd April 2012Additional test- Hess chart: to investigate incomitant

strabismus in order to asses paretic element

LE RE1. LE has smaller field than RE. Suggest LE affected eye.2. Sloping sides to field indicates V pattern.3. Compressed field of LE on nasal part.

• Underaction of Left MR, IO, SO4. Larger field of RE

• Overaction of Right SR, LR, IR

TYPE 1

-Poor abduction, good adduction

-agenisis of 6th nerve-3rd nerve split innervate LR, MR-adduction intact as most nerve goes to MR

TYPE 2

-Poor adduction, good abduction

-6th nerve intact-3rd nerve split innervate LR, MR-Poor adduction as LR contract against MR

TYPE 3

-Poor adduction, poor abduction

-6th nerve agenesis-3rd nerve split innervate LR, MR-The split is equal-Eye not moves in/out

TYPE 4

-Paradoxical abduction on attempt adduction

-6th nerve agenesis-3rd nerve split innervate LR, MR-most innervate LR-when ADD it ABD

TYPE 1(70-80%) ie: LE

TYPE 2(~7%) ie: LE

TYPE 3(~15%) ie: LE

TYPE 4 ie: LE

LE Esotropia with head straight

Face turn to affected side

Limited abduction left eye

-Normal or less adduction-Narrowing of fissure-Globe retraction

LE Exotropia with head straight

Face turn to non-affected side

Normal or less abduction

-Limited adduction-Narrowing of fissure-Globe retraction

-Marked upshoot and sometimes downshoot on adduction

Eyes are aligned in primary position with head straight

Limited abduction left eye

-Limited adduction-Narrowing of fissure-Globe retraction-Upshoot/ down shoot

Large LE Exotropia

Limited adduction RE

Simultaneous abduction when looking toward uninvolved side

-violating Hering’s law

Management of Duane’s syndrome

Correct refractive error

Treat amblyopiaIn this case, no patching treatment is indicated yet

as vision BE is almost similarMeridional amblyopia usually has good prognosis

with spectacles aloneTo monitor vision after correction after 3 months.

Surgery indicated if:Marked AHPDecompensatingCosmetically poor deviationDiplopia occurring more frequently

Refer to ophthalmology

To perform additional test for further evaluationForced duction test: to evaluate muscle palsy

(+ve forced duction test)

Suggestion for squint surgeryThe marked AHP is consistentTo improve cosmesis & comfort to patient

Duane’s syndrome is a congenital eye movement disorder in which there is miswiring of the eye muscles that typically can be recognized through a few ocular signs and symptoms.

As an optometrist, we should smartly recognized this syndrome according to the history taking and clinical findings in order to make an accurate diagnosis.

Although the syndrome is permanent, further managements is crucial in order to solve patient’s problems such as marked AHP and also on.

Conclusions

1. Fiona J. Rowe. Clinical orthoptics. 3rd edition. Wiley-blackwell.

2. http://emedicine.medscape.com/article/1198559-overview date: 20th April 2012

3. http://telemedicine.orbis.org/bins/volume_page.asp?cid=1-3-5-50

date: 20th April 2012

4. http://www.webmd.com/eye-health/duane-syndrome

date: 20th April 2012

5. http://childrenshospital.org/az/Site3103/mainpageS3103P0.html

date: 20th April 2012

REFERENCES

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