Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
DUANE’S SYNDROME

STUDENTS:
1.
ANIS SUZANA MOHAMAD
2.
SHAZ’ AIN RAZAK
LECTURER: PROF. SHARANJEET KAUR

A123369
A123368
DUANE’S SYNDROME
 aka Duane’s retraction syndrome
 a congenital eye movement disorder due to misdirection
of the nerve f...
 Aetiology:

1.

Mechanical factors
 fibrosed LR
 abnormally insertion of MR
 binding of MR sheath to wall

2.

Embryo...
Clinical features:
 limitation of abduction with or without limitation of







adduction
attempt adduction: retrac...
PATIENT: MALE/10/MALAY
FILE NO: 0377

Date: 28th February 2012

CHIEF COMPLAINT
-complaint of blur when seeing distance, w...
RE
VA

*with marked
AHP
: face turn R

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

PRIMARY
GAZE

6/24

Not able to read Snellen on
primary...
1.

LE Exotropia on primary gaze

2.

V pattern

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




A...
RE

Limitation of ADDUCTION of LE
2. Down shoot of LE
1.

*classic presentation of Duane’s Type 2

LE
RE

LE

KERATOMETRY

40.82@180
44.67@90
CA: -3.75x180

40.82@180
43.82@90
CA: -3.00x180

RETINOSCOPY

PL/-4.00X15 6/12-2

...
DIAGNOSIS
1. Low myope moderate astig
2. L Duane’s syndrome

MANAGEMENT
1. Prescribe Rx
2. Write referral letter to Hosp. ...
 The major complaint that pt has is blur at distance
 More specific- since when? is it sudden or gradually

blur?

 Fat...
DISCUSSION: CLINICAL FINDINGS
Reduction in vision BE

1.




Improvement with pinhole: reduction of vision can be
corre...
AHP
• Left exotropia. As face turn to right (non affected side), it

will compensate the deviation.
• To improve visual ac...
Refractive error

4.





Unaided VA RE 6/24 is correlate with refraction finding
-0.50/-3.00DCx10 (estimated astigmat...
Diagnosis 1: low myope with moderate astig

1.

Uncorrected moderate amount of astig presenting with
reduce of vision
Shou...
 Refer to BV: patient came on 2nd April 2012
 Additional test- Hess chart: to investigate incomitant
strabismus in order...
TYPE 1

TYPE 2

TYPE 3

TYPE 4

-Poor abduction,
good adduction

-Poor adduction,
good abduction

-Poor adduction,
poor ab...
TYPE 1
(70-80%)

ie: LE
LE
Esotropia
with head
straight
Face turn to
affected
side

TYPE 2
(~7%)
ie: LE
LE
Exotropia
with ...
 Management of Duane’s syndrome
 Correct refractive error
 Treat amblyopia
 In this case, no patching treatment is ind...
 Refer to ophthalmology
 To perform additional test for further evaluation
 Forced duction test: to evaluate muscle pal...
 Duane’s syndrome is a congenital eye movement disorder in

which there is miswiring of the eye muscles that typically
ca...
1. Fiona J. Rowe. Clinical orthoptics. 3rd edition.
2.
3.
4.

5.

Wiley-blackwell.
http://emedicine.medscape.com/article/1...
Thank You
Case Presentation: Duane's Syndrome
Upcoming SlideShare
Loading in …5
×

Case Presentation: Duane's Syndrome

9,537 views

Published on

I have an interested case to share with my beloved friends.

Published in: Health & Medicine
  • Be the first to comment

Case Presentation: Duane's Syndrome

  1. 1. DUANE’S SYNDROME STUDENTS: 1. ANIS SUZANA MOHAMAD 2. SHAZ’ AIN RAZAK LECTURER: PROF. SHARANJEET KAUR A123369 A123368
  2. 2. DUANE’S SYNDROME  aka Duane’s retraction syndrome  a congenital eye movement disorder due to misdirection of the nerve fibre on eye muscle  causing some eye muscle to contract when they shouldn’t, vice versa  can be unilateral or bilateral
  3. 3.  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  3. 4. Development of 3rd, 4th, and 6th cranial nerve occur Paradoxical innervation  Increase innervation to both MR & LR during ADD and relaxation of both MR & LR during ABD Trauma
  4. 4. 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 AHP Strabismus Amblyopia
  5. 5. 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
  6. 6. RE VA *with marked AHP : face turn R LE 6/12 PH: 6/9+ N5 @ 15cm PRIMARY GAZE 6/24 Not able to read Snellen on primary gaze AHP D N moderate XP PRIMARY GAZE COVER TEST 6/24 PH: 6/18+2 N5 @ 15cm D N large L XT HIRSCHBERG central Reflex at nasal AA 13,13,13 13,13,13 NPC 11cm LE deviates out STREOPSIS 240 arc (TNO) *not reliable
  7. 7. 1. LE Exotropia on primary gaze 2. V pattern LE has no problem when attempt on abduction (towards temporal) 3.   Abduction on elevation: normal Abduction on depression: normal LE has limitation on adduction (towards nasal) 4. 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  
  8. 8. RE Limitation of ADDUCTION of LE 2. Down shoot of LE 1. *classic presentation of Duane’s Type 2 LE
  9. 9. RE LE KERATOMETRY 40.82@180 44.67@90 CA: -3.75x180 40.82@180 43.82@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: 0.5 A/V: 2/3 cd ratio: 0.6 A/V: 2/3
  10. 10. DIAGNOSIS 1. Low myope moderate astig 2. L Duane’s syndrome MANAGEMENT 1. Prescribe Rx 2. Write referral letter to Hosp. Terengganu 3. Refer pt to BV clinic for further assessment - 9 Apr 2012 4. KIV AA with Rx
  11. 11.  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 error  The reason of failure wear glasses?  Ask more about symptoms of amblyopia. Any eye turning in? Eye rubbing? See at very close distance?
  12. 12. DISCUSSION: CLINICAL FINDINGS Reduction in vision BE 1.    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 Marked AHP- face turn R 2.    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.
  13. 13. 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
  14. 14. Refractive error 4.     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.
  15. 15. Diagnosis 1: low myope with moderate astig 1. Uncorrected moderate amount of astig presenting with reduce of vision Should suggest meridional amblyopia? Management: prescribe Rx to provide optimum correction & prevent moderate amblyopia    Diagnosis 2: Left Duane’s syndrome 2. 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
  16. 16.  Refer to BV: patient came on 2nd April 2012  Additional test- Hess chart: to investigate incomitant strabismus in order to asses paretic element LE 1. 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, SO 4. Larger field of RE • Overaction of Right SR, LR, IR RE
  17. 17. TYPE 1 TYPE 2 TYPE 3 TYPE 4 -Poor abduction, good adduction -Poor adduction, good abduction -Poor adduction, poor abduction -Paradoxical abduction on attempt adduction -agenisis of 6th nerve -3rd nerve split innervate LR, MR -adduction intact as most nerve goes to MR -6th nerve intact -3rd nerve split innervate LR, MR -Poor adduction as LR contract against MR -6th nerve agenesis -3rd nerve split innervate LR, MR -The split is equal -Eye not moves in/out -6th nerve agenesis -3rd nerve split innervate LR, MR -most innervate LR -when ADD it ABD
  18. 18. TYPE 1 (70-80%) ie: LE LE Esotropia with head straight Face turn to affected side TYPE 2 (~7%) ie: LE LE Exotropia with head straight TYPE 3 (~15%) TYPE 4 ie: LE Eyes are aligned in primary position with head straight ie: LE Large LE Exotropia Face turn to nonaffected side Limited abduction left eye Normal or less abduction -Normal or less adduction -Narrowing of fissure -Globe retraction -Limited adduction -Narrowing of fissure -Globe retraction -Marked upshoot and sometimes downshoot on adduction Limited abduction left eye -Limited adduction -Narrowing of fissure -Globe retraction -Upshoot/ down shoot Limited adduction RE Simultaneous abduction when looking toward uninvolved side -violating Hering’s law
  19. 19.  Management of Duane’s syndrome  Correct refractive error  Treat amblyopia  In this case, no patching treatment is indicated yet as vision BE is almost similar  Meridional amblyopia usually has good prognosis with spectacles alone  To monitor vision after correction after 3 months.  Surgery indicated if:  Marked AHP  Decompensating  Cosmetically poor deviation  Diplopia occurring more frequently
  20. 20.  Refer to ophthalmology  To perform additional test for further evaluation  Forced duction test: to evaluate muscle palsy (+ve forced duction test)  Suggestion for squint surgery  The marked AHP is consistent  To improve cosmesis & comfort to patient
  21. 21.  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.
  22. 22. 1. Fiona J. Rowe. Clinical orthoptics. 3rd edition. 2. 3. 4. 5. Wiley-blackwell. http://emedicine.medscape.com/article/119855 9-overview date: 20th April 2012 http://telemedicine.orbis.org/bins/volume_page. asp?cid=1-3-5-50 date: 20th April 2012 http://www.webmd.com/eye-health/duanesyndrome date: 20th April 2012 http://childrenshospital.org/az/Site3103/mainpa geS3103P0.html date: 20th April 2012
  23. 23. Thank You

×