Approach Considerations
Treatment should be directed at the underlying etiology.
Medical Care
Duane retraction syndrome [1, 2, 14, 15]
Correct refractive errors and treat amblyopia if present.
Patient can be kept under observation if there is no significant strabismus in primary gaze, anomalous head position, cosmetically unacceptable upshoots/downshoots, or globe retraction.
Orbital blowout fracture [3, 4, 5]
Patients should avoid nose blowing.
Oral antibiotics and nasal decongestants should be prescribed.
Cold compresses can be used to reduce eyelid edema to facilitate follow-up examinations.
Metastatic carcinoma [6, 7, 13, 8]
Patients should undergo appropriate systemic screening to identify primary tumor.
Orbital radiotherapy and/or systemic chemotherapy should be considered.
Surgical Care
Goals for surgery in Duane retraction syndrome include correction of ocular alignment in primary gaze, elimination of any abnormal head position, reduction of magnitude of upshoots/downshoots, and globe retraction, as follows [1] :
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Recession of ipsilateral medial rectus in type I when esotropia is less than 30 prism diopters
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Bilateral medial rectus recession in type I when esotropia is greater than 30 prism diopters
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Recession of ipsilateral lateral rectus muscle in type II
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Never perform rectus resection because this is likely to increase globe retraction.
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Recession of both horizontal recti to reduce globe retraction
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Splitting of lateral rectus in a Y configuration or using posterior fixation sutures on the lateral rectus may reduce upshoots.
Orbital blowout fractures should be repaired if there is obvious entrapment of an extraocular muscle, no improvement in diplopia, or unacceptable enophthalmos. [4] Autogenous or allogenic bone, demineralized bone, hydroxyapatite, and synthetic implants (eg, Teflon, Silastic, Supramid, porous polyethylene) may be used to repair the fracture. Surgical management of orbital and periorbital trauma may require cooperative efforts from otolaryngology and neurosurgery.
Consultations
Consultations include the following:
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Strabismus surgeon for extraocular muscle surgery in Duane retraction syndrome
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Orbital surgeon for repair of blowout fractures
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Oncologist and radiation oncologist for management of metastatic carcinoma
Activity
Patients with orbital blowout fractures should have limited activity.
Avoidance of Valsalva maneuver and blowing of nose is crucial to reduce probability of developing orbital emphysema.
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Patient presented with persistent diplopia after an interpersonal altercation. Forced ductions revealed tight inferior and medial rectus muscles on right side. CT scan revealed orbital floor and medial wall fractures in right orbit.
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Patient with metastatic breast carcinoma to the intraconal space of the right orbit resulting in mild globe retraction and enophthalmos.
