Clinical characteristics and surgical outcomes in exotropic Duane retraction syndrome

To evaluate the demographic and clinical characteristics, surgical techniques, and postoperative outcomes in patients with exotropic Duane retraction syndrome (DRS) at a tertiary referral strabismus center.

This retrospective study included 109 patients with exotropic DRS (Type 1, n = 78; Type 2, n = 20; Type 3, n = 11) evaluated between 1995 and 2023. Surgical indications were exotropia ≥ 20 prism diopters (PD) in primary position or abnormal head posture (AHP) ≥ 10°. Procedures included lateral rectus (LR) recession (3-7 mm), Y-splitting of the LR, vertical rectus transposition, and adjunctive techniques. Botulinum toxin type A (BTX-A) was administered in selected cases.

The cohort comprised 79 females (72.5%) and 30 males (27.5%), with a mean age of 12.57 ± 9.03 years (range, 2-45). The mean follow-up duration was 24.79 ± 30.03 months. Left eye involvement was predominant (74.3%). Surgical intervention was performed in 59 patients (54.1%); non-surgically managed patients showed no significant change in deviation over follow-up. The surgical group had greater preoperative deviation and a higher proportion of Type 2 DRS than the non-surgical group (p < 0.001, p = 0.010). Y-splitting and LR recession produced significant reductions in deviation angles across all subtypes (all p < 0.05), though motility restriction showed only limited improvement. AHP improved in 57.1% of operated patients (p = 0.027). Orthotropia or residual deviation ≤ 10 PD was achieved in 66.1% after the initial procedure. Reoperation was required in 20 patients, with a secondary success rate of 54.5%. Preoperative distance deviation angle was the only independent predictor of surgical failure (odds ratio 1.14, 95% CI 1.06-1.23; p = 0.001; AUC = 0.84).

Y-splitting and LR recession are effective surgical options for improving ocular alignment and abnormal head posture in exotropic DRS; however, persistent motility limitation and considerable variability across subtypes indicate that a uniform surgical approach is insufficient. These findings support the need for individualized, subtype-guided treatment strategies and long-term postoperative surveillance.