Adhesion after Y-split procedure can affect its mechanism for treating overshoots in Duane’s syndrome

  • Young Choi
  • Sungmin Jang
  • Soo Youn Choi
  • Seung-Hyun Kim
  • Young-Woo SuhEmail author



To investigate the extent of adhesion and changes in the Y configuration after the Y-split procedure, compared with the posterior fixation suture.


Twelve New Zealand white rabbits were included in the study. The 10-mm Y-split procedure was performed in the superior rectus muscle (SR) of one eye, and the 10-mm posterior fixation suture was made in the SR of the other eye. Six weeks after surgery, the Y arm lengths and lengths of adherence to the sclera were measured. If the adhesion involved the whole Y arm, the distance between the original SR insertion and most proximal part of the adhered SR was measured. In the eyes with posterior fixation suture, the distance between the SR insertion and most proximal part of the adhered SR was evaluated.


The average nasal and temporal Y arm lengths were 6.37 ± 0.65 and 6.54 ± 0.63 mm, respectively, a significant decrease from those measured immediately after surgery (P = 0.002 and 0.002, respectively). Adhesions involved the entire Y arms in 11 of 12 SRs (91.7%), with an average adhesion length of 7.01 ± 1.04 mm. In SRs with posterior fixation sutures, the average adhesion was 9.18 ± 0.62 mm from the insertion, which was only 2.17 mm posterior to proximal portion of adhesion in Y-split SR (P < 0.001).


Healing process reduces the Y arm length. Adhesion may involve the entire Y arm and could weaken or alter the therapeutic mechanism after the Y-split procedure.


Strabismus Overshoots Y-split procedure Posterior fixation suture Duane’s syndrome 



This study was funded by a grant from Korea University (K1422451).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All applicable international, national, and/or institutional guidelines for the care and use of animals were followed.


  1. 1.
    Oystreck DT, Engle EC, Bosley TM (2011) Recent progress in understanding congenital cranial dysinnervation disorders. J Neuroophthalmol 31:69–77. CrossRefGoogle Scholar
  2. 2.
    von Noorden GK, CE (2002) Binocular vision and ocular motility, 6th edn. Mosby, St. LouisGoogle Scholar
  3. 3.
    Rogers GL, Bremer DL (1984) Surgical treatment of the upshoot and downshoot in Duanes' retraction syndrome. Ophthalmology 91:1380–1383CrossRefGoogle Scholar
  4. 4.
    Sukhija J, Kaur S (2013) Isolated Y splitting and recession of the lateral rectus muscle in patients with exo-Duane syndrome. Strabismus 21:1–2. CrossRefGoogle Scholar
  5. 5.
    Sprunger DT (1997) Recession of both horizontal rectus muscles in Duane syndrome with globe retraction in primary position. J AAPOS 1:31–33CrossRefGoogle Scholar
  6. 6.
    Mohan K, Saroha V (2002) Vertical rectus recession for the innervational upshoot and downshoot in Duane's retraction syndrome. J Pediatr Ophthalmol Strabismus 39:94–99CrossRefGoogle Scholar
  7. 7.
    Awadein A (2013) Inferior oblique myectomy for upshoots mimicking inferior oblique overaction in Duane retraction syndrome. J AAPOS 17:253–258. CrossRefGoogle Scholar
  8. 8.
    Farid MF (2016) Y-split recession vs isolated recession of the lateral rectus muscle in the treatment of vertical shooting in exotropic Duane retraction syndrome. Eur J Ophthalmol 26:523–528. CrossRefGoogle Scholar
  9. 9.
    Kekunnaya R, Kraft S, Rao VB, Velez FG, Sachdeva V, Hunter DG (2015) Surgical management of strabismus in Duane retraction syndrome. J AAPOS 19:63–69. CrossRefGoogle Scholar
  10. 10.
    Rao VB, Helveston EM, Sahare P (2003) Treatment of upshoot and downshoot in Duane syndrome by recession and Y-splitting of the lateral rectus muscle. J AAPOS 7:389–395. CrossRefGoogle Scholar
  11. 11.
    Velez FG, Velez G, Hendler K, Pineles SL (2012) Isolated y-splitting and recession of the lateral rectus muscle in patients with exo-duane syndrome. Strabismus 20:109–114. CrossRefGoogle Scholar
  12. 12.
    Scott AB (1977) The faden operation: mechanical effects. Am Orthopt J 27:44–47CrossRefGoogle Scholar
  13. 13.
    Ahn SE, Han JY, Kim SH, Cho YA, Suh YW (2014) Stability of Y-splitting procedure combined with hang-back recession of the rectus muscle in rabbit eyes. Graefes Arch Clin Exp Ophthalmol 252:59–62. CrossRefGoogle Scholar
  14. 14.
    Takeuchi K, Nakazawa M, Metoki T, Yamazaki H, Miyagawa Y, Ito T (2011) Effects of solid hyaluronic acid film on postoperative fibrous scar formation after strabismus surgery in animals. J Pediatr Ophthalmol Strabismus 48:301–304. CrossRefGoogle Scholar
  15. 15.
    Akar S, Gokyigit B, Aygit ED, Sabanci S, Demirok A (2013) Is y-split recession of the medial rectus muscle as effective as scleral retroequatorial myopexy of the medial rectus muscle for partially accommodative esotropia with convertgence? A report of results in 61 cases. Binocul Vis Strabolog Q Simms Romano 28:167–175Google Scholar
  16. 16.
    Wipf M, Priglinger S, Palmowski-Wolfe A (2017) Y-Split recession of the medial rectus muscle as a secondary and/or unilateral procedure in the treatment of esotropia with distance/near disparity. J Ophthalmol 2017:6472690. Google Scholar
  17. 17.
    Hoerantner R, Priglinger S, Koch M, Haslwanter T (2007) A comparison of two different techniques for oculomotor torque reduction. Acta Ophthalmol Scand 85:734–738. CrossRefGoogle Scholar
  18. 18.
    Hoerantner R, Priglinger S, Haslwanter T (2004) Reduction of ocular muscle torque by splitting of the rectus muscle II: technique and results. Br J Ophthalmol 88:1409–1413. CrossRefGoogle Scholar
  19. 19.
    Haslwanter T, Hoerantner R, Priglinger S (2004) Reduction of ocular muscle power by splitting of the rectus muscle I: biomechanics. Br J Ophthalmol 88:1403–1408. CrossRefGoogle Scholar
  20. 20.
    Suh YW, Park JH, Cho YA (2011) The effect of botulinum toxin injection on the hang-back recession of rectus muscles. Graefes Arch Clin Exp Ophthalmol 249:921–924. CrossRefGoogle Scholar
  21. 21.
    Ryu WY, Bae JB (2013) Changes in sagging extraocular muscle following surgical recession of the superior rectus muscle in rabbit eyes. J Pediatr Ophthalmol Strabismus 50:162–168. CrossRefGoogle Scholar
  22. 22.
    Chang M, Kim JH, Kim SH (2011) The change of the extraocular muscle insertion after a slanted recession in rabbit eyes. Graefes Arch Clin Exp Ophthalmol 249:1373–1377. CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of OphthalmologyKorea University College of MedicineSeoulSouth Korea
  2. 2.Department of OphthalmologyKorea University Ansan HospitalAnsan-siSouth Korea

Personalised recommendations