Surgical Management of a Prominent Adduction-Induced Upshoot in Duane Retraction Syndrome Type III: A Case Report.

Duane retraction syndrome (DRS) with good primary gaze alignment and no abnormal head posture is often managed conservatively to avoid worsening alignment. However, surgical intervention may be considered when significant cosmetic concerns are present. We present the case of a 29-year-old male patient with type III DRS of the right eye and a prominent upshoot. Despite having good primary gaze alignment, the patient desired cosmetic improvement. Forced duction testing revealed restrictions in multiple directions. Based on the spring-back balance test, we performed an 8.0 mm recession of the lateral rectus muscle and a 6.0 mm recession with partial nasal transposition of the superior rectus muscle. One year postoperatively, the vertical deviation had improved to 8 prism diopters (PD) at distance and 12 PD at near. The upshoot was significantly reduced, and there were no new limitations or diplopia. The patient achieved cosmetic satisfaction. Combined lateral and superior rectus recession effectively reduced an adduction-induced upshoot in DRS type III. Surgery may be considered for patients with good primary gaze alignment and significant cosmetic concerns.