Clinical characteristics and surgical outcomes in exotropic Duane retraction syndrome.

PURPOSE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.