ObjectiveTo delineate a clinically actionable phenotype of consecutive esotropia with V-pattern following surgery for intermittent exotropia and to determine whether the initial surgical approach-bilateral lateral rectus recession versus unilateral recession-resection-is associated with differential patterns of V-pattern presentation and accommodative convergence/accommodation behavior among patients who develop consecutive esotropia. Clarifying these associations may inform postoperative surveillance and the selection of secondary surgical strategies in consecutive esotropia complicated by pattern deviation.MethodsWe retrospectively reviewed patients who developed consecutive esotropia after surgery for intermittent exotropia and were evaluated/managed at our center between 2016 and 2024. Thirty-four patients with consecutive esotropia had previously undergone bilateral lateral rectus recession (bilateral lateral rectus recession group), and twenty-six had previously undergone recession-resection (recession-resection group). Intermittent exotropia stage and consecutive esotropia clinical data were extracted, including ocular motility (with emphasis on abduction limitation), refractive status, presence and magnitude of V-pattern, and accommodative convergence/accommodation ratio measured using the gradient method. Comparisons were performed between groups at each stage and within individuals across the intermittent exotropia-to-consecutive esotropia transition.ResultsBaseline distance exodeviation was comparable between groups (bilateral lateral rectus recession: 38.92 ± 12.78Δ at 6 m and 36.47 ± 13.47Δ at 33 cm; recession-resection: 39.04 ± 12.91Δ at 6 m and 40.60 ± 10.54Δ at 33 cm), whereas near exodeviation was greater in the recession-resection group than in the bilateral lateral rectus recession group. No patient demonstrated a preoperative pattern deviation. Among consecutive esotropia cases, V-pattern was observed more frequently in the bilateral lateral rectus recession-derived consecutive esotropia cohort than in the recession-resection-derived cohort (15/34 vs. 3/26). During intermittent exotropia stage, accommodative convergence/accommodation ratios did not differ between groups; however, accommodative convergence/accommodation ratios increased after consecutive esotropia onset and were higher in the bilateral lateral rectus recession-derived consecutive esotropia cohort than in the recession-resection-derived cohort. These findings indicate that, once consecutive esotropia develops, the postoperative phenotype may vary according to initial procedure, with a stronger association between bilateral lateral rectus recession-derived consecutive esotropia and both V-pattern presentation and elevated accommodative convergence/accommodation.ConclusionsAmong patients who developed consecutive esotropia after intermittent exotropia surgery, bilateral lateral rectus recession-derived consecutive esotropia was more commonly accompanied by V-pattern and a higher accommodative convergence/accommodation ratio than recession-resection-derived consecutive esotropia. The increase in accommodative convergence/accommodation from the intermittent exotropia stage to the consecutive esotropia stage suggests that accommodative mechanisms may contribute to the consecutive esotropia-with-pattern phenotype and should be assessed when planning postoperative monitoring and secondary correction. Importantly, this study characterizes phenotypic differences among consecutive esotropia cases and does not estimate the incidence of consecutive esotropia or V-pattern consecutive esotropia after bilateral lateral rectus recession or recession-resection.

ObjectivesTo evaluate the risk factors associated with consecutive esotropia, as well as the changes in deviation angle and the prevalence of esotropia in patients who underwent surgery for exotropia.MethodsThe records of patients with basic-type exotropia who underwent either bilateral lateral rectus recession (symmetric surgery) or unilateral lateral rectus recession combined with medial rectus resection (asymmetric surgery), and who were followed for at least one year, were retrospectively reviewed. Preoperative, early postoperative, and late postoperative findings were analyzed for both groups: symmetric surgery (Group 1) and asymmetric surgery (Group 2). Consecutive esotropia was defined as ≥5 prism diopters of esotropia at either distance or near fixation.ResultsOf the 114 patients included, 52 (46%) were female and 62 (54%) were male. The mean age at surgery was 20.42 years in Group 1 and 15.59 years in Group 2 (p>0.05). Group 2 had significantly lower visual acuity, stereopsis, and fusion rates, and higher rates of amblyopia and anisometropia compared to Group 1. At the final follow-up examination, the deviation angles decreased significantly in both groups (p<0.001), and the prevalence of consecutive esotropia reduced from 17% to 7% in Group 1 and from 30% to 19% in Group 2 (p=0.031). While stereopsis did not significantly improve postoperatively in Group 1, increased significantly in Group 2 (p=0.031). Fusion improved significantly in both groups (p<0.001). Refractive error, anisometropia, preoperative and early postoperative deviation angles, and the extent of surgery were identified as significant risk factors for consecutive esotropia (p<0.05).ConclusionAlthough initial overcorrection following exotropia surgery tends to decrease over time, patients with high preoperative and early postoperative deviation angles, high refractive errors, anisometropia, and greater surgical amounts should be carefully monitored for the development of consecutive esotropia.

To investigate the unique postoperative pattern following intermittent exotropia (IXT) surgery. A retrospective review of patients younger than 18 years who underwent bilateral lateral rectus (BLR) recession or unilateral lateral rectus weakening and medial rectus strengthening surgery for IXT, with a postoperative follow-up period of 2 years or more was done. Patients who developed esodeviation after initially recovering to orthotropia within 1 month postoperatively were classified as having delayed-onset consecutive esotropia. The clinical characteristics of these patients were analyzed and the associated preoperative factors were assessed. Delayed-onset consecutive esotropia was observed in 6.4% of patients after IXT surgery. This phenomenon was observed approximately 4 months postoperatively. Risk factors were younger age, larger preoperative deviation angles, and undergoing BLR recession. Similar phenomenon of worsening of the deviation angle toward esotropia (rebound esodrift) was also observed in the patient groups with constant exotropia and continuous consecutive esotropia. Patients showing rebound esodrift shared the same risk factors as those with delayed-onset consecutive esotropia. This study identified patients exhibiting delayed-onset consecutive esotropia in the early postoperative period following IXT surgery. Close monitoring and suitable treatment of these patients are essential for optimal outcomes.

Background:Intermittent exotropia (IXT) is a prevalent strabismus in Asian children. While surgery is the main treatment, its long-term success can be influenced by postoperative exodrift. Therefore, accurately assessing this exodrift is essential to determine the optimal early postoperative alignment.Objectives:To investigate postoperative exodrift changes following unilateral lateral rectus recession combined with medial rectus plication (RP) procedure for children with basic type intermittent exotropia (IXT).Design:Retrospective, Cohort study.Methods:A retrospective review was conducted on the clinical data of patients with basic type IXT who underwent surgical intervention between 2022 and 2023, with a minimum follow-up of 12 months. Based on the postoperative ocular alignment at near within the first week, patients were divided into three groups: Group exo with exodeviation equal or exceeding 5 prism diopter (PD); Group ortho with exodeviation or esodeviation less than 5 PD; and Group eso with esodeviation equal or exceeding 5 PD. The successful motor outcome was defined as exodeviation or esodeviation equal to or less than 10 PD. The recurrent exotropia was defined as exodeviation exceeding 10 PD, and consecutive esotropia was defined as esodeviation exceeding 10 PD. The clinical features associated with motor outcomes and sensory outcomes were analyzed.Results:Final exodrift magnitudes were comparable across groups: Group exo (distance: 10.18 ± 10.55 PD, near:7.71 ± 9.82 PD), Group ortho (distance: 8.27 ± 7.23 PD, near: 9.13 ± 8.13 PD), Group eso (distance: 12.50 ± 10.71 PD, near: 12.80 ± 11.69 PD), (p = 0.149 for distance; p = 0.157 for near). Patients exhibiting overcorrection and ortho during the early postoperative period tended to have a better motor outcome compared to those undercorrection. Fusion function improved significantly regardless of the early postoperative ocular alignment (p < 0.001).Conclusion:Children with basic type IXT who exhibit varying ocular alignment in the early postoperative period demonstrated a comparable magnitude of 10 PD for long-term exodrift. It is recommended to overcorrect within the range of 0 to 10 PD following RP techniques.

To investigate the long-term surgical outcomes of augmented bilateral lateral rectus recession (BLRrec) for intermittent exotropia (XT). Patients treated with BLRrec for basic-type XT were divided into two groups. In the standard surgery group, the standard formula for BLRrec was used, whereas in the augmented surgery group, 1.0–1.5 mm was added bilaterally to the standard formula for BLRrec. Patients were followed up for 3 years. In total, 119 patients were enrolled, including 56 in the standard surgery group and 63 in the augmented surgery group. The success rate in the augmented surgery group was 44.4% at 3 years, which was higher than that in the standard surgery group (25.0%; P = .011). The incidence of consecutive esotropia (ET) was significantly higher in the augmented surgery group 1 year after surgery; however, the significance disappeared after 2 years. Immediate postoperative overcorrection in the standard surgery and augmented surgery groups was 14.8 prism dioptre (PD) ET and 21.0 PD (P < .001), respectively; moreover, the total exotropic drift at 3 years was 25.6 PD and 27.9 PD (P = .602), respectively. Augmented BLRrec showed better long-term surgical outcomes than standard BLRrec because of the larger immediate postoperative overcorrection. Although consecutive ET was more frequent in the augmented surgery group in the first year after surgery, it gradually resolved with conservative management.

Objective: To compare unilateral supra maximal lateral rectus recession (ULR) and bilateral lateral rectus recession (BLR) surgery in terms of efficacy and success rate in cases of mild to moderate degree exotropia. Study Design: Quasi experimental study. Place and Duration of Study: Combined Military Hospital Multan, Pakistan from Feb 2023 to Jan 2024. Methodology: 60 patients having exotropia in the prism diopters (PD) range of 10–30 were included in the study. Randomized sampling was done, and the patients were divided into 2 groups. 30 patients with exotropia underwent unilateral lateral rectus recession surgery (Group-A) whereas other 30 patients underwent bilateral lateral rectus recession surgery (Group-B). Results: After one week of surgery, the angle of deviation in PD was seen to be 3.33±4.17 PD in Group-A and 2.8±4.12 PD in Group-B (p= 0.801). Following each surgical procedure, there was a significant improvement in the angle of strabismus (p&lt;0.05). At final evaluation (3 months after surgery) exotropia improved on average by 15.66±6.28 PD in Group-A &amp; 16.86 ± 4.66 PD in Group-B (p &lt;0.05) Conclusion: Success rate range was high and comparable in both the groups. When correcting mild to moderate angle exotropia (≤30 PD), unilateral supra maximal lateral rectus recession is more beneficial than bilateral lateral recession because of reduced anaesthesia time, reduced surgical risks such as scleral perforation, retinal detachment and endophthalmitis. Furthermore, the rate of consecutive esotropia and over-correction is decreased.

Introduction This study compared three surgical approaches for convergence insufficiency intermittent exotropia (CI-X[T]) in children to identify the most effective method. Methods Fifty-eight children aged 4–13 years with CI-X(T) and near-distance disparity ≥10 prism diopters (PD) were prospectively randomized to: (1) Bilateral Lateral Rectus Recession (BLR), (2) Unilateral Recession–Resection (RR), or (3) Medial Rectus Resection (MRR). Surgical outcomes were defined as postoperative deviation within 5 PD of esophoria/tropia and 10 PD of exophoria/tropia. Patients were followed for 24 months. Results At the final follow-up, cumulative success rates were similar among BLR (52.4% near, 81.0% at distance), RR (30.4% near, 43.5% at distance), and MRR (27.3% near, 50.0% at distance). Near exodeviation decreased significantly in all groups (p &lt; 0.001). NDD correction was achieved in 59.1% of MRR, 50.0% of BLR, and 30.4% of RR patients (p = 0.142). Stereopsis improved comparably across groups. Complications included overcorrection and A/V patterns in BLR, undercorrection in RR, and persistent consecutive esotropia in MRR. Discussion All three surgical approaches were effective, with BLR favoring distance correction, RR showing short-term near benefits, and MRR demonstrating balanced long-term outcomes, including improvement in the AC/A ratio. Conclusion MRR appears to be the most reliable overall, although individual patient characteristics should guide surgical choice. Larger, long-term studies are needed.

Purpose: Consecutive esotropia (CET) following intermittent exotropia [IX(T)] surgery can cause significant concern among patients and their parents due to esodeviation and diplopia. We evaluated whether CET can be prevented and explored exotropia recurrence after combined bilateral lateral rectus (LR) and unilateral medial rectus (MR) muscle recession.Methods: This retrospective, exploratory case series included patients who underwent bilateral LR recession for IX(T) of ≥ 25 prism diopters (∆). Thirteen patients demonstrated strong MR tension confirmed by forced duction, and spring-back balance tests during surgery and nasal deviation on the Hirschberg test after LR recession. These patients underwent concurrent bilateral LR and unilateral MR recessions (three-muscle recession). The MR recession ranged from 3 to 5 mm based on the degree of MR tension and nasal deviation. Patients were followed for a minimum of one year (12-73 months) to assess the occurrence of CET (&lt; -5∆) and recurrent IX(T) (&gt; +10∆).Results: The mean age at surgery was 7.60 ± 2.14 years. The mean preoperative IX(T) was 28.62 ± 2.22∆ at far distance and 26.92 ± 10.32∆ at near distance. Postoperative mean deviations were +2.15∆ at 1 month, +2.50∆ at 6 months, +3.83∆ at 1 year, +5.82∆ at 2 years, and +5.33∆ at 3 years. CET (-8∆) developed in two patients, whereas five experienced recurrent IX(T). The mean time to IX(T) recurrence was 18.20 ± 19.23 months post-surgery.Conclusions: In patients with IX(T) ≥ 25∆ and strong MR tension who are at risk of CET, three-muscle recession may offer a novel preventive approach. However, considering the study’s limitations, including its retrospective design, these findings should be interpreted with caution. Future prospective, large-scale randomized controlled trials are needed.

ABSTRACT To compare the incidence of consecutive esotropia post bilateral lateral rectus recession (BLR) surgery using absorbable compared to non-absorbable sutures for the treatment of childhood exotropia. Retrospective Cohort study. Medical records of all children who underwent BLR surgery between January 2019 and January 2022 in a single medical center by a single surgeon were analyzed. Either absorbable or non-absorbable sutures were used. The incidence of consecutive esotropia (greater than 8 PD) was the primary outcome. A total of 130 children were included. The mean age was 6.45 ± 3.13 years, 54% were female. Sixty-five of the children underwent surgery with the use of absorbable sutures and 65 with the use of non-absorbable sutures. Consecutive esotropia occurred in 14 children (21.5%) in the absorbable group and in 5 children (7.7%) in the non-absorbable group (OR = 3.29, 95% CI = 1.11–9.77; p = .025). After adjustment for follow-up time using the Kaplan – Meier survival analysis, the difference between groups remained significant (p = .049). Secondary surgery due to consecutive esotropia occurred in 10 children (15.4%) in the absorbable group and in 3 children (4.6%) in the non-absorbable group (OR = 3.75, 95% CI = 1.001–14.628; p = .04). There were no other complications in either of the groups. The use of non-absorbable sutures in BLR surgery reduces the incidence of consecutive esotropia compared to absorbable sutures.

To evaluate the surgical outcomes of a modified normogram for bilateral lateral rectus recession in the surgical management of intermittent exotropia, with a focus on achieving small overcorrection. A retrospective medical chart review of 242 patients who underwent surgery for intermittent exotropia between October 2014 and June 2020 was performed. Our modified normogram reducing amount of recession targeted for small postoperative overcorrection within 5 prism diopters (PD). Patients were observed for at least 3 years. Esodeviation was denoted by negative numbers and positive values indicated exodeviation. A satisfactory outcome was defined as if distant angle of deviation ranged between ≤10 PD of exotropia and ≤5 PD of esotropia. Recurrence was defined as an exodeviation of >10 PD at distance. Overcorrection was defined as an esodeviation of >5 PD at distance. The mean preoperative deviation angles were 29.32 ± 3.92 PD at distance and 29.88 ± 4.41 PD at near. At postoperative day 1, the mean deviation angles at distance and near were -6.22 ± 1.44 and -6.22 ± 1.49 PD, respectively. Overcorrection within 6 PD of esodeviation was seen in 168 patients (69.42%), undercorrection with exophoria was noted in 11 patients (4.55%), and overcorrection by more than 6 PD of esodeviation was seen in 63 patients (26.03%) at postoperative day 1. The long-term success rate at postoperative 3 years was 77.27% (187 of 242), with a recurrence rate of 19.83% (48 of 242) and an overcorrection rate of 2.89% (7 of 242). A positive correlation between the angle of deviation at postoperative day 1 and 3 years was observed (r = 0.22, p = 0.001). The final success rate at the final examination after a mean follow-up of 38.60 ± 7.99 months was 83.06%. Our modified normogram for bilateral lateral rectus recession in intermittent exotropia surgery resulted in successful surgical outcomes with small overcorrection, reducing the risk of consecutive esotropia due to excessive overcorrection.

To report long-term ocular alignment and sensory outcomes after medial rectus recession for high accommodative convergence/accommodation (AC/A) ratio esotropia. The medical records of consecutive patients who had undergone unilateral or bilateral medial rectus recession for high AC/A ratio esotropia and were observed postoperatively for a minimum of 5 years were reviewed retrospectively. A total of 34 patients were included. Twenty-three patients (68%) used bifocals preoperatively. The mean age at surgery was 11.5 ± 4.4 years (range: 2.5 to 19.0 years). The mean postoperative follow-up was 7.5 ± 2.3 years (range: 5.0 to 15.25 years). Overall, 21 patients (62%) had surgical success at their last follow-up visit. Age at surgery, preoperative angle of distance and near deviation, distance-near disparity, and preoperative bifocal wear did not predict motor outcome after surgery. Preoperative presence of peripheral binocular single vision was a significant favorable factor for surgical success. At the last follow-up visit, 21% of patients had a recurrence of high AC/A ratio esotropia and 9% each had consecutive exotropia (intermittent [3%] and constant [6%]) and basic esotropia. Peripheral binocular single vision was achieved in 64% of patients and stereopsis in 28%. Bifocal segment was eliminated postoperatively in 70% of patients. Nearly two-thirds of patients with high AC/A ratio esotropia achieved a successful long-term motor outcome and peripheral binocular single vision, and nearly one-fourth achieved stereopsis. Recurrence of high AC/A ratio esotropia occurred in some patients, and consecutive exotropia and basic esotropia in a few. Bifocal segment was eliminated postoperatively in 70% of patients. [J Pediatr Ophthalmol Strabismus. 20XX;X(X):XX-XX.].

Surgical management of superior oblique palsy with coexisting exotropia

PurposeTo determine the relationship between consecutive esotropia (ET) and passive duction force (PDF) in patients with intermittent exotropia (XT).MethodsThe study enrolled 70 patients in whom PDF was measured under general anesthesia prior to XT surgery. The preferred eye for fixation (PE) and the nonpreferred eye for fixation (NPE) were determined using a cover–uncover test. The patients were subdivided into two groups according to the angle of deviation at 1 month postoperation: (1) consecutive ET (CET group), >10 prism diopters (PD) of ET; and (2) non-CET (NCET group), ≤10 ET or residual exodeviation. The relative PDF of the medial rectus muscle (MRM) was obtained by subtracting the ipsilateral PDF of the lateral rectus muscle (LRM) from the PDF of the MRM.ResultsThe PDFs for the LRM in the PE in the CET and NCET groups were 47.28 g and 58.59 g, respectively (p = 0.147), and 56.18 g and 46.59 g for the MRM (p = 0.11), and in the NPE were 59.84 g and 55.25 g, respectively, for the LRM (p = 0.993), and 49.12 g and 50.53 g, respectively, for the MRM (p = 0.81). However, in the PE, the PDF in the MRM was larger in the CET group than in the NCET group (p = 0.045), which was positively associated with the postoperatively overcorrected angle of deviation (p = 0.017).ConclusionsAn increased relative PDF in the MRM in the PE was a risk factor for consecutive ET after XT surgery. Quantitative evaluation of the PDF could be considered when planning strabismus surgery to achieve the desired surgical outcome.

To determine the relationship between consecutive esotropia (ET) and passive duction force (PDF) in patients with intermittent exotropia (XT). The study enrolled 70 patients in whom PDF was measured under general anesthesia prior to XT surgery. The preferred eye for fixation (PE) and the nonpreferred eye for fixation (NPE) were determined using a cover-uncover test. The patients were subdivided into two groups according to the angle of deviation at 1 month postoperation: (1) consecutive ET (CET group), >10 prism diopters (PD) of ET; and (2) non-CET (NCET group), ≤10 ET or residual exodeviation. The relative PDF of the medial rectus muscle (MRM) was obtained by subtracting the ipsilateral PDF of the lateral rectus muscle (LRM) from the PDF of the MRM. The PDFs for the LRM in the PE in the CET and NCET groups were 47.28 g and 58.59 g, respectively (p = 0.147), and 56.18 g and 46.59 g for the MRM (p = 0.11), and in the NPE were 59.84 g and 55.25 g, respectively, for the LRM (p = 0.993), and 49.12 g and 50.53 g, respectively, for the MRM (p = 0.81). However, in the PE, the PDF in the MRM was larger in the CET group than in the NCET group (p = 0.045), which was positively associated with the postoperatively overcorrected angle of deviation (p = 0.017). An increased relative PDF in the MRM in the PE was a risk factor for consecutive ET after XT surgery. Quantitative evaluation of the PDF could be considered when planning strabismus surgery to achieve the desired surgical outcome.

Abstract The incidence of consecutive esotropia developing after exotropia surgery has been reported to be 6%–20%. Consecutive esotropia with limited abduction requires reoperation on the muscles that were operated during the first surgery. It is difficult to predict the result of the second surgery because it may convert to exodeviation after the advancement of lateral rectus (LR) muscle, the contracture of the previously recessed muscle, or hypertrophy of resected medial rectus (MR). We present a case of 20-year-old woman with infantile exotropia who underwent bilateral lateral rectus recession and left MR resection in view of a large primary position deviation of 55 prism diopter (PD) at a 6-meter distance. But the patient developed large consecutive esotropia of 50 PD within 3 weeks of surgery with abduction limitation in the left eye, which was highly suspicious of slippage of the left LR. But when the LR was explored, it was found at 16 mm from the limbus without any evidence of slippage. In view of the abnormal response after the first surgery, the LR was advanced by 9 mm, and was inserted at 7 mm from limbus. The patient was orthophoric on the first postoperative day, and the alignment was maintained till 6 months of follow-up. This case is unique in terms of unexpected large consecutive esotropia of 50 PD after uncomplicated routine strabismus surgery, which was corrected by advancement of one LR only. This event could be possibly due to lack of binocularity and fusion in these patients with an associated component of dissociated horizontal deviation. This report emphasizes the possibility of some unusual postoperative outcomes in spite of careful and meticulous preoperative workup, and uneventful squint surgery in patients with infantile deviation.

To evaluate the long-term surgical efficacy of lateral rectus advancement (LRadv) in patients with consecutive esotropia (CET). The medical records of 30 patients who developed CET after bilateral lateral rectus (BLR) recession for exotropia (XT) between 2012 and 2020 were reviewed. The characteristics of patients during their XT surgery were summarized. Among them, 15 patients who underwent LRadv as CET treatment with at least a 1-year follow-up were included to evaluate the long-term efficacy of this surgical approach. The main outcomes were the pre- and post-operative angle of deviation after LRadv. Surgical success was defined as the postoperative deviation within 10 prism diopters (PD), and reoperation was not needed. All data were expressed as median and interquartile ranges. The median follow-up was 34months after LRadv surgery. The median postoperative deviation ranged from 28 to 1 PD at 1year (P < 0.05) and to 5 PD at the final follow-up (P < 0.05). The deviation at each follow-up time showed no statistically significant difference (P > 0.05). The final surgical success was reduced compared to 1day and 1year postoperatively (60% VS 100% and 66.7%, respectively). Undercorrection and overcorrection both occurred at the final follow-up. Although the immediate surgical outcome of LRadv was satisfactory, the success rate reduced with time, which suggests long-term observation is necessary to detect and timely provide appropriate interventions for overcorrection or undercorrection.

Standard versus reduced numbers for the management of intermittent exotropia in children ≤6 years

Purpose:To analyze the efficacy of fusional vergence therapy (FVT) in management of consecutive esotropia with diplopia after intermittent exotropia (IXT) surgery. The current study is carried on how FVT affects the duration of treatment, sensory fusion, and exotropic drift.Methods:This was a retrospective study for the medical record of 11 patients with consecutive esotropia after IXT surgery of 543 patients over the period of 5 year, with mean surgery age of 9.5 (range: 4–33 y). FVT was planned after minimum 6 weeks of surgery and was considered for maximum 24 weeks. Patients underwent a combination of office-based and home-based FVT. Successful outcome of therapy was considered where diplopia resolves in free space and achieves sensory fusion, stereopsis with no manifest deviation.Results:Record of 543 patients who had horizontal muscle surgery for IXT were identified and reviewed. Records of 11 patients who showed consecutive esotropia of 10 prism diopter (PD) or more with normal retinal correspondence, with or without diplopia complaint, after 6 week of surgery and had undergone vision therapy management were reviewed. A successful outcome of binocular single vision with good sensory and motor fusion with no manifest deviation or prism requirement was achieved with in the mean duration of 4.8 month of therapy. With a mean duration of 4 weeks of therapy, the mean angle of deviation reduced by 53% for distance (17 PD to 8 PD) and 27% for near (11 PD to 8 PD) and mean stereopsis improvement by 80% with 94% patients demonstrating sensory fusion on Bagolini test and 94% of patients having no symptoms of diplopia or squint.Conclusion:With nonsurgical management involving refractive error correction, FVT, and prism, consecutive esotropia was resolved in 74% cases. Management of consecutive esotropia with FVT can result in satisfactory sensory fusion and successful motor alignment.

Background Following surgery to address intermittent exodeviation, consecutive esotropia (ET), in which postoperative ET continues for more than 6 months, may arise. Both lateral rectus advancement (LRA) and medial rectus recession (MRR) are effective in correction of consecutive ET. Purpose The aim of this study was to compare the results of LRA and MRR in correction of consecutive ET (within 40 PD) following bilateral lateral rectus recession for treatment of intermittent exotropia. Patients and methods This was a randomized double-blind controlled trial that included 30 patients who were divided into two groups: group 1 (LRA group, 15 patients) and group 2 (MRR group, 15 patients). Unilateral or bilateral LRA or MRR was done according to the preoperative angle of deviation. All patients had preoperative ocular examination, which included history taking, visual acuity testing, slit-lamp examination, fundus examination, preoperative angle of deviation at near and far using the Krimsky method, stereopsis using the Titmus test, and suppression using the Worth 4-dot test. The patients were followed up at 1, 3, and 6 months after surgery. Results There was no statistically significant difference between the two groups in the preoperative angle of deviation (P=0.213). In group 1, the mean preoperative angle of consecutive ET was 29.0±6.14 PD, which improved to 0.87±3.56 PD 6 months after surgery, with a statistically significant difference (P&lt;0.001). In group 2, the mean preoperative angle of consecutive ET was 25.47±8.81 PD and improved to 1.67±4.58 PD 6 months after surgery, with a statistically significant difference (P&lt;0.001). However, there was no statistically significant difference between the two groups in the postoperative angle of deviation (P=0.562). Six months postoperatively, there were two (13.3%) undercorrected cases and one (6.7%) overcorrected case, with a success rate of 80% in group 1, whereas in group 2, there were two (13.3%) undercorrected cases and two (13.3%) overcorrected cases, with a success rate of 73.4%, with no statistically significant difference between the two groups in the success rate (P=0.66). In group 1, the mean preoperative stereoacuity value was 291.7±206.5, which improved significantly postoperatively to 140±35.71 (P=0.005). Similarly, in group 2, the mean preoperative stereoacuity value was 506.7±810.5 and improved significantly postoperatively to 150±46.41, (P=0.003). Conclusion Both LRA and MRR were effective in the correction of consecutive ET.

ABSTRACT Exotropia (XT) in internuclear ophthalmoplegia (INO) is a difficult problem to treat. The purpose of this study is to describe surgical approaches in treating INO and glean insight into various pre-operative factors that may affect outcomes for XT in INO. We conducted a retrospective review from 1 January 1995 – 5 January 2021 and identified seven patients with INO who underwent strabismus surgery for XT. Patient age, sex, etiology of INO, pre-operative alignment and sensorimotor exam, presence of diplopia, surgery performed, subsequent surgeries, use of adjustable sutures, post-operative alignment, presence of post-operative diplopia, presence of post-operative diplopia with use of prism correction, and length of follow-up were all collected. Initial surgeries undertaken included unilateral medial rectus (MR) plication and lateral rectus (LR) recession, bilateral medial rectus (MR) plications or resections, or bilateral MR plications combined with either unilateral or bilateral LR recessions. Chart review yielded ten charts, however two were excluded due to manifest esotropia (ET), and one was excluded due to incomplete records. Seven total patients were used in final analysis. The cohort age range was from 29 to 79 years. Pre-operative horizontal distance alignment ranged from 35 to 95 XT with an average exodeviation of 67.8 ± 22.6 prism diopters (PD). Horizontal adduction deficit ranged from −1 to −4 and was present bilaterally in all patients. A variety of initial surgical approaches were undertaken. After two muscle surgeries, distance deviation had an average change of 57.3 PD. After three muscle surgeries, distance deviation had an average change of 75 PD. After four muscle surgeries, distance deviation had an average change of 60 PD. Three patients required additional surgery for XT. Time to follow-up ranged from 1 to 58 months. Horizontal distance alignment in primary gaze at latest follow-up ranged from 30 ET to 30 XT with an average of 0 (orthotropia) ± 16.0 PD. One patient had a consecutive esotropia of 30 PD, one had a persistent exotropia of 30 PD, and five patients were orthotropic at distance. All patients reported relief of diplopia in primary gaze at near and distance either with or without use of prism. Horizontal ductions improved to some degree in all patients. Horizontal rectus surgery can treat many cases of XT in INO. Surgeons should consider INO etiology and concomitant vertical deviations when considering surgery. The degree of pre-operative adduction limitation is another important factor, though did not always dictate final motor and sensory outcomes.