PurposeTo compare the effectiveness of botulinum toxin (BTX) injection to bilateral medial rectus recession (BMR) in partially accommodative esotropia (PAET).MethodsThis retrospective study reviewed the medical records of 107 children younger than 15 years of age treated for PAET with BTX injection or bilateral medial rectus recession (BMR) surgery at a single institution between 2015 and 2022. PAET was defined as residual esotropia of at least 14 prism diopters (PD) after six weeks of continuous wear of full cycloplegic refraction. Primary success was defined as a distance alignment of ≤ 10 PD after a single treatment (BTX injection or BMR surgery). Secondary success was defined as achieving this alignment after repeated treatment.ResultsOf 107 patients, 51 received BTX injection and 56 underwent surgery. The surgery group had a significantly higher primary success rate (83.9%) than the BTX injection group (50.9%). No demographic factors correlated with treatment success. After repeat interventions, the cumulative success rate rose to 78.4% in the BTX injection group and 87.5% in the surgery group. Six patients (11.7%) in the BTX injection group eventually required surgical intervention. The complications rate was 4.8% in the BTX injection group (temporary ptosis covering visual axis), and 3.57% in the surgery group (consecutive exotropia necessitating medial rectus advancement).ConclusionSurgical intervention (BMR surgery) demonstrated significantly higher primary success rates for PAET than a single BTX injection. However, repeated BTX injections ultimately achieved comparable long-term success rates. While BTX offers less invasiveness and reduced anesthesia time, the potential need for multiple injections should be considered when counseling patients and their families.

Surgical Outcomes in Partially Accommodative Esotropia Using Augmented Distance Angle Averaging With and Without Hyperopic Correction

Predictors of nonsurgical consecutive exotropia following accommodative esotropia.

Because surgical tables have not previously been available for consecutive exotropia, this study aimed to determine the appropriate surgical dosing for medial rectus (MR) advancement in this condition. Retrospective case series. Data were reviewed for patients with consecutive exotropia who underwent MR advancement with or without lateral rectus (LR) recession. A total of 44 patients were included averaging 35 ± 20 (stamdard deviation ) years of age. Mean preoperative exotropia was 29 ± 15∆ at distance and 33 ± 19∆ at near. Thirty-four patients underwent unilateral or bilateral MR advancement, and 10 patients underwent MR advancement combined with LR recession. For the MR advancement group, mean advancement was 4.9 ± 1.4 mm. At the last follow-up visit, exotropia at distance was reduced from 26 ± 12∆ to 7 ± 11∆. For the MR advancement + LR recession group, mean MR advancement was 6.2 ± 2.0 mm, and the mean total surgical dose, including LR recession, was 14.6 ± 4.7 mm. Overall, distance exotropia at last follow-up was surgically reduced from 39 ± 18∆ to 9 ± 14∆. Exodrift from initial to final follow-up was 6.6∆ for MR advancement alone and 7.5∆ for MR advancement + LR recession. Regression analysis of surgical dose-response suggests that each MR advancement should be augmented by 2 mm more than Parks' general surgical recommendation for treating exotropia by MR resection. Augmentation of MR advancement may improve the correction of consecutive exotropia and is effective while affording opportunity to explore the MR muscle.

Abstract PURPOSE: To investigate the ophthalmological characteristics and accommodative components of cases with spontaneous consecutive exotropia (SCXT). MATERIALS AND METHODS: After retrospectively scanning medical records, patients with SCXT (group, n = 11) and those with no exotropia (control group, n = 22) were enrolled. The data detailed ophthalmic examination results, accommodative convergence/accommodation ratio (AC/A), amplitude of accommodation, fusional vergence, and near point of convergence (NPC) obtained were compared between the groups. RESULTS: Remote NPC was observed in three patients in the SCXT group (27.2%) but not in the control group ( P = 0.03). The stereopsis rate was higher in the control group than in the SCXT group ( P = 0.018). AC/A ratios were significantly lower in the SCXT group ( P ≤ 0.001). No significant differences were observed in the mean amplitude of accommodation or fusional vergence measurements. CONCLUSION: Binocular vision deficiency was observed in patients with SCXT. The AC/A ratios were higher in the control group. The mean period of spontaneous conversion to exotropia was 6.40 ± 3.50 years after hyperopia correction; therefore, the long-term follow-up is needed.

012 Surgical approach for consecutive exotropia in children

Purpose: To assess the efficacy of the modified hang-back technique (HBT) in comparison to conventional HBT. In this study, we have compared the two techniques in treating esotropia in terms of surgical success, development of consecutive exotropia, and the need for reoperation.Method: A retrospective medical record review of all patients who underwent bilateral medial rectus recession (BMR) between January 2016 and December 2020, with modified HBT or conventional HBT at our institution by four strabismologists. Angles of deviation were measured preoperatively, at one week, at 6-12 weeks, and at final follow-up postoperatively. We evaluated surgical success (alignment within 10 prism diopters [PD] of orthotropia) and complications such as the development of consecutive exotropia and the need for reoperation.Results: The record review identified 103 patients who underwent BMR: 83 in modified HBT vs. 20 in conventional HBT. The overall success rate at final follow-up was similar between the two groups: the success rate in the conventional HBT group was 83.3% (median interquartile range [IQR]) follow-up months 11.0 (6.0-12.8) compared to 72.6% (median IQR) follow-up months 12.0 (12.0-20.0) in the modified HBT group (p=0.435). The rate of consecutive exotropia development was higher in modified HBT (4.83%) vs. 0% in conventional HBT. Reoperation was required for two patients in the modified HBT group (2.4%), both for overcorrection, compared to one patient in the conventional HBT group (5%) for undercorrection (p=0.536).Conclusion: Conventional HBT is a comparable method to the modified HBT in bilateral medial rectus recession for treating esotropia with similar surgical outcomes.

To perform a systematic review and meta-analysis comparing the efficacy of botulinum toxin A (BTX-A) and bilateral medial rectus recession (BMR) surgery for partially accommodative esotropia (PAET). PubMed, EMBASE, and the Cochrane database were searched on May 29, 2024 for studies comparing BTX-A and BMR in patients with PAET, reporting at least one outcome of interest. The odds ratio (OR) and 95% CI were used for binary outcomes. Heterogeneity was assessed using I2 statistics. The analysis was performed using R software version 4.3.2. The Risk of Bias Summary for Non-randomized Studies tool was used to assess the risk of bias. Four observational studies comprising 521 patients were eligible for inclusion. BTX-A and BMR groups had comparable motor success rates (OR: 1.14; 95% CI: 0.27 to 4.81; P = .861; I2 = 88%). However, consecutive exotropia was reported exclusively after BMR only (OR: 0.08; 95% CI: 0.01 to 0.46; P = .004; I2 = 0%). All studies accounted for heterogeneity in the leave-one-out sensitivity analysis. Two studies were judged as moderate risk of bias and two as serious. Assessment of Grading of Recommendations Assessment Development and Evaluation resulted in moderate certainty in the outcome of motor success rates. BTX-A might be a good alternative to BMR in patients with PAET. Randomized controlled trials with larger sample sizes and longer duration of follow-up are needed. Studies should also focus on sensory outcomes in addition to motor outcomes.

To assess the clinical characteristics and risk factors associated with spontaneous consecutive exotropia (ScXT) in children diagnosed with refractive accommodative esotropia (RAET). A retrospective analysis of medical records was conducted on 19 patients who demonstrated a spontaneous transition from RAET to exotropia (XT). Patients who received strabismus surgery or botulinum toxin injection were excluded from the study. The control group consisted of 31 age-matched patients with RAET who demonstrated successful optical alignment at both near and distance. The ophthalmological examination findings of the study and control groups were compared. Independent two-sample t-test and Pearson's chi-square test were used to evaluate the data of the patients. The study examined patients diagnosed with RAET who developed consecutive XT. Among them, 15 (78.9%) were female and 4 (21.1%) were male. The mean age at esotropia (ET) onset was 22.68 months (standard deviation [SD]: 12.91). The control group consisted of 16 (51.6%) female and 15 (48.4%) male patients, with a mean age at ET onset of 25.09 months (SD: 15.47). Mean age at onset did not differ between the groups (p=0.55). The mean interval between ET onset and appearance of XT was 7.53 years (SD: 1.49). Cycloplegic refraction measurements taken during the initial examination indicated that the study group exhibited greater degrees of hypermetropia in their right (p=0.01) and left (p=0.04) eyes than did the control group. Furthermore, the incidence of inferior oblique muscle overaction was higher among the study group (p=0.03). The findings indicate that patients with high hypermetropic refraction values should be monitored for an extended period due to the increased risk of developing subsequent XT. Concomitant inferior oblique overaction can increase the risk of ScXT.

To assess the efficacy of botulinum toxin type A injection as a re-treatment procedure in patients with consecutive exotropia. The medical records of 34 patients who underwent botulinum toxin type A injection for consecutive exotropia were retrospectively reviewed. Five units of botulinum toxin type A was applied to the unilateral lateral rectus muscle, and the injection was administered under electromyography guidance. Successful motor alignment was defined as a far deviation within 10 prism diopters (PD). A total of 34 patients were included in the study. Twenty-six patients (76.5%) had acquired esotropia and 8 patients (23.5%) had infantile esotropia. The average age of the patients was 169 ± 88.9 months. The mean time elapsed between the last surgery and botulinum toxin injection was 67.8 ± 78 months. The mean before botulinum toxin type A injection deviation was 20.03 ± 8.42 PD at near and 21.41 ± 8.87 PD at distance. The deviation after botulinum toxin type A injection was 9.65 ± 7.42 PD at near and 10.82 ± 7.33 PD at distance. All patients were followed up for 19.8 ± 20 months. The average number of injections was 1.6 ± 1.1. The final success rate was 73.5%. The first month's near deviation was significantly associated with treatment success (P = .012). Post-injection fusion potential had a weak association with the 6-month and overall treatment success (P = .073 and .057, respectively). The results of this study demonstrate that botulinum toxin type A injection can be an effective, safe treatment option in consecutive exotropia. [J Pediatr Ophthalmol Strabismus. 2025;62(4):258-264.].

To compare the results of botulinum toxin A injection and bridge Faden operation performed with bimedial rectus recession in the treatment of large-angle esotropia. The medical charts of patients with large-angle esotropia who underwent bimedial rectus recession combined with the Faden operation or botulinum toxin A injection between January 2018 and March 2022 were retrospectively screened. The degree of deviations measured before surgery and at 1, 3, 6, and 12 months after surgery were compared between the two groups. The sample consisted of 26 patients, of whom 15 (57.7%) were male and 11 (42.3%) were female. In the botulinum toxin A group (n = 11), the mean age was 42.1 ± 22.6 months at admission and 65.3 ± 17.1 months at surgery, and the mean preoperative near and far distance deviations were 49.8 ± 8.4 and 44.3 ± 9.4 PD, respectively. In the Faden group (n = 15), the mean age was 54.9 ± 21.7 months at admission and 71.3 ± 12.6 months at surgery, and the mean preoperative deviations at near and far distances were 49.3 ± 11.2 and 44.3 ± 9.2 PD, respectively. The complete success rates of the botulinum toxin A and Faden groups evaluated 12 months after treatment were 63.6% and 66.7%, respectively, for the near distance deviation and 72.7% and 73.3%, respectively, for the far distance deviation. After the botulinum toxin A injection, 2 patients developed transient ptosis and 1 developed consecutive exotropia. As an alternative to multi-muscle surgery in large-angle esotropia, botulinum toxin A injection and Faden procedures, performed with bilateral medial rectus recession, provide successful results. [J Pediatr Ophthalmol Strabismus. 2025;62(2):128-134.].

ABSTRACT Introduction: Although there are guidance tables in the literature on surgical dosage for primary medial rectus resection-lateral rectus recession surgery, there is a lack of consensus on the surgical gains in medial rectus re-advancement (MRR) for the management of consecutive exotropia. We compared the surgical outcomes of primary medial rectus resection-lateral recession (RR) surgery, to MRR in patients with consecutive exotropia. Methods: Retrospective, electronic note review of consecutive patients undergoing primary RR surgery for basic exotropia (RR group), convergence insufficiency-type exotropia, and divergence excess, and consecutive patients undergoing MRR with or without lateral rectus recession (MRR group) for consecutive exotropia in a teaching university hospital. Results: There were 84 patients in the RR group and 27 patients in the MRR group. The median age in the RR group was 25.50 years (range 4–79) and 45 years (18–87) in the MRR group (p = .002). Median follow-up was 7 months (3–43) in the RR group and 1 month (1–12) in the MRR group. Post-operatively, there was a median exotropia reduction of 27.00 prism diopters (PD) (range +5, –65; p < .0001) for near, and 27.00 PD (+10, –51; p < .0001) for distance in the RR group. In the MRR group, the median exotropia reduction was 34.50 PD (2, –67; p < .0001) for near and 33.00 PD (1, –67; p < .0001) for distance. There was a greater reduction in the exotropia in the MRR group compared to the RR group for distance (p = .047), but this did not meet statistical significance for near (p = 0.10). The median dose–effect relationship (PD/millimeter) was higher in the MRR group both for near deviation (2.90 vs 2.15, p = .0073) and for distance deviation (2.91 vs 2.15, =0.0041). Conclusion: Based on our study cohort, medial rectus re-advancement appears to have a greater dose-effect in reducing the distance angle of deviation for both near and distance compared to primary recess-resect surgery. Further prospective longitudinal studies would shed further light on the dose–effect relationship over time.

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.].

To compare the results of bilateral medial rectus recession (BMRc) versus bilateral medial rectus recession with Faden operation (BMRF) in the treatment of large-angle infantile esotropia. A double blinded, parallel, randomized controlled trial. Patients with large-angle infantile esotropia (≥ 60 prism diopters, [PD]) aged between 3 and 15 years old were included and assigned to either the BMRc or BMRF group. Mean difference and mean reduction of angle deviation between the two groups were compared at 1 week, 1, 3, and 6 months by using generalized estimating equations analysis. Surgical success rates, defined as an esodeviation ≤ 10 PD at near fixation, were evaluated at 6 months postoperatively. Complications from the surgical procedures were observed. Of 40 enrolled patients, the mean (SD) age of the patients in the BMRc group was 3.4 (1.9), and in the BMRF group, 5.2 (3.8) years old. The overall mean differences of angle reduction between both groups were not significant (-6 PD, 95%CI -14 to 2, P = .12). The surgical success rate at 6 months in the BMRF group (72%) was not different compared to BMRc group (84%, P = .45). Overall consecutive exotropia was 5%, not different between groups (P > .99). There was no difference of complications between the two groups (P = .51). BMRF and BMRc approaches show no difference in treatment of large-angle infantile esotropia. Nevertheless, a long-term assessment for consecutive exotropia should be considered for both surgical procedures.

Purpose: To compare the effect of bilateral medial rectus injection of botulinum toxin A (BTX-A), bilateral medial rectus muscle recession surgery (BMR rc), or unilateral medial rectus muscle recession combined with lateral rectus muscle resection surgery (R&R), in the management of partially accommodative esotropia (PAET) in children.Design: Retrospective comparative clinical study.Methods: The study cohort included 98 patients diagnosed with PAET who had BTX-A injection or incisional surgery between December 2014 and January 2023. The main outcome measures included motor and sensory results as well as complications. Follow-up was at least 12 months for all patients.Results: There were 28 patients in the BTX-A group, 45 in the R&R group, and 25 in the BMR rc group. The motor success rates at distance and near fixation respectively were 50% (14/28) and 54% (15/28) in the BTX-A group, which were lower than that of the R&R group [78% (35/45), 84% (38/45)] and the BMR rc group [72% (18/25), 84% (21/25)] (P = 0.042 for near and P=0.006 for distance). For patients with onset age <2.5 years old, there was no statistical difference amongst the three surgical approaches (P=0.656). For patients with onset age ≥2.5 years, the motor success rate of the R&R group [81% (26/32)] and the BMR rc group [88% (14/16)] was higher than that in the BTX-A group [38% (5/13); P=0.004]. There was no statistical difference in sensory outcomes for patients regardless of onset age or treatment methods (P>0.05 for all). During follow-up, 4% (2/45) of patients in the R&R group and 20% (5/25) in the BMR rc group developed consecutive exotropia; no patient in the BTX-A group was overcorrected (P=0.017).Conclusions: Bilateral medial rectus muscle injection with BTX-A in patients with PAET is a safe, accessible, and low-cost alternative. Although motor success rates were higher, overall, in patients treated with incisional surgery, for patients with earlier age of onset (≤ 2.5 years old), BTX-A injection may be preferred to incisional surgery. In older children treated with unilateral recession-resection surgery, fewer developed consecutive exotropia.

To compare the surgical outcomes in patients who had a failed botulinum toxin A injection before surgery versus those who had surgery as primary treatment (primary surgery) for infantile esotropia. The files of patients who had strabismus surgery in the Strabismus Unit of Beyoglu Eye Training and Research Hospital between January 2012 and March 2022 were reviewed. This study included 104 eyes of 52 patients with infantile esotropia. The angle of deviation before and 1, 3, and 6 months after botulinum toxin A injection or surgery, complications, pattern deviations, family history, abnormal head position, history of prematurity, intensive care unit admission, and consanguineous marriage were noted. A successful outcome was defined as ocular alignment of 10 prism diopters (PD) or less. The study population consisted of 52 patients: 27 (52%) boys and 25 (48%) girls. In the botulinum toxin A group (n = 26), the mean age at admission was 14.0 ± 6.8 months, whereas the mean preoperative near and far angle of deviation were 41.92 ± 12.2 and 41.3 ± 13.0 PD, respectively. The mean age at the time of surgery was 40.6 ± 18.1 months. In the primary surgery group (n = 26), the mean age at admission was 34.0 ± 15.9 months. The mean preoperative near and far angle of deviation were 37.3 ± 8.0 and 35.3 ± 10.5 PD, respectively. The mean age at the time of surgery was 48.1 ± 18.5 months. The success rates 6 months after treatment in the botulinum toxin A group and the primary surgery group were 76.9% and 88.5% in near (P > .05) and 80.8% and 88.5% in far (P > .05), respectively. Three patients had transient ptosis and one had consecutive exotropia after botulinum toxin A injection. In infantile esotropia treatment, strabismus surgery after failed botulinum toxin A injection compared to primary surgery has statistically comparable surgical success rates. [J Pediatr Ophthalmol Strabismus. 2024;61(4):245-251.].

Background and Objective: Consecutive exotropia after unilateral or bilateral medial rectus recession is a common clinical problem. One surgical intervention to address the misalignment involves isolating and reattaching healthy muscle to the globe. The purpose of this study was determining factors indicative of surgical success in medial rectus resection and advancement with non-adjustable sutures for consecutive exotropia. Methods: Through retrospective chart review, 118 patients were identified to have consecutive exotropia using billing codes from June 2016 to October 2020 at Indiana University Health. 60 of these patients who maintained adequate follow-up either underwent the above intervention (n = 49) or underwent resection only (n = 11). Exclusion criteria included lack of medial rectus procedure or poor postoperative documentation. Patient demographics and data were gathered, including preoperative and intraoperative measurements, final postoperative deviation, and whether additional surgeries were necessary. Chi-squared and two-sample t-tests were performed to analyze the effect of each parameter on surgical success, defined as distance deviation ≤ 10 prism diopters of esotropia or exotropia at final postoperative visit. Results: Smaller total intraoperative adjustment–resection plus advancement–was significantly associated with surgical success (p = 0.044). Additionally, smaller preoperative deviations were significantly associated with patients who underwent unilateral surgery (p = 0.0093 near and 0.0021 distance). Conclusion: Patients with smaller preoperative deviations tended to have better outcomes, and those patients tended to have unilateral surgery. It is unclear whether a smaller deviation might have led surgeons to select unilateral medial rectus surgery or if the smaller deviation itself is a predictor of success. Relatively limited time of follow-up is a limitation in this study, as there is well-documented postoperative drift of increasing exotropia over time. A larger cohort or randomized controlled trial may provide additional insight that could increase the percentage of successful outcomes with a single surgery.

Background: Consecutive exotropia is an exodeviation type that appears after surgically correcting esodeviation and is distinguished by postoperative exotropia lasting longer than a month. Aims: to assess the bilateral medial rectus advancement (MRA) compared to bilateral lateral rectus recession (LRR) among patients with consecutive exotropia. Methods At Menoufia University Hospital, a prospective clinical trial included 24 patients was conducted in the period from May 2022 to June 2023. The patients were divided into 2 groups, each group contained 12 patients who underwent bilateral medial rectus advancement and bilateral lateral rectus recession. Demographic data, as well as preoperative and postoperative ocular alignment were determined for each patient. All patients were followed up by one weeks, 2, 4, 8, and 12 months postoperative. Results: Half of group MRA group's patients (50%) were males vs five (41.66%) of the LRR group's patients, with no obvious differences between the two groups (P=0.682). There were no appreciable changes between the MRA and LRR groups (P>0.05) in preoperative and postoperative ocular alignment. The two surgery groups in this study did not significantly differ from one another. Both of these surgical techniques can be used to effectively treat consecutive exotropia, but LR recession is a reasonably straightforward to perform. Recession of the LR should be performed on patients with chronic exotropia and no vertical abnormalities.

To report long-term motor and sensory outcomes after unilateral medial rectus recession-lateral rectus resection for infantile esotropia. The medical records of patients who had undergone unilateral medial rectus recession-lateral rectus resection for infantile esotropia and were followed up postoperatively for a minimum of 10 years were reviewed retrospectively. A total of 100 patients were included. The mean age at surgery was 2.9 ± 2.2 years (range: 2.5 months to 9.0 years). The mean postoperative follow-up was 15.7 ± 4.4 years (range:10.0 to 27.5 years). Overall, 54 patients (54%) had surgical success at their last follow-up visit. Age at first surgery, strabismus duration, degree of hyperopia, preoperative size of deviation, presence of dissociated vertical deviation, inferior oblique overaction, or both dissociated vertical deviation and inferior oblique overaction, and the number of esotropia surgeries did not predict motor outcome after surgery. Consecutive exotropia developed in 43% of patients (constant in 18% and intermittent in 25%). Residual and recurrent esotropia occurred in 20% and 21% of patients, respectively. Refractive accommodative esotropia developed in 17% of patients and there was a high accommodation convergence/accommodation ratio esotropia in 2%. Peripheral binocular single vision was achieved in 54% of patients and stereopsis in 1%. Patients with 1.5 years or less of strabismus duration had better chances of achieving peripheral binocular single vision. Nearly half of the patients with infantile esotropia achieved a successful long-term motor outcome and peripheral binocular single vision. Consecutive exotropia occurred frequently. Recurrent esotropia and refractive accommodative esotropia developed in some patients, and a high accommodation convergence/accommodation ratio esotropia in a few. Stereopsis outcome was extremely poor. [J Pediatr Ophthalmol Strabismus. 2024;61(2):106-113.].

Nonsurgical Consecutive Exotropia Following Childhood Esotropia: A Multicentered Study