Surgery For Exotropia Research Articles

Survival analysis of 365 patients with exotropia after surgery

Few reports have included large numbers of exotropia patients. Thus, we undertook this study to perform a survival analysis of over 350 patients with exotropia and to determine which factors might affect the outcome of exotropia surgery. The clinical records of 365 patients who underwent exotropia surgery by one surgeon were retrospectively reviewed. Preoperative patient characteristics, surgical procedures performed, and early postoperative ocular alignment were evaluated as potential risk factors of surgical outcome using survival analysis. The estimated median time from surgery to recurrence was 48.3 months. None of the characteristics or procedures were found to be significantly associated with surgical outcome. The likelihood of a good postoperative surgical outcome was highest with an initial postoperative alignment of more than 10 prism diopters of esotropia (P<0.001). Early postoperative overcorrection was the only predictor of a successful long-term outcome after exotropia surgery.

Long-term outcome of intermittent exotropia surgery in 585 children with short-time occlusion

Introduction: To evaluate the long-term results of surgery in intermittent exotropia (X(T)) undergoing short-time patching therapy. Methods: The subjects were composed of 585 patients with X(T) who underwent surgery and had been followed up for more than 6 months. They underwent short-time patching of 2 to 3 hours daily before and after surgery for at least 6 months, respectively. Orthophoria was defined as the angle of deviation between 10Δ exophoria and 5Δ esophoria. Results: The average postoperative follow-up period was 30.3 ± 1.2 months (6-168).

The clinical course of consecutive esotropia after surgical correction.

PurposeTo investigate the clinical course in patients who underwent surgical correction of consecutive esotropia.MethodsThe medical records of 13 patients who underwent surgical correction of consecutive esotropia were reviewed retrospectively. The authors investigated the deviation and surgical method at the time of exotropia surgery. During the follow up period, the authors also studied incidence of amblyopia development, the effect of occlusion therapy, surgical methods for consecutive esotropia, and postoperative change of deviation.ResultsThe average exodeviation was 27.1 prism diopter (PD). Bilateral lateral rectus muscle recession was performed in all patients. In all patients, alternate occlusion was tried from 2 weeks after development of consecutive esotropia. However, there was no effect on 7 patients. None of the patients developed amblyopia. Surgery for consecutive esotropia was performed on the average 15.3 months after exotropia surgery. The average esodeviation was 21.1PD. Medial rectus muscle recession was performed in 10 patients and lateral rectus muscle advancement in 3 patients. The average deviation of the subject group immediately after surgery was 1.2PD esodeviation, 0.9PD esodeviation one month after surgery, 2.4PD exodeviation 6 months after surgery, and 4.7PD exodeviation at the last follow up, and it showed a tendency to progress to exodeviation as the follow up period increased. Ten patients (76.9%) showed deviation within 8PD at the last follow up.ConclusionsThe success rate of surgical correction for consecutive esotropia was a favorable outcome. But, careful decisions of the surgical method and amount is needed because the conversion of exodeviation during long-term follow-up is possible.

Relationship Between Surgical Result and Alignment on The Day of Surgery in Intermittent Exotropia

Purpose: We assessed the relationship between the surgical outcome of intermittent exotropia and initial postoperative alignment by checking it on the first postoperative day or the day of strabismus surgery. Methods: Seventy-three patients with intermittent exotropia underwent bilateral lateral rectus recession or unilateral medial rectus resection and lateral rectus recession. Thirty-two patients had their postoperative alignment checked on the day of surgery, and forty-one patients were checked on the first postoperative day. Success was defined as sustained alignment six months postoperatively from esotropia 10PD to exotropia 10PD. Overcorrection was defined as esotropia greater than 11PD, and undercorrection was exotropia greater than 11PD. We assessed the relationship between the alignment on the day of surgery or on the first postoperative day and also at six months postoperatively, as well as the success rate according to the initial postoperative alignment. Results: There was a statistically significant relationship between alignments on the day of surgery or on the first postoperative day and those at six months postoperatively (p

Consecutive Esotropia in Intermittent Esotropia Patients with Immediate Postoperative Overcorrection More Than 17 Prism Diopters

PurposeTo report the incidence and the factors of consecutive esotropia (ET) in patients with immediate postoperative overcorrection of at least 17 prism diopters (PD) after surgery for intermittent exotropia (X(T)).MethodsFour-hundred-five patients under the age of 18 were included in this study. They underwent bilateral lateral rectus recession (LROU-rec) or unilateral recession-resection (R&R) for X(T). On postoperative day one, the patients with at least 17 PD overcorrection were classified as group 1 and those with less than 17 PD as group 2. Age, refractive error, type of surgery, lateral incomitancy, and the incidence of consecutive ET were analyzed for each group.ResultsGroup 1 consisted of 116 patients (28.6%) and group 2 consisted of 289 (71.4%). At the six-month follow-up visit, consecutive ET had developed in 16 patients (13.8%) in group 1, and in five patients (1.7%) in group 2 (p<0.001). The occurrence of consecutive ET was not related to age at the time of surgery (p=0.46 in group 1 ; p=0.54 in group 2), refractive error (p=0.18 in group 1 ; p=0.08 in group 2), or the type of surgery (p=0.69 in group 1 ; p=1.00 in group 2). The incidence in group 1 was 23.8% in patients with lateral incomitancy and 8.1% in patients without lateral incomitancy (p<0.05). In group 2, the incidence was 4.4% in patients with lateral incomitancy and 0.5% in patients without lateral incomitancy (p=0.04).ConclusionsConsecutive ET developed in 13.8% of patients with immediate overcorrection of at least 17 PD. Lateral incomitancy was the most important risk factor.

Timing of Surgery for Primary Exotropia in Children

Objective To compare the postoperative alignment and sensory functions in patients with primary exotropia who had been operated at an early age (< 7 years) with those in patients who had been operated at an older age (> 7 years). Methods In a consecutive retrospective cohort study, 112 patients who had had a surgical intervention for primary exotropia between 1997 and 2003 were evaluated for postoperative results. After applying criteria for eligibility, the group of patients was divided into two groups: those who had had surgery before the age of seven years (n = 24) and those who had had surgery after the age of seven years (n = 36). Age at surgery, preoperative alignment and sensory functions were correlated with the postoperative status. The follow-up was at least one year (1.0 year to 7 years; median: 2.3 and 3.5 years, respectively). Results Patients who had had surgery before the age of seven had significantly better alignment and sensory functions. The univariate logistic regression model confirmed a statistically significant association between motor outcome (exodeviation less than 10 diopters) and age at the time of surgery (before or after the age of seven; p = 0.002). In the multivariate model, the association between age at time of surgery and motor outcome was even stronger. The number of re-operations in the group operated before the age of 7 years was significantly less than in the group operated after the age of seven (2 versus 12, p = 0.023). Conclusion The postoperative alignment and sensory functions for patients with primary exotropia who had had a surgical intervention before the age of seven years were, in this study, better than those in patients who had had surgery after the age of seven years.

Factors Affecting the Surgical Outcome of Primary Exotropia

Aims To identify the predictors for motor outcome and response to surgical treatment of primary exotropia. Setting Taunton and Somerset Hospital, Somerset, United Kingdom. Study type Retrospective analysis of the surgical treatment of primary exotropia performed in our department over a period of 12 years from April 1991 to May 2003. Methods Case-notes of the patients who had surgical treatment for primary exotropia for the specified period were identified by a hospital computer database (MDI coding). All case-notes were reviewed and the following data were recorded and used for statistical analysis: age at the time of surgery, type and severity of exotropia, presence of amblyopia, AV pattern and vertical deviation, the level of stereopsis, type of surgery, and motor and cosmetic results. The surgical outcome was determined as good motor outcome if tropia was within 10 PD of orthotropia. The response to surgery was derived from the difference between the preoperative and postoperative angle of deviation for distance per amount of muscle surgery in millimetres. Results A total of 124 cases were included in the study. Good motor outcome was achieved in 83 (67%) cases. There was a positive correlation between the preoperative angle of deviation at distance and dose response to surgery (r = 0.6 and p < 0.001) and a negative correlation between average corrected visual acuity and response (r = −0.21 and p = 0.025). There was a statistically significant negative relationship between preoperative stereopsis and response to surgery (p = 0.02). Conclusions Surgical treatment for exotropia is effective and the dose response is correlated to the preoperative angle of deviation and average visual acuity. Poor or no preoperative stereopsis was associated with better response to surgery.

Long-Standing, Large-Angle Exotropia in Adults

Introduction and PurposeThis study examines the sensory and motor results in adult patients with large-angle exotropia treated with nonadjustable bilateral recess-resect procedures.MethodsA consecutive series of adult patients undergoing four-muscle surgery for exotropia ≤ 50Δ with no previous surgery were identified by retrospective medical record review. All patients had nonadjustable symmetric bilateral medial rectus resections and bilateral lateral rectus recessions performed between 1995 and 2006. Data on postoperative alignment, stereoacuity, and the presence or absence of diplopia were collected.ResultsEight patients met the inclusion criteria. Seven of eight patients required only one surgical procedure for correction of the exotropia with final postoperative deviations within 10Δ of orthophoria. One patient required reoperation resulting in a final postoperative measurement of 10Δ of esotropia. At final examination, no patient reported diplopia. Four of eight patients had postoperative stereoacuity ranging from 200 to 40 seconds of arc.ConclusionsLong-standing, presumably constant, large-angle exotropia does not preclude the recovery of stereopsis after surgical alignment. Permanent postoperative diplopia did not occur in our series. In spite of the large deviations, nonadjustable surgery produces good alignment in most cases, possibly because these patients retain some fusion ability.

Binocular Status After Surgery for Constant and Intermittent Exotropia

To investigate whether constant exotropia patients with a previous history of intermittent exotropia X(T), like X(T) patients, can achieve postoperative bifixation, and whether they have a better postoperative sensory outcome than those without previous history of X(T). Prospective comparative clinical study. Sixty-three consecutive patients with intermittent or constant exotropia were divided into three groups: X(T) (group 1), constant exotropia with a previous history of X(T) (group 2), and constant exotropia without previous history of X(T) (group 3). The surgical outcomes were assessed and compared in motor and sensory terms separately between the three groups. Successful motor alignment was defined as within 8 prism diopters (PD) (exo or eso). A stereoacuity < or =60 seconds of arc was considered as bifixation, and a stereoacuity < or =800 seconds of arc was considered as gross stereopsis. The successful motor alignment rates of group 1, group 2, and group 3 were 79%, 71%, and 67%, respectively (group 1 vs group 2, P = .826; group 1 vs group 3, P = .551; group 2 vs group 3, P = 1.000). Twenty-five (74%) patients in group 1 achieved bifixation and none achieved in group 2 or group 3 (group 1 vs group 2, P = .001; group 1 vs group 3, P = .001). Meanwhile, 34 patients (100%) in group 1, 11 (79%) in group 2, and 5 (33%) in group 3 achieved gross stereopsis (group 1 vs group 2, P = .021; group 2 vs group 3, P = .025; group 1 vs group 3, P = .001). Compared with patients in the two constant exotropia groups, patients in X(T) group had a significantly better sensory outcome in both bifixation and gross stereopsis. Patients in group 2 had a better sensory outcome than those in group 3 in gross stereopsis. Constant exotropia patients with a previous history of X(T) have a better postoperative sensory outcome in gross stereopsis than those without previous history of X(T), but a worse surgical sensory outcome when compared with X(T) patients in both bifixation and gross stereopsis. Constant exotropia patients decompensated from X(T) may have missed the best time for treatment.

Clinical study on crossed disparity and uncrossed disparity in intermittent exotropia before and after surgery

To understand the clinical variety of zero disparity, crossed disparity and uncrossed disparity in intermittent exotropia before and after strabismus surgery. 100 cases of intermittent exotropia were involved in the study. Before and after surgery, zero disparity stereo-acuity, crossed disparity and uncrossed disparity stereo-acuity were examined with stereogram designed by Yan Shaoming, distance fusion range and distance stereo-acuity were examined with traditional and random dot synoptophore stereogram. The patients were divided into four groups based on the results of the stereogram examination before surgery. In the 100 cases, there was no coexistence of zero disparity and uncrossed disparity, no coexistence of crossed and uncrossed disparity, and no existence of only crossed disparity or only uncrossed disparity. Postoperative zero disparity, crossed disparity, uncrossed disparity, distance fusion range and distance stereo-acuity improved significantly compared with the preoperative results for each group (P < 0.01). The comparison of distance fusion range was not prominent before and after strabismus surgery in the 4 groups (P > 0.05). The distribution of distance stereo-acuity was prominent after strabismus surgery in the 4 groups (P < 0.01). Distance stereo-acuity rebuilding after surgery in group 1 and group 2 was better than that in group 3 and group 4. (1) In the cases with intermittent exotropia, zero disparity stereo-acuity, crossed disparity and uncrossed disparity stereo-acuity are abnormal. The sequential damage of stereopsis is uncrossed disparity, crossed disparity and zero disparity. The sequential rebuilding of stereopsis is zero disparity, crossed disparity and uncrossed disparity. (2) The serious damage or disappearance of uncrossed disparity stereo-acuity is the indication of intermittent exotropia surgery for perfect binocular vision rebuilding.

Timing of Surgery for Primary Exotropia in Children

Objective: To compare postoperative alignment and sensory functions in children with primary exotropia who were operated at an early age (< 7 years) with patients who were operated at an older age (> 7 years). Methods: In a consecutive retrospective cohort study, 112 patients who had a surgical intervention for primary exotropia between 1997 and 2003 were evaluated for postoperative results. After applying criteria for eligibility, the group of patients was divided into two groups: those who had surgical intervention before the age of seven years (n = 24) and those who had surgery after the age of seven years (n = 36). Age at surgery, preoperative alignment and sensory functions were correlated with the postoperative status. The follow-up was at least one year (1.0 year to 7 years; median: 2.3 and 3.5 years, respectively). Results: Children who had surgery before the age of seven had significantly better alignment and sensory functions. The univariate logistic regression model confirmed a statistically significant association between motor outcome (exodeviation less than 10 prism-diopters) and age at the time of surgery (before or after the age of seven; p = 0.002). In the multivariate model, the association between age at time of surgery and motor outcome was even stronger. The number of reoperations in the group operated before the age of 7 years was significantly less than in the group operated after the age of seven (2 versus 12, p = 0.023). Conclusion: The postoperative alignment and sensory functions in patients with primary exotropia who had surgical intervention before the age of seven years were, in this study, better than in patients who had surgery after the age of seven years.

Orbital Cellulitis After Strabismus Surgery

Serious infection is uncommon after eye muscle surgery. Orbital cellulitis is a rarely reported but is potentially vision- and life-threatening complication after strabismus surgery. In this report, we describe a case of unilateral orbital cellulitis after strabismus surgery for sensory exotropia in a healthy adolescent boy.

Preoperative and postoperative observation of intermitent exotropia

目的 对比,探讨间歇性外斜视手术前后视网膜对应性质及立体视功能.方法40例间歇性外斜视,术后1～5年随访视网膜对应性质及立体视功能.结果术后异常视网膜对应85.00%的病例可以恢复;异常立体视觉80.00%的病例可以恢复.结论间歇性外斜视异常视网膜对应及异常立体视功能术后可以重建。

Survival analysis of 365 patients with exotropia after surgery

Few reports have included large numbers of exotropia patients. Thus, we undertook this study to perform a survival analysis of over 350 patients with exotropia and to determine which factors might affect the outcome of exotropia surgery. The clinical records of 365 patients who underwent exotropia surgery by one surgeon were retrospectively reviewed. Preoperative patient characteristics, surgical procedures performed, and early postoperative ocular alignment were evaluated as potential risk factors of surgical outcome using survival analysis. The estimated median time from surgery to recurrence was 48.3 months. None of the characteristics or procedures were found to be significantly associated with surgical outcome. The likelihood of a good postoperative surgical outcome was highest with an initial postoperative alignment of more than 10 prism diopters of esotropia (P<0.001). Early postoperative overcorrection was the only predictor of a successful long-term outcome after exotropia surgery.

Long-Term Outcome of Patients with Large Overcorrection following Surgery for Exotropia

To provide long-term surgical results for patients with large initial overcorrection following surgery for exodeviation, 68 consecutive patients with initial overcorrection of 20 prism diopters (PD) or more at distance or near following surgery for exodeviation performed between 1994 and 2002 were included in this study. The patients were managed with an alternate full-time occlusion, echothiophate iodide, or prism glasses for the period of overcorrection. One day postoperatively, the amount of overcorrection was 8–40 PD at distance and 0–35 PD at near, and decreased to 10 PD or less both at distance and near vision within 4 weeks postoperatively in 49 patients (72%). Seven patients needed prism glasses for esotropia of less than 10 PD. Four patients (5.9%) needed a reoperation for consecutive esotropia and 1 patient for postoperative hypotropia following recession of the superior and lateral rectus. The final outcome showed orthophoria to exo/esodeviation of ≤10 PD in 48 patients (71%) and exodeviations of >10 PD in 11 patients (16%) at near or distance. In conclusion, overcorrection was reduced to 10 PD or less at distance and near within 4 weeks after surgery in most patients. Even with initial overcorrection of 20 PD or more after surgery for exodeviation, reoperation for consecutive esotropia was necessary only in 5.9% of the patients.

‘Largest angle to target’ in surgery for intermittent exotropia

To evaluate the safety of the approach based on the notion that the surgical dose for intermittent exotropia should be based on the largest angle ever measured. Prospective case series of 33 patients. A total of 33 patients with intermittent exotropia, in whom angles of misalignment at distance or near showed a difference of 15 prism diopters (PD) or more among visits, were included. All the patients were treated by bilateral lateral rectus recession by the same surgeon (JMH), and all were followed up for a minimum of 6 months postoperatively. Short- and long-term surgical results after the initial procedure for intermittent exotropia were analysed. The short-term average result at a postoperative 1 week was 9.3 PD esotropia at distance (range 30 esotropia-16 exotropia). The long-term average results postoperative 6 or 9 months were 4.8 PD exotropia at distance (range 12 esotropia-30 exotropia). At the last follow-up, no overcorrection over 2 PD esophoria at distance was found, and 9 PD of intermittent esotropia and esophoria at near was observed in two patients, respectively. The strategy of surgical dose for intermittent exotropia based on the largest angle ever measured did not result in overcorrections and is believed to be safe.

Long-Term Results of Bilateral Medial Rectus Recession for Congenital Esotropia

This study assessed the long-term results of orthophoria obtained with bilateral medial rectus recession for congenital esotropia. The medical records of 214 patients who underwent bilateral medial rectus muscle recession between January 1995 and January 2000 were reviewed. Patients were excluded if neurological abnormalities or developmental delays were documented and if structural eye abnormalities were present. Mean follow up was 54.2 months (range, 36 to 96 months). Rates of reoperation for residual esotropia, consecutive exotropia, oblique muscle overaction, or dissociated vertical deviation were determined. Forty-five (21%) patients underwent surgery for residual esotropia, 32 (15%) underwent surgery for consecutive exotropia or dissociated horizontal deviation, and 39 (18%) underwent surgery for oblique muscle overaction and dissociated vertical deviation. To maintain long-term alignment of congenital esotropia, additional surgical procedures may be required. The success rate of bilateral medial rectus recession for ocular realignment with one operation is approximately 50%. This method is quicker, simpler, and less traumatic than three or four muscle operations. In addition, the lateral rectus and oblique muscle are left unoperated for future surgeries if necessary.

The surgical management of consecutive exotropia

Purpose To review the results and techniques of surgical treatment of consecutive exotropia. Methods We performed a retrospective chart review of all patients who underwent surgery for consecutive exotropia in a pediatric ophthalmology practice between 1992 and 2001. Patients were excluded if follow-up lasted < 6 weeks or if exotropia was caused by other ocular disorders such as previous trauma or congenital cataracts. Results Fifty-nine patients were identified. The procedure performed in the majority of cases was unilateral lateral rectus recession and medial rectus advancement to the original insertion. Seven patients underwent bilateral lateral rectus recession, and 6 underwent lateral rectus recession combined with medial rectus resection. The mean interval between original surgery and surgery for consecutive exotropia was 14.1 years (range 4 months to 47.5 years). The mean preoperative distance exodeviation was 31.7 prism diopters (PD). Satisfactory alignment (ie, within 10 PD of orthophoria) was achieved in 36 patients (61%) at week 1 and 42 patients (71%) at final follow-up. Mean follow up was 16.0 months. Thirty-nine patients (66%) demonstrated an exodrift after surgery (mean 7.6 PD). Conclusion Consecutive exotropia may occur many years, even decades, after esotropia surgery. Lateral rectus recession with advancement of the previously recessed medial rectus is an effective treatment. An exotropic drift occurs after consecutive exotropia surgery, usually within the first 6 weeks. A suitable ocular alignment immediately after surgery for consecutive exotropia is a small-angle esotropia of 5 to 10 PD.

Adjustable sutures in children using a modified technique

Purpose Adjustable-suture techniques are commonly used to decrease the reoperation rate in adults undergoing strabismus surgery, but they are infrequently used in children because of the difficulty of performing adjustments on a conscious child. The purpose of this study is to evaluate a new technique for using adjustable sutures in children, which makes the second stage of the procedure unnecessary if no adjustment is needed. Methods This was a retrospective study of children who underwent surgery for exotropia or esotropia. The technique used was a variation of the standard fornix-based adjustable suture with a separate slipknot. The pole sutures were buried within the sclera and tied; then the incision of the conjunctiva was closed to cover the adjustable sutures. The patients were then measured 4 to 6 hours after the initial surgery. The decision of whether to adjust was based on predetermined criteria. Those children not adjusted were discharged with no further manipulation needed because the conjunctiva was already closed. For those children who were adjusted, the adjustment was made with the patient under intravenous propofol sedation or laryngeal mask anesthesia. Results A total of 61 consecutive children ages 12 months to 14 years underwent surgery using this technique. Patients were followed-up after surgery for a minimum of 6 weeks (median 19.4). Fifty-four of the 61 patients (88%) were within 10 prism diopters ( PD) of orthophoria on their final postoperative visit. Of the 22 patients who underwent an adjustment, 20 (91%) were within 10 PD of orthophoria at their final postoperative visit. The median follow-up was 19.4 weeks (range 6 to 45.9). Conclusions This new adjustable-suture technique was associated with excellent short-term eye alignment. It is particularly suited for pediatric surgery because it eliminates the necessity of further manipulation of children who do not require adjustment.

The application of statistical process control to horizontal strabismus surgery

Purpose Although originally developed to evaluate quality in manufacturing, statistical process control (SPC) techniques may be applicable to other frequently performed standardized processes. SPC analysis has rarely been used in medicine. We employed SPC charts to analyze the outcomes of one- and two-muscle horizontal strabismus surgery for esotropia and exotropia. Methods During a 33-month period between October 1, 1998 and July 1, 2001, we evaluated 95 patients undergoing strabismus surgery on either one or two previously unoperated eye muscles in one or both eyes. SPC charts were used to evaluate the success and validity of our surgical guidelines for horizontal recession and resection procedures. Data were divided into 2 groups, patients with esotropia and patients with exotropia, for computerized statistical analysis using QI Analyst (SPSS, Chicago, IL). Results Our results after horizontal strabismus surgery, both esotropia and exotropia repair, appear to follow the laws of statistical fluctuation or normal random variation. Our dose-response schedule produced a resultant ocular alignment or exit angle that appeared to be in statistical control, ie, variation from orthotropia that can be expected simply from normal random chance error with only a limited number of outliers. Conclusion The resultant ocular alignment or exit angle after one- or two-muscle strabismus surgery may be described by standard models of statistical fluctuation. SPC may be a valuable method to analyze the variability of the results of many ophthalmologic procedures or treatments over time with the ultimate goal of producing better patient outcomes by decreasing variability.