Lateral Recession Research Articles

Comparison of the Stability of Postoperative Alignment in Sensory Exotropia: Adjustable Versus Non-Adjustable Surgery

PurposeTo compare the success rates and stabilities of postoperative alignment between adjustable and the non-adjustable surgeries in the treatment of sensory exotropia.MethodsA retrospective analysis was performed on all patients with sensory exotropia who had undergone unilateral lateral rectus recession and medial rectus resection (R&R) between January 1998 and August 2005. Thirty-four patients underwent conventional R&R, and 20 patients underwent R&R with adjustable suture of the lateral rectus. The surgical results between the two groups were analyzed with regard to the preoperative and post-operative deviation angles and the postoperative drift. The postoperative deviation angle was measured on postoperative day 1 as well as at two weeks, three months, six months and the final visit after surgery.ResultsThere were no statistically significant differences in the mean preoperative and postoperative deviation angles between the two groups. In 30 (88%) patients in the non-adjustable group and 15 (75%) patients in the adjustable group, postoperative deviation was less than 15 prism diopters (PD) at the three month follow-up. There was no significant difference in the mean postoperative drift between the two groups.ConclusionsStrabismus surgery with adjustable sutures did not show a significantly better result than surgery without adjustable sutures in the treatment of sensory exotropia. Considering the amount of postoperative exodrift in both groups, we postulate that the immediate ocular alignment after surgery for sensory exotropia should be orthophoric or 5-6 PD of esodeviation.

Strabismus surgery for internuclear ophthalmoplegia with exotropia in multiple sclerosis

Internuclear ophthalmoplegia (INO) is a disabling condition affecting up to 40% of patients with multiple sclerosis (MS). Management of bilateral internuclear ophthalmoplegia (BINO) with exotropia in MS has been controversial because of the uncertain course of MS. Diplopia associated with INO severely impacts the patient's quality of life and, therefore, treatment should be considered. Three patients (ages 28, 62, and 82 years) who had BINO with exotropia and disabling diplopia secondary to MS underwent bilateral medial rectus resections with either unilateral or bilateral adjustable lateral rectus recession(s). Alignment was measured preoperatively and postoperatively, and symptoms were recorded. Preoperative exotropia ranged from 40(Delta) to 64(Delta) for distance fixation and from 50(Delta) to 70(Delta) for near fixation. Preoperatively, all patients had diplopia at distance and near fixation. Immediately after surgery, patients were adjusted to 10(Delta) to 18(Delta) ET at distance fixation with the expectation of an exotropic drift. None of the patients had a tropia at distance and near fixation 6 months after surgery, with single vision in primary position and reading. Two patients had a 2-year follow-up examination; 1 required a small amount of base-in prism for comfortable reading. Three patients who had BINO with exotropia secondary to MS all benefited from surgery. Surgery should be considered as an option for symptomatic patients who have BINO with exotropia caused by MS.

The Effect of Lateral Rectus Muscle Advancement in Consecutive Esotropia After Bilateral Rectus Muscle Recession

Purpose: To investigate the clinical outcomes of unilateral lateral rectus muscle advancement in patients with consecutive esotropia after bilateral lateral rectus muscle recession. Methods: We investigated the results of 13 patients who underwent unilateral lateral rectus muscle advancement for consecutive esotropia after bilateral lateral rectus muscle recession. We evaluated the amount of deviation, changes of angle deviation, corrected amount/mm, and sensory status after each surgery. Results: The average angle deviation of exotropia was 30.42±5.41PD, and the average amount of bilateral lateral rectus muscle recession was 6.73±0.59 mm. The average angle deviation of esotropia one day after the surgery was 13.17±5.15PD. Occlusion treatment was performed during follow-up. The surgery for consecutive esotropia was performed after an average of 12.0±7.25 months of follow-up. In Worth-4-dot tests, 12 patients showed diplopia, and 1 patient showed suppression after the surgery for exotropia. Nine patients showed diplopia, and 4 patients showed suppression just before the surgery for consecutive esotropia. One patient showed mild limitation of motion of the lateral rectus muscle (-1 degree). The average angle deviation before the surgery for consecutive esotropia was 19.42±4.20PD. An average of 6.73±0.79 mm of unilateral lateral rectus muscle advancement was performed. After surgery, the average angle deviation was 1.25±2.73PD esodeviation, and 1.42±4.44PD exodeviation after 6 months. In Worth-4-dot tests, 6 patients showed fusion, 2 patients showed diplopia, and 5 patients showed suppression after surgery for consecutive esotropia. Conclusions: Unilateral lateral rectus muscle advancement was an effective procedure for patients with consecutive esotropia under 25PD who did not show any limitation of motion after bilateral lateral rectus recession.

The Effect of Unilateral Medial Rectus Muscle Resection in Patients with Recurrent Exotropia

PurposeTo investigate the effect of unilateral medial rectus muscle resection for recurrent exotropia after bilateral lateral rectus muscle recession for intermittent exotropiaMethodsA retrospective analysis was made of thirtypatients who underwent unilateral medial rectus resection for recurrent exotropia. All had prior bilateral lateral rectus recession for intermittent exotropia. Data were collected for age, the preoperative deviation, the postoperative deviation at 2 weeks, 3 months, 6 months and the last visit, and the amount of medial rectus resection performed.ResultsThe average preoperative deviation was 27.0±3.6 PD. After unilateral medial rectus resection, average deviation at distance was 2.8 PD at postoperative 2 weeks, 4.5 PD at 3 months, 5.1 PD at 6 months and 5.8 PD at last visit. The average deviation corrected per millimeter of medial rectus resection was 3.53±0.17 PD/mm.ConclusionsConsidering that deviation angles of recurrent exotropia is smaller than those of primary surgery and the possibility of saving the other medial rectus muscle, unilateral rectus muscle resection could be effective surgical method for recurrent exotropia.

Changes in Binocular Alignment After Surgery for Concomitant and Pattern Intermittent Exotropia

Introduction: Although early post-surgical over-correction for intermittent exotropia is widely advised, post-operative drift has not been well quantified in concomitant intermittent exotropia, and has not been described specifically with A and V patterns. While such patterns have been proposed to result from abnormal locations of the rectus muscle pulleys, others have suggested that A and V patterns may result from the disruption of fusion arising from exotropia itself. Methods: We prospectively performed Hess screen analysis in 20 exotropic patients (mean age 42 ± 16 yrs) before and two to six times after strabismus surgery, with a post-operative follow-up of 2-108 weeks. Primary surgery cases included medial rectus resection (2) and lateral rectus recession (10), combined resection/recession (6), and superior oblique tenectomy (2). Alignment trends in primary and secondary gazes were analyzed for concomitant, pattern, and re-operated subgroups. Results were also analyzed by type of surgery performed. Results: Mean pre-operative central gaze exotropia was 8.6 ± 7.1°. Twelve cases were concomitant, while 8 exhibited A or V patterns. Twelve cases were re-operations. In initial surgery for concomitant exotropia, there was a well-defined exotropic drift approaching 5° by 30 weeks post-operatively (linear regression, r = 0.43, p = 0.01). There was similar exo drift in re-operations. However, in pattern exotropia, post-operative drift was more variable, with mean esotropic drift of approximately 5° (r = 0.18, p = 0.43). For all patients, final post-operative central gaze exotropia was 1.9 ± 5.8°, with significant pattern collapse (p < 0.01). Discussion: Post-operative exo-shift of about 5° occurs in initial and re-operated concomitant exotropia. However, in A and V patterns, there is no definitive direction of post-operative drift, suggesting that pattern strabismus may be more likely due to mechanical factors in the orbit than to neural factors associated with fusion disruption. Conclusions: Alignment following strabismus surgery differs in concomitant vs. pattern exotropia. Initial over-correction of about 5° is advisable for concomitant exotropia, but should be avoided in A and V patterns.

Clinical Study on Factors Associated with Recurrence and Reoperation in Intermittent Exotropia

Purpose: The purpose of this study is to analyze factors associated with recurrence and reoperation in intermittent exotropia. Methods: The medical records of 285 patients who had undergone the bilateral lateral recti recessions for intermittent exotropia with at least 1 year of postoperative follow-up were reviewed retrospectively. Surgical success was defined as a final deviation less than 10PD, overcorrection more than 10PD and recurrence less than 10PD at postoperative 3 months but recurring later, so being exodeviated more than 10PD in primary gaze at postoperative 1 year. Reoperation was performed when the eye was excessively exodeviated with follow-up, requiring surgical revision clinically. We investigated factors associated with recurrence, comparing recurrence group to success group, and also investigated factors associated with reoperation, comparing reoperation group to recurrence group. Results: Alignment at postoperative 1 day was proved to be significant factor influencing on recurrence. The age at the time of operation, preoperative alignment, stereopsis, etc were not associated with recurrence. Also, stereopsis was associated with reoperation, but there were no relationship between reoperation and other factors. Conclusions: Alignment at postoperative 1 day was related to recurrence and poor stereopsis (≥400 sec) was associated with reoperation. Therefore, sensory function, such as stereopsis should be considered more important than motor control when considering reoperation.

Traction Sutures in the Management of Long-Standing Third Nerve Palsy

Background: Exotropia in long-standing third nerve palsy presents a significant cosmetic problem and the management is difficult. Method: A retrospective review of patients with long-standing exotropia secondary to third nerve palsy between 1996 and 2006 was carried out. Patients underwent large lateral rectus recession and medial rectus resection, combined with muscle traction sutures left in situ for 6 weeks. Results: Thirty-three patients were treated, with a mean follow up of 16 months, ranging from 3 to 108 months; the age range was 3 to 66 years with a mean of 28.8 years. The cause of third nerve palsy was congenital in 39%, orbital or intracranial tumour 21%, trauma 15%, microvascular 9%, complication of neurosurgery 9%, and unknown in 6%. Pre-operative angle measurements ranged from 25 to 95PD exotropia, mean 60PD exotropia. After removal of the traction sutures, the eye maintained a good cosmetic position in all but 3 patients. Final angle measurement ranged from 16 to 40PD exotropia, mean: 14.5PD exotropia. Post-operative motility was extremely limited; very limited abduction was a good indicator of the final eye position. Complications included conjunctival hypertrophy, suture infection, and “cheese wiring” of sutures. Conclusion: Adducting traction sutures combined with large recess-resect of the horizontal rectus muscles are safe and effective in the management of long-standing strabismus due to third nerve palsy.

Sensory results after lateral rectus muscle recession for intermittent exotropia operated before two years of age

Early surgical treatment of early-onset intermittent exotropia is controversial. The condition does not always progress, and postoperative esotropia can produce adverse consequences, such as suppression, amblyopia, and loss of binocular vision, particularly stereopsis. It is not known whether surgery before age two years affects the sensory outcome. Using a noncomparative (nonrandomized, uncontrolled) interventional case series, we reviewed the medical records during a 14-year period of 24 patients with intermittent exotropia with onset before age 1 year who also received bilateral lateral rectus muscle recessions before two years of age. Twelve patients were identified who received follow-up examinations at ages > or =4 years, when testing with Worth 4-Dot and Titmus stereo circles would likely be reliable. Mean age of the patients at last follow-up examination was 87 months. Stereoacuity was measured at 40 arcsec in 2 patients, 100 arcsec in 3 patients, 140-400 arcsec in 2 patients, and none in 5 patients. Among the 5 patients without demonstrated stereopsis, 1 had a history and clinical course consistent with congenital exotropia, and 1 had a nonstrabismic explanation for poor stereopsis. Overall, 7 patients (58%) ultimately obtained favorable motor alignment, defined as a phoria or intermittent tropia <10(Delta) at distance and near. No patient required treatment for amblyopia. Early-onset intermittent exotropia usually responds well to surgical treatment, and high-grade stereopsis can be achieved in some cases. More than one clinical entity presenting as intermittent exotropia in infancy probably exists.

Binocular Photophobia After Surgical Treatment in Intermittent Exotropia

This study examined the rate of binocular photophobia in intermittent exotropia patients before surgical correction, and the factors affecting this rate. The study also investigated the factors affecting postsurgical disappearance of binocular photophobia. The study involved 162 basic type intermittent exotropia patients who underwent surgical correction between March 2001 and January 2006. The study did not include patients with entropion, congenital cataract, or retinal abnormalities. Parents of the patients were questioned to determine which patients had monocular eye closure in bright light and which had disappeared after bilateral lateral rectus recession. Data was analyzed to determine the factors affecting monocular eye closure before surgery and disappearance after surgery. Of 162 patients, 96 patients had binocular photophobia (60.2%). Photophobia was found to be associated with an angle of exodeviation at distance >25 Prism Diopter (Delta) (p = 0.02), and stereoacuity worse than 60 s (p = 0.02). We defined satisfactory surgical outcome as a deviation of <10 Delta. Of the 81 patients with satisfactory outcomes, 46 showed disappearance of binocular photophobia (53.5%). No factor was found to be associated with loss of binocular photophobia. The angle of strabismus and stereoacuity were found to affect the occurrence of binocular photophobia. Successful surgery treated binocular photophobia in 53.5% of patients. Regardless of the surgical result, clinicians should educate patients in terms of the possibility of persistence of postsurgical photophobia.

Surgical management of large-angle incomitant strabismus in patients with oculomotor nerve palsy

To evaluate the surgical options in treating strabismus caused by different degrees of oculomotor nerve palsy. Surgical procedures for 13 patients with unilateral oculomotor nerve palsy were retrospectively studied. Eight patients had partial paralysis with isolated or multiple muscle involvement. A greater amount of lateral rectus recession and medial rectus resection than is usual was performed in six cases; transposition combined with resection of the medial rectus was performed in two cases with limited hypotropia. Of five patients with total oculomotor nerve paralysis, three underwent transposition of the superior oblique tendon to the superior site of the medial rectus insertion. The other two patients, having total oculomotor nerve paralysis combined with trochlear nerve palsy, underwent fixation of the globe to the anterior lacrimal crest by half a tendon width of the medial rectus. Extremely large (10-12 mm) lateral rectus recessions were performed in all patients. Pre- and postoperative horizontal and vertical deviations were measured to assess the surgical outcomes. Preoperative deviations of the affected eye were exotropia of 80(Delta) to 120(Delta), five cases with hypotropia of 15(Delta) to 35(Delta), and two cases with hypertropia of 15(Delta) to 20(Delta). After 6 to 27 months of postoperative follow-up, eye alignment showed horizontal residual deviation of 0(Delta) to 20(Delta) exotropia and vertical residual deviation of 4(Delta) to 10(Delta) hypotropia. By choosing the appropriate surgical procedure, eye alignment in the primary position was achieved, but recurrence of the exotropia was unavoidable, and a residual exotropia of 10(Delta) to 20(Delta) remained in most patients.

A comparison of hang-back with conventional recession surgery for exotropia

The hang-back loop suspension surgical technique for rectus muscle recession offers potential advantages over the conventional rectus muscle recession, including better exposure at the site of scleral sutures, shorter procedure duration, and lower risk of scleral perforation. Previous reports suggest that the hang-back technique for lateral rectus recession for exotropia results in poorer surgical success and may require a different surgical dosage. We compared strabismus in a nonrandomized series of 55 children with exotropia treated with conventional surgery or hang-back surgery. Those in the hang-back (suspension) recession group were on average 2.5 years younger and had 8(Delta) more preoperative exotropia at distance. Surgical outcomes were not significantly different in the two treatment groups. Multivariate logistic regression suggests that outcomes are at least equivalent to conventional surgery after adjusting for age, severity, and other preoperative factors likely associated with outcome. The hang-back surgical technique was as effective as conventional lateral rectus recession surgery for children with exotropia.

Corneal ‘Dellen’ as a complication of strabismus surgery

This paper presents results of an analysis on patients operated on for strabismus in order to evaluate frequency and clinical characteristics of corneal alterations. In our experience, this kind of complication occurs more frequently after reoperation and/or after surgery for esotropia in sixth nerve palsy using transposition procedures. A retrospective analysis was made of 655 consecutive patients operated on for strabismus on the recti muscles with a limbal approach from January 2001 to July 2003 (30 months). We found 30 corneal dellen out of the 184 eyes (16.30%) reoperated on medial rectus muscles, 7 corneal dellen out of the 37 eyes (18.92%) operated on using transposition procedures, 4 corneal dellen out of the 101 eyes (3.96%) operated of lateral rectus muscle recession combined with medial rectus muscle resection and no corneal dellen in the other 976 eyes operated of using different surgical procedures on the recti muscles. All patients had been operated on using a conjunctival limbal approach. All corneal dellen disappeared in about 10-15 days, using topical antibiotics and a firm bandage applied to the eye at night, leaving permanent alterations in corneal homogeneity in 8 eyes (19.51%). This study showed that this kind of complication is relatively frequent after reoperations and/or transposition procedures, thus indicating that it is possible to identify surgical procedures which might play a role in the development of corneal dellen. Therefore, the post-operative monitoring of patients at risk should not be delayed for more than one week, in order to avoid possible corneal perforation.

Refractive effect of the horizontal rectus muscle recession

To determine refractive and corneal topographic changes after horizontal rectus muscles recession. In a noncomparative interventional case series, 49 eyes of 27 patients were evaluated in two groups: (1) exotropic patients (24 eyes) who underwent lateral rectus muscle(s) recession, and (2) esotropic patients (25 eyes) who underwent medial rectus muscle(s) recession. Full ophthalmic examination including cycloplegic automated refraction was carried out before, 1 and 3 months after surgery. Corneal topography was performed preoperatively and repeated at 3 months postoperatively. In eyes underwent medial rectus recession, there were statistically significant myopic shifts in spherical equivalent at month 1 (from +2.09+/-1.82 to +1.88+/-1.83 diopters, P=0.03) and in astigmatic power at both month 1 (from -0.85+/-0.67 to -1.15+/-0.65 diopter, P=0.04) and month 3 (from -0.85+/-0.67 to -1.16+/-0.65 diopter, P=0.01). Myopic shifts were also noted following lateral rectus recession; however, there were not statistically meaningful. Significant astigmatic axis shift, which was toward with the rule astigmatism, was detected only after lateral rectus recession at both month 1 (P=0.02) and month 3 (P=0.02). Corneal power measured by topography was also demonstrated a statistically significant reduction (less than 0.3 diopter) after recession of either medial (P<0.001) or lateral (P<0.001) rectus muscle. In spite of being statistically significant in some parts, the amounts of refractive and corneal topographic changes were not clinically remarkable. Therefore, it does not seem necessary to perform cycloplegic refraction early after horizontal rectus muscle recession; however, a precise refraction in all cases of strabismus should not be deferred later than 3 months.

Augmented bilateral lateral rectus recessions in basic intermittent exotropia

To compare the outcomes of conventional surgery with the outcomes of surgeries using augmented amounts of symmetric lateral rectus recessions in the treatment of patients with basic intermittent exotropia. One hundred seven patients were enrolled in this study; the patients were followed for more than 6 months. The study group was composed of 41 patients who had undergone conventional surgery, and 66 who had augmented surgery. The amount of recession in conventional surgery was determined according to Parks' formula; the augmented amount ranged from 1.5 to 2.5 mm more per eye in augmented surgery. The success rate was 68.2% in subjects who had undergone augmented surgery, compared with the 43.9% observed in those who had undergone the conventional procedure (p = 0.01). The under correction rate was 53.7% in those who had undergone conventional surgery and 30.3% in those who had undergone augmented surgery (p = 0.02). The overcorrection rate was similar in the two groups (conventional, 2.4%; augmented, 1.5%). The augmented formula may be preferable to the standard formula for patients undergoing symmetric surgery to correct basic intermittent exotropia.

Accommodative ability in exotropia: Predictive value of surgical success

To evaluate the state and symmetry of accommodative response in the two eyes of patients with basic intermittent exotropia and to determine whether accommodative response is a predicting factor to the outcome of unilateral recession-resection procedures or symmetric lateral rectus recessions. Dynamic retinoscopy was performed preoperatively on 47 patients with basic intermittent exotropia with the capacity for fusion who were undergoing a first operation for intermittent exotropia. To obtain a clinical measurement of the degree of binocular accommodative response, the monocular estimate method was used. Patients were divided into two groups: those with an "equal effective accommodative response" and those with an "unequal accommodative response" between the two eyes. Both groups received either unilateral recession-resection procedures or symmetric lateral rectus recessions. Thirty-two of 47 patients (68%) showed a persistent interocular difference in accommodative amplitude (asymmetric accommodation) of at least 0.75 D. Among these 32 patients with an "unequal effective accommodation," 5 of 14 patients (35.7%) receiving lateral rectus recessions had a satisfactory outcome compared with 13 of the 18 patients (72%) receiving recess/resect procedures (p = 0.039). Of the 15 patients with an "equal effective accommodation," 7 of 8 (87%) receiving recession-resection procedures had a satisfactory outcome compared with 5 of 7 patients (71%) who had lateral rectus recessions (p = 0.57). Data suggest that patients with an asymmetric accommodative response benefit more from recession-resection procedures. A decrease in accommodative response of the nondominant eye could be a predicting factor on the outcome of exotropia surgery.

Combining recessions (nystagmus and strabismus) with tenotomy improved visual function and decreased oscillopsia and diplopia in acquired downbeat nystagmus and in horizontal infantile nystagmus syndrome

To investigate the effects of combined tenotomy and recession procedures on both acquired downbeat nystagmus and horizontal infantile nystagmus. Patient 1 had downbeat nystagmus with a chin-down (upgaze) position, oscillopsia, strabismus, and diplopia. Asymmetric superior rectus recessions and inferior rectus tenotomies reduced right hypertropia and rotated both eyes downward. Patient 2 had horizontal infantile nystagmus, a 20 degrees left-eye exotropia, and alternating (abducting-eye) fixation. Lateral rectus recessions and medial rectus tenotomies were performed. Horizontal and vertical eye movements were recorded pre- and postsurgically using high-speed digital video. The eXpanded Nystagmus Acuity Function (NAFX) and nystagmus amplitudes and frequencies were measured. Patient 1: The NAFX peak moved from 10 degrees up to primary position where NAFX values improved 17% and visual acuity increased 25%. Vertical NAFX increased across the -10 degrees to +5 degrees vertical range. Primary-position right hypertropia decreased approximately 50%; foveation time per cycle increased 102%; vertical amplitude, oscillopsia, and diplopia were reduced, and frequency was unchanged. Patient 2: Two lateral, narrow high-NAFX regions (due to alternating fixation) became one broad region with a 43% increase in primary position (acuity increased approximately 92.3%). Diplopia amplitude decreased; convergence and gaze holding were improved. Primary-position right exotropia was reduced; foveation time per cycle increased 257%; horizontal-component amplitude decreased 45.7%, and frequency remained unchanged. Combining tenotomy with nystagmus or strabismus recession procedures increased NAFX and visual acuities and reduced diplopia and oscillopsia in downbeat nystagmus and infantile nystagmus.

Sensory results after lateral rectus muscle recession for intermittent exotopia operated before two years of age

Introduction: Early surgical treatment of early-onset intermittent exotropia is controversial. The condition does not always progress and postoperative esotropia can produce adverse consequences, such as suppression, amblyopia, and loss of binocular vision, particularly stereopsis. It is not known whether surgery prior to age 2 years improves or worsens the prospects for normal sensory outcome. Methods: We reviewed medical records of 23 patients with intermittent exotropia with onset before age 1 year and also received bilateral lateral rectus muscle recessions prior to age 2 years. Ten were identified who received follow-up examinations at age = 4 years, when testing with Worth 4-Dot and Titmus stereo circles would likely be reliable. Results: Mean age at follow-up examination was 82 months. Stereoacuity was measured at 40 arcsec in three patients, 100 arcsec in two patients, 140 to 400 arcsec in two patients, and none in three patients. Among the three patients without demonstrated stereoacuity, one had a history and clinical course consistent with congenital exotropia, and two were developmentally delayed. Overall, seven patients (70%) had favorable motor alignment, defined as a phoria or intermittent tropia <10Δ at distance or near with no deviation >15Δ. No patient required treatment for amblyopia. Conclusions: Early-onset intermittent exotropia appears to respond well to surgical treatment. Sensory outcomes demonstrate that high-grade stereopsis can be achieved in some cases. More than one clinical entity presenting as intermittent exotropia in infancy probably exists. It is not clear whether early surgical intervention improves sensory outcomes over nonsurgical management.

Traction sutures for exotropia in longstanding third nerve palsy

Background: Exotropia in longstanding third nerve palsy presents a significant cosmetic problem and the management is difficult. Methods: A retrospective review of patients with longstanding exotropia secondary to third nerve palsy between 1996 and 2006 was carried out. Patients underwent large lateral rectus recession and medial rectus resection, combined with muscle traction sutures. Traction sutures were passed through superior and inferior rectus insertions and through the fornix to the medial canthus; the eye was adducted and sutures were brought through the lid to the skin surface and tied over bolsters. Traction sutures were left in situ for 6 weeks. Results: Thirty-three patients were treated, with a mean follow up of 16 months (range, 3-108 months). The age range was 3 to 66 years (mean, 28.8). The cause of third nerve palsy was congenital in 39%; orbital or intracranial tumor in 21%; traumatic in 15%; microvascular in 9%; complication of neurosurgery in 9%; and unknown in 6%. Prism cover test (PCT) measurements ranged from 25Δ to 95Δ exotropia preoperatively (mean, 60Δ exotropia). After removal of the traction sutures, the eye maintained a good cosmetic position in all but three cases. Final PCT ranged from 16Δ esotropia to 40Δ exotropia (mean, 14.5Δ exotropia). Postoperative motility was extremely limited. Very limited abduction was a good indicator of the final eye position. Complications included conjunctival hypertrophy, suture infection, and cheese wiring. Conclusions: Adducting traction sutures combined with large recess-resect of the horizontal recti are safe and effective in the management of longstanding strabismus in third nerve palsy.

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.