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.

Characteristics and results of surgery for residual esotropia.

To analyze the effect of systemic steroid treatment in children with benign acquired isolated sixth nerve palsy (BAISNP) regarding healing, recurrence risk and late sequelae. A retrospective cohort design was used. The clinical database of a single medical center was reviewed for all children with BAISNP between 2016 and 2024. Data were collected as follows: demographics, age at initial presentation, complete eye and neurological examinations at presentation and every follow-up visit, neuroimaging and LP findings, treatments at presentation or for residual ocular misalignment, recovery periods and recurrences. Systemic steroids (1mg/kg/day oral prednisolone for 10 days) were recommended by certain physicians, to whom some patients were randomly assigned. Twenty-seven children were included in the study. Mean age at presentation was 2.6 ± 2.2 years with a follow-up of 2.0 ± 2.3 years. BAISNP completely resolved after 3.2 ± 3.1 months in all children. Nine children (33%) had a recurrence that resolved after 1.8 ± 0.7 months. Residual comitant esotropia (RCE) exceeding 10 prism diopters persisted in six children (22%) despite resolution of the abduction weakness. Three of them underwent surgery and none regained stereopsis. Fifteen children (56%) received systemic steroids upon presentation. Steroid treatment affected neither time to resolution nor recurrence rate. However, fewer children treated with steroids developed RCE (6% vs. 45%, p = 0.026). A multivariable analysis for RCE development found that only steroids had a statistically significant impact (β=-0.58, p = 0.006). Systemic steroids reduce the rates of RCE when administered during an acute episode of BAISNP.

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

To evaluate the surgical outcomes of a combined modified Nishida's procedure with medial rectus (MR) recession augmented with lateral rectus (LR) plication in patients with long-standing complete sixth nerve palsy presenting with large-angle esotropia (ET). This retrospective interventional case series included three patients with chronic traumatic complete sixth nerve palsy and large-angle ET (70 to 75 prism diopters [PD]). Postoperatively, two patients achieved orthophoria at distance and near and one patient had a small residual ET of 5 PD at 6 months. The combination of modified Nishida's procedure with MR recession and LR plication appears to be an effective single-stage surgical approach for large-angle esotropia (approximately 70 PD) associated with complete sixth nerve palsy. The technique provides substantial alignment correction, improved abduction, resolution of diplopia, and a reduced risk of anterior segment ischemia compared to full-tendon vertical rectus transposition.

To investigate the use of fascia lata (FL) grafts for eye muscle tendon elongation in patients with complex and residual strabismus types apart from Graves' orbitopathy. In this retrospective study, a heterogeneous group of 27 eyes of 21 patients with complex and residual strabismus types who underwent elongation of the eye muscle tendon with FL were included. Orthoptic and ophthalmological examinations including measurement of the head posture, the extent of deviation in primary position (PP), and monocular excursion were conducted preoperatively and after a mean postoperative time of 12.2 (6.0 - 37.0, median 7.0) months in all patients. Eight patients (12 eyes) with residual exotropia, 4 patients (4 eyes) with residual esotropia, 4 patients (6 eyes) with partial abducens nerve palsy, 4 patients (4 eyes) with vertical deviation, and 1 patient (1 eye) with Duane's retraction syndrome (DRS) type I were included. A residual squint angle of 10Δ or less was achieved in 57.1% of the patients at the last follow-up. The head posture was significantly reduced at the last follow-up compared to preoperatively in patients with residual exotropia (p = 0.002), esotropia (p = 0.040), abducens nerve palsy (p = 0.005), and vertical deviation (p = 0.005). At the last follow-up, a significant reduction in the squint angle occurred in patients with residual exotropia (p = 0.001), abducens nerve palsy (p = 0.046), and vertical deviation (p = 0.033). FL grafts may offer safe and effective surgical options for complex and residual strabismus types. No significant reduction in the excursion into the fields of action of the affected muscles was witnessed.

IntroductionThe onset of ocular misalignment can be either congenital or acquired, with each type of strabismus exhibiting distinct clinical features that help differentiate it from others. In this case, we aim to discuss conditions that mimic restrictive strabismus and their management.Case descriptionA 14-year-old girl presented with a complaint of her left eye turning inward, which had been present since infancy. Clinical examination revealed bilateral medial rectus overaction. She had underwent surgery for a meningocele five years ago. The left eye examination: visual acuity was 2/60, anterior segment was normal, esotropia, and a -3 limitation of abduction and the force duction test was positive. She was diagnosed with congenital esotropia, with restrictive esotropia considered as a differential diagnosis. She underwent surgery to released cicatricial tissue and recession rectus medial. After the surgery, the left eye esotropia still remained. Neuroimaging was conducted to identify the underlying cause. The result described left fronto-orbital meningoencephalocele caused fibrosis around the left medial rectus tendon. A second surgery involving lateral rectus resection was performed, and orthophoria was achieved at both eyes.ConclusionsThis case report illustrates that any abnormalities involving the orbital structures can be a potential cause of restrictive strabismus, especially when certain clinical features are incongruent with the initial diagnosis. Meticulous history taking and thorough clinical examination are essential to achieve an accurate diagnosis and management.

Outcomes of Nishida Muscle Transposition Procedure for Abducens Nerve Palsy.

We investigated the long-term outcomes of unilateral medial rectus (UMR) recession surgery in partially accommodative esotropia (PAET). Children aged ≤ 10 years with PAET who had residual esotropia of ≤ 25 prism diopters (PD) after full hypermetropic correction and underwent UMR recession were included. Medical records of patients who were followed up for at least 1 year postoperatively were retrospectively reviewed. Successful outcome was defined as phoria of ≤ 5 PD. Total of 28 patients were included. The mean preoperative esodeviation at distance fixation was 15.5 ± 3.7 PD (range, 10–25 PD). The mean dose of UMR recession was 5.6 ± 0.7 mm (range, 4.0–7.0 mm). The average postoperative follow-up time was 4.4 ± 3.1 years. At the last examination, esodeviation significantly decreased to 6.2 ± 13.8 PD and the surgical success rate was 53.6%. In the success group, the age at surgery was older (P = 0.005), the duration of wearing prism glasses was longer (P = 0.030), and the amount of UMR recession was greater (P < 0.001) than in the failure group. Only half of the patients with small to moderate angle PAET achieved successful long-term outcomes through UMR recession. Having sufficient time to wear prism glasses before surgery to achieve good binocularity and receiving a sufficient amount of surgical correction may improve surgical success.

Aims/Purpose: To describe the clinical characteristics and outcomes of a series of strabismus patients with horizontal recti palsies treated surgically with a Modified Nishida Procedure (MNP).Methods: A retrospective review of patients who underwent a MNP at Hospital de Santa Maria in Lisbon, Portugal, between November 2023 and February 2024 (n = 5). MNP is a no‐tenotomy, no‐splitting transposition of 1/3 of the muscle body of the vertical recti to the midpoint between itself and the affected horizontal rectus muscle. Inclusion criteria included diplopia due to Grade IV or V palsies of the lateral rectus (LR, n = 4) due to VI nerve palsy or of the medial rectus (MR, n = 1) due to III nerve palsy. A 3‐month post‐operative follow‐up was required. Surgical success was defined as post‐operative horizontal deviation ≤14 prism diopters (PD) and absence of horizontal diplopia in primary gaze.Results: Mean age was 60±13 years. Two patients had bilateral LR palsy with &gt; 85PD esotropia (ET) and received bilateral MNP combined with 6mm MR recession, with additional MR botulinum toxin (BT) injection two weeks later. Two patients had unilateral LR palsy with 45 PD ET with previous 7mm MR recession: these received unilateral MNP. Surgical success was achieved in 3 of these 4 cases. The unsuccessful case had 40PD residual ET and diplopia at 4 months follow‐up. There were two cases of self‐limiting post‐operative ptosis and one case of a surgical complication where the whole vertical rectus body was transposed due to high muscle friability. The MR paralysis patient had 40PD exotropia and MNP was combined with 7mm LR recession. Surgical success was achieved in this case, and no intra‐ or post‐operative complications occurred. No cases of anterior segment ischemia were detected in this series.Conclusions: MNP is an effective surgical option as it greatly reduces the horizontal deviations and diplopia associated with severe cranial nerve palsies and has a reduced risk of complications.

Aims/Purpose: To describe the clinical characteristics and outcomes of a series of strabismus patients with horizontal recti palsies treated surgically with a Modified Nishida Procedure (MNP).Methods: A retrospective review of patients who underwent a MNP at Hospital de Santa Maria in Lisbon, Portugal, between November 2023 and February 2024 (n = 5). MNP is a no‐tenotomy, no‐splitting transposition of 1/3 of the muscle body of the vertical recti to the midpoint between itself and the affected horizontal rectus muscle. Inclusion criteria included diplopia due to Grade IV or V palsies of the lateral rectus (LR, n = 4) due to VI nerve palsy or of the medial rectus (MR, n = 1) due to III nerve palsy. A 3‐month post‐operative follow‐up was required. Surgical success was defined as post‐operative horizontal deviation ≤14 prism diopters (PD) and absence of horizontal diplopia in primary gaze.Results: Mean age was 60±13 years. Two patients had bilateral LR palsy with &gt; 85PD esotropia (ET) and received bilateral MNP combined with 6mm MR recession, with additional MR botulinum toxin (BT) injection two weeks later. Two patients had unilateral LR palsy with 45 PD ET with previous 7mm MR recession: these received unilateral MNP. Surgical success was achieved in 3 of these 4 cases. The unsuccessful case had 40PD residual ET and diplopia at 4 months follow‐up. There were two cases of self‐limiting post‐operative ptosis and one case of a surgical complication where the whole vertical rectus body was transposed due to high muscle friability. The MR paralysis patient had 40PD exotropia and MNP was combined with 7mm LR recession. Surgical success was achieved in this case, and no intra‐ or post‐operative complications occurred. No cases of anterior segment ischemia were detected in this series.Conclusions: MNP is an effective surgical option as it greatly reduces the horizontal deviations and diplopia associated with severe cranial nerve palsies and has a reduced risk of complications.

PurposeWe aimed to investigate the effects of Fresnel prism treatment for small-angle esotropia (≤ 20 prism diopters [PD]) with fixation preference.MethodsWe included 32 patients with remaining esotropia ≤ 20 PD measured using the simultaneous prism and cover test (SPCT) after full refractive error correction. Fresnel prism was applied to make patients orthotropic with glasses. Treatment was discontinued if remaining esotropia ≤ 4 PD was sustained during two consecutive follow-ups (2-month intervals) or if the angle continued to increase with prism adaptation. Patients were divided into treatment success and failure groups. Treatment success was defined by motor and visual acuity (VA) aspects. Criteria for motor success was residual esotropia ≤ 8 PD in patients with initial esotropia > 8 PD and a 30% decrease of esotropia in those with initial esotropia ≤ 8 PD. VA success was improvement of > 0.2 logMAR in the non-dominant eye.ResultsThe initial esodeviation angle was 6.92 ± 4.66 PD at distance and 10.53 ± 5.58 at near. The logMAR VA was 0.10 ± 0.13 and 0.26 ± 0.20 in the dominant and non-dominant eye, respectively. Among the 32 patients, 14 showed motor success. Among 26 patients whose VA could be measured, 15 showed VA success. Factors influencing motor success were a small amount of maximum prescribed Fresnel prism, less frequent need for Fresnel prism adaptation, and high percentage of achieving orthotropia with Fresnel prism treatment. VA success was influenced by low frequency of anisometropia and the small amount of maximum prescribed Fresnel prism.ConclusionFresnel prism could be a non-invasive treatment option for some patients with small-angle esotropia with fixation preference.Key messagesWhat is knownThe optimal approach for addressing small-angle esotropia is a topic of debate.Not much research has been conducted on Fresnel prism treatment in patients with small-angle esotropia.What is newMotor success and visual acuity improvement were observed in some patients undergoing Fresnel prism treatment.Factors contributing to motor success were the small maximum angle of esodeviation, the less frequent necessity for Fresnel prism adaptation, and the achievement of orthotropia during Fresnel prism treatment.Visual acuity improvement was hindered by the presence of anisometropia and the large maximum prescribed amount of Fresnel prism.Fresnel prism treatment can be used as a treatment option for some patients with small-angle esotropia with fixation preference.

Background Muscle resection or plication is a common treatment for strabismus by strengthening the muscle. Lateral rectus muscle resection is a basic surgical technique for correcting residual esotropia. Plication approach is an alternative surgical technique to resection. Aim Is to compare the result of lateral rectus plication versus lateral rectus resection in patients with residual esotropia. Patients and methods This is a prospective, comparative, randomized interventional study which was carried on 40 eyes of 20 patients with residual esotropia All the patients underwent surgery to both eyes, they were divided into two groups according to surgical technique. Group A: 20 eyes of 10 patients underwent lateral rectus resection surgery. Group B: 20 eyes of 10 patients underwent lateral rectus plication. Results Postoperative success rate in two groups was 80% with main postoperative angle of deviation higher on group B. Conclusion Lateral rectus muscle plication technique is an alternative to resection that has the same effect as resection as obvious by the similar success rate that can be used on horizontal muscles especially when anterior ciliary vessel sparing is needed.

A modified Nishida procedure for management of myopic strabismus fixus

Persistent diplopia after rectus muscle myectomy is not uncommon but challenging in patients with Graves' ophthalmopathy. We investigated the role of lateral rectus muscle resection for patients after medial rectus muscle myectomy in Graves' ophthalmopathy. We retrospectively reviewed and collected data from patients with persistent diplopia after medial rectus muscle myectomy for Graves' ophthalmopathy who underwent unilateral or bilateral lateral rectus muscle resection. The eyeball deviations in the primary and reading positions before and after the operation were measured. A successful surgical outcome was defined as having less than five prism diopters (PD) in the primary gaze and functional binocular vision in the central 30° field postoperatively. A total of fifteen patients were included (mean post-myectomy deviation: 35.9 PD, range: 14 to -75 PD). The lateral rectus muscle resection after medial rectus muscle myectomy achieved an 80.0% success rate, with one patient over-corrected and two patients under-corrected. The lateral rectus muscle resection is an effective and predictable procedure for managing residual esotropia in Graves' ophthalmopathy patients who have previously undergone medial rectus muscle myectomy.

Preoperative prism adaptation (PPA) simulates postoperative status and possibly can predict postoperative undercorrection before surgery in esotropia. The present study aimed to assess the effect of 4-week PPA in preventing postoperative residual esotropia. Seventy-five (75) esotropes who had undergone surgery at a single strabismus center were retrospectively enrolled. They included 25 basic, 31 acute comitant, 10 partially accommodative, and 9 recurrent esotropia patients. The preoperative deviation angle, which had been determined using the alternating prism and cover test, was fully corrected with press-on prisms 4 weeks before surgery. If there was an increase of 5 PD or more of esodeviation, the prisms were changed accordingly at 2 weeks. The deviation angle measured at 4 weeks was determined as the surgical target angle. Patients were then divided into increase (≥ 5 PD increase of angle during 4-week PPA) and non-increase groups. Success was defined as either esodeviation of 8 PD or under or exodeviation of 5 PD or under at distance at postoperative 6 months. The increase group included 44 patients (58.7%). The mean deviation angle before PPA was 27.4 PD, and after the 4-week PPA, there was an average increase of 9.4 PD. The success rate was 90.9% in the increase group and 96.8% in the non-increase group (p = 0.316). There were no intergroup differences in preoperative clinical characteristics, esotropia types, postoperative deviation angle or postoperative near stereopsis (p > 0.05). The results of this study indicated a beneficial effect of 4-week PPA in esotropia of various types, specifically by uncovering the hidden esodeviation in the increase group and simulating the postoperative alignment in both the increase and the non-increase groups.

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.].

Infantile esotropia (IE) is the inward deviation of the eye. Various aspects of the clinical management of IE are unclear; mainly, the most effective type of intervention and the age at intervention. To examine the effectiveness and optimal timing of surgical and non-surgical treatment options for IE to improve ocular alignment and achieve or allow the development of binocular single vision. We searched CENTRAL, MEDLINE, Embase, one other database, and three trials registers (November 2021). We did not use any date or language restrictions in the electronic searches for trials. SELECTION CRITERIA: We included randomized trials and quasi-randomized trials comparing any surgical or non-surgical intervention for IE. We used standard Cochrane methodology and graded the certainty of the body of evidence for six outcomes using the GRADE classification. We included two studies with 234 children with IE. The first study enrolled 110 children (mean age 26.9 ± 14.5 months) with an onset of esotropia before six months of age, and large-angle IE defined as esotropia of ≥ 40 prism diopters. It was conducted between 2015 and 2018 in a tertiary care hospital in South Africa. It compared a maximum of three botulinum toxin injections with surgical intervention of bimedial rectus muscle recession, and children were followed for six months. There were limitations in study design and implementation; the risk of bias was high, or we had some concerns for most domains. Surgery may increase the incidence of treatment success, defined as orthophoria or residual esotropia of ≤ 10 prism diopters, compared with botulinum toxin injections, but the evidence was very uncertain (risk ratio (RR) of treatment success 1.88, 95% confidence interval (CI) 1.27 to 2.77; 1 study, 101 participants; very low-certainty evidence). The results should be read with caution because 23 children with > 60 prism diopters at baseline in the surgery arm also received botulinum toxin at the time of surgery to augment the recessions. There was no evidence of an important difference between surgery and botulinum toxin injections for over-correction (> 10 prism diopters) of deviation (RR 0.29, 95% CI 0.06 to 1.37; 1 study, 101 participants; very low-certainty evidence), or additional interventions required (RR 0.66, 95% CI 0.36 to 1.19; 1 study, 101 participants; very low-certainty evidence). No major complications of surgery were observed in the surgery arm, while children experienced various complications in the botulinum toxin arm, including partial transient ptosis in 9 (16.7%) children, transient vertical deviation in 3 (5.6%) children, and consecutive exotropia in 13 (24.1%) children. No other outcome data for our prespecified outcomes were reported. The second study enrolled 124 children with onset of esotropia before one year of age in 12 university hospitals in Germany and the Netherlands. It compared bilateral recession with unilateral recession surgeries, and followed children for three months postoperatively. Very low-certainty evidence suggested that there was no evidence of an important difference between bilateral and unilateral surgeries in the presence of binocular vision (numbers with event unclear, P = 0.35), and over-correction (RR of having exotropia 1.09, 95% CI 0.45 to 2.63; 1 study, 118 participants). Dissociated vertical deviation, latent nystagmus, or both were observed in 8% to 21% of participants. Medial rectus recessions may increase the incidence of treatment success compared with botulinum toxin injections alone, but the evidence was very uncertain. No evidence of important difference was found between bilateral surgery and unilateral surgery. Due to insufficient evidence, it was not possible to resolve the controversies regarding type of surgery, non-surgical intervention, or age of intervention in this review. There is clearly a need to conduct good quality trials in these areas to improve the evidence base for the management of IE.

Purpose The aim of this study was to assess the change in alignment following a fixed dose of bupivacaine (BPX) and/or botulinum A toxin (BTXA) injection into the extraocular muscles in children with concomitant horizontal strabismus. Patients and methods This prospective interventional study was conducted on 76 children aged 2–14 years with concomitant horizontal strabismus. They were divided into three groups. In group A (20 cases) with angle of strabismus less than 16 prism diopters (PD), BPX 0.75% was injected into the agonist muscle of each eye. In group B (23 patients) with angle of 16–30 PD, BTXA 5 U was injected into the antagonist muscle of each eye. In group C (33 patients) with angle greater than 30 PD, BPX 0.75% and BTXA 5 U were injected into the agonist and antagonist muscles of each eye, respectively. Ocular motility and alignment were evaluated preoperatively and at 1 week, 1, 3, and 6 months postoperatively. Results In group A, 11 (55%) patients were orthotropic, six (30%) had residual esotropia (ET), and three (15%) had residual exotropia (XT). The mean preinjection angle was 13.55±2.56 PD, and the postinjection angle was 8.45±6.13 PD (P=0.001). In group B, eight (34.8%) patients were orthotropic, two (8.7%) had residual ET, and 13 (56.5%) had residual XT. The mean preinjection angle was 28.0±3.28 PD, and the mean postinjection angle was 15.25±10.79 PD (P&lt;0.001). In group C, 10 (30.3%) patients were orthotropic, 14 (42.2%) had residual ET, and nine (27.2%) had residual XT. The mean preinjection angle was 52.50±14.03 PD, and the mean postinjection angle was 24.75±21.32 PD (P&lt;0.001). Conclusion Pharmacological treatment resulted in clinically significant correction of concomitant horizontal strabismus in children and may be used as an alternative to surgery.

Abstract Purpose: The purpose of this article is to study the factors affecting postoperative alignment in patients of infantile esotropia with deviation more than or equal to 30 prism diopter (PD) after 12 weeks of follow-up. Materials and Methods: A total of 23 patients with infantile esotropia were included in this study over a period of 18 months. All the patients were assessed preoperatively and postoperatively at day 1, 3rd week, 6th week, and 12th week. The patients underwent horizontal muscle surgery alone or vertical combined with horizontal muscle surgery wherever required. All surgeries were planned and performed according to W.E. Scott table by a limbus-based approach. Results: Mean age of our study population was 13.36 ± 8.0 years (1.5–30 years). Fifteen (65.2%) patients were hypermetropic, 5 (21.7%) patients were emmetropic and 3 (13.1%) were myopic. Among the study participants, amblyopia was present in 13 patients (56.6%). The mean preoperative horizontal deviation was 48.04 PD ± 13.3 PD (range = 30–70 PD). Eleven patients had preoperative esotropia of &gt;50 PD and 12 had &lt;50 PD. The mean postoperative horizontal deviation was 5.1 ± 3.1 PD (range = 2–14 PD). Twenty-one (91.30%) patients had orthophoria, 2 (8.70%) patients had residual esotropia and none had overcorrection. Conclusion: The postoperative alignment was not influenced by age at the time of surgery (P = 0.67) and magnitude of preoperative deviation (P = 0.67) Further, the postoperative outcome was independent of the laterality of surgery (unilateral vs. bilateral, P = 0.6) and extraocular muscles operated (horizontal vs. combined horizontal and vertical, P = 0.537).