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To compare the surgical outcomes of the plication technique with the resection method to treat exotropic patients. In this prospective randomized clinical trial, a total of 52 exotropic patients (27 females and 25 males) who were candidates for medial rectus resection were randomly classified into the plication (n = 24) and resection (n = 28) groups. Comprehensive ophthalmic examination included cyclorefraction, assessment of the best corrected visual acuity (BCVA), evaluation of the extraocular muscle, ocular deviation measurement and stereopsis measured using a Titmus test. Ocular anterior and posterior segments were examined using slit-lamp and indirect ophthalmoscopy. Patients were randomly divided to medial rectus plication and medial rectus resection groups. The plication technique was the same as for resection, but in the last step the muscle was folded. Examinations were repeated at the 1- and 3-day as well as 1-, 2-, 3- and 6-month follow-ups. If the postoperative ocular deviation was in the range of 5 PD esotropia to 10 PD exotropia, it was considered a successful surgical outcome. Results show that there was no statistically significant difference between the two groups regarding near and far deviations (PN = 0.298, PF = 0.103), surgical dose response (P = 0.904) and postoperative success rate (plication, 87% and resection, 89.3%, P > 0.99). Reoperation was needed in 13% and 10.7% of the plication and resection groups, respectively (P > 0.05). Medial rectus plication is an effective and appropriate alternative option for medial rectus resection in exotropic patients.

Purpose: To report long-term motor and sensory outcomes after unilateral lateral rectus recession–medial rectus resection for basic intermittent exotropia. Methods: The medical records of patients who had undergone unilateral lateral rectus recession–medial rectus resection for basic intermittent exotropia and were observed postoperatively for a minimum of 10 years were reviewed retrospectively. Results: A total of 41 patients were included (mean age: 6.07 ± 2.96 years; range: 3 to 17 years). The mean postoperative follow-up was 13.28 ± 3.27 years (range: 10 to 23 years). Overall, 19 patients (46%) had surgical success at their most recent follow-up visit. Age at onset of strabismus, age at surgery, strabismus duration, preoperative size of near and distance deviation, presence of stereopsis, and initial postoperative overcorrection did not predict motor outcome after surgery. Twenty-five patients (74%) achieved stereopsis. None of the 4 patients without binocular single vision preoperatively achieved stereopsis, compared to 3 of 7 patients (43%) with peripheral binocular single vision ( P = .02). Five of 7 patients (71%) with a preoperative stereoacuity of 120 to 240 seconds of arc improved to 60 seconds of arc. Age at surgery did not predict stereopsis. Patients with a strabismus duration of 5 years or less achieved a better stereopsis. Conclusions: Fewer than half of the patients with basic intermittent exotropia achieved a successful long-term surgical outcome. Age at surgery, strabismus duration, preoperative stereopsis, and an initial postoperative overcorrection did not predict motor outcome. A pre-operative absence of binocular single vision indicated a poor prognosis for stereopsis. A shorter duration of strabismus predicted a better stereopsis after surgery. [ J Pediatr Ophthalmol Strabismus . 2020;57(5):326–332.]

Purpose: The aim of this study was to analyze the amount of medial rectus (MR) advancement in the treatment of consecutive exotropia by comparing it with the amount of MR resection in a sample of patients with constant exotropia and evaluate the effectiveness of MR advancement with lateral rectus (LR) recession in the management of consecutive exotropia.Materials and Methods: A retrospective chart review of patients who underwent unilateral MR strengthening with LR weakening due to consecutive or constant exotropia was performed. Patients with consecutive exotropia underwent MR advancement with LR recession, and those with constant exotropia underwent MR resection with LR recession. The surgical dosages were determined according to a standard table. A successful result was defined as alignment within 10 prism diopters of orthotropia.Results: A total of 36 patients fulfilled the inclusion criteria: 18 had consecutive exotropia and 18 had constant exotropia. Successful alignment was obtained in 83.3% of patients with consecutive exotropia and 88.9% of patients with constant exotropia. There was no difference between the amount of MR advancement performed in consecutive patients with exotropia and the amount of MR resection performed in patients with constant exotropia. Postoperatively, while consecutive exotropes with a poor result showed overcorrection, constant exotropes with a poor result showed undercorrection.Conclusion: This study suggests that there is no difference between the amount of previously recessed MR advancement and that of untouched MR resection. They also showed that MR advancement with LR recession is an effective means of correcting secondary exotropia., Amaç: Bu çalışmada konsekütif ekzotropya tedavisinde medial rektus (MR) ilerletme miktarını sabit ekzotropyası olan hastalardaki MR rezeksiyonu ile karşılaştırarak incelemek ve konsekütif ekzotropya tedavisinde MR ilerletmesi ile birlikte lateral rektus (LR) geriletmesinin etkinliğinin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: Konsekütif veya sabit ekzotropya nedeniyle tek taraflı MR güçlendirilmesi ile birlikte LR zayıflatılması yapılmış hastaların kayıtları retrospektif olarak incelendi. Konsekütif ekzotropyalı hastalarda MR ilerletmesi ile birlikte LR geriletmesi ve sabit ekzotropyalı hastalarda MR rezeksiyonu ile birlikte LR geriletmesi yapılmıştı. Cerrahi dozlar standart bir tabloya göre belirlenmişti. 10 prizma dioptri ve daha az kayma başarılı sonuç olarak kabul edildi.Bulgular: 18 konsekütif ekzotropyalı ve 18 sabit ekzotropyalı toplamda 36 hasta çalışmaya kabul edilme kriterlerini karşıladı. Başarılı hizalanma konsekütif ekzotropyalı hastaların %83.3’ ünde, sabit ekzotropyalı hastaların %88.9’unda elde edildi. Konsekütif ekzotropya olan hastalarda yapılan MR ilerletme miktarı ile sabit ekzotropya olan hastalarda yapılan MR rezeksiyonu miktarı arasında fark yoktu. Postoperatif dönemde, başarısız sonuç elde edilen konsekütif ekzotropyalı hastalarda fazla düzelme mevcut iken, başarısız sonuç elde edilen sabit ekzotropyalı hastalarda yetersiz düzelme vardı.Sonuç: Bu çalışma daha önceden geriletilmiş MR’nin ilerletilme miktarı ile cerrahi olarak hiç dokunulmamış MR’nin rezeksiyon miktarı arasında bir fark olmadığını öne sürmektedir. Bu çalışma aynı zamanda MR ilerletmesi ile birlikte LR geriletmesinin sekonder ekzotropyayı düzeltmek için etkili bir yöntem olduğunu göstermiştir.

Objective To evaluate the surgical outcome of unilateral medial rectus resection with small advancement for recurrent exotropia, ≤30 prism diopters (PD), and verify new attachment site anatomically using anterior segment optical coherence tomography (ASOCT). Method This study is a retrospective chart review of patients who underwent 1.0 mm advancement of unilateral resected medial rectus from original medial rectus (OMR) insertion for recurrent exotropia since 2014. The age at operation, sex, preoperative angle of deviation, near stereopsis, and suppression were evaluated. Success was defined as ≤5 PD of esodeviation or ≤10 PD of exodeviation at the final visit. Preoperative scleral thickness was measured using ASOCT, 1.0 and 0.5 mm anterior to OMR insertion, and at the insertion. Results A total of 76 patients, including 30 males (40.2%), were reviewed retrospectively. Continuous values were presented as mean ± standard deviation. Age at operation was 11.6 ± 6.6 years. The preoperative deviation was 20.9 ± 3.6 PD, and the amount of resected unilateral medial rectus was 4.5 ± 0.6 mm. The minimum required follow-up period after operation was 12 months after surgery. The postoperative follow-up period was 21.3 ± 8.0 months. A total of 65 patients (87.8%) showed successful outcome at the final visit. Preoperative scleral thickness at 1.0 and 0.5 mm anterior to OMR insertion site, and at OMR insertion site were 0.52 ± 0.05, 0.52 ± 0.06, and 0.43 ± 0.04 mm, respectively. Scleral thickness at OMR insertion site was significantly less compared with 1.0 and 0.5 mm from the OMR insertion site (p = 0.03). Conclusion The scleral thickness 1.0–0.5 mm anterior to OMR insertion site was thicker that than at the OMR insertion site. The new technique of medial rectus resection with small advancement may be safer and more effective than conventional technique.

To describe characteristics of recurrent intermittent exotropia after bilateral lateral rectus (BLR) recession, and identify factors associated with poor outcome after unilateral medial rectus (MR) resection for recurrent intermittent exotropia. We retrospectively reviewed 124 patients who have undergone unilateral MR resection for recurrent intermittent exotropia after BLR recession. Patients were followed for at least 2 years after MR resection. Clinical characteristics and risk factors associated with poor outcome after unilateral MR resection were evaluated. Successful outcome was defined as distant deviation within the range of 4 prism diopters (PD) esotropia and 10 PD exotropia at last visit after MR resection. Among 124 patients, 50 patients (41.1%) were male, and the mean age at the time of MR resection was 9.5 ± 3.1 years. The average follow-up period after MR resection was 43.8 ± 23.7 months. Forty-seven patients (37.9%) were classified to have poor outcome at last visit, and 29 patients (23.4%) underwent third operation. None of the patients was overcorrected after MR resection. Multiple logistic regression analyses showed that distant deviation at post-operative 3 months and male gender were associated with poor outcome (OR 1.49; 95% CI 1.27–1.73; P

BACKGROUND/OBJECTIVES: The objective of this study is to compare the long-term outcomes of bilateral and unilateral medial rectus (BMR/UMR) resection for recurrent exotropia after bilateral lateral rectus (BLR) recession. SUBJECTS/METHODS: Retrospective study was performed of 99 patients who underwent BMR resection (BMR group) or UMR resection (UMR group) for recurrent exotropia of 20–30 prism diopters (PD), with a minimum follow-up of 5 years. Surgical outcomes including success rate, exodrift rate, and average effect of MR resection were compared between two groups. The risk factors associated with poor outcomes were evaluated. RESULTS: At 5 years after surgery, 57% in the BMR group and 62% in the UMR group showed successful outcome. Success and recurrence rates were not significantly different between two groups, whereas the overcorrection rate was significantly higher in the BMR group (35% vs. 15%; p = 0.039). The average effect of MR resection was significantly greater after BMR throughout the whole postoperative period. The average effect of UMR resection was significantly greater in those who had previously undergone a large amount of BLR recession compared with those with a smaller dosage (p = 0.006). By multivariate analysis, a large amount of previous BLR recession and initial overcorrection of >10 PD of esotropia were found to be significant risk factors of overcorrection. CONCLUSION: In moderate angles of recurrent exotropia, large UMR resection is a safe and efficient procedure. However, if a large BLR recession was performed previously, surgical dosage for UMR resection should be reduced because of the high risk of long-term overcorrection.

AIM: To investigate the efficacy of unilateral medial rectus resection in children with residual and recurrent exotropia and analyze the influence of difference types of strabismus and methods of primary surgery on the surgical outcome. METHODS:This investigation was a retrospective case series study that examined data from 48 pediatric patients(48 eyes)who underwent unilateral medial rectus resection between January 2009 and February 2013 for residual and recurrent exotropia. We surveyed the outcome of eye alignment, lateral incomitance, fusion function, stereoacuity in children at 1d, 6wk and at last follow-up of 6-32(mean 11.99±7.06)mo after the surgery. RESULTS: At 1d after the surgery, the rate of surgical success was 83%(40/48), and the rate of undercorrection and overcorrection was 4%(2/48)and 13%(6/48), respectively. At 6wk after the surgery, the rate of surgical success was 81%(39/48), and the rate of undercorrection and overcorrection was 13%(6/48)and 6%(3/48), respectively. At the final follow-up of 6-32(mean 11.99±7.06)mo, the surgical success rate was 75%(36/48), and the rate of undercorrection was 25%(12/48). No patient exhibited overcorrection. There were no significant differences in the surgical success rate either among pediatric patients who had previously undergone different types of surgery or among patients who had been diagnosed with different types of exotropia(P=0.168 and P=0.50, respectively). No patients presented with lateral incomitance or limited ocular motility. CONCLUSION: Unilateral medial rectus resection is a safe and effective surgical approach for treating in children with residual and recurrent exotropia. In addition, it may achieve the same surgical effectiveness regardless of the patients' previous surgical procedures or types of exotropia.

Background To investigate the dose response according to tendon width of the medial rectus in patients with recurrent exotropia who underwent unilateral medial rectus resection. Methods Patients with basic recurrent exotropia after bilateral lateral rectus recession were included. All patients underwent unilateral medial rectus resection according to the preoperative angle of deviation. Under general anesthesia, the tendon width of the medial rectus in the operated eye was measured. The patients were divided into 2 groups (narrow and wide) according to the median value of the tendon width of the medial rectus. The angle of deviation at postoperative day 1 was measured. The dose response was calculated based on the amount of correction and resection. Results This study included 38 patients. Age and preoperative angle of deviation were 11.0 ± 3.0 years (range, 6 – 19 years) and 21.3 ± 3.2 prism diopters (PD; range, 15 – 25 PD), respectively. Tendon width of the medial rectus was 7.6 ± 0.7 mm (range, 6.0 - 8.5 mm) and the median value of tendon width was 7.5 mm. The dose response was 4.6 ± 0.8 PD/mm (range, 2.4 - 5.6 PD/mm). The dose response was significantly greater in the wide than in the narrow tendon width group (p < 0.001). Tendon width of the medial rectus was significantly correlated with age, the preoperative angle of deviation and surgical dose response (all, p < 0.05). Conclusion The tendon width of the medial rectus could be a predictor for estimating the surgical dose response when considering unilateral medial rectus resection in patients with the moderate angle of recurrent exotropia.

Intermittent exotropia (X(T)) is one of the most common form of strabismus with surgery being the mainstay of treatment. The main goal of surgery is to preserve binocular vision and stereopsis and to prevent its further loss. The decision to operate is mainly based on four aspects: increasing angle of exodeviation, deteriorating control of X(T), decrease in stereopsis for near or distance and quality of life. Bilateral lateral rectus muscle recession and unilateral lateral rectus recession with medial rectus resection, are the two most common surgical procedures performed and have been studied extensively in basic, divergence excess and convergence insufficiency types of X(T). However, there is no consensus over the relative efficacy of the two procedures in terms of postoperative alignment, residual or recurrent exotropia and consecutive esotropia with widely variable results, which can be attributed to poor understanding of the natural course of the disease. Multiple demographic, clinical and anatomic features that may influence the surgical outcomes have been studied to explain this variability. Moreover, most of the evidence regarding surgical outcomes of X(T) is from retrospective studies and the ongoing randomised prospective trials can shed light on long-term efficacy of these procedures. The goal of this review is to give a comprehensive overview of the outcomes of various surgical techniques in the management of different types of X(T), the preoperative and postoperative factors that may affect the surgical outcomes and to discuss the dilemmas faced by the treating surgeons including the effective management of overcorrection and undercorrection.

Aim To evaluate the relationship between early postoperative deviation and long-term outcome after unilateral recession and resection surgery for adult exotropia, and to evaluate exotropic shift after surgery. Methods This was a retroprospective study involving adult patients with exotropia who underwent unilateral recession and resection surgery and were followed up for at least 2y. The results were evaluated at 2y and the final visit. Factors influencing a successful outcome were analyzed. Early postoperative deviation at 1wk was used to evaluate relationship with long-term outcome. The long-term outcome was classified into 3 groups: successful, acceptable, and poor. Successful outcome was defined as a distance deviation between esodeviation 8 prism diopters (PD) and exodeviation 10 PD. Results Forty-two patients were enrolled. The mean age at surgery was 26y (range, 15-49y). The median follow-up period was 30mo (range, 24-108mo). Successful outcome was found in 81% of patients at 2y and in 71% at the final visit. Overcorrection at 1wk postoperatively was associated with a successful outcome at 2y. Initial postoperative alignment between orthotropia and esodeviation of 8 PD had the highest chance of a successful outcome (RR=2.2). The mean postoperative exotropic drift was 4.7 PD at the first month and 9.3 PD at 2y. Conclusion Initial postoperative deviation can predict long-term outcome after unilateral recession and resection surgery for adult exotropia. The most desirable outcome at 1wk post-operatively was orthotropia to small esodeviation. Most patients have exotropic drift at a subsequent follow-up, especially in the first month after surgery.

The purpose of this study is to investigate clinical and histopathologic features of consecutive exotropia.Thirty patients with consecutive exotropia and negative forced duction testing underwent unilateral medial rectus resection and advancement. Abnormal scleral attachment (appearance of stretched scar or slipped muscle) was documented and compared with histopathology results. The term "stretched scar" is used when tendon-like scar appears between muscle fibers and scleral attachment. The term "slipped muscle" is used when a thin capsule is attached to the sclera and the muscle fibers retracted posteriorly in the capsule. Histopathologic results of resected medial rectus muscles of 11 control patients were compared with cases of consecutive exotropia. Surgical success was defined as10 PD deviation at both distance and near, 6 months after the surgery. Dose-response and risk factors for abnormal scleral attachment were also evaluated.Forty percent of the cases had abnormal scleral attachment. Nineteen patients (63%) showed successful results. The mean dose-responses were for near 4.7 and for distance 4.2 prism diopters per millimeters of resection plus advancement. Preoperative medial rectus underaction was a risk factor for abnormal scleral attachment. The mean muscle percentage in pathology was 10 ± 18.7 in patients with abnormal scleral attachment, 28.3 ± 27.9 in other consecutive exotropia patients, and 26.5 ± 30.6 in 11 control eyes.This study showed surgical success of 63% with one-muscle surgery in consecutive exotropia. Calculated dose-responses could be helpful in surgical planning. In the cases with preoperative medial rectus underaction, risk of abnormal scleral attachment is increased.

To compare postoperative drift after bilateral lateral rectus recession (BLR) and after unilateral recession combined with medial rectus resection (RR) in children with primary moderate-angle intermittent exotropia.The medical records of children with intermittent exotropia in the range of 25A total of 330 children were included (BLR, 175; RR, 155). Exotropic drift was greater in the RR group in the period between day 1 and 6 weeks and from 6 to 12 months (P0.05). Surgical successful rates in each group were comparable: 57.7% in the BLR group and 60.6% in the RR group (P 0.05). However, higher overcorrection rates were noted in the BLR group at 6 and 12 months (16.6% vs 6.5 % at 12 months [P = 0.003]). There were more patients with deteriorated stereopsis after surgery in the BLR group (P = 0.025).In our study cohort, BLR was associated with more stable long-term ocular alignment and a higher rate of overcorrection than RR. Postoperative day 1 overcorrection of16

Purpose To investigate the variability of preoperative measurements in patients with intermittent exotropia and to compare surgical outcomes according to the variability. Methods Patients who underwent unilateral lateral rectus recession and medial rectus resection and had 24 months' postoperative follow-up were enrolled. Patients were divided into three groups according to variability, which was defined as the largest angle minus the smallest angle ever measured during the preoperative visits; group C comprised patients with consistent exodeviation; group VL, patients with less variability ( Results A total of 344 patients were included: 128 in group C, 155 in group VL, and 61 in group VM. The largest variability was 20Δ and 62.8% (216/344, group VL + group VM) of the patients showed variable angles of deviation during the preoperative measurements. The postoperative exodeviation increased in all groups over the 24-month follow-up; however, the postoperative exodeviation of group VM was lower than that of both groups C and VL (repeated-measure ANOVA, P = 0.032). There was a trend toward decreased rates of reoperation from group VM compared with groups VL and C (linear by linear association, P = 0.004). Conclusions More than half of patients with intermittent exotropia showed variable angles of deviation during the preoperative measurements. The surgical outcomes were better in those with variable preoperative measurements than in those with consistent preoperative measurements.

Purpose To compare the success rates and stabilities of postoperative alignment between adjustable and the non-adjustable surgeries in the treatment of sensory exotropia. Methods A 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. Results There 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. Conclusions Strabismus 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.

To evaluate the long-term results of slanted medial rectus (MR) resection for intermittent exotropia (X(T)) of the convergence insufficiency type.In all, 10 patients with an X(T) greater at near than at distance by 10 prism diopters (PD) or more were included in this prospective study. Patients received slanted bilateral MR resection. The upper edge of the MR was resected according to the distance exodeviation and the lower edge of the MR was resected according to near exodeviation. The postoperative follow-up period was between 6 and 62 months with a mean of 38.9 months. The paired t-test was used to compare: mean distance angle of deviation preoperatively and postoperatively; mean near angle of deviation preoperatively and postoperatively; and mean near-distance exodeviation difference preoperatively and postoperatively.Bilateral slanted MR resections reduced mean exodeviation at distance from 23.0+/-7.2 to 16.3+/-5.4 PD (P=0.03); mean exodeviation at near from 34.3+/-7.7 to 24.6+/-6.9 PD (P=0.01); and mean near-distance difference from 11.4+/-2.6 to 8.3+/-3.5 PD (P=0.04). At the final follow-up examination, all patients demonstrated an exodeviation of 10 PD or more at distance and near, and the exodeviation difference between distance and near deviation was within 10 PD in five of the 10 patients. Three patients had an esodeviation at distance after surgery, but all resolved within 4 weeks.Bilateral slanted MR resections in patients with X(T) of the convergence insufficiency type resulted in undercorrection in all patients.

To investigate the outcomes of unilateral medial rectus resection (UMR-res) for the treatment of small to moderate angles of recurrent exotropia in children followed up for a minimum of 6 months.This study is a retrospective, consecutive, interventional case series in which 48 children who underwent UMR-res (range 4.0-7.5 mm) for recurrent exotropia [range 12-25 prism diopters (PD)] between January 2009 and February 2013 were enrolled. Of these 48 children, 32 had recurrent intermittent exotropia, and 16 had recurrent constant exotropia. A successful surgical alignment was defined as +5 to -10 PD of orthophoria in the primary position while viewing distant or near targets.At a mean follow-up of 12 months, the surgical success rate was 75 % (36/48), and the undercorrection rate was 25 % (12/48). No patient exhibited overcorrection. The success rates of the UMR-res in the recurrent intermittent exotropia group and recurrent constant exotropia group were 78 % and 69 %, respectively, and were not significantly different (P = 0.50). In the initial surgical procedure groups, the success rates of patients with bilateral lateral rectus recession, unilateral lateral rectus recession, and unilateral lateral rectus recession combined with medial rectus resection were 81.8 % (18/22), 81.25 % (13/16), and 50 % (5/10), respectively. The surgical success rates did not differ among these three groups (P = 0.122).Based on our results, UMR-res would appear to be an effective and safe procedure for the treatment of intermittent or constant recurrent exotropia of ≤25 PD in children.

Purpose. To evaluate the surgical outcomes of unilateral or bilateral medial rectus (MR) muscle resection for recurrent exotropia after bilateral lateral rectus (BLR) muscle recession based on a novel surgical formula.Methods. Forty-one consecutive patients with unilateral or bilateral MR muscle resection for recurrent exotropia after BLR muscle recession were included in this retrospective study. All surgeries were performed according to the formula: 1.0 mm MR muscle resection for every 5 prism dioptres (PD) of exotropia, with an addition of 0.5 mm to each MR muscle operated on.Results. The mean recurrent exotropia distant deviation was 28 PD ± 11.2 (range 14 to 55 PD). Overall at postoperative 1 month, 36 (88%) achieved successful outcomes, 4 (10%) had undercorrection, and 1 (2%) had overcorrection. At postoperative 6 months, 29 (71%) achieved successful outcomes, 12 (29%) had undercorrection, and none had overcorrection. Subgroup analysis showed no statistically significant difference in success rates between unilateral and bilateral MR groups.Conclusion. Unilateral or bilateral MR muscle resection using our surgical formula is a safe and effective method for calculating the amount of MR resection in moderate to large angle recurrent exotropia, with a low overcorrection rate.

Background: The surgical results for intermittent exotropia of the convergence insufficiency type have been reported to be of varying success. The purpose of this study is to evaluate the surgical results of medial rectus muscle (MR) resection(s) with adjustable suture for this condition. Methods: Twenty-one consecutive patients with intermittent exotropia of the convergence insufficiency type were included in this retrospective study. All patients had a history of prolonged difficulties at near work unrelieved by nonsurgical treatment. Unilateral or bilateral MR resection(s) were done with the adjustable suture, which was tied at the first postoperative day. The target angle was an esotropia of 10 to 20 PD at distance and an esotropia of 5 to 10 PD at near. Postoperatively Fresnel prisms were used temporarily in patients manifesting a consecutive esotropia with diplopia at distance. Postoperative follow-up period was between 6 months and 24 months with a mean of 9.1 months. Results: MR resection(s) with the adjustable suture reduced the mean exodeviation at near from 25.7 to 3 PD. It also reduced the exodeviation at distance from 11.4 to −2 PD (esodeviation). The mean near-distance difference was collapsed from 14.3 PD preoperatively to 5 PD postoperatively. Conclusions: MR resection(s) with adjustable suture combined with intentional postoperative aggressive overcorrection and the use of Fresnel prisms is useful in intermittent exotropia of the convergence insufficiency type. The intentional overcorrection during the immediate postoperative period at distance and near is required to prevent long-term undercorrection. (J AAPOS 2001;5:13-7)

Purpose To prospectively determine the long-term success of medial rectus advancement alone or in combination with other procedures in the management of consecutive exotropia. Methods All patients with consecutive exotropia who underwent medial rectus advancement alone or in combination with medial rectus resection or lateral rectus recession or both, performed by a single surgeon between 1999 and 2010, were included. Initially, a retrospective review was performed. Patients were then recalled and examined by a masked observer. Good results were defined as final alignment within 10 Δ of orthotropia. Results A total of 46 patients were enrolled in the study with a mean age of 43 ± 15.5 years (range, 14-76) and a mean exotropia of 32 ± 18 Δ (range, 10-90). Good results were achieved in 33 patients (72%) at a mean follow-up time of 2.5 years. Of the 21 patients returning for prospective examination, 15 (71%) had good alignment at an average follow-up of 4.2 years (range, 6.9 months to 8.6 years). Adduction deficits were improved in 30 of 33 (91%) patients at final follow-up. Conclusions In patients with consecutive exotropia, surgery including medial rectus advancement alone or in combination with resection or lateral rectus recession or both usually is effective.

Strabismus surgery can lead to successful eye alignment but may cause scarring and distortion of conjunctiva and adjacent structures in some cases. We report two patients who developed epiphora when the lacrimal caruncles became distorted after strabismus surgery. Both cases followed successful medial rectus muscle resections for exotropia. A simple excision of the caruncles improved the epiphora and produced a satisfactory appearance.

Purpose: To investigate the dose-effect relationship of unilateral medial rectus resection for recurrent exotropia after bilateral lateral rectus recession. Methods: This study comprised 39 patients who underwent unilateral medial rectus resection for recurrent exotropia under 25 PD and bilateral rectus recession for prior surgery of exotropia. The medial rectus was resected from 5.0 to 7.0 mm according to angle deviation at a distance. The postoperative deviated angle was checked at one week, 3 months and 6 months postoperatively to investigate the amount of corrected deviation per resected muscle. Results: The average preoperative deviation was 21.33 ± 2.96 PD. We resected mean 6.26 ± 0.57 mm of the medial rectus muscle. The postoperative deviated angle was 0.82 ± 3.47, 1.87 ± 3.10 and 5.40 ± 4.79 PD at 1 week, 3 months and 6 months after surgery, respectively. The corrected deviated angle per millimeter (mm) was 3.29 ± 0.68, 3.17 ± 0.58 and 2.75 ± 0.89 PD at 1 week, 3 months and 6 months after surgery. There were no significant differences among the changes of postoperative deviation per millimeter according to the amount of medial rectus (MR) resection (p-value = 0.423, 0.382) The success rate was 89.75%, 92.31% and 87.18% at 1 week, 3 months and 6 months after surgery, respectively. The expected corrected angle according to the amount of resection remained constant and was 3.04-3.22 PD/mm at 3 months after surgery and 2.79-2.82 PD/mm at 6 months after surgery. Conclusions: The dose-effect per millimeter was decreased as time passed. There was no statistical difference among the corrected deviation angles per millimeter according to the amount of MR resection. We expect that the calculated dose-effect relationship may be a useful guideline for unilateral medial rectus resection for recurrent exotropia. J Korean Ophthalmol Soc 2015;56(3):420-426

Purpose: To assess clinical features of sensory exotropia with distant-near disparity, surgical outcome, and compare according to amount of medical rectus resection. Methods: Authors retrospectively reviewed medical records of patients of sensory exotropia with follow-up over 6 months. We defined patients with over 10 prism diopter (PD) disparity as distant-near disparity sensory exotropia (DND-XT) and without disparity as basic sensory exotropia (B-XT). First, we analyzed and compared data of visual acuity, cause and age of visual loss, amount of deviation. Second, Surgical failure was analyzed with dividing DND-XT into conventional surgery group as Parks’ formula and reduced medial rectus resection group in accordance with disparity. Surgical success was defined as less than 10 PD deviation in distant, near fixation. Results: B-XT consisted of 58 patients (40 males) and DND-XT of 33 patient (13 males). There was no significant difference between 2 groups in onset and cause of visual loss, deviation at distant fixation. But, log MAR visual acuity of worse eye was better in DND-XT than B-XT (1.74 ± 0.78, vs. 2.10 ± 0.74, p = 0.039). Average deviation in distant fixation in DND-XT was 46.55 ± 16.59 PD in distant and 14.93 ± 8.91 PD in near fixation. All patients underwent surgery of medial rectus resection and lateral rectus recession and average deviation was 6.83 ± 7.71 PD at distant fixation, 3.02 ± 0.69 PD at near fixation at last follow-up. Among 33 patients, 16 patients underwent conventional amount of surgery and 17 patients with reduced medial rectus resection. In patient with conventional surgery, 9 patients were surgical failure (8 patients of over-, 1 patient of under-correction) but in patient with reduced amount of resection, only 1 patient was under-correction. Conclusions: As a result of medial rectus resection and lateral rectus recession in DND-XT, more surgical failures due to over-correction were observed with conventional resection and higher surgical success was attained in consideration of disparity. J Korean Ophthalmol Soc 2015;56(10):1599-1603

Purpose: The purpose of this study is to investigate the effect of unilateral medial rectus muscle resection (UMR) for the treatment of recurrent intermittent exotropia after bilateral lateral rectus muscle recession (BLR). Methods: Medical records of 121 subjects who underwent UMR for the treatment of recurrent intermittent exotropia after BLR with more than six months of follow-up were reviewed. Patients were classified into two groups, the 4-mm group who underwent 4-mm UMR and the 5-mm group who underwent 5-mm UMR. Successful postoperative motor alignment was defined as within 10 prism diopters (PD) of exotropia and four PD of esotropia. Results: The mean time interval between the primary surgery and recurrence was 13.55 ± 20.78 months (1-120 months). Average follow-up period after secondary surgery was 27.42 ± 15.98 months (6-48 months). Cumulative success rate at six months after UMR was 87.1% in the 4-mm group and 88.2% in the 5-mm group, respectively, and that at 24 months was 72.7% in the 4-mm group and 50.0% in the 5-mm group (p = 0.132). The average effect of resection was 4.87 ± 0.91 PD/mm in the 4-mm group and 4.73 ± 0.84 PD/mm in the 5-mm group (p = 0.374). Conclusions: Because of recurrent intermittent exotropia, less time is required for surgery in UMR after BLR, and patients and parents are more likely to accept a secondary surgery because of single muscle surgery. Therefore, UMR may be an effective surgical method for patients with 16-30 PD of recurrent intermittent exotropia. J Korean Ophthalmol Soc 2014;55(11):1681-1686

Background The purpose of this study was to measure the success rate of unilateral lateral rectus recession and medial rectus resection in primary exotropia. Methods This is an interventional case series of 55 patients with primary exotropia (degree of deviation 15–85 PD), above the age of 5 years. Patients were treated in the Department of Ophthalmology, Jinnah Postgraduate Medical Center, Karachi, Pakistan, during the period of July 2009 to March 2010. All the patients underwent surgical procedure i.e., lateral rectus muscle recession (maximum up to 10 mm) and medial rectus muscle resection (up to 6 mm) of one eye, according to the Park’s method. Surgery was done based on prism cover test measurements obtained at 6 m with appropriate optical correction in place. Patients were re evaluated at one day, one month, two months and six months post operatively. Final outcome was considered at the end of six months at which achievement of ≤10 PD of exotropia was the success. Data was analyzed on SPSS version 17.0. Results We obtained success (≤10 PD) in 42 out of 55 patients (76.4%) and 13 out of 55 patients (23.6%) did not meet our criteria for surgical success (>10 PD). Analysis of success with the type of primary exotropia showed that success was achieved in 22 out of 24 cases of intermittent type (91.6%) and 20 out of 31 cases of constant type (64.5%)(P Value 0.019). The highest percentage of success was achieved in patients with the pre-operative deviation of ≤70 PD i.e., 93.3% (42 out of 45 cases), while none of the patients with the pre-operative deviation of >70 PD (10 out of 10 cases) achieved the criteria for success. Conclusion We conclude that pre-operative deviation is one of the strongest predictor for favorable surgical outcome. Therefore, eliminating the factors causing error in the correct determination of pre-operative deviation should improve the success and predictability of the surgical outcome. Despite the obstacles in the surgical management of strabismus, our results are encouraging.

Purpose: To investigate changes in corneal astigmatism and refractive power in intermittent exotropia after lateral rectus recession with or without medial rectus resection. Methods: We compared visual acuity, spherical equivalent, refractive power, astigmatism from cycloplegic refraction, and Orbscan corneal topography in two groups consisting of 40 eyes from 20 patients who underwent bilateral lateral rectus recession (Group 1) and 33 eyes from 33 patients who underwent monocular medial rectus resection with lateral rectus recession (Group 2) immediately preoperatively and at 1 and 4 weeks postoperatively. Results: In Group 1, the refractive power changed +0.12 D on average in the horizontal median and -0.08 D on average in the vertical median at 1 week postoperatively. The refractive power changed +0.07 D on average in the horizontal median and -0.04 D on average in the vertical median at 4 weeks postoperatively. No significant change in the corneal astigmatic axis was detected. In Group 2, the refractive power changed +0.4 D on average in the horizontal median and -0.19D on average in the vertical median, and the corneal astigmatic axis significantly shifted by +0.51 D in the ‘with-the-rule astigmatism’ direction at 1 week postoperatively (p=0.02). However, the refractive power changed +0.2 D on average in the horizontal median and -0.09 D on average in the vertical median, and the corneal astigmatic axis changed +0.2 D at 4 weeks postoperatively, although these values were not statistically significant. Conclusions: Postoperative refractive power and corneal astigmatism did not change significantly, as compared to preoperative values, at 4 weeks postoperatively in the lateral rectus recession-only or medial-and-lateral rectus recession group.

Purpose: To investigate the effect of unilateral medial rectus resection in recurrent exotropia under 25 Prism Diopter after unilateral or bilateral lateral rectus recession. Methods: A retrospective chart analysis was conducted for 21 patients who underwent unilateral medial rectus resection for recurrent exotropia under 25PD and uni- or bilateral lateral rectus recession for prior surgery of exotropia. The medial rectus was resected from 5.0 to 7.0 mm by 0.5 mm according to angle deviation at a distance. The postoperative deviated angle was checked at one week, three months and six months postoperatively to investigate the amount of corrected deviation per resected muscle. Results: The average preoperative deviation was 20.573.37PD. We resected mean 6.10.62 mm of the medial rectus. At one week after the surgery, the postoperative deviated angle was 2.004.32PD, After six months it was 6.577.40PD, and there appeared to be an increase of deviation. Ten patients (48%) fused before surgery and 12 (57%) after surgery. The corrected deviation per resected muscle was 2.881.08PD. Conclusions: Unilateral medial rectus resection is an effective surgical method for the treatment of recurrent exotropia under 25 PD after lateral rectus recession.

Twenty-six patients with small-angle constant or intermittent exotropia of up to 7 degrees, and eight patients with small-angle exophoria of the convergence-insufficiency type, underwent unilateral medial rectus resection. Of the 34 patients, 9 were cured, 19 improved and in 6 surgery failed or there was early recurrence. Improvement occurred usually in patients who had basic microexotropia and in some who had homonymous abnormal retinal correspondence, a factor which limited the sensory results. The sensory, motor, and mechanical factors influencing the procedure are discussed in detail. The resection technique employed is reviewed, demonstrating the advantage of well-controlled results. This paper shows that resecting the medial recti is useful, not only in convergence insufficiency, but also in related small-angle exodeviations, for which a classification is proposed.