Surgical results of consecutive exotropia

Outcomes of Consecutive Exotropia Surgery at a Tertiary Eye Hospital in Saudi Arabia

Purpose

This study aimed to evaluate surgical outcomes, compare success rates, and identify potential risk factors for failure of various surgical procedures for consecutive exotropia.

Patients and Methods

This retrospective cohort study was conducted at a tertiary eye hospital in Saudi Arabia and included patients with consecutive exotropia treated between 2007 and 2020. Patients with a follow-up of <3 months were excluded. The type of surgery performed was based on surgeon experience and factors, such as the angle of deviation, adduction limitation, and intraoperative findings. Successful outcome was defined as a deviation of ≤10 prism diopters (PD) at the last follow-up visit.

Results

A total of 59 patients were included in this study. Preoperatively, the mean near and distance deviations were 33 ± 14 PD and 32 ± 14 PD, respectively. Among the included patients, 27.1% underwent medial rectus advancement with or without resection, 28.8% underwent lateral rectus recession, and 44.1% underwent combined surgery. At 12 months postoperatively or the last follow-up visit, the overall success rate of distance-deviation correction and near-deviation correction were 80.6% and 67.8%, respectively. Success rates of different surgeries were not significantly different. The severity of amblyopia and number of muscles operated on did not influence the success rate.

Conclusion

Medial rectus advancement and combined medial rectus advancement with lateral rectus recession were associated with better surgical outcomes than lateral rectus recession alone, although the difference was not statistically significant. The only factor that negatively affected the outcome was a high preoperative near angle of deviation.

Surgical outcomes of medial Rectus advancement for consecutive exotropia

PURPOSE

To evaluate the surgical results of medial rectus muscle advancement for consecutive exotropia.

METHODS

The medical data of patients that underwent reoperation between the years 2000-2020 were collected and reviewed retrospectively. Patients who underwent medial rectus advancement for consecutive exotropia were included. The exclusion criteria were follow-up period shorter than 6 months, past reoperations and restrictive or paralytic strabismus. Success was defined as alignment within 10 PD of orthophoria at last follow-up. The success group of patients was compared with the failure group.

RESULTS

Twenty patients with mean postoperative follow-up from the second surgery of 34.7  ±  29.2 months were included. On last follow-up examination, 9 (45.0%) patients had a successful result. Nine patients had undercorrection and 2 had overcorrection. The two groups were similar in the preoperative amount of mean exotropia, 23.3  ±  9.9 PD in the success group and 29.8  ±  14.0 PD in the failure group. On last follow-up examination, the amount of mean deviation was 2.7  ±  2.6 PD exotropia in the success group and 13.4  ±  23.6 PD exotropia in the failure group.

CONCLUSION

Medial rectus advancement for the correction of consecutive exotropia was successful in almost half of the cases. Failure was usually due to undercorrection.

Evaluation of the insertion distance of the medial rectus in consecutive exotropia by means of intraoperative measure and optical coherence tomography

PURPOSE

To assess the agreement between the measurements of the distance from the medial rectus muscles insertion to the limbus measured by intra-operative spectral-domain optical coherence tomography (SD-OCT) in consecutive exotropia (cXT).

METHODS

An analysis was performed on total of 14 medial rectus (MR) muscles of 14 patients who underwent surgery for the treatment of cXT. The limbus-insertion distance of the MR muscles was measured using preoperative SD-OCT and intraoperatively using a calliper. The intraclass correlation coefficient (ICC) and Bland Altman plots were calculated to determine the agreement between the two methods, as well as the correlation.

RESULTS

Mean age was 36.3 ± 16.0 years (range 13-60), with 60% being women. Mean preoperative deviation was 38.7 ± 16.9 prismatic dioptres (PD) (range 16-65), being +1.3 ± 6.3 PD (range -12 to +10 PD) after surgery. Intraoperatively the MR insertion was found at 8.7 ± 2.1 mm (range 5.5-12.0) and by OCT at 7.7 ± 1.2 mm (range 5.3-10.0). The ICC showed a moderate to good agreement (0.659; 95% confidence interval: 0.157-0.885; p < 0.001), with a correlation of R = 0.792 (p = 0.011). A better agreement was observed in those MR that were less retro-inserted.

CONCLUSIONS

SD-OCT is able to measure the insertion to the limbus distance of the medial rectus muscles that have been previously operated on, showing moderate to good agreement with intraoperative measurements. However, the agreement was poor in muscles with a large retro-insertion.

Surgical treatment of consecutive exotropia: Comparison of different surgical methods applied to one eye in one session

PURPOSE

To compare the different surgical methods performed on a single eye in a single session and the factors that affect the success of patients having consecutive exotropia (XT) developed after esotropia surgery.

METHODS

The medical data of the patients who underwent surgery for consecutive XT were reviewed retrospectively. Patients with followed of 6 months or more were divided into four groups; patients with medial rectus (MR) advancement (Group 1 = 10), MR advancement and MR resection (Group 2 = 12), MR advancement and lateral rectus (LR) recession (Group 3 = 13), MR advancement, MR resection, and LR recession (Group 4 = 14). Success results and possible risk factors were investigated.

RESULTS

Forty-nine patients with consecutive XT (21 female, 28 male) were enrolled in the study. The mean age of overall patients was 22.97 years at surgery for consecutive XT. The groups did not display significant differences in terms of surgery ages, gender, refraction values, visual acuity, amblyopia, inferior oblique overaction, limitation of adduction, surgical success rates, and follow-up time (p > 0.05). Patients of Group 4 had larger preoperative and postoperative deviation, while Group 1 had smaller (p < 0.05). The surgical success rates of Groups 1, 2, 3, 4 were 90%, 75%, 76.9%, and 50%, respectively (p = 0.192). Statistically, no factor was found to be effective in surgical success rates (p > 0.05).

CONCLUSION

Surgical treatment of consecutive XT is successful in most of the patients with numerous surgical options performed on a single eye in a single session. Patients, particularly with a high amount of deviation should be warned about the possibility of additional surgery.

Surgical management of consecutive exotropia: Long-term outcomes

PURPOSE

To compare lateral rectus recession (LRc) and medial rectus advancement (MRadv) for correction of consecutive exotropia (CXT).

METHODS

Of the 43 exotropic patients 20 of them underwent LRc (group 1) and 23 of them underwent MRadv (group 2). Postoperative exodrift, strabismic angle, dose effect relationship were compared with minimum 2 years follow‑up.

RESULTS

An average dose-effect in group 2 is higher than group 1 in the early postoperative period, however there was no significant difference at the second year follow-up (p=0,109). An average exodrift after 2 year follow-up was 6,6±7,12 PD in group 1, and 8,13±7,45 PD in group 2. Postoperative overall success rate was 50% in group 1 and 65% in group 2 at the last follow-up. The success rates were not significantly different between the groups (chi-square, p =0.31).

CONCLUSION

Although there was no statistically significant difference at the last follow-up, better results were obtained with MRadv than LRc in the treatment of CXT.

Management of consecutive exotropia

Purpose:

To determine the clinical characteristics and surgical outcomes of medial rectus (MR) advancement with or without lateral rectus (LR) recession in patients with consecutive exotropia.

Methods:

This interventional case series was performed on patients with consecutive exotropia of more than 15 prism diopters (PD) at least 6 months after the esotropia surgery. All patients were operated using either unilateral or bilateral MR muscle advancement with or without simultaneous LR recession. Ocular deviation at far and near distances, adduction limitation, and exoshift were investigated at the follow-ups of 1 week, as well as 1, 3, and 6 months after the surgery. Operation was considered successful when the postoperative far deviation was <10 PD.

Results:

Thirty patients were evaluated. The mean amount of MR advancement was 5.69 ± 1.33 mm with the mean dose response of 4.7 ± 3.3 and 4.55 ± 4.01 PD at 3 and 6-month follow-ups, respectively. Success rate was reduced from 93% at week 1 to 73% at month 6 due to postoperative exodrift, especially during the first 3 months. Preoperative exotropia was the only contributing factor in our study.

Conclusions:

MR advancement was an effective surgical method for consecutive exotropia correction, especially in cases with MR underaction. Bilateral MR advancement and/or LR recession are suggested in cases with higher preoperative exodeviation. The presence of postoperative exodrift indicates longer follow-ups for patients.

Medial Rectus Advancement for Secondary Exotropia

PURPOSE

To determine the preoperative characteristics and surgical results after medial rectus advancement in patients with secondary exotropia.

DESIGN

Retrospective, interventional case series.

METHODS

Setting: Tertiary Care University Medical Center. PatientPopulation: 221 patients with a diagnosis of secondary exotropia who underwent medial rectus advancement surgery by a single surgeon.

OBSERVATION

Preoperative demographics, exodeviation and motility, intraoperative findings, and postoperative results were recorded. MainOutcomeMeasure: Success of surgery, defined as Esotropia <15 prism diopters (pd) at postoperative week 1, or any deviation of <8 pd at postoperative month 2 (POM2).

RESULTS

A total of 98 patients underwent unilateral medial rectus advancement (UMRadv), 89 underwent UMRadv with lateral rectus recession (LRc), and 34 underwent bilateral medial rectus advancement (BMRadv). POM2 success rates were 66.7% in UMRadv patients, 62.1% in UMRadv + LRc, and 56% in BMRadv. A total of 117 patients had preoperative adduction deficits, which were significantly associated with the finding of an intraoperative stretched scar (P < .001). Larger preoperative duction deficits were associated with larger stretched scars (P < .001). At POM2, the mean effect of surgery (pd of correction/mm) was 2.3 ± 1.4 pd/mm for UMRadv, 2.5 ± 0.8 pd/mm for UMRadv + LRc, and 2.8 ± 1.1 pd/mm for BMRadv. Patients with a stretched scar had significantly less correction per millimeter (2.2 ± 1.2 pd/mm) compared with those without (2.6 ± 1.2 pd/mm, P < .001). A total of 38.6% of patients experienced exodrift greater than 10 pd. Exodrift was significantly larger in the BMRadv group (P < .005).

DISCUSSION

These results provide guidance for surgical correction based on preoperative deviation and ductions. Adduction deficits indicate a stretched scar, which must be treated with resection and advancement of the medial rectus. A larger amount of surgery is needed in patients with a stretched scar. Exodrift is common, and therefore aiming for approximately 10 pd of overcorrection at postoperative week 1 can improve final outcomes.

CONCLUSION

Medial rectus advancement results in successful surgical results at POM2 for secondary exotropia.

Evaluation of the insertion distance of the medial rectus in consecutive exotropia by means of intraoperative measure and optical coherence tomography

PURPOSE

To assess the agreement between the intraoperative measurements of the distance from the medial rectus muscles insertion to the limbus and preoperative spectral-domain optical coherence tomography (SD-OCT) in consecutive exotropia (cXT).

METHODS

An analysis was performed on total of 14 medial rectus (MR) muscles of 14 patients who underwent surgery for the treatment of cXT. The limbus-insertion distance of the MR muscles was measured using preoperative SD-OCT and intraoperatively using a calliper. The intraclass correlation coefficient (ICC) and Bland Altman plots were calculated to determine the agreement between the two methods, as well as the correlation.

RESULTS

Mean age was 36.3±16.0 years (range 13-60), with 60% being women. Mean preoperative deviation was 38.7±16.9 prismatic dioptres (PD) (range 16 to 65), being +1.3±6.3 PD (range -12 to +10 PD) after surgery. Intraoperatively the MR insertion was found at 8.7±2.1mm (range 5.5 - 12.0) and by OCT at 7.7±1.2mm (range 5.3 - 10.0). The ICC showed a moderate to good agreement (0.659; 95% confidence interval: 0.157-0.885; P<.001), with a correlation of R=0.792 (P=.011). A better agreement was observed in those MR that were less retro-inserted.

CONCLUSIONS

SD-OCT is able to measure the insertion to the limbus distance of the medial rectus muscles that have been previously operated on, showing moderate to good agreement with intraoperative measurements. However, the agreement was poor in muscles with a large retro-insertion.

Comparison of surgical outcomes between lateral rectus recession and medial rectus advancement for postoperative consecutive exotropia

To compare the surgical outcomes of medial rectus advancement and lateral rectus recession in postoperative consecutive exotropia with single-stage adjustable suture surgery.Among 1003 patients who underwent bilateral medial rectus recession between November 1996 and March 2013, the patients who required surgery for consecutive exotopia were retrospectively reviewed. Nineteen patients underwent medial rectus advancement and 15 patients underwent lateral rectus recession. All patients underwent single-stage adjustable surgery under topical anesthesia and were followed up for at least 12 months.The mean follow-up duration was 2.4 years. At final follow-up, a successful surgical outcome was found in 12 patients (63.0%) in the medial rectus advancement group and 14 patients (93.3%) in the lateral rectus recession group (P = .039). The change in ocular deviation was correlated with the amount of recession (P = .008) and preoperative angle (P < .001) in the lateral rectus recession group.Lateral rectus recession showed a higher success rate with predictable and easily performed procedure than medial rectus advancement for the treatment of postoperative consecutive exotropia with adjustable suture.

Factors associated with atypical postoperative drift following surgery for consecutive exotropia

PURPOSE

To evaluate the associations of clinical and surgical factors with atypical postoperative drift following surgery for consecutive exotropia.

METHODS

A total of 66 patients with consecutive exotropia (≥10^Δ at distance), after historical surgery for esotropia were retrospectively identified at a tertiary medical center. All patients underwent unilateral lateral rectus recession (on adjustable suture) with medial rectus advancement and/or resection. Immediate postoperative target angle was 4^Δ-10^Δ of esotropia at distance, anticipating mild postoperative exodrift. Actual postoperative drift was calculated as change in distance deviation from immediately postadjustment to 6 weeks. Typical drift was defined as 0^Δ-9^Δ of exodrift. Excessive exodrift was defined as ≥10^Δ. Esodrift was defined as 1^Δ or more. Univariate and multiple logistic regression analyses were performed to evaluate for associations with a wide range of clinical and surgical factors.

RESULTS

Overall there was a median exodrift (4^Δ, quartiles 0^Δ-10^Δ). Of the 66 patients, 18 (27%) showed excessive exodrift; 15 (23%), esodrift. In multiple logistic analyses, larger preoperative distance exodeviation was associated with excessive exodrift (P = 0.01), and non-normal medial rectus attachment status (abnormal [stretched scar, pseudo-tendon], attached to pulley, or behind pulley) was associated with esodrift (P = 0.02).

CONCLUSIONS

Approximately half of patients show atypical drift following unilateral surgery for consecutive exotropia, with larger preoperative distance exodeviation associated with exodrift and non-normal medial rectus muscle status with esodrift. Knowing these associations may help when counseling patients regarding surgical outcomes.

The Incidence of Reoperation and Related Risk Factors Among Patients With Infantile Exotropia

PURPOSE

To determine the incidence and related risk factors of reoperation among patients with infantile exotropia who were operated on at Imam Hossein Medical Center, Tehran, Iran, from 2001 to 2015.

METHODS

In this study, 82 children (55 girls and 27 boys) with infantile exotropia were divided into two groups 3 months after their first operation: children with horizontal deviation of 10 prism diopters (PD) or less (n = 64; success group) and those with horizontal deviation greater than 10 PD (n = 18; failure group). Patients with deviation of 20 PD or greater were indicated for reoperation. Factors including age at the first operation, preoperative angle of deviation, inferior oblique muscle overaction, dissociated vertical deviation, and A- or V-pattern in relation to reoperation were studied. Sensory status of children older than 5 years was also evaluated using Worth 4-dot and Titmus tests.

RESULTS

Reoperation was indicated in 18.3% (n = 15) of patients after 11.5 ± 19 months of follow-up. Preoperative angle of deviation (P < .001) and surgical approach (P = .017) were statistically different between the failure and success groups. The majority of patients (71%) achieved fusion and gross stereopsis (< 3,000 seconds of arc) after surgery.

CONCLUSIONS

According to the results, 18.3% of patients with infantile exotropia, especially those with more preoperative exotropia, needed reoperation to achieve good alignment. Although the recession-resection method had better motor results, the authors could not recommend it as a first operation for all patients with infantile exotropia because it was only performed on patients with amblyopia. Gross stereopsis and binocular fusion were seen in the majority of patients. [J Pediatr Ophthalmol Strabismus. 2017;54(1):22-30.].

Long-term Cosmetic Alignment Following Surgery for Esotropia Versus Exotropia in Childhood: A Comparison Using Survival Curves

PURPOSE

Although long-term results following repair of esotropia and exotropia in childhood have been reported, the two entities have never been directly compared.

METHODS

Records of all children younger than 18 years who underwent horizontal strabismus surgery from 2000 through 2012 were reviewed. Children with structural eye pathology, severe vision loss, neurologic disorders, and incomitant or combined horizontal and vertical deviations were excluded. Failure was defined by a second horizontal surgery or a primary position deviation greater than 20 prism diopters (PD) at any time during follow-up (as long as 10 years). A threshold of 20 PD was chosen because families often consider deviations important enough to warrant a first or second surgery if it is larger but not if it is smaller.

RESULTS

Of 317 children, 235 with esotropia had surgery at a mean age of 42 months and 82 with exotropia had surgery at a mean age of 60 months. Overall, surgery was successful in 78% of those with esotropia and 65% of those with exotropia. A second surgery was performed in 29 (12%) of those with esotropia and 15 (18%) of those with exotropia. The mean deviation at last follow-up, using absolute values, was 9 PD for esotropia and 10 PD for exotropia. Survival curve success was better for esotropia (P = .008).

CONCLUSION

By survival curve analysis, success was more likely among children with esotropia. Many "failures" slipped beyond the 20 PD threshold only transiently and had deviations that were not noticeable to family or friends. Overall, children did reasonably well long-term following surgery for both esotropia and exotropia. Only 14% of the entire group required a second surgery during an average of 41 months of follow-up.