PURPOSE: To investigate the long-term clinical course of intermittent exotropia after surgical treatment to determine whether and when postoperative exo-drift stabilizes, and the required postsurgery follow-up duration in cases of intermittent exotropia. METHODS: We retrospectively reviewed the medical records of patients diagnosed with intermittent exotropia who underwent surgical treatment between January 1992 and January 2006 at Yeungnam University Hospital and postoperatively performed regular follow-up examinations for up to 7 years. We also analyzed the difference in exo-drift stabilization, according to surgical procedure. RESULTS: A total of 101 patients were enrolled in the study. Thirty-one patients underwent lateral rectus recession and medial rectus resection (R&R) and 70 patients underwent bilateral lateral rectus recession (BLR). The postoperative angles of deviation increased significantly during the initial 36 months, but no subsequent significant changes were observed for up to 84 months. Follow-ups for 7 years revealed that more than 50% of the total amount of exo-drift was observed within the first postoperative year. In addition, the angles of deviation at 1 year correlated with those at 7 years postoperatively (Pearson correlation coefficient r = 0.517, p < 0.001). No significant exo-drift was observed after 36 months in patients who underwent BLR, whereas after 18 months in patients who underwent R&R. CONCLUSIONS: The minimum postoperative follow-up required after surgical treatment to ensure stable results is 36 months. In particular, careful follow-up is necessary during the first postoperative year to detect rapid exo-drift. Patients who underwent BLR required a longer follow-up than those who underwent R&R to ensure stable postoperative alignment.
Child ; Child, Preschool ; Exotropia/*physiopathology/surgery ; Female ; Follow-Up Studies ; Humans ; Male ; Oculomotor Muscles/*physiopathology/surgery ; *Ophthalmologic Surgical Procedures ; Postoperative Complications/*physiopathology ; Retrospective Studies ; Vision, Binocular/physiology ; Visual Acuity/physiology

PURPOSE: To compare postoperative exodrift of the first unilateral lateral rectus (ULR) muscle recession with the exodrift of the second contralateral ULR muscle recession in patients with recurrent small-angle exotropia (XT). METHODS: We evaluated the results of a second ULR muscle recession in 19 patients with recurrent XT with deviation angles under 25 prism diopter (PD), following a first procedure of ULR muscle recession for small-angle XT. Recession of the lateral rectus muscle ranged from 8 to 9 mm. The postoperative motor alignment and degree of exodrift were investigated after the first ULR muscle recession and the second ULR muscle recession in the same patients. RESULTS: Observed differences in postoperative ocular alignment between the first ULR muscle recession and the second ULR muscle recession were statistically significant at follow-up periods of six months (7.84 +/- 4.43 vs. 3.89 +/- 3.47 PD), one year (9.58 +/- 4.97 vs. 5.21 +/- 4.94 PD), and at a final follow-up (21.11 +/- 2.98 vs. 7.52 +/- 4.06 PD) after surgery (p = 0.006, 0.013, and 0.000). Postoperative exodrift was statistically different between the first and second ULR muscle recessions at three to six months (2.89 +/-3.75 vs. 0.63 +/- 3.45 PD) and one year to final follow-up (11.52 +/- 5.50 vs. 2.32 +/- 3.53 PD) (p = 0.034 and 0.000). All of the first ULR muscle recession patients showed XT with deviation angles of more than 15 PD at the final follow-up. Regardless, the surgical success rate (<8 PD) after the second ULR recession was 63.16% (12 patients) among the total amount of patients with recurrent XT. CONCLUSIONS: This study shows that changes in exodrift after a second ULR muscle recession are less than changes after the first URL muscle recession among patients with recurrent XT. A second ULR muscle recession may be a useful surgery for small-angle XT patients with deviation angles of 25 PD or less after a first ULR muscle recession.
Child ; Child, Preschool ; *Exotropia/etiology/physiopathology/surgery ; Female ; Follow-Up Studies ; Humans ; Male ; Oculomotor Muscles/physiopathology/*surgery ; *Ophthalmologic Surgical Procedures ; *Postoperative Complications ; Recurrence ; Retrospective Studies ; Vision, Binocular/physiology

PURPOSE: To investigate and compare the clinical courses and surgical success rates of secondary operations in recurrent exotropia according to the type of first operation for correction of exotropia. METHODS: A retrospective chart review was performed for all patients with recurrent exotropia of the basic or pseudodivergence excess types. In group A (36 patients), bilateral lateral rectus (LR) recession was performed as the first operation and uni- or bilateral medial rectus (MR) resection was performed as the second operation. In group B (19 patients), unilateral LR recession-MR resection (R&R) was performed as the first operation and LR recession or R&R in contralateral eye as the second operation. RESULTS: There were no significant differences between the 2 groups when considering age at each operation, frequency of the amblyopia, prescription of prism, time interval for recurrence and reoperation and the final and cumulative success rates. No postoperative complications were observed in either group. The mean number of used muscles for the first and second operation was 3.9 +/- 0.4 in group A, and 3.4 +/- 0.5 in group B (p = 0.001). Mean time interval for occurrence of postoperative orthophoria was 3.7 +/- 6.2 months in group A and 6.5 +/- 16.2 in group B (p = 0.047). In group B, the incidence of esodeviation tended to increase after postoperative 1 month. CONCLUSIONS: The final success rates of reoperation between the 2 types of the first operation in recurrent exotropia were similar. Mean time between postoperative overcorrection of orthophoria was shorter in the group with bilateral LR recession followed by secondary MR resection than in the other group. Unilateral R&R followed by LR recession or R&R in contralateral eye may be more helpful to decrease the number of used muscles than in the bilateral LR recession followed by secondary MR resection.
Amblyopia ; Esotropia ; Exotropia* ; Humans ; Incidence ; Muscles ; Postoperative Complications ; Prescriptions ; Recurrence ; Reoperation* ; Retrospective Studies

PURPOSE: To investigate and compare the clinical courses and surgical success rates of secondary operations in recurrent exotropia according to the type of first operation for correction of exotropia. METHODS: A retrospective chart review was performed for all patients with recurrent exotropia of the basic or pseudodivergence excess types. In group A (36 patients), bilateral lateral rectus (LR) recession was performed as the first operation and uni- or bilateral medial rectus (MR) resection was performed as the second operation. In group B (19 patients), unilateral LR recession-MR resection (R&R) was performed as the first operation and LR recession or R&R in contralateral eye as the second operation. RESULTS: There were no significant differences between the 2 groups when considering age at each operation, frequency of the amblyopia, prescription of prism, time interval for recurrence and reoperation and the final and cumulative success rates. No postoperative complications were observed in either group. The mean number of used muscles for the first and second operation was 3.9 +/- 0.4 in group A, and 3.4 +/- 0.5 in group B (p = 0.001). Mean time interval for occurrence of postoperative orthophoria was 3.7 +/- 6.2 months in group A and 6.5 +/- 16.2 in group B (p = 0.047). In group B, the incidence of esodeviation tended to increase after postoperative 1 month. CONCLUSIONS: The final success rates of reoperation between the 2 types of the first operation in recurrent exotropia were similar. Mean time between postoperative overcorrection of orthophoria was shorter in the group with bilateral LR recession followed by secondary MR resection than in the other group. Unilateral R&R followed by LR recession or R&R in contralateral eye may be more helpful to decrease the number of used muscles than in the bilateral LR recession followed by secondary MR resection.
Amblyopia ; Esotropia ; Exotropia* ; Humans ; Incidence ; Muscles ; Postoperative Complications ; Prescriptions ; Recurrence ; Reoperation* ; Retrospective Studies

PURPOSE: To evaluate the changes of refractive astigmatism after horizontal rectus muscle surgery in intermittent exotropic children. METHODS: Sixty-nine exotropic patients were retrospectively reviewed. Of those, 35 patients received unilateral lateral rectus recession (BLR group, 35 eyes) and 34 patients received unilateral lateral rectus recession and medial rectus resection (R&R group, 34 eyes). Non-cycloplegic refractions were measured until 6 months postoperatively. Spherical equivalent (SE), J0 and J45 using power vectors were calculated to determine and compare the changes of refractive astigmatism and axis in both groups. RESULTS: SE significantly decreased after surgery for the first week and did not changed thereafter in both groups (p = 0.000 and p = 0.018, respectively). In BLR group, J0 showed significant changes at the first week and 1 month after surgery (p = 0.005 and p = 0.016, respectively), but in R&R group, J0 changed significantly between 1 week and 3 months postoperatively (p = 0.023 and p = 0.016, respectively). J45 did not change significantly as time passed in both groups (all p > 0.05). There was no statistically significant difference in the magnitude of changes in SE, J0 and J45 between the two groups after the 6-month follow-up (p = 0.500, p = 0.244 and p = 0.202, respectively). CONCLUSIONS: Horizontal rectus muscle surgery in intermittent exotropic children tends to induce a statistically significant change in astigmatism in the with-the-rule direction and myopic shift in SE. This astigmatism change seems to occur within the first 3 months after surgery. Thus, astigmatism induced by surgery should be checked and corrected at least 3 months after horizontal strabismus surgery.
Adolescent ; Astigmatism/*etiology/physiopathology ; Child ; Child, Preschool ; Exotropia/complications/physiopathology/*surgery ; *Eye Movements ; Female ; Follow-Up Studies ; Humans ; Male ; Oculomotor Muscles/surgery ; Ophthalmologic Surgical Procedures/*methods ; Retrospective Studies ; Treatment Outcome ; Vision, Binocular/*physiology

PURPOSE: To suggest a surgical normogram for lateral rectus recession in exotropia associated with unilateral or bilateral superior oblique muscle palsy (SOP). METHODS: We retrospectively reviewed the charts of 71 patients with exotropia who were successfully corrected over one year. Each patient had undergone unilateral or bilateral rectus recession associated with uni- or bilateral inferior oblique (IO) 14 mm recession, using a modified surgical normogram for lateral rectus (LR) recession, which resulted in 1 to 2 mm of reduction of LR recession. We divided all patients into 2 groups, the 34 patients who had undergone LR recession with unilateral IO (UIO) recession group and the remaining 37 patients who had undergone LR recession with bilateral IO (BIO) recession group. Lateral incomitancy was defined when the exoangle was reduced by more than 20% compared to the primary gaze angle. The surgical effects (prism diopters [PD]/mm) of LR recession were compared between the two groups using the previous surgical normogram as a reference (Parks' normogram). RESULTS: The mean preoperative exodeviation was 20.4 PD in the UIO group and 26.4 PD in the BIO group. The recession amount of the lateral rectus muscle ranged from 4 to 8.5 mm in the UIO group and 5 to 9 mm in the BIO group. Lateral incomitancy was noted as 36.4% and 70.3% in both groups, respectively (p = 0.02). The effect of LR recession was 3.23 +/- 0.84 PD/mm in the UIO group and 2.98 +/- 0.62 PD/mm in the BIO group and there was no statistically significant difference between two the groups (p = 0.15). CONCLUSIONS: Reduction of the LR recession by about 1 to 2 mm was successful and safe to prevent overcorrection when using on IO weakening procedure, irrespective of the laterality of SOP.
Child ; Exotropia/complications/physiopathology/*surgery ; Eye Movements ; Female ; Follow-Up Studies ; Humans ; Male ; *Nomograms ; Oculomotor Muscles/physiopathology/*surgery ; Ophthalmologic Surgical Procedures/*methods ; Retrospective Studies ; Treatment Outcome ; Trochlear Nerve Diseases/*complications/physiopathology/surgery

An 11-year-old female presenting diplopia only at distance was found to have comitant esotropia of 20 prism diopters (PD) at distance and normal alignment at nearer proximity. Other ocular movement, including abduction, was normal and a thorough neurologic examination was also normal. The deviation angle of esotropia was increased to 35 PD in 6 months, and a brain magnetic resonance imaging with venogram at that time demonstrated no intracranial lesion. A lumbar puncture showed increased opening pressure but the cerebrospinal fluid composition was normal. The patient was diagnosed as having idiopathic intracranial hypertension and treated with oral acetazolamide. Three months after treatment, the deviation angle decreased to 10 PD. This is a case report of divergence insufficiency in pediatric idiopathic intracranial hypertension, with an increasing deviation angle of esotropia. Although sixth cranial nerve palsy is a common neurologic manifestation in intracranial hypertension, clinicians should be aware of the possibility of divergence insufficiency. Also, ophthalmoparesis may not be apparent and typical at first presentation, as seen in this case, and therefore ophthalmologists should be aware of this fact, while conducting careful and proper evaluation, follow-up, and intervention.
Acetazolamide/administration & dosage ; Administration, Oral ; Child ; Diagnosis, Differential ; Diuretics/administration & dosage ; Esotropia/diagnosis/*etiology/physiopathology ; Exotropia/diagnosis/*etiology/physiopathology ; Eye Movements ; Female ; Follow-Up Studies ; Humans ; Intracranial Pressure ; Magnetic Resonance Imaging ; Pseudotumor Cerebri/*complications/diagnosis/drug therapy ; Spinal Puncture/methods ; Vision, Binocular ; Visual Acuity

The changes of higher-order aberrations (HOAs) after bilateral lateral rectus muscle recession were evaluated. Forty eyes of 20 children were enrolled and their wavefront information was assessed until postoperative 3 months. Even though the root mean square (RMS) of total aberration was not changed, the RMS of HOA was transiently increased at postoperative 1 week and returned to baseline level after 1 month. Among individual Zernike coefficient, secondary astigmatism, quadrafoil, secondary coma, secondary trefoil, and pentafoil showed similar tendency with the RMS of HOA. However, coma, trefoil, and spherical aberration were not changed. Regarding recession amount, it did not correlate with any Zernike coefficient. In summary, our data imply that the HOAs are transiently increased after lateral rectus recession surgery. These results are in collusion with previous reports that strabismus surgery induced transient corneal astigmatism.
Adolescent ; Astigmatism/*etiology ; Child ; Child, Preschool ; Exotropia/*surgery ; Female ; Humans ; Male ; Postoperative Care ; *Postoperative Complications/epidemiology/pathology ; Vision Tests

A 4-year-old boy visited the hospital with exotropia after brain hemorrhage caused by trauma. He had undergone decompressive craniectomy and cranioplasty 18 months prior to presentation at our hospital. An alternate prism cover test showed more than 50 prism diopters (PD) of left exotropia when he was fixing with the right eye and 30 PD of right exotropia when he was fixing with the left eye at near and far distance. On the Hirschberg test, 60 PD of left exotropia was noted in the primary position. Brain computerized tomography imaging performed 18 months prior showed hypodense changes in the right middle cerebral artery and anterior cerebral artery territories. Subfalcian herniation was also noted secondary to swelling of the right hemisphere. The patient underwent a left lateral rectus muscle recession of 7.0 mm and a left medial rectus muscle resection of 3.5 mm. Three weeks after the surgery, the Hirschberg test showed orthotropia. On alternate prism cover testing, 8 PD of left exotropia and 8 PD of right esotropia were noted at distance. We report a patient who developed dissociated horizontal deviation after right subfalcian subdural hemorrhage caused by trauma.
Brain Injuries/*complications ; Child, Preschool ; Decompressive Craniectomy/*adverse effects ; Esotropia/*etiology/surgery ; Exotropia/*etiology/surgery ; Hematoma, Subdural/etiology/radiography/*surgery ; Humans ; Male ; Oculomotor Muscles/*surgery ; Tomography, X-Ray Computed ; Treatment Outcome

We report the effects of unilateral recession-resection surgery of the horizontal recti muscles with inferior displacement and augmented anterior transposition of the inferior oblique muscle with a posterior intermuscular suture in a patient with large exotropia and considerable hypertropia.
Exotropia/*complications/*surgery ; Humans ; Male ; Middle Aged ; Oculomotor Muscles/*surgery ; Strabismus/*complications/*surgery ; Treatment Outcome