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Consecutive Exotropia Following Surgery Br J Ophthalmol: first published as 10.1136/bjo.67.8.546 on 1 August 1983. Downloaded from British Journal ofOphthalmology, 1983, 67, 546-548 Consecutive exotropia following surgery EUGENE R. FOLK, MARILYN T. MILLER, AND LAWRENCE CHAPMAN From the Department ofOphthalmology, the Abraham Lincoln School ofMedicine, Illinois Eye and Ear Infirmary and Cook County Hospital, USA SUMMARY We studied 250 patients with consecutive exotropia. The interval between the surgical procedure and the onset of the consecutive exotropia may take many years. Consecutive exotropia occurred with all types of corrective esotropia surgery that we studied. Amblyopia and medial rectus limitation postoperatively seemed to be common factors associated with consecutive exotropia. Surgically overcorrected esotropia is a frequent who had an exotropia in the up or down position, but problem confronting the ophthalmologist. Most had straight eyes or an eso deviation in the primary reports on the subject'` analyse the characteristics of position, were excluded. the preoperative esotropia state, the amount of surgery, and the postoperative findings. Factors Results usually mentioned as being responsible'` for the overcorrection include excessive amount of surgery, The age of onset of the esotropia was one of the amblyopia, high hyperopia, and failure to recognise factors investigated. The majority of patients were the patient and evaluate his condition preoperatively. younger than 1 year at the onset (Table 1). This is not We reviewed a large series of patients with con- unusual, because early-onset esotropia most often secutive exotropia to determine common charac- requires surgical correction. It could also be teristics that contributed to overcorrection. speculated that children with an early-onset deviation http://bjo.bmj.com/ are less likely to have stable binocular vision and are Patients and methods more likely to develop a consecutive exotropia. We investigated the age of the patient at the time of We analysed 250 patients with consecutive exotropia surgery and the interval between the onset of the seen during a 10-year period from 1970 to 1980. All deviation and the surgical intervention. There the patients were examined by the authors or by the seemed to be no difference in these groups of patients late Dr Martin Urist. These patients were from 4 with respect to an increased frequency of consecutive on September 26, 2021 by guest. Protected copyright. different sources: the motility clinics of Cook County exotropia. However, it should be noted that only 5 Hospital and of the Illinois Eye and Ear Infirmary patients had surgery before the age of 1 year. The (82;33%), the Motility Consultation Clinic (131 ;52%) more recent patients tended to undergo surgery at an of the Infirmary (patients referred by ophthalmolo- earlier age or closet to the onset of their deviation, gists in private practice), and the private practice of which reflects a current trend throughout the country. one ofthe authors (37;15%). By using these 4 different We found that all surgical procedures we studied sources a variety of surgical procedures could be (Table 2) could produce consecutive exotropia. evaluated in terms of their effect on the production of Patients with initial medial rectus recessions of more consecutive exotropia, different management regimens could be assessed, and a large population Table 1 Age ofonset ofesotropia as reported by patient with consecutive exotropia could be studied. or parent Only patients who had a manifest exotropia in the primary position greater than 10 prism dioptres or 5° Age Number ofpatients for or distance near were included in the study. Those Birth 98 (39%) Correspondence to Dr E. R. Folk, Department of Ophthalmology, ' I year 53 (21%) Illinois Eye and Ear Infirmary, 1855 W Taylor Street, Chicago, > I year 82 (33%) Illinois 60612, USA. Unknown 17 (7%) 546 Br J Ophthalmol: first published as 10.1136/bjo.67.8.546 on 1 August 1983. Downloaded from Consecutive exotropia following surgery 547 Table 2 Types ofsurgery performedfor correction Table 4 Incidence ofamblyopia ofesotropia Number ofpatients Surgery Number ofpatients Amblyopia present 94 (38%) Bilateral medial rectus Amblyopia absent 156 (62%) recession (without displacement) 57 (23%) Recess/resect 118 (47%) 40 patients were observed to be exotropic on the first Other* 75 (30%) postoperative visit (Table 5). This figure probably * Patients having a variety of surgical or multiple surgical procedures. represents iatrogenic cases or those perhaps due to e.g., bilateral medial rectus recession and a resection of one lateral some slippage of the muscle or to an excessive rectus. amount ofsurgery for the deviation. The usual course for patients who developed a deviation later was an than 5 mm were excluded from this study. A surgical acceptable initial postoperative period with a gradual procedure that is generally considered relatively development of an exotropia. Only about a third of ineffective, namely, a unilateral 10 mm lateral rectus these patients developed an exotropia of more than resection, produced a consecutive exotropia in 2 10 prism dioptres in less than one year. An exotropia patients. did not develop until at least one year after surgery in The majority of patients in this study developed a 50% of the patients; 25% did not develop an consecutive exotropia after a single surgical exotropia until 5 years after surgery. Many of these procedure, although 33 patients had multiple surgical -patients were orthophoric for distance and near procedures before becoming exotropic. Frequently vision and were straight in all positions of gaze in the one surgical procedure (i.e., one medial rectus) immediate postoperative period. The surgeon would leave the patient undercorrected, and the same thought an excellent result had been achieved. The procedure on the fellow eye would produce a subsequent exotropia was a disturbing finding. Many significant overcorrection. of the 250 patients demonstrated an exodeviation in A high degree of hyperopia has been thought to be the straight up or straight down position prior to responsible or an important factor in producing a developing a deviation in the primary position. consecutive exotropia. Our study did not show this to The function of the medial rectus muscle was be true (Table 3). Only 28 of 250 (11%) patients evaluated by the Urist version reflex test8 (normal showed a hyperopia in excess of 2-50 dioptres. In medial rotation greater than 35°). All patients who had adduction of less than 24° were described as addition 3 patients showed a myopia in excess of 9 00 http://bjo.bmj.com/ dioptres (1%). The remainder of the patients (219) having limited medial rectus function. A comparative had a refractive error between +2-50 and -1P50 study of 50 surgical patients who either had an (88%). A high degree of anisometropia, which had esotropia that was undercorrected or did not show an been expected, was also not found. exodeviation demonstrated medial rectus function of Amblyopia has commonly been identified as one of 30° or more by the Urist test. In patients with con- the factors important in the development of a con- secutive exotropia the incidence of limitation was secutive exotropia. This was true in our series as well almoE twice that of patients with an absence of (Table 4). Of 250 patients 94 had amblyopia (38%). limitation or a normal function. The greatest degree on September 26, 2021 by guest. Protected copyright. Amblyopia was defined as a visual acuity difference of limitation seemed to be in patients who had of 2 lines where the visual acuity in the poorer eye multiple surgical procedures. The incidence was the could not be improved with lenses. same in the group that underwent a bilateral medial An attempt was made to estimate the length of rectus recession as in the recess-resect group. time between the last surgical procedure and the However, in the rectus recession group an occasional beginning of the consecutive exotropia. Previous reports' indicate that most of the deviations occurred Table 5 Duration between time ofoperation in the immediate postoperative period. In our series and appearance ofexotropia noted Table 3 Refractive error in patients with consecutive Exotropia Number ofpatients exotropia (spherical equivalent calculated and included) Overcorrection noted at first postoperative visit 40 (16%) Refractive error Number ofpatients Overcorrection < I year 55 (22%) Overcorrection 1-4 years 51(20%) - 1 50 to +2 50 219 (88%) Overcorrection 5-8 years 31 (12%) Hyperopia over +2 50 28 (11%) Overcorrection > 8 years 37 (15%) Myopia over -1-50 3 (1%) Unknown 36 (15%) Br J Ophthalmol: first published as 10.1136/bjo.67.8.546 on 1 August 1983. Downloaded from 548 Eugene R. Folk, Marilyn T. Miller, and Lawrence Chapman patient had one medial rectus with a function of less recessions. Urist (personal communication) too was than 240 and a normal postoperative medial rotation always concerned about the possibility of consecutive in the other. exotropia. Large resections of the lateral rectus can cause a limitation of medial rectus function. Discussion Undoubtedly some of the patients in this study with medial rectus underaction represent flaws in the This study emphasises the necessity of studying the surgical technique of rectus recession. However, the long-term history ofstrabismus. The success or failure long duration postoperatively before the onset of of a surgical approach cannot be evaluated within a exotropia suggest5 that control is possible, and short follow-up period. The consecutive exotropia everything should be done to maintain this. may not develop until years after the surgery for esotropia. Not infrequently consecutive exotropia This work was supported in part by Core Grant No. 1792 from the occurred after 'successful' esotropia surgery. The National Institutes of Health, Bethesda, Maryland. incidence in reported series of consecutive exotropia ranged from 4%9 to 20%.'1 It is noteworthy that the 20% incidence occurred in the group of patients with References the longer follow-up.
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