The long-term surgical outcomes of lateral rectus advancement in consecutive esotropia.

PURPOSE: To evaluate the long-term surgical efficacy of lateral rectus advancement (LRadv) in patients with consecutive esotropia (CET). METHODS: The medical records of 30 patients who developed CET after bilateral lateral rectus (BLR) recession for exotropia (XT) between 2012 and 2020 were reviewed. The characteristics of patients during their XT surgery were summarized. Among them, 15 patients who underwent LRadv as CET treatment with at least a 1-year follow-up were included to evaluate the long-term efficacy of this surgical approach. The main outcomes were the pre- and post-operative angle of deviation after LRadv. Surgical success was defined as the postoperative deviation within 10 prism diopters (PD), and reoperation was not needed. All data were expressed as median and interquartile ranges. RESULTS: The median follow-up was 34 months after LRadv surgery. The median postoperative deviation ranged from 28 to 1 PD at 1 year (P < 0.05) and to 5 PD at the final follow-up (P < 0.05). The deviation at each follow-up time showed no statistically significant difference (P > 0.05). The final surgical success was reduced compared to 1 day and 1 year postoperatively (60% VS 100% and 66.7%, respectively). Undercorrection and overcorrection both occurred at the final follow-up. CONCLUSION: Although the immediate surgical outcome of LRadv was satisfactory, the success rate reduced with time, which suggests long-term observation is necessary to detect and timely provide appropriate interventions for overcorrection or undercorrection.

Unilateral lateral rectus muscle advancement surgery based on one-fourth of the angle of consecutive esotropia.

BACKGROUND: To evaluate the efficacy of unilateral lateral rectus muscle advancement surgery based on one-fourth of the angle of consecutive esotropia within 25 prism diopters (PD) occurring after bilateral lateral rectus muscle recession for intermittent exotropia. METHODS: Medical records of 11 patients who underwent unilateral lateral rectus muscle advancement for consecutive esotropia from 2011 to 2014 and who were observed for at least 6 months after surgery were retrospectively reviewed. The change in angle of deviation from before to after consecutive esotropia surgery, as well as the success rate and surgical effect, were evaluated. RESULTS: Preoperative esodeviation was -19.6 ± 4.7 PD [median - 20.0 PD, interquartile range (IQR) 9.0] at distance and -16.5 ± 7.4 PD [median - 18.0 PD, IQR 17.0] at near. The mean surgical amount of unilateral lateral rectus muscle advancement surgeries, based on one-fourth of the angle of consecutive esotropia, was 4.8 ± 1.1 mm [median 5.0 mm, IQR 2.0]. Of the 11 patients, 10 (91%) recovered to orthotropia or exodeviation within 8 PD. The surgical effects of unilateral lateral rectus muscle advancement were 3.3 ± 0.7 PD/mm [median 3.6 PD/mm, IQR 1.0] after 1 day, 3.7 ± 0.6 PD/mm [median 3.8 PD/mm, IQR 1.0] after 1 week, and 3.8 ± 0.7 PD/mm [median 3.8 PD/mm, IQR 1.5] after 6 months. CONCLUSIONS: Unilateral lateral rectus muscle advancement surgery based on one-fourth of the angle of consecutive esotropia within 25 PD was successful in all 11 patients. The surgical effect was significantly greater in unilateral lateral rectus muscle advancement than in primary lateral rectus muscle recession. Reduction in the amount of surgery should be considered carefully in unilateral lateral rectus muscle advancement for consecutive esotropia.

Slanted and Standard Lateral Rectus Recession Procedures for Convergence Insufficiency-Type Intermittent Exotropia in Children: A Retrospective Cohort Study.

Purpose: To evaluate the efficacy and safety of slanted bilateral lateral rectus recession (BLR-rec) for treating convergence insufficiency-type intermittent exotropia (CI-IXT) in children. Methods: In this retrospective cohort study, 26 patients aged <16 years with CI-IXT who underwent BLR-rec between August 2016 and July 2021 with six months of follow-up data post-surgery were classified into slanted BLR-rec group (n = 14) and standard BLR-rec group (n = 12; equal-length recession of the upper and lower horns of the LR muscle). Surgical outcomes were compared between the groups. Results: In the slanted and standard groups, the preoperative distance exodeviation was 27.9 ± 5.5 and 30.8 ± 10.0 prism diopter (PD) (p = 0.63), near exodeviation was 41.1 ± 5.6 and 42.9 ± 9.2 PD (p = 0.75), and difference between near and distance deviation (N-D deviation difference) was 13.2 ± 3.2 and 12.1 ± 3.3 PD (p = 0.30), respectively. The ratio of postoperative and preoperative N-D deviation difference was compared between the slanted BLR and standard BLR groups at six months postoperatively. The results revealed that the ratio for slanted-BLR was 0.44 ± 0.19, and for standard-BLR was 0.84 ± 0.24. In the standard group, stereoacuity remained unchanged post-surgery compared to that pre-surgery, while the slanted group showed significant improvement (p < 0.05, Wilcoxon signed-rank test). Conclusion: Compared with the standard BLR-rec procedure, the slanted BLR-rec procedure reduced N-D deviation differences in CI-IXT, positively impacting gross stereopsis.

Convergence insufficiency with diplopia: Surgical treatment in adults.

OBJECTIVE: To study the outcomes of treatment with central mini-plication of the medial rectus (MR) muscles in adult convergence insufficiency with diplopia. METHODS: The study sample comprised 9 cases (7 women). The length of MR plication was collected. Other variables reported were postsurgical deviation, overcorrections in the early postoperative period and at the end of follow-up, final horizontal deviation at near and at distance vision, diplopia, and mean follow-up from surgery. Surgical outcome was considered to be favorable when diplopia and symptoms were resolved and final exotropia at near was ≤8 pd at the end of follow-up. RESULTS: A central mini-plication of the MR was performed in 9 patients (8 unilateral). Mean (±SD) age was 58.66 (21.39) years. Mean near preoperative deviation: 16.22 (±2.9) pd and distance preoperative deviation: 6.88 (±4) pd Overcorrection at distance vision was recorded in 5 cases; this resolved by 3 months postoperatively. There was not overcorrection at near vision except one case. None of the cases operated on had overcorrection at the end of follow-up. The final horizontal deviation was ≤8 pd at near vision, except for 3 cases (mean: 6.22). Symptoms and diplopia resolved in 8 cases. The mean follow-up was 10.33 months. CONCLUSION: Central mini-plication of 1 or 2 medial rectus muscles can improve the symptoms and signs of exotropia associated with convergence insufficiency when exercises and the prisms are rejected by the patients and when these approaches have not solved the problem.

Results of fusional vergence therapy in managing consecutive esotropia: A case series.

Purpose: To analyze the efficacy of fusional vergence therapy (FVT) in management of consecutive esotropia with diplopia after intermittent exotropia (IXT) surgery. The current study is carried on how FVT affects the duration of treatment, sensory fusion, and exotropic drift. Methods: This was a retrospective study for the medical record of 11 patients with consecutive esotropia after IXT surgery of 543 patients over the period of 5 year, with mean surgery age of 9.5 (range: 4-33 y). FVT was planned after minimum 6 weeks of surgery and was considered for maximum 24 weeks. Patients underwent a combination of office-based and home-based FVT. Successful outcome of therapy was considered where diplopia resolves in free space and achieves sensory fusion, stereopsis with no manifest deviation. Results: Record of 543 patients who had horizontal muscle surgery for IXT were identified and reviewed. Records of 11 patients who showed consecutive esotropia of 10 prism diopter (PD) or more with normal retinal correspondence, with or without diplopia complaint, after 6 week of surgery and had undergone vision therapy management were reviewed. A successful outcome of binocular single vision with good sensory and motor fusion with no manifest deviation or prism requirement was achieved with in the mean duration of 4.8 month of therapy. With a mean duration of 4 weeks of therapy, the mean angle of deviation reduced by 53% for distance (17 PD to 8 PD) and 27% for near (11 PD to 8 PD) and mean stereopsis improvement by 80% with 94% patients demonstrating sensory fusion on Bagolini test and 94% of patients having no symptoms of diplopia or squint. Conclusion: With nonsurgical management involving refractive error correction, FVT, and prism, consecutive esotropia was resolved in 74% cases. Management of consecutive esotropia with FVT can result in satisfactory sensory fusion and successful motor alignment.

Effect of age on reoperation rate in children undergoing exotropia surgery.

PURPOSE: To determine the effect of age on the reoperation rate in children undergoing exotropia surgery. METHODS: This was a population-based retrospective cohort study using claims data that included children ≤ 12 years who had undergone exotropia surgery as the first strabismus operation and had ≥ 3 years of continuous enrolment were selected from the Optum de-identified Clinformatics Data Mart Database (2003-2019). Patient age at the first exotropia surgery was grouped into three categories; 0-3, 4-6, and 7-12 years. We assessed the sex, race, age, surgical methods, continuous enrolment period after the first surgery, and the time between the first surgery and reoperation. Cox regression analysis was used to estimate the risk of reoperation at different ages. The hazard ratio of reoperation in children undergoing exotropia surgery according to the age at the first exotropia surgery. RESULTS: Among 2015 children, 312 (15.5%) underwent one or more reoperations. A reoperation was more often performed for recurrent exotropia (n = 231) than for consecutive esotropia (n = 81). The time between the first surgery and reoperation was shorter for reoperation for consecutive esotropia (376 days) than for recurrent exotropia (672 days) (p < 0.001). Younger children showed a higher reoperation hazard ratio than older children (p < 0.001). In reoperation for consecutive esotropia, the patients aged 0-3 years showed a high hazard ratio (2.82; 95% CI, 1.59-5.01). CONCLUSION: Children undergoing exotropia surgery at a younger age have a higher reoperation rate than those undergoing surgery at an older age.

Predicting Risk Factors for Consecutive Esotropia Failed with Conservative Therapy.

Purpose: To investigate risk factors predisposing to the failure of nonsurgical treatment of consecutive esotropia.Methods: A retrospective review was carried out for all cases diagnosed as having developed consecutive esotropia who following surgical correction of intermittent exotropia between 2013 and 2018 and have failed to conservative treatment. Performing 1:2 case-control match, control subjects were randomly selected from patients who underwent surgeries for intermittent exotropia during the same period but did not develop consecutive esotropia. Various factors were examined for assessing the risks for the failure of nonsurgical intervention in the treatment of consecutive esotropia.Results: A total of 270 patients were enrolled in the study. Ninety cases were diagnosed as consecutive esotropia and 180 as controls. Univariate analysis showed significant association of consecutive esotropia for ineffective nonsurgical treatment with age of the patient at the onset of exotropia, age of the patient at the time of surgery, amblyopia, preoperative deviation, the type of surgical procedure, and the vertical components combined with exotropia (p<0.01).To further explore potential risk factors of consecutive esotropia, conditional logistic regression model was applied. Patients aged below 3 years old at the time of surgery and bilateral lateral rectus recession were shown in conditional logistic regression analysis to be significantly associated with higher incidence of consecutive esotropia (p<0.01).Conclusion: The presence of an early age (below 3 years old) at surgery and bilateral symmetric procedure may be associated with a high risk of consecutive esotropia who failed with conservative therapy. Systematic preoperative examination, close supervision, suitable surgical approach could be optimized to reduce the risk of consecutive esotropia.

High Accommodative Convergence/Accommodation Ratio Consecutive Esotropia Following Surgery for Intermittent Exotropia: Clinical Feature, Diagnosis, and Treatment.

Consecutive esotropia is a common and stereopsis-threatening consequence of surgery for intermittent exotropia. However, too little attention has been paid to the accommodative convergence per accommodation (AC/A) ratio in this condition. We aimed to describe the clinical features of patients who developed consecutive esotropia with a high AC/A following surgery for intermittent exotropia, compared to those with normal AC/A. In this retrospective cohort study, we identified 54 patients with consecutive esotropia who remained esotropic at one month after surgery. Patients were divided into two groups: normal AC/A and high AC/A groups. Clinical features and outcomes were compared between the two groups. Fourteen (25.9%) of the 54 were classified as high AC/A consecutive esotropia. Good preoperative control at near was the only significant preoperative factor associated with the development of high AC/A consecutive esotropia. Bifocal glasses were prescribed for all patients with high AC/A consecutive esotropia, and 11 (78.6%) of them achieved satisfactory alignment at distance and near fixations using bifocals. Patients with high AC/A consecutive esotropia had a significantly more successful alignment (0.9 vs. 13.0 prism diopters, p < 0.001) and better stereopsis (67.9 vs. 670.0 arc seconds, p = 0.04) than the normal AC/A counterparts at the final follow-up. We suggest that high AC/A consecutive esotropia could be successfully managed by wearing bifocals in most cases. A high AC/A ratio in patients with consecutive esotropia may be considered as a clinical marker heralding a better prognosis.

Consecutive Esotropia with and without Abduction Limitation - Risk Factors and Surgical Outcomes of Lateral Rectus Advancement.

Purpose: To identify risk factors for abduction limitation in consecutive esotropia following surgical correction of exotropia. To study outcomes of lateral rectus advancement for consecutive esotropia correction.Methods: Patients with consecutive esotropia (>10PD) operated between 2007 and 2019 with a minimum follow-up of 2 months were reviewed retrospectively. Preoperative and postoperative alignment and ocular motility were recorded. Patients were classified into those with full abduction (group-A) and with abduction limitation (group-B). Success was defined as deviation ≤10 PD of esotropia or exotropia in the primary position.Results: Forty-cases fulfilled the inclusion criteria (group-A = 28 and group-B = 12). Median age at surgery was five years, median consecutive esotropia was 20PD and follow-up was 29.18 months. Abduction limitation (group-B) was associated with constant exotropia (p = .01) and larger bilateral lateral rectus recession (group-A = 13 mm, group-B = 15 mm; p = .04). Nineteen patients underwent lateral rectus advancement (group-A = 12, group-B = 7), one underwent medial-rectus recession and two were excluded due to lack of postoperative follow-up. Five patients had spontaneous resolution with good alignment (group-A = 3, group-B = 2), two refused surgery, three were observed and eight were lost to follow-up. Success following second surgery was similar in both groups (group-A = 86%, group-B = 77%)(p = 1).Conclusion: Constant exotropia and larger lateral rectus recession were associated with abduction limitation in consecutive esotropia. Lateral rectus advancement produced good outcomes irrespective of abduction limitation.

Clinical Manifestations of Delayed-onset Consecutive Esotropia after Surgical Correction of Intermittent Exotropia.

PURPOSE: To evaluate the clinical features and prognosis of a delayed-onset consecutive esotropia (ET) after surgical correction of intermittent exotropia. METHODS: Thirty-four patients who developed consecutive ET after primary bilateral lateral rectus recession for the surgical correction of intermittent exotropia were evaluated retrospectively and were divided into two groups: delayed-onset consecutive ET group and the continuous consecutive ET group. Patients who developed esodeviation after once recovering to orthotropia within 1 month after the operation were included in the delayed-onset consecutive ET group, and patients with continuous esodeviation after the operation were included in the continuous consecutive ET group. We evaluated preoperative and postoperative angle of deviation, suppression, stereopsis, and follow up periods between the two groups and compared re-operation and success following non-surgical treatment between the continuous consecutive ET group and the delayed-onset consecutive ET group. RESULTS: Among 34 patients with consecutive ET, 27 patients (79.4%) were included in the delayed-onset consecutive ET group, and seven patients (23.3%) were included in the continuous group. Success rate of non-surgical treatment was not statistically significant between two groups (p = 0.55), but it was higher in the delayed-onset group with 37.5%, and 25% of patients in continuous group were successfully recovered to straight alignment. Duration of orthotropia in delayed-onset group was 7.4 ± 6.0 months (range, 2-29 months). Age, sex, preoperative refractive error, preoperative exodeviation, suppression, and near steroacuity were not statistically significant between two groups (p > 0.05, all). In the delayed-onset group, three patients (11.1%) underwent re-operation, while three patients (42.9%) in continuous consecutive ET group underwent re-operation (p = 0.048). CONCLUSIONS: Re-operation rate of delayed-onset consecutive ET after surgical correction of intermittent exotropia was lower than that of continuous consecutive ET.

Central Mini-plication of the Medial Rectus for Convergence Insufficiency.

Five cases with a mean (± SD) age of 61 (12.02) years are described to study the outcomes of treatment with central mini-plication of the medial rectus (MR) muscles in adult convergence insufficiency with diplopia and near exotropia: mean preoperative deviation: 18 (± 2) pd. Surgical outcome was considered to be favorable when diplopia and symptoms were resolved and final exotropia at near was ≤8 pd at the end of follow-up. A central mini-plication of the medial rectus (MR) muscles was performed in 5 patients (4 unilateral). Overcorrection at distance vision was recorded in 3 cases; this resolved by 3 months postoperatively. There was not overcorrection at near vision in any case. None of the cases operated on had overcorrection at the end of follow-up. The final horizontal deviation was ≤8 pd at near vision, except for 1 case. Symptoms and diplopia resolved in every case but 2/5 required reoperations. The mean follow-up was 8 (2.12) months. Central mini-plication of 1 or 2 medial rectus muscles can improve the symptoms and signs of exotropia associated with convergence insufficiency when exercises and the prisms are rejected by the patients and when these approaches have not solved the problem.

Consecutive cyclic esotropia - A case report.

Cyclic esotropia, a rare condition of obscure etiology characterized by regularly alternating periods of esotropia and orthophoria. We present a case of a 7-year-old boy who underwent surgical correction for intermittent exotropia elsewhere and developed esotropia with cyclic pattern post-operatively. Initially the cycle was of half-day orthophoria and half-day esotropia, which later became one full day of esotropia and one day of orthophoria. During re-surgery, right lateral rectus was found to have a stretched scar which was resected and then advanced and medial rectus was recessed. Post-surgery the child was orthophoric without cyclic pattern.

Curso clínico de una endotropía consecutiva una cirugía de estrabismo. Reporte de un caso / Clinical course of a consecutive esotropia from an strabismus surgery. Case Report

Propósito: analizar y describir el curso clínico de una exotropía recurrente, que luego de la re operación presenta un endotropía consecutiva. Métodos: paciente femenina de 4 años 5 meses, con diagnóstico de exotropía intermitente. Se le realizó retroinserción derechos laterales a 6,5 mm en ambos ojos. La exotropía recurrió en un año. Posteriormente se le realizó resección de rectos medios de 6 mm. El resultado posoperatorio fue una endotropía consecutiva de involución espontánea. Resultados: al realizar la primera cirugía para exotropía, se obtuvo un resultado de micro endotropía que evolucionó a exotropía recurrente. En la re operación se obtuvo una endotropía consecutiva de 20 dioptrías prismáticas que actualmente está en involución. Conclusión: Debe considerarse una hipercorrección inicial en la cirugía de exotropía. En el caso de una segunda operación para exotropía recurrente, se debe tener en cuenta que ésta puede volvera recurrir, aun cuando la tasa de recurrencia es menorque en la primera cirugía, y una nueva hipercorrección puede también ser recomendable. La endodesviación pos tiende a disminuir y dejar de persistir a los seis meses posoperatorios.

Purpose: to analyze and describe the clinical course of a recurrent exotropia, which after re-surgery developed a consecutive esotropia. Methods: female subject, 4 year and 5 months old, with an intermittent exotropia diagnosis. A retro insertion of the lateral rectus to 6,5 mm in both eyes was performed. Exotropia reappeared in one year. Subsequently, a 6 mm resection of both middle rectus was performed. The postoperatory result was a self involutive consecutive esotropia. Results: after first surgery for exotropia, a micro esotropia was obtained and it evolved to recurrent exotropia. In the new surgery a 20 prismatic diopters consecutive esotropia was obtained and it is currently involutioning. Conclusion: an hypercorrection should be considered in the procedure. In the case of a second surgery for recurrent exotropia, it should be considered that exotropia could reappear, although in a less recurrence rate that in the first one, so another hypercorrection should be considered too. Postoperative esodeviation after exotropia surgery tends to diminish and stop persisting after six months.