Unilateral Lateral Rectus Muscle Recession and Medial Rectus Muscle Resection With or Without Advancement for Postoperative

Consecutive Exotropia
Kanwar Mohan, MS,a Ashok Sharma, MS,a and S. S. Pandav, MSb Purpose: To evaluate the effectiveness of unilateral lateral rectus muscle recession and medial rectus muscle resection with or without advancement in treating postoperative consecutive exotropia. Methods: We performed a retrospective review on 31 patients with consecutive exotropia who were treated with unilateral lateral rectus muscle recession and medial rectus muscle resection (17 patients) or unilateral lateral rectus muscle recession and medial rectus muscle partial resection combined with advancement (14 patients). All patients had exotropia with a less than 10 prism diopters (PD) distance near-disparity. The characteristics studied before surgery included type of esotropia surgery, detection of amblyopia, presence of an A or V pattern, dissociated vertical deviation, limitation of adduction, deviation angle measurement, and forced duction testing. Ocular alignment and status of adduction postoperatively at the last follow-up were recorded. Results: Nineteen patients (61.3%) had amblyopia, 17 patients (54.8%) had limitation of adduction, 8 patients (25.8%) had dissociated vertical deviation, and 5 patients (16.1%) had an A or V pattern. The mean preoperative exodeviation was 47.3 PD. Overall 21 (67.7%) of 31 patients achieved a successful postoperative result (alignment within 10 PD of orthophoria). There was no signicant difference in successful alignment in patients treated with unilateral medial rectus muscle resection compared with those treated with unilateral medial rectus muscle partial resection combined with advancement. There was no inuence of amblyopia on the result. Twelve (70.6%) of the 17 patients with limited adduction preoperatively showed normalization of adduction postoperatively. Conclusions: Unilateral lateral rectus muscle recession and medial rectus muscle resection with or without advancement is an effective alternative for treating postoperative consecutive exotropia. (J AAPOS 2006;10:220-224)
onsecutive exotropia after surgery for esotropia is known to occur in 20% to 27% of patients.1,2 The presence of amblyopia, postoperative limitation of adduction, dissociated vertical deviation, an A or V pattern, high hypermetropia, absence of binocularity, and simultaneous surgery for 3 or 4 muscles are probable contributing factors for the development of postoperative consecutive exotropia.1,3-8 Several surgeons have reported treating consecutive exotropia by operating either on the lateral rectus muscle(s) or the medial rectus muscle(s) alone. Various surgical

From the Squint Centre,a Chandigarh, India; and Department of Ophthalmology,b Postgraduate Institute of Medical Education and Research, Chandigarh, India. Submitted May 20, 2005. Revision accepted January 13, 2006. Reprint requests: Kanwar Mohan, MS., Squint Centre, SCO 833-834 (2nd oor), Sector 22-A, Opp. Parade Ground, Chandigarh-160022, India. Copyright 2006 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2006/$35.00 0 doi:10.1016/j.jaapos.2006.01.182

procedures that have been performed include unilateral or bilateral lateral rectus muscle recession3,9,10 and unilateral or bilateral medial rectus muscle advancement with or without resection.9,11,12 A few surgeons have reported performing bilateral lateral rectus muscle recession combined with advancement of one or both medial rectus muscles to the original insertion.3 Treatment of consecutive exotropia with unilateral lateral rectus muscle recession combined with medial rectus muscle resection or advancement has not drawn much attention, and we could nd only one such study reported in the literature. Donaldson et al13 treated consecutive exotropia with unilateral lateral rectus muscle recession and medial rectus muscle advancement to the original insertion in majority of their patients and with unilateral lateral rectus muscle recession combined with medial rectus muscle resection in a few patients. In this retrospective study, we sought to evaluate the effectiveness of unilateral lateral rectus muscle recession and medial rectus muscle resection with or without advancement in treating postoperative consecutive exotropia.
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MATERIALS AND METHODS

Patients who (1) had consecutive exotropia of 20 PD or more at both near and distance xation and a less than 10 PD distance near-disparity and (2) did not have a slipped or lost medial rectus muscle were studied. Unilateral lateral rectus muscle recession, combined with (1) medial rectus muscle resection without advancement or (2) medial rectus muscle resection with advancement or (3) medial rectus muscle advancement without resection. Of the 43 patients treated with this unilateral approach, 31 (9 boys and 22 girls) were included in the present study. Four patients were excluded because they were treated with unilateral lateral rectus muscle recession combined with medial rectus muscle advancement without resection, and 8 patients were excluded because of less than 6 months follow-up. We also excluded patients with less than 20 PD exotropia, who were treated with unilateral lateral rectus muscle recession alone. Patient ages ranged from 3 to 49 years (mean, 19.4 years). Surgery for exotropia was performed by one surgeon between January 1992 and August 2003. The following characteristics were studied before surgery: type of esotropia surgery, detection of amblyopia, presence of an A or V pattern, dissociated vertical deviation or any vertical tropia, limitation of adduction, deviation angle measurement, and forced duction test. Amblyopia was dened as a difference of 2 or more lines between the best corrected visual acuity of the 2 eyes on the Snellen chart and was treated with patching wherever possible before performing surgery for consecutive exotropia. We decided to perform unilateral surgery on 2 muscles instead of bilateral surgery on both lateral rectus muscles, both medial rectus muscles, or some other combination. The eye chosen for surgery had a limitation of adduction in 17 patients and normal adduction in 14 patients. The initial surgical procedures for esotropia in the 17 patients with limited adduction were recession-resection (9 patients), bimedial recession (4 patients), and unilateral medial rectus muscle recession (4 patients). Three patients had bilateral mild limitations of adduction, and none of them had a strong xation preference. Therefore, we chose to leave the limitation of adduction uncorrected surgically in the fellow eye. Unilateral lateral rectus muscle recession combined with medial rectus muscle resection was planned on the exotropic eye for the largest deviation according to a standard surgical table.14 We chose the nondominant eye for surgery. The largest deviation was dened as the maximum deviation measured on repeated prism cover testing with the patient xating at a 6-m distance target. Advancement of the medial rectus muscle was performed only if the desired amount of resection of the muscle was not possible as the result of a far posterior position of the muscle (more than 11 mm from the limbus) because the muscle had been recessed a large amount and

we could not get sutures back to the additional amount desired to do the resection. There was no other factor that inuenced this decision. We considered that 1 mm advancement would correct exodeviation equivalent to that of 1 mm resection of the medial rectus muscle, as did Donaldson and associates.13 The muscle was advanced equal to the amount of desired resection if it was not possible to resect the muscle. If only a partial resection of the muscle was possible, it was performed and the partly resected muscle was advanced equal to the remaining amount of desired resection. The surgical decision making was not based upon intraoperative ndings such as forced ductions or position under anesthesia. Of the 31 patients, 17 underwent lateral rectus muscle recession and medial rectus muscle resection and 14 underwent lateral rectus muscle recession and medial rectus muscle partial resection combined with advancement. Three patients had an associated an A or V pattern, which was treated with vertical transposition of the lateral and medial rectus muscles concurrently. Patients were followed-up for a period of 6 months to 12 years. Twelve of 31 patients were followed-up for 6 months to 2 years (mean, 1.1 year) and 19 were followed-up for 2 to 12 years (mean, 5.1 year). Ocular alignment and status of adduction at the last follow-up were recorded. We evaluated adduction clinically by having the patient follow a penlight through adduction. Adduction was considered normal if in maximal adduction an imaginary vertical line through the lower lacrimal punctum passed between the inner one third and outer two thirds of the cornea, mildly restricted if this line passed through the nasal limbus, moderately restricted if this line passed through the sclera and severely restricted if the eye could not be moved past the midline. None of the postoperative outcome measurements were made as a result of manipulating accommodation by using over minus lenses or removing plus lenses. We considered a successful postoperative result to be an alignment within 10 PD of orthophoria. Data were analyzed using Z test for proportions and analysis of variance.

RESULTS
The procedures performed for the initial surgical correction are presented in Table 1. Twenty-four patients (77.4%) had undergone 1 operation and 7 patients (22.6%) had undergone 2 operations for esotropia before presenting with consecutive exotropia. Three of the 7 patients with 2 operations had undergone both operations on the same eye. Before surgery for consecutive exotropia, 19 patients (61.3%) had amblyopia, 17 patients (54.8%) had limitation of adduction, 8 patients (25.8%) had dissociated vertical deviation or vertical tropia, and 5 patients (16.1%) had an A or V pattern. The mean preoperative exodeviation was 47.3 PD (range, 20 to 80 PD). Forced duction testing was performed in 8 of the 17 patients with limited adduction. The test was positive in 5 and negative

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TABLE 1. Various surgeries performed for correction of esotropia Type of surgery No. of patients First Surgery Unilateral MR recession and LR resection Bilateral MR recession Unilateral MR recession Second Surgery MR recession and LR resection Same eye Other eye MR recession Same eye Other eye
LR: lateral rectus muscle; MR: medial rectus muscle.

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18 7 6

1 2 2 2

in 3 patients. Only 3 of the 22 patients with amblyopia were younger than 10 years of age and underwent amblyopia treatment with patching before surgery for consecutive exotropia. Twenty-one (67.7%) of 31 patients achieved a successful postoperative result, 7 (22.6%) had residual exotropia, and 3 (9.7%) had consecutive esotropia at the last followup. Postoperative ocular alignment in relation to the type of surgery for consecutive exotropia is presented in Table 2. Patients treated with lateral rectus muscle recession and medial rectus muscle resection had a successful alignment in 64.7% of cases compared with 71.4% of those treated with lateral rectus muscle recession and medial rectus muscle partial resection combined with advancement, and this difference was statistically not signicant (Z 0.40, P 0.688). Success rate as a function of how far the medial rectus muscle ended up from the limbus is presented in Table 3. There was statistically no signicant difference in the success rate in patients with medial rectus muscle placement at 6-10 mm (mean, 8.3 mm) from the limbus compared with those with medial rectus muscle placement at 11-12 mm (mean, 11.4 mm) from the limbus (Z 1.40, P 0.161). Eleven (57.9%) of the 19 patients with amblyopia had a successful alignment compared with 10(83.3%) of the 12 patients without amblyopia, and this difference was statistically not signicant (Z 1.63, P 0.103). For analyzing successful alignment in relation to the follow-up duration, the patients were divided in 2 groups; those who were followed-up for 2 years or less and those who were followed-up for more than 2 years. Twelve patients were followed-up for 2 years or less (mean, 1.1 year) and 19 patients were followed-up for more than 2 years (mean, 5.1 year). Eleven (91.7%) of the 12 patients who were followed-up for 2 years or less had a successful alignment at the last follow-up compared with 10 (52.6%) of the 19 patients who were followed-up for more than 2 years, and this difference was statistically signicant (Z 2.80, P 0.005). Of the 17 patients who had a limitation of adduction preoperatively, 12 (70.6%) regained a normal adduction, 3 (17.6%) showed a residual limitation of adduction, and 2

(11.6%) showed no improvement in adduction postoperatively. The postoperative medial rectus muscle placement from the limbus was 6 to 10 mm (mean, 8.4 mm) in patients with a normal adduction, 7.5 to 10.0 mm (mean, 9.2 mm) in patients with a residual limitation of adduction, and 11 to 12 mm (mean, 11.5 mm) in patients with no improvement in adduction. One way analysis of variance showed that the postoperative medial rectus muscle placement from the limbus made a signicant difference in adduction improvement (F 4.461, P 0.032). Post hoc test using least signicant difference showed that there was no signicant difference in adduction improvement when the postoperative medial rectus muscle placement was at a mean 8.4 mm versus 9.2 mm from the limbus (P 0.39) and at a mean 9.2 mm versus 11.5 mm from the limbus (P 0.09). There was a signicant difference in adduction improvement when the postoperative medial rectus muscle placement was at a mean 8.4 mm versus 11.5 mm from the limbus (P 0.010). Five of the 7 patients with a residual exotropia had a limitation of adduction preoperatively. The limitation of adduction persisted in 2 of the 5 patients and both patients had the medial rectus placement at 11 mm and 12 mm, respectively.

DISCUSSION
Consecutive exotropia has been previously treated with different surgical options, including unilateral or bilateral lateral rectus muscle recession, unilateral or bilateral medial rectus muscle advancement with or without resection, and bilateral lateral rectus muscle recession combined with unilateral or bilateral advancement of the medial rectus muscle.3,9-12 Patel and colleagues10 performed bilateral lateral rectus muscle recession for consecutive exotropia and achieved a successful alignment (within 10 PD of orthophoria) in 65% of the patients at a mean follow-up of 30 months. Gomez De Liano Sanchez and associates3 treated consecutive exotropia with bilateral lateral rectus muscle recession and/or unilateral medial rectus muscle advancement to the original insertion site and achieved an alignment within 10 PD of orthophoria in 70% of cases. Mittelman and Folk9 performed a 12 mm advancement and resection of the underacting medial rectus muscle in 27 consecutive exotropes with limitation of adduction and achieved a successful correction of exotropia in 75% of these cases. Unilateral lateral rectus muscle recession combined with medial rectus muscle resection with or without concurrent advancement for treating consecutive exotropia has not been investigated rigorously. In a recently reported series of 59 patients with consecutive exotropia, Donaldson and associates13 treated 42 patients with unilateral lateral rectus muscle recession combined with medial rectus muscle advancement and achieved a satisfactory alignment (within 10 PD of orthophoria) in 69% of the patients at a mean follow-up of 16 months. They performed unilateral lateral rectus muscle recession combined

Journal of AAPOS Volume 10 Number 3 June 2006 TABLE 2. Postoperative ocular alignment in relation to the type of surgery for consecutive exotropia

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Postoperative ocular alignment Type of surgery LR recession and MR resection LR recession and MR partial resection and advancement No. of patients 17 14 Within 10 PD of orthophoria, no. (%) 11 (64.7) 10 (71.4) Residual XT, no. (%) 4 (23.5) 3 (21.4) Consecutive ET, no. (%) 2 (11.8) 1 (7.1)

LR: lateral rectus muscle; MR: medial rectus muscle; XT: exotropia; ET: esotropia.

TABLE 3. Surgical outcome in relation to the distance between the limbus and the medial rectus muscle (MR) placement LimbusMR placement, mm 610 1112 No. of patients 26 5 Surgical outcome Success, no. (%)* 119 (73.1) 2 (40.0) Failure, no. (%) 7 (26.9) 3 (60.0)

*Success was dened as an ocular alignment within 10 PD of orthophoria.

with medial rectus muscle resection in a few patients only. We treated consecutive exotropia with unilateral lateral rectus muscle recession and medial rectus muscle resection with or without advancement, and achieved a successful alignment (within 10 PD of orthophoria) in 68% of the cases. The success rate dropped off signicantly from 92% at a mean follow-up of 1.1 year to 53% at a mean follow-up of 5.1 year. Coopers dictum often is cited for planning surgery for consecutive exotropia. Cooper15 suggested that overcorrections after strabismus surgery should be evaluated anew and that the surgical plan should be based on the characteristics of the new postoperative deviation rather than undoing what was done. It does not take into account limitations of rotation that may occur because of a muscle having been excessively recessed or excessively resected. Because our patients had a less than 10 PD near disparity in deviation, we planned to perform unilateral lateral rectus muscle recession combined with medial rectus muscle resection on the exotropic eye. However, we were able to perform the desired amount of resection of the medial rectus muscle in only approximately half of our patients and achieved a successful alignment in 65% of these cases. In the remaining patients, we had to perform lateral rectus muscle recession and medial rectus muscle partial resection with concurrent advancement and achieved a successful alignment in 71% of these cases. Mittleman and Folk9 suggested advancement of the medial rectus muscle for patients with limited adduction. Ohtsuki and associates11 performed advancement of the medial rectus muscle in all patients irrespective of whether they had a normal adduction or a limitation of adduction. Our decision to perform advancement of the medial rectus muscle was not based on the presence of limitation of adduction. Rather, we performed advancement of the medial rectus muscle in those patients only where the

desired amount of resection of the muscle was not possible because of a far posterior position of the muscle as the result of a previous large recession and we could not get sutures back to the additional amount required to do the desired resection. We considered a 1 mm advancement equivalent to a 1 mm resection of the muscle. Theoretically, each millimeter of advancement of the muscle is expected to have a greater effect than a millimeter of resection because of the increase of arc of contact. We, however, did not nd any signicant difference in the successful outcome in patients treated with unilateral lateral rectus muscle recession and medial rectus muscle partial resection combined with advancement compared with those treated with unilateral lateral rectus muscle recession and medial rectus muscle resection. Also, there was no signicant difference in the success rate in patients in whom the medial rectus muscle ended up at a mean 8.3 mm from the limbus compared with those in whom the medial rectus muscle ended up at a mean 11.4 mm from the limbus. Amblyopia has been considered to be a contributing factor in the development of consecutive exotropia in 20% to 53% of the patients.3,4,6,13 Approximately 61% our patients had amblyopia. We did not nd any inuence of amblyopia on the successful result, as observed by Donaldson and associates.13 The presence of limited adduction after surgery for esotropia also has been identied as a risk factor in producing a consecutive exotropia in 42% to 82% of the patients.3,6,9 Because we did not perform forced duction testing on all of our patients, we cannot draw any conclusions about the predictive power of forced duction testing in this patient population. Ohtsuki et al11 reported normalization of adduction deciency in 71% of their patients after advancement of the medial rectus muscle to the original insertion for consecutive exotropia. In our patients, 70.6% of those who had adduction limitation preoperatively exhibited normal adduction after medial rectus muscle resection with or without advancement. How far the medial rectus muscle was left from the limbus made a signicant difference in the improvement of adduction. Our patients who had the medial rectus muscle at an average 8.4 mm from the limbus achieved normalization of adduction and those who had the medial rectus muscle at an average 11.5 mm from the limbus did not have im-

224 Mohan, Sharma, and Pandav

provement in adduction. The patients with residual exotropia in whom the limitation of adduction persisted also had the medial rectus muscle at an average 11.5 from the limbus. Although we did not nd a signicant difference in successful alignment in our patients in whom the medial rectus muscle was resected or resected and advanced, the advancement of the medial rectus muscle did improve adduction in patients with limitation of adduction. These observations indicate that the medial rectus muscle should be routinely advanced in patients who have consecutive exotropia with limitation of adduction. We preferred medial rectus muscle resection over advancement for 2 reasons. The surgical dosage for medial rectus muscle advancement for treating consecutive exotropia was not available in tables. Ohtsuki et al11 advanced the medial rectus muscle to the original insertion, whereas Biedner and associates12 suggested medial rectus muscle advancement to the original insertion for deviations up to 25 PD and 2 mm beyond the original insertion for deviations from 30 to 35 PD. We considered 1 mm of advancement equivalent to 1 mm of resection of the medial rectus muscle, as did by Donaldson and associates.13 Additionally, we speculated that the advanced muscle could adhere to the sclera at the site of previous insertion, where it would pass over raw tissue exposed after disinsertion. Adhesions could form between the undersurface of the muscle and sclera in this area. We believe this could become a form of posterior xation on the muscle that could decrease the effect of advancement and perhaps affect ocular rotation. Admittedly, this was not reected in the outcomes of the small number of medial rectus muscle advancement cases, but this possibility could warrant further investigation. The observations from this study indicate that unilateral lateral rectus muscle recession and medial rectus muscle resection with or without advancement is an effective alternative for treating consecutive exotropia.

Journal of AAPOS Volume 10 Number 3 June 2006 The authors wish to thank Dr. Surest K. Sharma, Department of Statistics, Panjab University, for performing statistical analysis of this study. References
1. Yazawa K. Postoperative exotropia. J Pediatr Ophthalmol Strabismus 1981;18:58-64. 2. Stager DR, Weakley DR Jr, Everette M, Birch EE. Delayed consecutive exotropia following 7-milimeter bilateral medial rectus recession for congenital esotropia. J Pediatr Ophthalmol Strabismus 1994; 31:147-50. 3. Gomez De Liano Sanchez P, Ortega Usobiaga J, Moreno GarciaRubio B, Merino Sanz P. Cirugia de la exotropia consecutiva. Arch Soc Esp Oftalmol 2001;76:371-8. 4. Folk ER, Miller MT, Chapman L. Consecutive exotropia following surgery. Br J Ophthalmol 1983;67:546-8. 5. Windsor CE. Surgically overcorrected esotropia: a study of its causes, sensory anomalies, functional results and management. Am Orthopt J 1966;16:8-15. 6. Oguz V, Arvas S, Yolar M, Kizilkaya M, Tolun H. Consecutive exotropia following strabismus surgery. Ophthalmologica 2002;216: 246-8. 7. Spaeth EB. Factors related to postoperative exotropia. J Pediatr Ophthalmol 1972;9:47-51. 8. Bradbury JA, Doran RML. Secondary exotropia: a retrospective analysis of matched cases. J Pediatr Ophthalmol Strabismus 1993;30: 163-6. 9. Mittelman D, Folk ER. The surgical treatment of overcorrected esotropia. J Pediatr Ophthalmol Strabismus 1979;16:156-9. 10. Patel AS, Simon JW, Lininger LL. Bilateral lateral rectus recession for consecutive exotropia. JAAPOS 2004;4:291-4. 11. Ohtsuki H, Hasebe S, Tadokoro Y, Kobashi R, Watanabe S, Okano M. Advancement of medial rectus muscle to the original insertion for consecutive exotropia. J Pediatr Ophthalmol Strabismus 1993;30: 301-5. 12. Biedner B, Yassur Y, David R. Advancement and reinsertion of one medial rectus muscle as treatment for surgically overcorrected esotropia. Binocular Vision 1991;6:197-200. 13. Donaldson MJ, Forrest MP, Gole GA. The surgical management of consecutive exotropia. JAAPOS 2004;8:230-6. 14. Burke MJ. Intermittent exotropia. In: Nelson LB, Wagner RS, editors. International Ophthalmology Clinics. Vol 25, No. 4. Boston (MA): Little, Brown and Company; 1985. p. 53-68. 15. Cooper EL. The surgical management of secondary exotropia. Trans Am Acad Ophthalmol Otolaryngol 1961;65:595-608.