Spontaneous consecutive exotropia after conservative management of accommodative esotropia

@#Spontaneous consecutive exotropia (SCXT) in conservatively managed accommodative esotropia is not widely discussed. The author presents a case series of 4 patients with SCXT describing patient characteristics and possible risk factors. Management modifications based on this series are proposed. Four cases of patients who initially presented with accommodative esotropia and later developed SCXT are presented. The age range at presentation was between 4 months to 3 years, with total follow-up ranging between 8–15 years. All four cases presented with esotropia on or before the age of 3 years, with initial hyperopia ranging between +1.50 to +4.25. The SCXT occurred between ages 2–7 years. Possible risk factors identified include amblyopia, dissociated vertical deviation, rapid control of esodeviation, inferior oblique overaction, and poor follow-up during the course of their strabismus. The author recommends earlier tapering of hyperopia correction following initial control with full cycloplegic refraction. Identified risk factors should alert the specialists to be wary of SCXT.

Risk Factors for Consecutive Exotropia and Hyperopic Changes after Bilateral Medial Rectus Recession

PURPOSE: To define risk factors for and to analyze changes in hyperopic refractive error during development of postoperative exotropia (XT) after bilateral medial rectus (BMR) recession to treat infantile esotropia. METHODS: We retrospectively examined 50 patients with infantile esotropia who underwent BMR recession from January 2005 to December 2010. All were +2.0 D) prior to BMR recession and a marked fall in the extent of hyperopia (−1.0 D/year) after recession may be associated with a high risk of consecutive XT. Thorough follow-up is necessary when IOOA develops after BMR recession.

Clinical Characteristics of Exodeviated Patients with Accomodative Esotropia and Hyperopia without Strabismus

PURPOSE: To evaluate the clinical characteristics of exodeviated patients with accomodative esotropia and orthophoric hyperopia. METHODS: We conducted a retrospective chart review of patients with accommodative esotropia and hyperopia who later developed exotropia and visited the Department of Ophthalmology of Wonju Severance Christian Hospital from January 1, 1997 to December 31, 2013. RESULTS: The study included 13 patients with a mean age of 4.1 years at initial referral. At the initial visit, nine patients (69.2%) had accommodative esotropia with a median of 25.5 PD esotropia at near gaze. Among the esotropic patients, four patients (44.4%) had unilateral amblyopia and five patients (55.6%) had bilateral amblyopia. The spherical equivalent was +6.09 D in the amblyopic eye and +5.63 D in the dominant eye. In the cases of bilateral amblyopia, the spherical equivalent was +5.875 D. Spontaneous consecutive exotropia developed at a mean age of 8.63 years (average follow-up of 56.38 months). Mean exodeviation was 10.33 PD. Among the four patients (30.8%) who were orthophoric at their initial visit, two patients (50%) had unilateral amblyopia and two (50%) had bilateral amblyopia. The spherical equivalents of the amblyopic eye and the dominant eye were +5.63 D and +3.13 D, respectively. In cases of bilateral amblyopia, a mean spherical equivalent of +5.50 D was observed. The mean age when exodeviation occurred was 10.75 years, which was 64 months after the initial visit. The average exodeviation was 6.5 PD. CONCLUSIONS: When treating accommodative esotropia and hyperopia, long-term observation is necessary since exodeviation could develop. Exotropia was successfully managed with spectacle correction. Further studies are needed for possible surgical intervention.

Surgical Outcomes and Prognostic Factors of Consecutive Exotropia

PURPOSE: In this study we evaluated the prognostic factors by comparing the clinical manifestation of consecutive exotropia after consecutive exotropia surgery. METHODS: We performed a retrospective study of 65 patients who had surgery due to consecutive exotropia after esotropia surgery in Yeungnam University Medical Center between July 1988 and December 2013. The type of esotropia, age at diagnosis of esotropia, type of esotropia surgery, age at esotropia surgery, type of consecutive exotropia surgery, age at consecutive exotropia surgery, presence of adduction limitation, presence of amblyopia, and preoperative and postoperative angles of strabismus were analyzed. RESULTS: The mean follow-up time after consecutive exotropia surgery was 5.1 +/- 5.2 years and 50 of 65 patients showed successful surgical outcomes at the last follow-up. Cumulative success rate of consecutive exotropia remained stable postoperatively in 68.2% of patients after 7.7 years. When comparing the success group and the recurrent group, the age at consecutive exotropia surgery was significantly younger and mean follow-up time was significantly longer in the recurrent group. The mean interval between consecutive exotropia surgery and recurrence of exotropia was 16.9 months in the recurrent group. The mean angle of strabismus at postoperative 1 week was significantly different between the 2 groups; 0.5 prism diopters (PD) esodeviation in the success group and 4.5 PD exodeviation in recurrent group. CONCLUSIONS: Recurrence of consecutive exotropia frequently developed with younger age at consecutive exotropia surgery and exodeviation at postoperative 1 week. Recurrent consecutive exotropia should be observed for an extended period, thus requiring periodic long-term postoperative follow-ups.

Consecutive Exotropia After Bilateral Medial Rectus Recession for Infantile Esotropia

PURPOSE: To evaluate associated factors by comparing the patients with consecutive exotropia to the patients with orthophoria after undergoing surgery for infantile esotropia. METHODS: The study consisted of 50 patients who underwent bilateral medial rectus recession and attended follow-ups until eight years of age. The authors retrospectively investigated the clinical characteristics ofage at operation, duration between diagnosis and operation, the spherical equivalent of both eyes, the deviated angle at the first visit and immediately before the operation, the recession amount, and the total follow-up period. RESULTS: During the mean follow-up period of 78.51+/-54.70 months, 13 patients (26%) had consecutive exotropia, 27 patients (54%) had orthophoria and 10 patients (20%) had remnant esotropia. As the result of comparing orthophoric patients to consecutive exotropic patients, there were no significant differences in the birth weights, the deviated angles at the first visit and immediately before the operation, the spherical equivalents of both eyes, the ages at operation, the recession amounts, and the durations between diagnosis and operation. However, in consecutive exotropia, inferior oblique muscle overaction was 46.5%, dissociated vertical deviation was 46.5% in orthophoric patients, inferior oblique muscle overaction was 19.24%, and dissociated vertical deviation was 8.7%. CONCLUSIONS: A thorough follow-up is necessary when inferior oblique muscle overaction and dissociated vertical deviation occur after undergoing a bilateral medial rectus operation.

Clinical Manifestation and Surgical Outcomes of Consecutive Exotropia

PURPOSE: To evaluate the causative factors related to the development of consecutive exotropia and surgical outcomes. METHODS: We reviewed the surgical results of 53 patients underwent strabismus surgery for consecutive exotropia retrospectively. The followings were checked before surgery: onset of exotropia, visual acuity, angle of deviation, presence of vertical deviation, ocular motility including adduction limitation, refractive errors, and sensory status. RESULTS: There were 3 different types of preceding esotropia: infantile esotropia 43 patients, accommodative esotropia 8 patients, and partially accommodative esotropia 2 patients. Forty-three patients underwent surgery for esotropia developed exotropia after 69.8 months of follow-up. On the other hand, 10 patients of spontaneous consecutive exotropia showed outward deviation after 8.3 years from the onset of esotropia. Consecutive exotropia were accompanied with the other ocular deviations in 33 patients. A-pattern exotropia was accompanied in 24.5% of patients and it was more common than V-pattern developed in 9.4% of patients. Limitation of adduction after surgery for esotropia was found in 20.9%, amblyopia in 47.2%, and nystagmus in 13.2% respectively. The mean preoperative and postoperative exodeviation was 32.6 PD, 7.5 PD respectively. At 1 year and last follow-up, 20 of 30 patients and 38 of 53 patients showed the satisfactory surgical outcomes, respectively. CONCLUSIONS: We found out that consecutive exotropia was frequently accompanied with cyclovertical deviations, especially A-pattern exotropia. Presence of amblyopia and adduction limitation after correction for esotropia may be the causative factors of the consecutive exotropia. However, these factors were not statistically associated with unsuccessful outcomes (p>0.1, x2 test). Twenty of 30 patients (66.7%) revealed satisfactory results at 1 year follow-up.

The Clinical Consideration of Consecutive Extropia

We evaluated retrospectively the clinical characteristics of 16 consecutive exotropia patients over 10PD following surgery for esotropia, the patients were differentiated into nonoperative and operative group. The nonoperative group comprised of 11 patients with exodeviation 10PD through 20PD(mean 12.9PD) and the orthphoria through 15PD(mean 10.5PD) at final visit. The operative group of 5 patients with exodeviation of 10PD through 30PD(mean 21PD) at postoperatively 2 weeks and 20PD through 35PD(mean 24PD) before operation of consecutive exotropia. In the second operatio, 3 patients with adduction limitation were operated with advancement of medial rectus or recession of lateral rectus of same eye. Four patients showed orthotropia at postoperatively 2 weeks, and 2 patients revealed orthotropia at the final visit. The results suggest that the degree of deviation and adduction limitation will influence the choice of therapy and second operation method.

The Clinical Consideration of Consecutive Extropia

We evaluated retrospectively the clinical characteristics of 16 consecutive exotropia patients over 10PD following surgery for esotropia, the patients were differentiated into nonoperative and operative group. The nonoperative group comprised of 11 patients with exodeviation 10PD through 20PD(mean 12.9PD) and the orthphoria through 15PD(mean 10.5PD) at final visit. The operative group of 5 patients with exodeviation of 10PD through 30PD(mean 21PD) at postoperatively 2 weeks and 20PD through 35PD(mean 24PD) before operation of consecutive exotropia. In the second operatio, 3 patients with adduction limitation were operated with advancement of medial rectus or recession of lateral rectus of same eye. Four patients showed orthotropia at postoperatively 2 weeks, and 2 patients revealed orthotropia at the final visit. The results suggest that the degree of deviation and adduction limitation will influence the choice of therapy and second operation method.

Seven-Millimeter Bilateral Recessions of the Medial Rectus Muscles for Congenital Esotropia

We studied the success rate of bilateral 7mm medical rectus recession for 24 patients with large angle congenital esotropia through long-term follow-up. The success rate was 100%(24/24) at immediate postoperative period, 83.3%(20/24) at postoperative 6 months, 79.1%(19/24) at postoperative 1 year, 64.1%(9/14) at postoperative 18 months and 54.5% (6/11) at postoperative 2 years. Residual esotropia rate was 0%(0/24) at immediate postoperative period, 16.6%(4/24) at postoperative 6 months, 16..6%(4/24) at postoperative 1 year, 14.2%(2/14) at postoperative 18 months and 18.1%(2/11) at postoperative 2 years. Consecutive exotropia rate was 0%(0/24) at immediate postoperative period, 0%(0/24) at postoperative 6 months, 4.1 %(1/24) at postoperative 1 year, 21.4%(3/14) at postoperative 18 months and 27.2%(3/11) at postoperative 2 years. Residual esotropia may develop before 6 months and consecutive exotropia after 1 year postoperatively.

The Factors Affecting Consecutive Exotropia with Angle of 20 Prism Diopters or More following Surgery for Esotropia

The purpose of this study is to evaluate the factors that may have a role in the development of postoperative exotropia with the angle of 20 prism diopters (PD) or more. The study group was subdivided into three groups depending on the amount of deviation for consecutive exotropia; group A is the angle of 20PD or more, group B is between 10PD and 18PD, and group C is orthophoria. Comparing group A with C, the presence of amblyopia(p<0.05), postoperative limitation on adduction(p<0.01), postoperative binocular vision(p<0.05) and postoperative A or V pattern(p<0.05) were statistically significant. Among the factors of group A and B, the presence of postoperative limitation on adduction(p<0.05) and refractive error of 3D or more(p<0.05) were signifi cant. We suggest that these factors may have a role to develop large consecutive exotropia, therefore close observation is necessary when these factors are found.