Graefe's Archive for Clinical and Experimental Ophthalmology

https://doi.org/10.1007/s00417-017-3868-6

PEDIATRICS

Early postoperative changes of motor alignment after surgery

for intermittent exotropia
Seok Hyun Bae 1 & Young Bok Lee 1 & Soolienah Rhiu 2 & Joo Yeon Lee 3 & Mi Young Choi 4 & Key Hwan Lim 5 &
Dong Gyu Choi 1

Received: 28 July 2017 / Revised: 2 December 2017 / Accepted: 11 December 2017

# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Purpose To evaluate the early postoperative changes of the angle of deviation after surgery for intermittent exotropia.
Methods We retrospectively reviewed the medical records of 114 patients who had been surgically treated for intermittent
exotropia and followed-up on postoperatively for 1 month or more. Patients were observed at postoperative 6 h, 1 day, 1 week,
and 1 month. The main outcome measure was the change of the angle of deviation during the early postoperative period (from 6 h
to 1 day postoperatively).
Results The mean preoperative angle of exodeviation was 26.3 ± 7.6 PD at distance and 25.4 ± 10.3 PD at near. The angle of
deviation was −3.3 (esodeviation) ± 7.0 PD at distance and −0.7 ± 7.1 PD at near at postoperative 6 h, and −3.7 ± 6.9 PD and
−0.8 ± 6.8 PD at postoperative 1 day. Neither of these sets represented a significant change from 6 h to 1 day postoperatively (p =
0.300 at distance, p = 0.945 at near). However, in 25 patients (21.9%) the angle of deviation changed 5 PD or more from 6 h to
1 day. Among them, ten showed exodrift and 15 esodrift. At postoperative 1 month, the deviations became significantly more
exotropic compared with postoperative 1 day (p < 0.001).
Conclusions The mean angle of deviation showed no significant change from 6 h to 1 day postoperatively, but 21.9% of patients
showed a change of 5 PD or more in this period. These results should be considered in determining the time and the target angle of
adjustment in adjustable strabismus surgery for exotropia.

Keywords Intermittent exotropia . Strabismus . Early change . Surgery

Introduction

The goal of strabismus surgery is to align the eyes as nearly as

* Dong Gyu Choi
possible with the minimum number of surgeries or manipula-
eyechoi@hallym.or.kr tions. Most strabismus surgeons agree that initial
overcorrection after surgery for exotropia is required due to
1
Department of Ophthalmology, Kangnam Sacred Heart Hospital, the tendency toward postoperative exotropic drift. Raab and
Hallym University College of Medicine, 1, Singil-ro, Parks first reported the importance of initial postoperative
Yeongdeungpo-gu, Seoul 07441, South Korea
alignment on subsequent results, suggesting that initial surgi-
2
Department of Ophthalmology, Dongtan Sacred Heart Hospital, cal overcorrection of 10–20 prism diopters (PD) is associated
Hallym University College of Medicine, Dongtan, South Korea
with a better result compared with either undercorrection or
3
Department of Ophthalmology, Hallym University Sacred Heart initial orthophoria [1].
Hospital, Hallym University College of Medicine, Anyang, South
Korea
Adjustable suture technique has been developed to permit
4
refinement of ocular alignment in the immediate postoperative
Department of Ophthalmology, Chungbuk National University
Hospital, Chungbuk National University College of Medicine,
period and, thereby, to improve surgical success rates [2, 3].
Cheongju, South Korea Whereas a delayed adjustable suture technique recently has
5
Department of Ophthalmology, Ewha Womans University Mokdong
been introduced, the suture adjustment typically is performed
Hospital, Ewha Womans University School of Medicine, within several hours to 1 day of surgery before permanent
Seoul, South Korea attachment of the extraocular muscle to the sclera [4–6].
 Graefes Arch Clin Exp Ophthalmol

To the best of our knowledge, in spite of the importance of Table 2 Preoperative demographic data
immediate postoperative motor change within 1 day of suture Variables Total (n = 114)
adjustment, there has as yet been no study that has compared
immediate postoperative motor alignment between several Age at surgery (years) 9.4 ± 7.5
hours and 1 day. Therefore, we performed the present study Sex (male/female) 60/54
in order to compare the motor outcomes at postoperative 6 h Preoperative angle of exodeviation (PD)
and 1 day and, additionally, to evaluate the possible factors At distance 26.3 ± 7.6
associated with the change of 5 prism diopters (PD) or more in At near 25.4 ± 10.3
this early postoperative period. BCVA (logMAR)
Dominant eye 0.03 ± 0.07
Non-dominant eye 0.04 ± 0.08
Materials and methods Refractive error (D)
Dominant eye −0.61 ± 2.08
Study design Non-dominant eye −0.74 ± 2.21
Lateral incomitance (n, %) 13 (11.4)
In this retrospective study, the medical records of 114 patients Amblyopia (n, %) 6 (5.3)
who had undergone surgery for intermittent exotropia be- Associated strabismus (n, %)
tween January and December 2014 were reviewed. Among Dissociated vertical deviation 6 (5.3)
them, 60 (52.6%) were male and 54 (47.4%) female. The Vertical deviation 27 (23.7)
exclusion criteria were as follows: (1) combined vertical or Oblique muscle dysfunction 18 (15.8)
oblique muscle surgery, (2) history of previous strabismus Good stereopsis (≤ 100 s, %) 79.4
surgery, (3) sensory, paralytic or restrictive exotropia, (4) other Fusion on Worth-4 dot test (%) 46.7
ocular disease, or (5) systemic disease such as Down syn-
drome or cerebral palsy. All of the procedures in this study PD, prism diopters; BCVA, best-corrected visual acuity; D, diopters;
conformed to the Declaration of Helsinki, and approval to Lateral incomitance: change of 20% or more in lateral gaze from primary
position
conduct the study was obtained from the Institutional
Vertical deviation: 5 PD-or-more hypertropia/hypotropia at primary
Review Board of Hallym University Medical Center (IRB position
No. 2015-03-33).
the alternate prism cover test at distance (6 m) and near
Preoperative examinations (33 cm) with the patients’ best optical correction. In the angle
of deviation, Bminus^ indicates esodeviation, and Bplus^
All of the patients underwent complete ophthalmologic eval- exodeviation. Refractive errors were determined using
uation prior to surgery. We noted preoperative characteristics cycloplegic refraction with 1% cyclopentolate hydrochloride
including gender, age at surgery, deviation at distance and and 1% tropicamide. Amblyopia was defined as a difference
near, best-corrected visual acuity (BCVA), refractive error, of 2 or more lines between the BCVA of each eye. Vertical
amblyopia, presence of vertical deviation, dissociated vertical deviation was defined as 5 PD-or-more hyper/hypotropia at
deviation (DVD), lateral incomitance, oblique muscle dys- the primary position. Lateral incomitance was defined as a
function, and stereopsis. The deviations were determined by change of 20% or more in the right or left gaze as compared

Table 1 Surgical dosages for intermittent exotropia patients Table 3 Mean angle of deviation at postoperative periods (PD)

PD BLR recession R&R (mm) ULR recession At distance P-value* At near P-value*
(mm) (mm)
Postoperative
15 4.0 4.0 / 3.0 8.0 6h −3.3 −0.7
20 5.0 5.0 / 4.0 9.0 1 day −3.7 0.300 −0.8 0.945
25 6.0 6.0 / 5.0 10.0 1 week 0.6 < 0.001 1.1 0.005
30 7.0 7.0 / 5.5 1 month 4.5 < 0.001 3.5 < 0.001
35 7.5 7.5 / 6.0
40 8.0 8.0 / 6.5 In the angle of deviation, the minus sign indicates esodeviation, and the
plus sign exodeviation
50 9.0 9.0 / 7.0
PD, prism diopters
PD, prism diopters; BLR, bilateral lateral rectus; R&R, unilateral lateral * Paired t-test for comparison between postoperative 6 h and other post-
rectus recess-medical rectus resect; ULR, unilateral lateral rectus operative variables
Graefes Arch Clin Exp Ophthalmol

Table 4 Postoperative mean angle of deviation (PD) at distance according to surgical procedures

BLR recession P-value* R&R P-value* ULR recession P-value*

Postoperative
6h −3.9 −5.5 0.5
1 day −4.3 0.437 −5.0 0.386 −0.5 0.114
1 week 0.4 < 0.001 −0.1 <0.001 2.0 0.154
1 month 5.0 < 0.001 3.2 < 0.001 4.3 0.002

In the angle of deviation, the minus sign indicates esodeviation, and the plus sign exodeviation
PD, prism diopters; BLR, bilateral lateral rectus; R&R, unilateral lateral rectus recess-medical rectus resect; ULR, unilateral lateral rectus
* Paired t-test for comparison between postoperative 6 h and other postoperative variables

with the primary position. Sensory status was evaluated with
the Titmus Stereotest (Stereo Optical Co., Inc., Chicago, IL,
USA) and the Worth 4-Dot test at distance. Stereoacuity of
100 s of arc or better was defined as good stereopsis.
Strabismus surgery
Five surgeons representing five institutions performed
all of the surgeries under general anesthesia. The selec-
tion of the surgical procedure, either bilateral lateral
rectus (BLR) recession or unilateral lateral rectus
recess-medical rectus resect (R&R), was made by the
operating surgeon according to their preference.
Unilateral lateral rectus (ULR) recession could be per-
formed in cases of exotropia less than 25 PD. The sur-
gical dosage was based on the angle of distant deviation
(Table 1). Adjustable suture technique was not
performed.
Postoperative management
The angle of deviation at distance and near was measured at
postoperative 6 h, 1 day, 1 week, and 1 month. Alternate full-
time patching was prescribed for the patients who had devel-
oped diplopia or esodeviation postoperatively, and was con-
tinued until the diplopia or esodeviation disappeared.
Statistical analysis
The statistical analyses were performed with SPSS version
23.0 (SPSS Inc., Chicago, IL, USA). Paired t-test was used
to compare the mean angles of exodeviation at distance and
near between the postoperative periods. The correlation be-
tween ocular deviation at postoperative 6 h and 1 day was
analyzed in reference to the Pearson coefficient. The Mann–
Whitney U-test, Pearson’s chi-square test and Fisher’s exact
test were used to analyze the possible factors associated with
the change of 5 PD or more from 6 h to 1 day. A p value less
than 0.05 was considered statistically significant.
Results
The patients’ preoperative characteristics are presented in
Table 2. The mean age at surgery was 9.4 years (range: 3–
58), and the mean preoperative angle of exodeviation was
26.3 ± 7.6 PD at distance and 25.4 ± 10.3 PD at near. Of 114
patients, 68 (59.6%) underwent BLR recession, 22 (19.3%)
R&R, and 24 (21.1%) ULR recession.
At postoperative 6 h, the mean angle of deviation was −3.3
± 7.0 PD at distance and −0.7 ± 7.1 PD at near, and at postop-
erative 1 day, −3.7 ± 6.9 PD and −0.8 ± 6.8 PD: The changes
from 6 h to 1 day postoperatively were not statistically signif-
icant both at distance (p = 0.300, paired t-test) and at near (p =

Outcome measures Table 5 Change of deviation angles from postoperative 6 h to 1 day

(n = 114)

The main outcome measure was the change of the angle of Change of deviation Number of
deviation during the early postoperative period in the overall angles patients (%)
population of subjects and in the subgroups according to the
< 5 PD 89 (78.1)
surgical procedures (BLR recession, R&R, and ULR reces-
5–10 PD 23 (20.1)
sion). Additionally we evaluated the possible factors associat-
> 10 PD 2 (1.8)
ed with a change of 5 PD or more from 6 h to 1 day
postoperatively. PD, prism diopters
 Graefes Arch Clin Exp Ophthalmol

0.945). On the other hand, the mean angles at postoperative
1 week were 0.6 ± 5.7 PD at distance and 1.1 ± 6.0 PD at near,
which showed significant exodrift compared with postopera-
tive 6 h (p < 0.001 at distance, p = 0.005 at near) and 1 day
(p < 0.001 at distance, p = 0.002 at near). At 1 month postop-
eratively, the deviations were 4.5 ± 6.2 PD at distance and 3.8
± 6.7 PD at near, which were more exotropic than at postop-
erative 6 h, 1 day, or 1 week (all p < 0.001) (Table 3).
Subgroups analysis was also performed according to the sur-
gical procedures. Although significant exodrift was shown at
postoperative 1 week and 1 month compared with postopera-
tive 6 h (all p < 0.050, except postoperative 1 week in ULR
group), the changes of the mean angle of deviation were not
significant from 6 h to 1 day (all p > 0.050) (Table 4).
Table 5 shows the distributions of the change in deviation
angle from postoperative 6 h to 1 day: The change was less
than 5 PD in 89 patients (78.1%), 5–10 PD in 23 (20.1%), and
more than 10 PD in two (1.8%). Among 25 patients in whom
the angle of deviation changed 5 PD or more from 6 h to 1 day,
ten showed exodrift and 15 esodrift. There was a significant
correlation between the motor alignment at postoperative 6 h
and that at 1 day (Pearson correlation coefficient: 0.839,
p < 0.001) (Fig 1).
Table 6 presents the possible factors associated with change
of deviation angles of 5 PD or more from postoperative 6 h to
1 day. There was no statistically significant difference in age at
surgery, preoperative deviation angles, surgical procedures,
BCVA, refractive error, lateral incomitance, amblyopia, asso-
ciated strabismus, fusion on Worth-4 dot test, or angle of
exodeviation at postoperative 6 h between the patients with
the changes < 5PD and those > 5PD from 6 h to 1 day. Table 7
compares the ratio of subjects with a change of deviation angle
of 5PD or more from 6 h to 1 day postoperatively between the
subgroup. There was no significant difference comparing
BLR recession and R&R, BLR and ULR recession, R&R
and ULR recession (p = 0.074, 0.583, 0.245 respectively).
Discussion
The usual goal of surgery for intermittent exotropia is a small
angle of initial postoperative esodeviation. Because small
esodeviation typically recovers to orthophoria within 2 weeks,
it does not require any manipulations. Von Noorden found that
lesser degrees of overcorrection were associated with recur-
rence of exodeviation and that higher degrees of
overcorrection increased the risk of reoperation for consecu-
tive esotropia [7]. Raab and Parks [1] suggested that the de-
sirable outcome was 10–20 PD of overcorrection, whereas
Scott [8] proposed the surgical goals of 4–14 PD esodeviation,
and McNeer [9] of 0–10 PD.
Adjustable suture technique has been known to be an ef-
fective method, allowing surgeons an additional opportunity
to modify the degree of surgical correction in the immediate
postoperative period [2, 3]. The surgical success rate of ad-
justable suture use for intermittent exotropia varied from 64.5
to 88% [10–12]. This approach usually is taken in the hours
immediately after surgery or on the first postoperative day.
Many authors reported a tendency toward postoperative
exotropic drift [13–15]. Cassin et al. found that 40% of pa-
tients who had undergone conventional (nonadjustable) hori-
zontal recti surgery showed a postoperative 1 day deviation

Fig. 1 Scattergram and

regression line of postoperative
motor alignment at 6 h and 1 day.
The regression line is indicated by
a solid line. The regression
equation is Y = 0.83X–0.94 (Y =
alignment at postoperative 1 day,
X = alignment at postoperative
6 h, R2 = 0.704). The upper area
above the upper dotted line means
an area of 5 PD or more exodrift
from postoperative 6 h to 1 day.
The lower area below the lower
dotted line is an area of 5 PD or
more esodrift. The middle shadow
area shows a change of less than
5 PD. BMinus^ indicates
esodeviation, and Bplus^
indicates exodeviation
PD, prism diopters.
Graefes Arch Clin Exp Ophthalmol

Table 6 Possible factors associated with a change of deviation angle of ≥ 5 PD from postoperative 6 h to 1 day (n = 114)

Variables Change of deviation angle from postoperative 6 h to 1 day P-value

< 5 PD ≥ 5 PD
(n = 89) (n = 25)

Age at surgery (years) 9.7 ± 8.2 8.3 ± 4.1 0.633*

Sex (male/female) 48/41 12/13 0.600†
Preoperative angle of exodeviation (PD)
At distance 26.7 ± 7.8 25.1 ± 6.9 0.391*
At near 25.8 ± 10.8 23.9 ± 8.2 0.327*
Surgical procedures 0.228†
BLR recession (n, %) 50 (73.5) 18 (26.5)
R&R (n, %) 20 (90.9) 2 (9.1)
ULR recession (n, %) 19 (79.2) 5 (20.8)
BCVA (logMAR)
Dominant eye 0.02 ± 0.06 0.04 ± 0.08 0.361*
Non-dominant eye 0.03 ± 0.08 0.04 ± 0.08 0.823*
Refractive error (D)
Dominant eye −0.71 ± 2.06 −0.26 ± 2.16 0.131*
Non-dominant eye −0.82 ± 2.20 −0.46 ± 2.27 0.128*
Lateral incomitance (n, %) 11 (12.4) 2 (8.0) 0.545†
Amblyopia (n, %) 2 (2.2) 0 (0.0) 0.450†
Associated strabismus
Dissociated vertical deviation (n, %) 5 (5.6) 1 (4.0) 0.749†
Vertical deviation (n, %) 9 (10.1) 5 (20.0) 0.183†
Oblique muscle dysfunction (n, %) 16 (18.0) 2 (8.0) 0.227†
Fusion on Worth-4 dot test (%) 50.0 35.0 0.234†
Postoperative angle of exodeviation at 6 h (PD)
At distance −2.6 ± 6.5 −5.8 ± 8.2 0.077*
At near −0.5 ± 6.7 −1.7 ± 8.3 0.844*

PD, prism diopters; BLR, bilateral lateral rectus; R&R, unilateral lateral rectus recess-medical rectus resect; ULR, unilateral lateral rectus; BCVA, best-
corrected visual acuity; D, diopters
* Mann–Whitney U-test; † Pearson chi-square test

angle different from that at postoperative 6 weeks [14].
However, to our knowledge, immediate postoperative chang-
es of motor alignment, despite their significance to the
adjustable-suture procedure, have not yet been reported.
Ours, then, is the first study to compare postoperative motor
Table 7 Comparison of the ratio of subjects with a change of deviation
angle of ≥ 5 PD from postoperative 6 h to 1 day between the subgroups
Comparison between surgical procedures P-value
BLR recession and R&R 0.074*
BLR recession and ULR recession 0.583†
R&R and ULR recession 0.245*
BLR, bilateral lateral rectus; R&R, unilateral lateral rectus recess-medical
rectus resect; ULR, unilateral lateral rectus
* Fisher’s exact test; † Pearson chi-square test
alignment on the day of surgery (i.e., 6 h postoperatively) with
that on postoperative 1 day. Our data revealed no statistically
significant differences in the overall population of subjects
and in the subgroups according to the surgical procedures. In
the subgroups, the difference between BLR recession and
R&R did not show statistical significance while p-value was
0.07, which may be due to the small sample size. Overall, we
could see that the R&R showed a trend of more angle change
between 6 h and 1 day after surgery. However, 21.9% of the
patients changed 5 PD or more; two patients, furthermore,
showed a change of more than 10 PD. These results indicate
that surgeons, in their treatment of intermittent exotropia,
should consider immediate postoperative changes of motor
alignment when adjusting adjustable sutures within 1 day.
The limitation of the present study should be noted. As a
retrospective study, there were a variety of exodeviation types
and surgical methods, and thus, selection bias could have been

incurred. Therefore, the results will need to be confirmed in a
further, randomized prospective study. And as five surgeons
participated in our study, it could have caused heterogenous
results. From another perspective, however, the surgical bias
that might occur when a single surgeon performs the opera-
tions could be diluted.
In conclusion, the patients’ postoperative 6 h and 1 day
mean deviations did not significantly differ. However, about
21.9% of patients showed a 5 PD-or-more change of deviation
angle. These results should be considered in determining the
time and the target angle of adjustment in adjustable strabis-
mus surgery for exotropia.
Funding No funding was received for this research.
For this type of study, formal consent is not required.
Compliance with ethical standards
Conflict of interest All authors certify that they have no affiliations with
or involvement in any organization or entity with any financial interest, or
non-financial interest in the subject matter or materials discussed in this
manuscript.
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