Research Article
Ophthalmic Res
DOI: 10.1159/000494560
Bilateral Lateral Rectus Recession for the
Treatment of Recurrent Exotropia after
Bilateral Medial Rectus Resection
Xi Wang a Xiaohang Chen b Longqian Liu a, b
a Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, China; b Department of
Optometry and Visual Science, West China Hospital, Sichuan University, Chengdu, China
Keywords
Recurrent exotropia · Bilateral lateral rectus recession ·
Bilateral media rectus resection
Abstract
Purpose: To evaluate the efficacy of bilateral lateral rectus
muscle recession (BLR) to treat recurrent exotropia after bi-
lateral medial rectus muscle resection (BMR). Methods:
Twenty-four patients who underwent BLR for recurrent exo-
tropia and were followed up for more than 6 months were
included in this retrospective study. All of them had prior
BMR. The angle of deviation, success rates, near stereopsis,
and surgical effect of BLR were evaluated. Surgical success
was defined as postoperative deviations ≤10 prism diopters
(PD). Results: The overall mean follow-up time after reopera-
tion for patients was 24.13 ± 15.01 months (range 6–60
months). The mean angle of deviation at distance was sig-
nificantly reduced from –37.75 ± 14.93 PD to +1.50 ± 6.43 PD
(p < 0.001). Twenty-two (91.6%) of 24 patients had successful
outcomes, 1 (4.2%) had overcorrection, and 1 (4.2%) had un-
dercorrection at the last follow-up. Improved stereopsis af-
ter reoperation was observed in 78.3% (18/23) of the pa-
tients. The mean surgical effect was 2.78 ± 0.71 PD/mm. Con-
© 2018 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/ore
Received: August 13, 2018
Accepted after revision: October 8, 2018
Published online: December 6, 2018
clusion: Based on our results, BLR could be an effective and
safe method for treating recurrent exotropia after a moder-
ate to large amount of BMR. © 2018 S. Karger AG, Basel
Introduction
Recurrent exotropia is a relatively common problem
that can occur after surgery to treat exotropia because pa-
tients with exotropia tend to exhibit exotropic drift. The
rate of recurrence is increasing over time, and the strabis-
mus surgeons are therefore often obliged to perform a
second surgery [1, 2]. Some studies have reported that
extraocular muscle surgeries could provide satisfactory
outcomes for recurrent exotropia after lateral rectus re-
cession [3–6], but few studies evaluated reoperations for
recurrent exotropia after medial rectus resection.
Surgical interventions for recurrent strabismus de-
pend on the previous surgery [7–9]. Surgical options for
patients who have undergone bilateral medial rectus re-
section (BMR) include bilateral medial rectus re-resec-
tion, unilateral lateral rectus recession and medial rectus
re-resection, and bilateral lateral rectus recession (BLR).
130.237.165.40 - 12/10/2018 8:04:14 AM
Longqian Liu
Stockholm University Library
Department of Ophthalmology, West China Hospital
Sichuan University, 37 Guoxue Xiang
Chengdu, Sichuan 610041 (China)
Downloaded by:
E-Mail b.q15651 @ hotmail.com
However, rectus muscle reoperation has disadvantages
because it is a more difficult surgical technique due to scar
tissues, it requires more time under anesthesia, and it has
a higher risk of limited ocular rotation [4, 10]. Therefore,
BLR, as the secondary operation, may achieve satisfactory
results for this condition. However, to our knowledge, the
results of BLR as a treatment for recurrent exotropia after
BMR have not been reported. Therefore, we performed
this study to evaluate the efficacy of BLR in patients with
recurrent exotropia who previously underwent BMR as
an initial surgery.
Subjects and Methods
After obtaining approval from the Ethics Committee of West
China Hospital of Sichuan University, we retrospectively reviewed
the medical records of patients who underwent symmetric BMR
surgery for constant or intermittent exotropia from 2011 to 2017.
Patients who were postoperatively diagnosed with recurrent exo-
tropia and underwent secondary symmetric BLR were included in
this study. All surgeries were performed under general anesthesia
using the same surgical table [11] by the same surgeon (L.Q.L.). No
adjustable sutures were used. The minimum required follow-up
period after reoperation was 6 months. Patients were excluded if
they had undergone a previous surgery for exotropia by another
surgeon, or if they had restricted or paralytic strabismus, dysfunc-
tion of oblique muscles, systemic diseases such as Down syndrome
or cerebral palsy, or ocular diseases other than strabismus.
All patients underwent complete ocular examinations, includ-
ing visual acuity testing, cycloplegic refraction, ocular motility,
and slit-lamp and fundus examinations. The angle of deviation was
measured by alternate prism cover test (PACT) at both distance
and near (6 m and 33 cm, respectively). The PACT was performed
again after occlusion of the monocular for 1 h in all patients with
intermittent exotropia and recurrent intermittent exotropia. Ste-
reoacuity was measured with Titmus stereotest when the patient
was able to cooperate and complete the test.
We noted preoperative patient characteristics, including their
age at the onset of deviation and at the time of surgery, gender, the
interval between consecutive operations, preoperative deviation at
distance and near, constancy of deviation (intermittent or con-
stant), the angle of deviation, stereopsis, the amount of medial rec-
tus muscle (MR) resection, the amount of lateral rectus muscle
(LR) recession, and the time period between second surgery and
last follow-up.
Surgical success was defined as an alignment between 10 prism
diopters (PD) of exodeviation and 10 PD of esodeviation at dis-
tance in the primary gaze. Undercorrection or recurrence was de-
fined as an alignment of >10 PD of exotropia, and overcorrection
was defined as >10 PD of esotropia [4, 12]. A stereoacuity of 100 s
of arc or better was defined as good.
All analyses were performed using SPSS software version 20.0
(SPSS Inc., an IBM company, Chicago, IL, USA). Continuous data
are presented as the mean with SD or median, and categorical data
are presented as counts. Independent t tests were used to compare
differences in angle of deviation between before and after bilateral
2 Ophthalmic Res
DOI: 10.1159/000494560
Table 1. Preoperative characteristics of the patients
Sex (m/f), n 13/11
Age at surgery, years
Primary operation 6.73±5.08
Reoperation 8.03±5.28
Interval between consecutive operations,
months 15.5±10.09
Preoperative deviation before primary surgery
Near, PD –72±33
Distance, PD –61.33±34.32
Surgical dosage for bilateral MR resection, mm 7.46 [5–10]
Postoperative deviation 1 day following primary
surgery, PD +1.63±7.09
Preoperative deviation before reoperation
Near, PD –43.5±18.45
Distance, PD –37.75±14.93
Surgical dosage for bilateral LR recession, mm 7 [4–9]
Follow-up, months 24.13±15.01
Vertical transposition, n (%) 7 (30.4)
Figures in square brackets indicate range. PD, prism diopters;
MR, medial rectus muscle; LR, lateral rectus muscle.
LR recession. The χ2 method was used to test the significance of
differences between proportions and categorical variables. A p val-
ue of <0.05 was considered statistically significant.
Results
The clinical records of 545 patients with exotropia who
underwent BMR were retrospectively reviewed. Among
these patients, 24 patients with recurrent exotropia who
underwent BLR were enrolled in this retrospective study.
Patient characteristics are described in Table 1. The mean
age at BMR surgery was 6.73 ± 5.08 years old, and the me-
dian MR resected at each eye was 7.0 mm (range 5–10
mm). Six (25%) patients had intermittent exotropia and
18 (75%) patients had constant exotropia. The immediate
mean angle of deviation after BMR was +1.63 ± 7.09 PD.
The mean age at BLR surgery was 8.03 ± 5.28 years old,
and the median LR recessed at each eye was 8.0 mm
(range 4–9 mm). Fifteen (62.5%) patients had intermit-
tent exotropia and 9 (37.5%) patients had constant exo-
tropia. The preoperative angle of deviation at near and
distance were –43.5 ± 18.45 PD and –37.75 ± 14.93 PD,
respectively. The overall mean follow-up time of patients
was 24.13 ± 15.01 months (6–60 months). No significant
observable postoperative limitation in extraocular move-
ments was noted in any of the patients.
130.237.165.40 - 12/10/2018 8:04:14 AM
Wang/Chen/Liu
Stockholm University Library
Downloaded by:
Table 2. Success rates of bilateral lateral muscle recession for recur-
rent exotropia
30

Follow-up Surgical outcomes 15

7.04
success overcorrection undercorrection 1.83 2.88
1.50

Angle of deviation
0
One day 18 (75%) 6 (25%) 0
One month 21 (87.5%) 3 (12.5%) 0 –15
Six months 20 (83.3%) 4 (16.7%) 0
Final follow-up 22 (91.6%) 1 (4.2%) 1 (4.2%) –30
–37.75
–45

–60
Table 3. Dose-effect ratio of bilateral lateral muscle recession ac- Pre-op 1 day 1 month 6 months Final
cording to the surgical amount Time

Resection amount Patients, Mean dose-effect ratio,

n PD/mm
Fig. 1. The mean distance deviations preoperatively and at the
≤5 mm 6 2.96±0.70 postoperative follow-up points following the bilateral lateral rectus
5< ≤7 mm 5 2.23±0.83 recession. The exodrift was observed over time. Pre-op, preopera-
>7 mm 13 2.91±0.61 tively.
Total 24 2.78±0.71

PD, prism diopters.

Regarding immediate surgical outcomes, 18 (75%) pa-
tients had successful outcomes, 6 (25%) exhibited over-
correction, and none exhibited undercorrection on post-
operative day 1. Regarding short-term surgical outcomes,
21 (87.5%) patients had successful outcomes, and 3
(12.5%) patients showed overcorrection at 1 month post-
operatively. At the last follow-up examination, there were
22 (91.6%) successful outcomes, 1 (4.2%) overcorrection,
and 1 (4.2%) undercorrection (Table 2).
Figure 1 shows the mean distance deviation preopera-
tively and at postoperative follow-up points following the
second surgery. The mean deviation angle at distance was
significantly reduced from –37.75 ± 14.93 PD preopera-
tively to +1.50 ± 6.43 PD at the final follow-up visit (p <
0.001). Exotropic drift of alignment was observed during
the postoperative follow-up period.
Table 3 provides a summary of the mean effect per mil-
limeter of lateral muscle recession. The ratio of corrected
angle of deviation to the sum amount of LR recession was
2.78 ± 0.71 PD/mm.
Good stereoacuity was defined as 100 s of arc or better
and was observed in 47.8% (11/23) of the patients at the
last follow-up. This result was better than the value of
17.4% (4/23) observed before the second surgery (p =
0.028). Improved stereoacuity after reoperation was ob-
served in 78.3% (18/23) of the patients, stationary stereo-
acuity was present in 21.7% (5/23) of the patients, and no
patients showed deteriorated stereoacuity.
Discussion
Recurrent exotropia is common after horizontal extra-
ocular muscle surgery for intermittent or constant exo-
tropia and is mainly caused by the postoperative exodrift
tendency [13]. There is overall agreement that an initial
overcorrection after exotropia surgery is required for the
treatment of exotropic drift. Raab and Parks [14] report-
ed that an overcorrection of 10 PD to 20 PD can lead to
good results. However, in our study, the immediate mean
angle of deviation after the first surgery was +1.63 ± 7.09
PD. We speculate that the small amount of overcorrec-
tion after the initial surgery was the reason why these pa-
tients in this study had recurrent exotropia.
To achieve a satisfactory ocular alignment and main-
tain binocular function, patients with recurrent exotropia
usually undergo an additional operation [2–8, 10]. Surgi-
cal interventions for recurrent exotropia depend on the
previous surgery. When patients have convergence insuf-
ficiency type exotropia [15] or large-angle exotropia [16],
BMR can be performed as the first procedure. For those
patients who have resected bilateral MR, surgeons tend to
130.237.165.40 - 12/10/2018 8:04:14 AM

Bilateral Lateral Rectus Recession for Ophthalmic Res 3

Stockholm University Library

Treating Recurrent Exotropia DOI: 10.1159/000494560

Downloaded by:
perform LR recession in a reoperation instead of MR re-
resection. This is because it is more difficult to perform a
repeat surgery on a muscle than it is to perform a surgery
on a muscle without previous surgery. After an initial sur-
gery, the position of the muscle and its insertions may
vary, and variable amounts of scar tissues may be present.
These conditions increase the difficulty of the surgical re-
operations. In addition, patients who undergo large re-
section or recession of extraocular muscles are at risk of
restricted ocular motility [17–19]. In this study, the me-
dian amount of BMR in the initial surgery was 7.0 mm.
Although this allowed for additional MR resection to be
performed, it was not enough to correct the moderate or
large deviation of these patients with recurrent exotropia,
which was –37.75 ± 14.93 PD. Alternatively, a larger
amount of MR resection may have caused a limitation of
abduction.
To the best of our knowledge, this retrospective study
is the first investigation to evaluate the outcomes of BLR
in patients with recurrent exotropia following BMR. In
this study, we found that the procedure yielded good mo-
tor and sensory results with a surgical effect of 2.78 ± 0.71
PD/mm. The overall success rate of BLR as a treatment of
recurrent exotropia was 83.3% (20/24) at 6 months post-
operatively and 91.6% (22/24) at the last follow-up (24.13
± 15.01 months). Seven patients underwent a simultane-
ous vertical transposition of MR for correction of an A or
V pattern at the first surgery. In addition, these patients
no longer showed an A or V pattern after the primary
surgery, and all of them achieved surgical success after
BLR surgery for recurrent exotropia.
In this study, the mean postoperative angle of devia-
tion after reoperation was +7.04 PD immediately after the
second surgery and +1.50 PD at the last follow-up. Our
results show that these patients had a tendency to drift
toward exodeviation with time after reoperation, but the
amplitude was slight (Fig. 1). This result is consistent with
previous reports of lower exodrift of recurrent exotropia
after a second surgery [2, 7]. In addition, 3 of the patients
in this study, who had a large initial overcorrection of 20
PD or more at the postoperative day 1, still had more than
15 PD of overcorrection at 6 months postoperatively, al-
though 2 of these individuals presented a decrease in
esodeviation and achieved surgical success at the final ex-
amination (33 and 31 months, respectively). Therefore,
an initial large overcorrection in BLR may not be needed
to correct patients with recurrent exotropia following
BMR as the primary surgery. However, further studies are
needed to support this claim.
4 Ophthalmic Res
DOI: 10.1159/000494560
The limitation of our study is that it was carried out
retrospectively. Selective bias might have occurred. In ad-
dition, this retrospective study is limited by incomplete
data: there were no data on the accommodative conver-
gence to accommodation (AC/A) ratio of patients. Fur-
thermore, this study did not compare the surgical out-
comes of BLR with those in other surgical procedures
used to treat patients with recurrent exotropia following
BMR surgery. Additionally, the patients who underwent
a simultaneous vertical transposition of MR at a primary
surgery were also included in this study. More prospec-
tive comparative studies, with stricter inclusion criteria
are needed to confirm the present results. However, for
reoperation for recurrent exotropia after BMR, this study
provides the first useful data supporting the efficacy of
BLR.
In conclusion, BLR could be an effective and safe
method for treating recurrent exotropia after BMR. We
recommend this procedure as a second surgery for those
patients who have undergone resection of a moderate to
large amount of BMR and subsequently developed recur-
rent exotropia with a moderate to large angle of devia-
tions.
Statement of Ethics
This retrospective study has been approved by the Ethics Com-
mittee of West China Hospital of Sichuan University.
Disclosure Statement
The authors have no conflict of interests.
Author Contributions
Xi Wang and Longqian Liu conceived the idea of the study. Xi
Wang and Xiaohang Chen collected data and performed data anal-
yses. The manuscript was drafted by Xi Wang and critically revised
by Longqian Liu.
130.237.165.40 - 12/10/2018 8:04:14 AM
Wang/Chen/Liu
Stockholm University Library
Downloaded by:
 References
 1 Leow PL, Ko ST, Wu PK, Chan CW. Exo-
tropic drift and ocular alignment after surgi-
cal correction for intermittent exotropia. J Pe-
diatr Ophthalmol Strabismus. 2010 Jan-Feb;
47(1):12–6.
  2 Kim WJ, Kim MM. The clinical course of re-
current intermittent exotropia following one
or two surgeries over 24 months postopera-
tively. Eye (Lond). 2014 Jul;28(7):819–24.
  3 Yazdian Z, Ghiassi G. Re-recession of the lat-
eral rectus muscles in patients with recurrent
exotropia. J AAPOS. 2006 Apr;10(2):164–7.
 4 Lueder GT, Galli M. Comparison of lateral
rectus muscle re-recession and medial rectus
muscle resection for treatment of postopera-
tive exotropia. Am J Ophthalmol. 2015 Apr;
159(4):812–5.
  5 Ren MY, Wang T, Wang Q, Guo JL, Wang
LH. Unilateral medial rectus resection for the
treatment of recurrent exotropia in children.
Jpn J Ophthalmol. 2015 Sep;59(5):341–5.
  6 Cho KH, Kim HW, Choi DG, Lee JY. Type of
the recurrent exotropia after bilateral rectus
recession for intermittent exotropia. BMC
Ophthalmol. 2016 Jul;16(1):97.
Bilateral Lateral Rectus Recession for
Treating Recurrent Exotropia
  7 Yang HK, Hwang JM. Bilateral vs unilateral
medial rectus resection for recurrent exotro-
pia after bilateral lateral rectus recession. Am
J Ophthalmol. 2009 Sep;148(3):459–65.
  8 Olitsky SE, Kelly C, Lee H, Nelson LB. Unilat-
eral rectus resection in the treatment of un-
dercorrected or recurrent strabismus. J Pedi-
atr Ophthalmol Strabismus. 2001 Nov-Dec;
38(6):349–53.
  9 Nucci P, Serafino M, Trivedi RH, Saunders RA.
One-muscle surgery in small-angle residual
esotropia. J AAPOS. 2007 Jun;11(3):269–72.
10 Kim JH, Kim HJ, Choi DG. Contralateral lat-
eral rectus recession versus recess-resect for
recurrent exotropia after unilateral recess-re-
sect. Br J Ophthalmol. 2013 Jun;97(6):752–6.
11 Wright KW. Color Atlas of Strabismus Sur-
gery: Strategies and Techniques. 3rd ed. New
York: Springer; 2007. pp. 219–20.
12 Choi MY, Hyung SM, Hwang JM. Unilateral
recession-resection in children with exotro-
pia of the convergence insufficiency type. Eye
(Lond). 2007 Mar;21(3):344–7.
Ophthalmic Res
DOI: 10.1159/000494560
13 Isenberg SJ, Abdarbashi P. Drift of ocular
alignment following strabismus surgery. Part
2: using adjustable sutures. Br J Ophthalmol.
2009 Apr;93(4):443–7.
14 Raab EL, Parks MM. Recession of the lateral
recti. Early and late postoperative alignments.
Arch Ophthalmol. 1969 Aug;82(2):203–8.
15 Hermann JS. Surgical therapy of convergence
insufficiency. J Pediatr Ophthalmol Strabis-
mus. 1981 Jan-Feb;18(1):28–31.
16 ElKamshoushy AA. Bilateral medial rectus
resection for primary large-angle exotropia. J
AAPOS. 2017 Apr;21(2):112–6.
17 Kang SJ, Jang JH. Motility restriction after re-
section of an extraocular muscle. Korean J
Ophthalmol. 2001 Dec;15(2):133–6.
18 Chang JH, Kim HD, Lee JB, Han SH. Super-
maximal recession and resection in large-an-
gle sensory exotropia. Korean J Ophthalmol.
2011 Apr;25(2):139–41.
19 Li JH, Zhang LJ. Three-muscle surgery for
very large-angle constant exotropia. J AA-
POS. 2013 Dec;17(6):578–81.
130.237.165.40 - 12/10/2018 8:04:14 AM
5
Stockholm University Library
Downloaded by: