870094

research-article2019
EJO0010.1177/1120672119870094European Journal of OphthalmologyFard and Ghahvehchian

EJO European
Journal of
Ophthalmology
Original research article

European Journal of Ophthalmology

Lateral rectus advancement versus

2021, Vol. 31(1) 258­–262
© The Author(s) 2019
Article reuse guidelines:
medial rectus recession for sagepub.com/journals-permissions
https://doi.org/10.1177/1120672119870094
DOI: 10.1177/1120672119870094

consecutive esotropia journals.sagepub.com/home/ejo

Masoud Aghsaei Fard and Hossein Ghahvehchian

Abstract
Purpose: To compare lateral rectus advancement with medial rectus recession for patients with consecutive esotropia
without abduction limitation.
Methods: Forty-three patients who developed consecutive esotropia following bilateral lateral rectus recession for
intermittent exotropia were reviewed retrospectively. Twenty-two patients underwent lateral rectus advancement
(lateral rectus advancement group) and medial rectus recession was performed in 21 patients (medial rectus recession
group). Success rate of the surgery was based on the percentage of postoperative esophoria or exophoria of less than 8
PD, which did not require a third surgery. Mean follow-up after second surgery was 23.5 ± 8.7 months.
Results: Mean consecutive esotropia in the lateral rectus advancement group was 24.8 ± 9.0 PD. Eight patients were
orthophoric after second surgery; mean postoperative esophoria and exophoria/tropia was 5.4 ± 3.4 PD and 6.5 ±
5 PD, respectively. Postoperative success rate in this group was 90.9%. Mean consecutive esotropia in the medial
rectus recession group was 21 ± 98.4 PD. Three patients were orthophoric after second surgery; mean postoperative
esotropia/phoria and exophoria was 9.5 ± 5.0 PD and 5.2 ± 1.3 PD, respectively. Postoperative success rate in this
group was 71.4%. Postoperative undercorrection rate of 4.5% in lateral rectus advancement group was significantly less
than the similar measure of 28.6% in medial rectus recession group (chi-square, P = 0.03).
Conclusion: Advancement of the previously recessed lateral rectus has improved consecutive esotropia better than
medial rectus recession.

Keywords
Eso and exo deviations, strabismus, strabismus surgery/complications, eye movement disorders, ocular motility
disorders, pediatric ophthalmology, amblyopia

Date received: 20 April 2019; accepted: 21 July 2019

Introduction Prismatic correction could achieve good motor outcome

Consecutive esotropia is a form of esodeviation that occurs
after surgical treatment of intermittent exodeviation and
defined when postoperative esotropia persists for more than 1
month.1 Most surgeons consider small amount of esodevia-
tion acceptable after bilateral lateral rectus (LR) muscle
recession because of the postoperative exodrift that has been
seen in many studies.2,3 While some authors believe that ini-
tial esodrift after exotropia surgery could be associated with
low recurrence within 2 years after surgery, it may not predict
long-term motor outcomes.4,5 On the contrary, “persistent”
overcorrection is not acceptable due to risk of amblyopia.6,7
Several measures including surgical and nonsurgical
approaches are taken to manage postoperative esotropia.
while maintaining a favorable sensory status.8 Surgical
approaches have also been used to correct the consecutive
esotropia but there is no universal guideline on the surgical
plans for consecutive esotropia. For consecutive esotropia
following bilateral LR recession for intermittent exodeviation
Farabi Eye Research Center, Farabi Eye Hospital, Tehran University of
Medical Sciences, Tehran, Iran
Corresponding author:
Masoud Aghsaei Fard, Farabi Eye Research Center, Farabi Eye Hospital,
Tehran University of Medical Sciences, Qazvin Square, Tehran 13366-
16351, Iran.
Email: masood219@gmail.com
Fard and Ghahvehchian 259
without any limitation of duction, surgical treatment options
are as follows: unilateral or bilateral medial rectus (MR)
recession or LR advancement. While unilateral LR muscle
advancement surgery was successful in one study,9 unilateral
MR recession had also acceptable outcomes in the correction
of consecutive esotropia in 62.5% of cases.10 Furthermore,
other methods have been used, and Park et al.11 concluded
that LR advancement with recession of the MR in the deviat-
ing eye has a high success rate compared to that of bilateral
MR recession.
However, it is not known whether later rectus advance-
ment is more effective than MR recession in alleviating
postoperative esotropia. Therefore, we compared the effect
of MR recession to LR advancement in the patient with
consecutive esotropia after bilateral LR recession for inter-
mittent exotropia.
Patients and methods
The medical records of a series of patients with consecu-
tive esotropia after bilateral LR recession for intermit-
tent exotropia in Farabi Eye Hospital who underwent
MR recession (2007–2012) or LR advancement (2012–
2017) by a single surgeon (M.A.F.) were reviewed. Data
collection was approved by the local institutional review
board. Initially, those patients with esotropia persisting
for longer than 2 weeks after surgery were managed with
alternating pathing, correction of hypermetropic refrac-
tive errors of more than +1.5 D, or base-out prisms.
However, some patients who had an esodeviation of 8
PD or greater for more than 6 months despite nonsurgi-
cal measures underwent surgery. The minimum follow-
up time after second surgery was 6 months. Patients with
more than –1 limitation of abduction, oblique muscle
overaction, significant A or V pattern, and distant-near
difference >10 PD were excluded from this study.
Surgical procedure was classified into two types: (a) LR
advancement group, in which dose effect of 1 mm
advancement for 3.5–4 PD esotropia was used,12 and (b)
MR recession group with 1 mm recession for 2.5–3 PD
esotropia.13 Unilateral or bilateral surgery was per-
formed and total amount of advancement or recession
was reported. Bilateral surgery was done if there was
more than 7 mm need for recess or advancement.
Age, refraction, type and amount of exodeviation,
amount of surgery for primary exotropia and consecu-
tive esotropia, and the time interval between them and
the follow-up duration were recorded. Prism and alter-
nate cover test, at far (6 m) and near (1/3 m), was used
to measure the deviation in pre-operative and postoper-
ative at last follow-up period. Postoperative undercor-
rection was defined as esotropia of more than 8 PD.
Exotropia of more than 8 PD was regarded as overcor-
rection. We considered success of surgery as postopera-
tive esophoria or exophoria of less than 8 PD, which did
not require a third surgery.
Statistical analysis was performed using Student’s t test
and χ2 test with SPSS, version 15 (SPSS Inc., Chicago, IL,
USA). Values of P < 0.05 were considered to indicate sta-
tistical significance.
Results
Forty-three cases of consecutive esotropia were identified
after excluding eight cases with short-term follow-up, sig-
nificant abduction limitation, and/or oblique muscle dys-
function. Mean age during the first operation (bilateral LR
recession) was 6.0 ± 3.8 (range: 2–22) years. Mean
amount of bilateral LR recession was 6.9 ± 1.1 mm for
31.9 ± 7.4 PD of intermittent exotropia for distance and
30.8 ± 8.1 PD for near. Twenty cases were basic type and
23 cases were pseudo-divergence excess intermittent exo-
tropia. There were 32 females and 11 males. The mean
spherical equivalent refraction was –1.0 ± 4.7 D and –0.6
± 3.9 D in the right and left eyes, respectively. Mean con-
secutive esotropia in central gaze was 23 ± 8 PD for dis-
tance and 23 ± 8 PD for near in all cases, which led to the
second operation after 8.6 ± 2.4 months. Ocular versions
were full in all patients. Mean follow-up after second sur-
gery was 23.5 ± 8.7 months. Twenty-two patients with
consecutive esotropia underwent LR advancement (LR
advancement group) and MR recession was performed in
21 patients (MR recession group). Two groups were not
significantly different with regard to age, amount of inter-
mittent exotropia, amount of first operation (bilateral LR
recess), amount of consecutive esotropia, time of the sec-
ond surgery, and mean follow-up (Table 1). Five patients
in LR advancement group and seven patients in MR reces-
sion group had bilateral surgery.
Mean consecutive esotropia in the LR advancement
group was 24.8 ± 9.0 PD and 25.4 ± 8.5 PD for far and
near, respectively, for which 6.2 ± 1.9 mm LR advance-
ment was performed. Eight patients were orthophoric after
second surgery; mean postoperative esophoria in 10
patients was 5.4 ± 3.4 PD at far and 4.3 ± 2.2 PD at near,
and mean postoperative exophoria/tropia in 4 patients was
6.5 ± 5 PD for far and near at the latest follow-up visit at
13.8 ± 5.5 months (range: 6–24). Two patients required
third surgery: one for 14 PD esotropia, for which LR re-
advancement was performed; another patient underwent
LR recession for 14 PD exotropia. Overall, postoperative
success rate in this group was 90.9%.
Mean consecutive esotropia in the MR recession group
was 21 ± 9.8 PD and 21.1 ± 8.6 PD for far and near,
respectively, for which the patients underwent 7.3 ± 2.3
mm MR recession. Three patients were orthophoric after
second surgery; mean postoperative esotropia/phoria in 13
patients was 9.5 ± 5.0 PD at far and 10.6 ± 4.5 PD at near,
and mean postoperative exotropia/phoria in 5 patients was
5.2 ± 1.3 PD and 7.0 ± 2.2 PD for far and near, respec-
tively, at the latest follow-up visit at 15.2 ± 6.6 months
(range: 6–24). Six patients needed third surgery, all of
260 European Journal of Ophthalmology 31(1)

Table 1.  Demographic and clinical data of patients (mean ± standard deviation).

LR advancement (N = 22) MR recession (N = 21) P value

Age (years) 5.5 ± 4.1 6.2 ± 3.4 0.738
Right eye refraction at reoperation (SE) (D) –0.58 ± 3.42 –1.56 ± 5.93 0.393
Left eye refraction at reoperation (SE) (D) –0.59 ± 3.45 –0.64 ± 4.52 0.868
Intermittent exotropia (far) (PD) 32.59 ± 7.9 31.19 ± 7.05 0.599
Intermittent exotropia (near) (PD) 30.77 ± 8.43 31 ± 8.06 0.877
Bilateral LR recess (mm) 6.8 ± 1 7 ± 1.33 0.192
Consecutive esotropia (far) (PD) 24.86 ± 9.08 21 ± 8.46 0.945
Consecutive esotropia (near) (PD) 25.41 ± 8.51 21.14 ± 8.68 0.906
Second surgery time (months) 8.6 ± 2.5 8.7 ± 2.4 0.536
LR advancement or MR recession (mm) 6.27 ± 1.89 7.33 ± 2.34 0.354
Follow-up period (months) 23.18 ± 9.59 23.9 ± 7.93 0.213

LR: lateral rectus; MR: medial rectus; SE: spherical equivalent (diopter); PD: prism diopter.

Table 2.  Literature review of the efficacy of MR recession versus LR advancement in consecutive esotropia.

Study Year Esodeviation (PD) Number Method of surgery Follow-up Success rate (%)
of cases (months)
Adamopoulou and Rao10 2015 19.43 16 UMR recession 28.3 62.50
Jung and Rah16 2007 21.1 13 BMR recession 17.1 76.9
Shin and Chang17 2003 31 20 UMR recession 12 <25
Choi and Choi18 2012 27.5 12 UMR recession 30 75
Park et al.11 2013 32.3 15 BMR recession 12 73
Park et al.11 2013 39.2 14 LR advancement + 12 85.7
MR recession
Kim and Lee9 2017 20 11 LR advancement 6 91
Lee et al.19 2008 19.42 13 LR advancement 6 100
Shin et al.20 2014 27.3 7 LR advancement 24 72
Kim et al.12 2014 25.5 11 LR advancement – 82

LR: lateral rectus; MR: medial rectus; PD: prism diopter; UMR: unilateral medial rectus recession; BMR: bilateral medial rectus recession.

them for residual esotropia, for which LR advancement
was performed. Overall, postoperative success rate in this
group was 71.4%.
Postoperative undercorrection rate of 4.5% in LR
advancement group was significantly less than the similar
measure of 28.6% in MR recession group (chi-square, P =
0.03). While the number of third surgery was fewer in LR
advancement group compared to MR recession group
(9.1% vs 28.6%, respectively), the difference was not sig-
nificant (chi-square, P = 0.10). Postoperative overcorrec-
tion rate was 4.5% in LR advancement group. No
overcorrection happened in MR recession group (chi-
square, P = 0.32).
Discussion
Consecutive esotropia after intermittent exotropia surgery
should be addressed with nonsurgical or surgical methods to
prevent binocular suppression. Prismatic correction in con-
secutive esotropia after bilateral LR recession is associated
with a desirable good long-term outcome.14 Lee et al.8
showed that in patients with consecutive esotropia after
bilateral LR recession that were treated with prism glasses,
the angle of esodeviation continuously decreased and 82%
were weaned off prism glasses. However, esotropia of more
than 14 PD after 6 months of operation, lateral incommi-
tancy that induced diplopia, loss of proper abduction, and
the patients that do not have good compliance for nonsurgi-
cal management should be considered for surgical manage-
ments.15 Several surgical options such as unilateral or
bilateral MR recession or LR advancement have been used
to correct the consecutive esotropia surgically. In this study,
we compared MR recession with LR advancement for cor-
rection of consecutive esotropia in 43 patients who under-
went bilateral LR recession for intermittent exotropia with a
long follow-up (average of 23.5 months). Our findings con-
firmed that LR advancement has led to significantly less
postoperative undercorrection than MR recession.
Few studies have assessed the various surgical methods of
consecutive esotropia correction, with variable reported suc-
cess outcomes (Table 2). Kim and Lee9 found that unilateral
LR muscle advancement surgery was successful in all 11
cases and the surgical effect was significantly greater in uni-
lateral LR muscle advancement than in primary LR muscle
Fard and Ghahvehchian 261
recession. Shin et al. evaluated bilateral and unilateral LR
advancement on 25 patients who had a bilateral and unilateral
LR recession for intermittent exotropia. Eighteen patients
(72.0%) showed satisfactory long-term motor and sensory
outcomes. The long-term motor success rate of the unilateral
LR group was better than that of the bilateral LR group.20
Whereas, Adamopoulou and Rao10 reported that unilateral
MR recession has 62.5% success rate in the correction of con-
secutive esotropia of 16 cases with unsatisfactory postopera-
tive alignment in six patients. Bilateral MR recession was
also used on the 13 patients with average esodeviation of 21.1
PD with resulting 76.9% success rate in 18-months follow-
up.16 It was believed that bilateral MR recessions was the rec-
ommended surgery in cases of consecutive esotropia
following bilateral LR recession with no abduction deficit
and LR advancement was the option if there was limitation of
abduction.21 However, in 29 patients with consecutive esotro-
pia without abduction limitation, a comparative study per-
formed LR advancement with MR recession in the chiefly
deviating eye in relation to bilateral MR recession. At 12
months postoperatively, the surgical success rate of 85.7%
was achieved in LR advancement with MR recession group
compared to 73.3% in bilateral MR recession group, without
a significant difference between them.11 While we found sim-
ilar success rate of 71.4% in MR recession group, LR
advancement achieved more success rate (90.9%) with under-
dercorrection rate of 4.5%, which was significantly less than
the undercorrection rate of 28.6% in MR recession group.
Therefore, the view of low predictability of surgery on the
previous operated LR muscle because of the lack of clear
guidelines needs to be revised with regard to previous studies
and our study.9,22,23 We speculate that operation on previous
LR based on one-fourth of the angle of deviation12 might cor-
rect the consecutive deviation without clinically evident
abduction limitation. In addition, there is a benefit of preserv-
ing the fresh MR for potential future surgeries.
There are several limitations in our study. First, the ret-
rospective nature of study and small sample size should be
considered and therefore there was no randomization into
the two groups, which may have affected our results.
Second, the sensory outcomes before and after surgery
were not recorded in this study. Finally, dose effect size for
MR recession and LR advancement which we used in our
study is varied in different studies24 and has effect on the
result of our study.
In conclusion, unilateral or bilateral advancement of
LR offer better postoperative results than unilateral or
bilateral MR recession for the correction of consecutive
esotropia following bilateral LR recession in eyes without
abduction limitation.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Masoud Aghsaei Fard https://orcid.org/0000-0003-4005-2967
Hossein Ghahvehchian https://orcid.org/0000-0001-6498-1408
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