983199

research-article2020
EJO0010.1177/1120672120983199European Journal of OphthalmologyCeylan et al.

EJO European
Journal of
Ophthalmology
Clinical trial protocol

European Journal of Ophthalmology

Surgical management of consecutive

1­–5
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exotropia: Long-term outcomes sagepub.com/journals-permissions
https://doi.org/10.1177/1120672120983199
DOI: 10.1177/1120672120983199
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Osman Melih Ceylan1 , Yeşim Gedik Oğuz2, Önder Ayyıldız2,

Serkan Köksal2, Erhan Yumuşak1 and Fatih Mehmet Mutlu3

Abstract
Purpose: To compare lateral rectus recession (LRc) and medial rectus advancement (MRadv) for correction of
consecutive exotropia (CXT).
Methods: Of the 43 exotropic patients 20 of them underwent LRc (group 1) and 23 of them underwent MRadv (group
2). Postoperative exodrift, strabismic angle, dose effect relationship were compared with minimum 2 years follow‑up.
Results: An average dose-effect in group 2 is higher than group 1 in the early postoperative period, however there was
no significant difference at the second year follow-up (p=0,109). An average exodrift after 2 year follow-up was 6,6±7,12
PD in group 1, and 8,13±7,45 PD in group 2. Postoperative overall success rate was 50% in group 1 and 65% in group 2
at the last follow-up. The success rates were not significantly different between the groups (chi-square, p =0.31).
Conclusion: Although there was no statistically significant difference at the last follow-up, better results were obtained
with MRadv than LRc in the treatment of CXT.

Keywords
Amblyopia, STRABISMUS, Eso and Exo deviations, Special forms (Duane, CPEO, MG, others), Strabismus Surgery/
Complications

Date received: 13 June 2020; accepted: 3 December 2020

Introduction a combination of these methods. Esotropia is generally

Consecutive exotropia (CXT) is a common complica-
tion that occurs early or late after esotropia surgery.
When non-surgical methods (botulinum toxin injec-
tion, prismatic glasses, alternating occlusion, and opti-
cal therapy) are ineffective, surgical approaches should
be considered.1,2 The most preferred surgery for eso-
tropia is bilateral medial rectus recession (BMRc).3,4
Age, accommodation, muscle slippage (disinserted
and retracted rectus muscle within its capsule and reat-
tachment to the sclera by an empty tendon sheath) and
stretched scar formation are effective factors in the
development of CXT.5–7 The slipped muscle creates a
varying degree of adduction limitation, while a stretch
scar is rarely associated with adduction limitation.6
Various surgical approaches are used to correct CXT,
including medial rectus advancement (MRadv) (with or
without resection), lateral rectus recession (LRc), and
preferred in the early postoperative period since there is a
risk of exodrift over time.8,9 On the other hand, there is no
consensus on the amount of esotropia to be targeted in the
postoperative period. This is why it is important to com-
pare surgical methods especially involving long-term
results.1,10–12 To the best of our knowledge, no previous
study has compared the long-term outcomes of MRadv
1
 epartment of Ophthalmology, University of Health Science, Gulhane
D
Training and Research Hospital, Ankara, Turkey
2
Department of Ophthalmology, Gulhane Training and Research
Hospital, Ankara, Turkey
3
Department of Ophthalmology, University of Health Science, Gulhane
School of Medicine, Ankara, Turkey
Corresponding author:
Osman Melih Ceylan, Department of Ophthalmology, University
of Health Science, Gulhane Training and Research Hospital, Ankara
06010, Turkey.
Email: drmelihceylan@yahoo.com.tr
2 European Journal of Ophthalmology 00(0)
and LRc in the treatment of CXT. Therefore, we aimed to
report the dose-effect relationship of surgery and results
in CXT patients.
Materials and methods
Subjects
This retrospective cohort study was carried out in accord-
ance with the principles of the Declaration of Helsinki after
obtaining the approval of the local ethics committee. The
medical records of patients who underwent BMRc without
lateral rectus resection for childhood esotropia between
January 1994 and April 2018 were reviewed. The indica-
tion for CXT surgery was exotropia ⩾12 prism diopters
(PD). Pre- and post-operative data collection and analysis
included age (initial surgery for esotropia and CXT), gen-
der, amount of previous BMRc, pre- and post-operative
ocular alignment, presence of muscle slippage or stretch
scar, adduction deficit, inferior oblique (IO) overaction,
hypertropia, A or V pattern without dissociated vertical
deviation (DVD), best-corrected visual acuity (BCVA),
cycloplegic refraction, anisometropia, presence of ambly-
opia, biomicroscopy, and fundus examination.
Inclusion and exclusion criteria
According to the type of surgery, we divided patients into
two groups: Group 1 consisted of patients who underwent
only LRc (unilateral or bilateral) and group 2 who only
had MRadv (unilateral or bilateral). Any patient with IO
overaction greater than +1, DVD, or dissociated horizon-
tal deviation (DHD), history of other eye surgery, neu-
rologic, traumatic or sensory strabismus, or additional
ocular pathologies of the cornea, lens, vitreous, retina and
optic nerve were excluded from the study. Furthermore,
patients who underwent combined surgery (LRc+MRadv)
or another squint surgery in addition to BMRc were not
included. Lastly, patients who had exotropia <12 PD in
the primary position and a follow-up time of <2 years
were excluded.
Preoperative management and examinations
The angle of deviation was measured using the alternate
prism cover test at near (30 cm) and distant (6 m) fixation
with spectacle correction in primary gaze and gaze-up/
down positions. The Krimsky method was used for unco-
operative cases. The absence of a central, steady, main-
tained fixation, a BCVA value of <0.6 or an interocular
BCVA difference of >2 lines (tumbling “E” or Snellen
chart) were defined as amblyopia.2,13 In patients aged
under 10 years, occlusion therapy was implemented before
surgery until no further improvement was observed for
three consecutive months. Anisometropia was defined as
an interocular difference in the spherical equivalent of at
least 1.00 D. The degree of duction deficit was graded on
a scale of −4 to 0, with −4 indicating no adduction beyond
midline, −3 indicating 75% adduction deficit, −2 indicat-
ing 50% adduction deficit, −1 indicating 25% adduction
deficit, and 0 indicating full adduction.14 Stereoacuity
was evaluated with the Titmus stereotest (Stereo Optical,
Chicago, IL, USA).
Surgical procedures and outcomes
All patients underwent either MRadv (unilateral or bilat-
eral) or LRc (unilateral or bilateral). The forced duction
test (FDT) was performed under general anesthesia before
starting the operation. If adduction limitation was evi-
dent and no limitation was determined with FDT, MRadv
(without resection) was performed. If no adduction limita-
tion was preoperatively or the lateral rectus muscle was
tight during FDT, single or bilateral LRc was performed
depending on the angle of strabismus. Unilateral LRc was
performed preferably on the non-fixating eye. All surgi-
cal operations were undertaken with a fornix-based inci-
sion with two double-armed 6.0 polyglactin 910 (Vicryl;
Ethicon, Inc, Somerville, NJ) sutures using halfwidth,
partial thickness bites, followed by two quarter-width
and then third-width, full-thickness reverse locking bites
at each edge with the non-adjustable technique. In the
presence of a stretch scar, resection was performed as
described by Ludwig and Chow.6 Success was defined as
deviation within 10 PD of orthophoria.1 Overcorrection
was defined as esotropia >10 PD, and undercorrection as
exotropia >10 PD.9 The postoperative angle of deviations
were measured at the first week, sixth week, sixth months,
and every 6 months thereafter. Surgical outcomes at the
sixth week and second year after MRadv or LRc were ana-
lyzed for the study.
Statistical analysis
Statistical analysis was performed using Student’s t-test
and Pearson’s chi-squared test with SPSS, version 16
(SPSS Inc., Chicago, IL, USA). Values of p < 0.05 were
considered to indicate statistical significance.
Results
The records of 64 patients diagnosed with CXT were
reviewed, of which 43 met the inclusion criteria. Twenty-
one patients were excluded for the following reasons; seven
did not have complete follow-up data, six had undergone
combined surgery (LRc+ MRadv), two had undergone
adjustable surgery, three had missing data, and three had a
neurological disease. There were 20 (10 male/10 female)
patients in group 1 and 23 (11 male/12 female) patients in
group 2. The mean age of the patients was 25.30 ± 7.45 years.
While 21 patients were initially operated elsewhere, 22
patients had their first surgery in our hospital. Of the 43
cases, 28 (65%) had infantile esotropia, nine (21%) had
partially accommodative esotropia, and six (14%) were
Ceylan et al. 3

Table 1.  Demographic and clinical data of patients.

LRc (n = 20) MRadv (n = 23) p Value

Age 22.90 ± 10.48 23.0 ± 9.17 0.974
RE refraction at reoperation (SE) 1.60 ± 2.80 1.15 ± 2.83 0.608
LE refraction at reoperation (SE) 1.79 ± 2.45 1.16 ± 2.81 0.445
The amount of LR or MR (mm) 6.17 ± 0.94 5.28 ± 0.36 0.879
Consecutive exotropia (far) 25.30 ± 7.45 25.48 ± 9.21 0.945
Consecutive exotropia (near) 23.40 ± 10.76 24.39 ± 9.51 0.750
Second surgery time (months) 72.88 ± 54.16 64.85 ± 50.71 0.641
Follow-up period (months) 61.00 ± 52.37 73.60 ± 68.37 0.506

LE: left eye; LR: lateral rectus; LRc: lateral rectus recession; MR: medial rectus; MRadv: medial rectus advancement; RE: right eye; SE: spherical
equivalent.

classified as unknown type (no available records of child-
hood esotropia). Bilateral surgery was performed in four
patients in each group. In group 1, 16 patients underwent
unilateral LRc, and in group 2, 19 patients underwent uni-
lateral MRadv. The average amount of LRc was 6.17 ± 0.94
(range: 5–8) millimeter (mm) in group 1 and the average
amount of MRadv was 5.2 ± 0.49 (range: 4–6) mm in group
2. The mean age at initial surgery was 3.12 ± 2.01 years, and
the mean age at surgery for CXT was 12.26 ± 9.61 years.
Forty-one patients (95%) had basic exotropia (distance and
near deviation within 10 PD), two (5%) had exotropia with
convergence insufficiency (near deviation exceeding dis-
tance deviation by 10 PD). Table 1 summarizes the demo-
graphic and clinical data of the patients.
The average deviation corrected per mm of LRc was
2.48 ± 1.12 PD at the sixth week and 2.13 ± 1.22 PD
in the second year. The average deviation corrected per
mm of MRadv was 3.70 ± 1.27 PD at the sixth week and
2.80 ± 1.39 PD at the second year. The effect of advanc-
ing medial rectus was more than LRc at the sixth week
follow-up (p = 0.002), but there was no statistically signifi-
cant difference between the two groups for the second year
follow-up (p = 0.109). In group 1, the mean preoperative
exotropia was 25.30 ± 7.45 PD and 23.40 ± 10.76 PD at
distance and near fixations, respectively. In the same group,
the mean postoperative exotropia was 8.15 ± 7.50 PD at
distance fixation and 6.25 ± 7.07 PD at near fixation, and
the mean postoperative esotropia/phoria was 0.90 ± 0.62
PD and 1.20 ± 0.65 PD, respectively at the latest follow-
up (61.00 ± 52.37 months). In group 2, the mean preopera-
tive exotropia was 25.48 ± 9.21 PD and 24.39 ± 9.51 PD
at distance and near fixations, respectively. In the same
group, the mean postoperative exotropia was 7.39 ± 2.07
PD at distance and 7.43 ± 1.98 PD at near fixation, and
the mean postoperative esotropia/phoria was 2.21 ± 1.05
PD and 1.60 ± 0.82 PD, respectively at the latest follow-up
(73.60 ± 68.37 months). The average exodrift was 3.1 ± 4.70
PD in group 1 and 2.50 ± 2.98 PD in group 2 at the sixth
week (p  = 0.621). The average exodrift was 6.6  ± 7.12
in group 1 and 8.13 ± 7.45 in group 2 at the second year
(p = 0.447). Ocular alignments measured at the sixth week,
sixth month, first year and second year after CXT surgery
Table 2.  Angle of deviations at 6 week, 6 month, 1 year, and
2 year after CXT surgery.
MRadv LRc p Value
6 Week XT 4.1 ± 4.53 6.53 ± 5.78 0.228
6 Month XT 5.50 ± 5.86 7.76 ± 5.74 0.282
1 Year XT 6.95 ± 6.08 8.47 ± 6.14 0.471
2 Year XT 7.30 ± 6.96 8.84 ± 7.15 0.501
LRc: lateral rectus recession; MRadv: medial rectus advancement; XT:
exotropia.
are given in Table 2. While alignment remained within 10
PD of orthotropia in 63% (27/43) of patients, five out of 16
(37%) patients who did not benefit from surgery were re-
operated. The overall postoperative success rate was 55%
(11/20) in group 1 and 70% (16/23) in group 2 at the sec-
ond year. There was no statistically significant difference
in terms of surgical success between the groups (p = 0.32).
In comparison, no statistically significant difference was
found between the two groups in terms of age, gender, pre-
operative angle of deviation, refractive error, stereopsis, IO
overaction, amblyopia, hypertropia, A- or V- pattern and
follow-up time, (p > 0.05). Amblyopia was present in 10
(23%) patients, two of them were in group 1 and eight were
in group 2 (p = 0.081). There was no statistically significant
difference in terms of surgical success between the patients
with and without amblyopia (p = 0.939). Five (12%) patients
had hypermetropia >2.50 D, four (9%) patients had hyper-
metropia <2.50 D and three (7%) of these patients also had
anisometropia. These patients were operated according to
the angle of deviation with spectacles. While adduction lim-
itation was present in a total of 15 (35%) patients before sur-
gery, −1 adduction limitation was detected in only two (5%)
patients postoperatively in group 2 at the last follow-up. The
data of stereopsis before and after BMRc were incomplete.
Of the 25 patients who were able to undergo stereopsis test-
ing before CXT surgery, 30% (6/20) of patients in group 1
and 39% (9/23) of patients in group 2 had gross stereopsis
(3000 s/arc) (p = 0.531). Postoperative gross stereopsis was
achieved in 45% (9/20) patients in group 1 and 48% (11/23)
patients in group 2.
4 European Journal of Ophthalmology 00(0)
Discussion
It has been reported that CXT may develop at a rate of 3% to
31% in the long term follow-up.11–13 Unlike other studies, we
investigated patients who underwent MRadv or LRc surgery
after BMRc at a minimum of 2 years follow-up.1,2,15 LRc is
generally used in basic or divergence excess exotropia where
medial rectus function is normal.2,9 Cooper13 suggested
weakening the intact lateral rectus instead of performing a
second surgery on the medial rectus. The success rate in Patel
et al.’s4 study where they applied bilateral LRc on CXT with
an average follow-up of 30 months was 65%. Donaldson
et al.9 reported 86% success in patients who underwent LRc
with a mean follow-up of 16 months. In the present study,
55% success rate in group 1 was lower than the previous two
studies. On the other hand, the follow-up period was longer
in our patients compared to the study by Donaldson et al.
Gesite-de Leon and Demer10 reported the success rate as
50% in different types of esotropic patients who underwent
MRadv for CXT at the last follow-up (1.6 ± 1.8 years). Cho
and Ryu16 reported 79.2% success rate after MRadv (unilat-
eral or bilateral) for CXT treatment at a minimum follow-up
of 3 years. In the current study, the success rate of group 2
(69%) was lower than the study of Cho and Ryu16 and higher
than that of Gesite-de Leon and Demer10. The lower success
rate of our study compared to the study of Cho and Ryu16
may be related to the lower number of patients who under-
went bilateral surgery. Mohan et al.17 reported 91% success
in a follow-up period of less than 2 years, but noted that this
rate decreased to 52% when the follow-up period was longer
than 2 years. Additionally, Rajavi et al.18 reported that esotro-
pia etiology did not show any relationship with the success
or failure of CXT surgery. In previous studies, controversial
results were obtained from various surgical methods, includ-
ing combined procedures in the treatment of CXT.1,8,9,17–19 In
this paper, long-term results of unilateral or bilateral surgery
on the same muscle are discussed excluding the results of
combined methods. On the other hand, there are studies tar-
geting different amounts (5–15 PD) of esotropia for the post-
operative period.9,10,20 Therefore, the long-term results of the
studies in CXT are indispensable.1,9,19,20 In several studies, an
average of 4 to 10 PD exodrift was reported in the early post-
operative period (4–8 weeks) including MRadv + LRc.1,8–10
Similarly, an average of 4.1 PD exodrift was reported with
a single MRadv in the early postoperative period by Tinley
et al.21 In the current study, an average of 3.1 ± 4.70 PD
exodrift was detected in group 1 and 2.5 ± 2.98 PD exodrift
was detected in group 2 at the sixth week, which were con-
sistent with previous studies. In a study by Cho and Ryu16 an
average of 8.6 to 9.3 PD exodrift was reported after MRadv
(50.6% unilateral/49.4% bilateral) in the long term follow-up
(12–47 months). Different from the other studies, an average
of 17 PD exodrift was reported after MRadv (90% bilateral,
10% unilateral) in the long term follow-up (1.6 ± 1.8-years)
by Gesite-de Leon and Demer.10 In the current study, an aver-
age of 8.13 ± 7.45 PD exodrift in group 2 and 6.6 ± 7.12 PD
exodrift in group 1 was observed at the second year follow-
up which were consistent with previous studies.
Another important point is that it is difficult to predict the
dose effect of MRadv and LRc. An average of 3 to 5 PD/mm
dose-effect has been reported by multiple authors for the cor-
rection of CXT including combined procedures.1,18,22,23 Lee
et al.1 reported the effectiveness of LRc to be 2.4 ± 0.5 PD/
mm and MRadv to be 3.6 ± 1.4 PD/mm in the first postopera-
tive month. Rajavi et al.18 reported that each 1 mm of LRc and
MRadv (with resection) corrected 2.20 ± 0.92 PD, 4.25 ± 2.27
PD over a 3-months follow-up, respectively. In the present
study, each 1 mm surgery provided a correction of 2.48 ± 1.12
PD in group 1 and 3.70 ± 1.27 PD in group 2 at sixth weeks
of follow-up. Our results at early follow-up were similar to
those of Lee et al.1 The results for group 2 can be considered
as poorer if we do not take into account MRadv applied with
resection in the series of Rajavi et al.18 Cho and Ryu16 reported
that each 1 mm of MRadv corrected 3.2 ± 1.17 PD at the end
of the 2-year follow-up. In our study, at the end of a 2-year
follow-up, each 1 mm of surgery corrected 2.13 ± 1.22 PD in
group 1 and 2.80 ± 1.39 PD in group 2. Compared to the study
of Cho and Ryu16 the correction of MRadv per 1 mm was
lower in our study. Although the two studies have the same
follow-up duration, the study groups differ in terms of first sur-
gical procedure, since Cho and Ryu16 evaluated patients with
or without LRc in addition to BMRc.
The mean preoperative exotropia at distance and
near fixations were 25.30 ± 7.45 PD and 23.40 ± 10.76
PD, respectively for group 1, and 25.48 ± 9.21 PD and
24.39 ± 9.51 PD, respectively for group 2. These results
are consistent with the average values of previous stud-
ies.9,16,21 Medial rectus slippage was reported in 22% to
36% of patients with CXT.10,16 We did not detect muscle
slippage in the present study, however we observed stretch
scar formation in two (5%) patients. Donaldson et al.9
did not find any difference between amblyopic (20.3%)
and non-amblyopic (79.7%) patients in terms of surgi-
cal results. In our study, amblyopia was present in 10
(23%) patients. Similar to the study of Donaldson et al.,
we found no statistically significant difference in terms of
surgical success between the amblyopic and non-ambly-
opic patients (p = 0.939). Previous studies reported 69%
to 100% improvement in adduction limitation following
MRadv.10,16,20,22,24 In the current study, adduction limita-
tion was improved in 13 (87%) patients after CXT surgery
consistent with the literature. However, −1 adduction limi-
tation remained in two (13%) patients in group 2 at the last
follow-up. In this study, the rate of gross stereopsis was
45% in group 1 and 48% in group 2, which was higher than
reported by Lee et al.1 (21.6%) in terms of same follow-
up period. We consider that the higher rate of stereopsis
among our patients may be related to the higher number
of patients with partially accommodative esotropic (21%)
patients compared to the Lee et al.1 (13.5%) study.
This study has some limitations. First, it had a retro-
spective design. Second, simultaneous prism cover test,
Ceylan et al. 5
which is thought to be particularly useful in patients with
accommodative esotropia and the monofixation syndrome
was not used in the study.25 Third, the data of stereopsis
both preoperatively and postoperatively were not available
for all cases. Fourth, since the same muscle surgery was
applied to all patients, the structural changes and unfavora-
ble insertions of unoperated rectus muscles could not be
examined; thus, the rates of muscle slippage and stretched
scar formation were limited. Finally, as recommended by
Ludwig and Chow,6 the use of non-absorbable sutures
could have improved the success rate in the present study.
In conclusion, MRadv and LRc are effective procedures
to correct CXT. In this study, an average dose-effect per
mm was higher in group 2 than group 1 in the early post-
operative period; however, there was no significant differ-
ence in the second-year follow-up (p = 0.109). Although
the surgical doses of MRadv were not presented in tables,
MRadv seemed to be more effective for the surgical treat-
ment of CXT with respect to LRc and should be preferred
in cases with adduction limitation, while LRc should be
considered in recurrent cases of CXT.
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
Osman Melih Ceylan https://orcid.org/0000-0002-8832-8013
Fatih Mehmet Mutlu https://orcid.org/0000-0002-7796-6511
References
1. Lee HJ, Yu YS and Kim SJ. Long-term surgical outcomes
of patients with consecutive exotropia. Graefes Arch Clin
Exp Ophthalmol 2019; 257(5): 1037–1044.
2. Mittelman D and Folk ER. The surgical treatment of over-
corrected esotropia. J Pediatr Ophthalmol Strabismus 1979;
16(3): 156–159.
3. Bachar Zipori A, Spierer O, Sherwin JC, et al. Why bilateral
medial rectus recession fails? Factors associated with early
repeated surgery. Int Ophthalmol 2020; 40(1): 59–66.
4. Patel AS, Simon JW and Lininger LL. Bilateral lateral rec-
tus recession for consecutive exotropia. J AAPOS 2000;
4(5): 291–294.
5. Parks MM and Bloom JN. The “slipped” muscle.
Ophthalmology 1979; 86(8): 1389–1396.
6. Ludwig IH and Chow AY. Scar remodeling after strabismus
surgery [published correction appears in J AAPOS 2001;
5(1): 17]. J AAPOS 2000; 4(6): 326–333.
7. Sawada M, Hikoya A, Negishi T, et al. Characteristics and
surgical outcomes of consecutive exotropia of different eti-
ologies. Jpn J Ophthalmol 2015; 59(5): 335–340.
8. Maxfield SD, Hatt SR, Leske DA, et al. Factors associated
with atypical postoperative drift following surgery for con-
secutive exotropia. J AAPOS 2017; 21(5): 360–364.
9. Donaldson MJ, Forrest MP and Gole GA. The surgical man-
agement of consecutive exotropia. J AAPOS 2004; 8(3):
230–236.
10. Gesite-de Leon B and Demer JL. Consecutive exotropia:
why does it happen, and can medial rectus advancement
correct it? J AAPOS 2014; 18(6): 554–558.
11. Stager DR, Weakley DR Jr, Everett M, et al. Delayed
consecutive exotropia following 7-millimeter bilateral
medial rectus recession for congenital esotropia. J Pediatr
Ophthalmol Strabismus 1994; 31(3): 147–152.
12. Ceylan OM, Gokce G, Mutlu FM, et al. Consecutive exo-
tropia: risk factor analysis and management outcomes. Eur
J Ophthalmol 2014; 24(2): 153–158.
13. Cooper EL. The surgical management of secondary exotropia.
Trans Am Acad Ophthalmol Otolaryngol 1961; 65: 595–608.
14. Ansons AM and Davis H. Diagnosis and management of
ocular motility disorders. Wiley Online Library, 2014.
15. Raz J, Bernheim J, Pras E, et al. Diagnosis and management
of the surgical complication of postoperative “slipped” medial
rectus muscle: a new “tendon step test” and outcome/results in
11 cases. Binocul Vis Strabismus Q 2002; 17(1): 25–33.
16. Cho YA and Ryu WY. The advancement of the medial rec-
tus muscle for consecutive exotropia. Can J Ophthalmol
2013; 48(4): 300–306.
17. Mohan K, Sharma A and Pandav SS. Unilateral lateral rec-
tus muscle recession and medial rectus muscle resection
with or without advancement for postoperative consecutive
exotropia. J AAPOS 2006; 10(3): 220–224.
18. Rajavi Z, Feizi M, Mughadasifar H, et al. Surgical results
of consecutive exotropia. J Pediatr Ophthalmol Strabismus
2013; 50(5): 274–281.
19. Chatzistefanou KI, Droutsas KD and Chimonidou E.
Reversal of unilateral medial rectus recession and lateral
rectus resection for the correction of consecutive exotropia.
Br J Ophthalmol 2009; 93(6): 742–746.
20. Kasi SK, Tamhankar MA, Pistilli M, et al. Effectiveness of
medial rectus advancement alone or in combination with
resection or lateral rectus recession in the management of
consecutive exotropia. J AAPOS 2013; 17(5): 465–70.
21. Tinley C, Evans S, McGrane D, et al. Single medial rectus
muscle advancement in stretched scar consecutive exotro-
pia. J AAPOS 2010; 14(2): 120–123.
22. Marcon GB and Pittino R. Dose–effect relationship of
medial rectus muscle advancement for consecutive exotro-
pia. J AAPOS 2011; 15(6): 523–526.
23. Biedner B, Yassur Y and David R. Advancement and rein-
sertion of one medial rectus muscle as treatment for sur-
gically overcorrected esotropia. Binocul Vis Strabismus Q
1991; 6: 197–200.
24. Ohtsuki H, Hasebe S, Tadokoro Y, et al. Advancement
of medial rectus muscle to the original insertion for con-
secutive exotropia. J Pediatr Ophthalmol Strabismus 1993;
30(5): 301–305.
25. Mehta A. Chief complaint, history and physical examina-
tion. In: AL Rosenbaum and AP Santiago (eds.) Clinical
strabismus management. Principles and surgical techniques.
Philadelphia (PA): WB Saunders Company, 1999. p. 14.