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Baek, Cho, Kim, Kim, Kong, and Baek: Long-Term Results of Intermittent Exotropia Surgery: Comparison between Motor and Functional Success
Original Article

J Korean Ophthalmol Soc 2014;55(7):1064-1070.

Published online: 30 August 2014

DOI: https://doi.org/10.3341/jkos.2014.55.7.1064

Long-Term Results of Intermittent Exotropia Surgery: Comparison between Motor and Functional Success

Ji Sun Baek, MD, Myung Jin Cho, MD, Ungsoo Samuel Kim, MD, Yong Ran Kim, MD, Sang Mook Kong, MD, PhD, Seung Hee Baek, MD, PhD

Myung-Gok Eye Research Institute, Department of Ophthalmology, Konyang University Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea

Address reprint requests to Seung Hee Baek, MD, PhD, Department of Ophthalmology, Konyang University Kim's Eye Hospital, #136 Yeongsin-ro, Yeongdeungpo-gu, Seoul 150-034, Korea, Tel: 82-2-2639-7812, Fax: 82-2-2639-9214, E-mail: drslitlamp@kimeye.com

Received 15 February 2013       Revised 4 February 2014       Accepted 10 June 2014

Copyright © 2014 The Korean Ophthalmological Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To evaluate the long-term surgical success rate (>3 years) and contributing success factors considering motor and sensory criteria for patients with intermittent exotropia.

Methods

Fifty-four patients who received surgery for intermittent exotropia and were followed-up for a minimum of 3 years, including reoperation, were retrospectively evaluated. The first procedure was unilateral recession and resection in 50 patients and bilateral lateral rectus recession in 4 patients. Patients were classified as achieving a good, fair or poor outcome based on motor and sensory criteria. Success rate and associated factors such as postoperative alignment, exotropia type, first surgical procedure, and proportion of patients receiving reoperations were analyzed.

Results

The mean follow-up period after the first surgery was 4.81 ± 1.30 years. The good outcome was achieved in 32 patients (59.3%), fair in 14 patients (25.9%), and poor in 8 patients (14.8%) considering motor criteria only. The good outcome was achieved in 29 patients (51.9%), fair in 12 patients (22.2%), and poor in 14 patients (25.9%) when considering combined motor/sensory (functional) criteria. No patient who received bilateral lateral rectus recession as the first procedure belonged to the good outcome group (p = 0.03 by motor criteria and p = 0.044 by functional criteria). Patients who received reoperation were significantly more likely to be in the good and fair groups (p = 0.009 by motor criteria and p = 0.02 by functional criteria).

Conclusions

Long-term surgical results of intermittent exotropia in this Korean population revealed 85.2% motor success rate and 74.1% functional success rate. Early postoperative overcorrection was not associated with long-term success. Recession and resection procedure and reoperations were significantly associated with better outcome based on motor and functional criteria. Diligent reoperations after the first surgery could possibly contribute to good long-term functional outcome in intermittent exotropia patients.

Keywords: Functional success rate, Intermittent exotropia, Korean, Long-term result

References

1. Friedman Z, Neumann E, Hyams SW, Peleg B. Ophthalmic screening of 38,000 children, age 1 to 2 1/2 years, in child welfare clinics. J Pediatr Ophthalmol Strabismus. 1980; 17:261–7.
crossref
2. Nusz KJ, Mohney BG, Diehl NN. The course of intermittent exotropia in a population-based cohort. Ophthalmology. 2006; 113:1154–8.
crossref
3. Preslan MW, Novak A. Baltimore Vision Screening Project. Ophthalmology. 1996; 103:105–9.
crossref
4. Park JY, Sohn HY, Cho YA. Is the nonsurgical treatment effective on intermittent exotropia in children of school-age. J Korean ophthalmol Soc. 1995; 36:1561–7.
5. Figueira EC, Hing S. Intermittent exotropia: comparison of treatments. Clin Experiment Ophthalmol. 2006; 34:245–51.
crossref
6. Koklanis K, Georgievski Z. Recurrence of intermittent exotropia: factors associated with surgical outcomes. Strabismus. 2009; 17:37–40.
crossref
7. Wu H, Sun J, Xia X, et al. Binocular status after surgery for constant and intermittent exotropia. Am J Ophthalmol. 2006; 142:822–6.
crossref
8. Lee JC, Lee YC, Lee SY. Comparison of postoperative outcomes according to deviation angle in moderate-angle intermittent exotropia of basic type. J Korean Ophthalmol Soc. 2013; 54:475–8.
crossref
9. Baek SU, Lee JY. Long-term outcome of surgery for intermittent exotropia. J Korean Ophthalmol Soc. 2013; 54:1079–85.
crossref
10. Cho SC, Yang HK, Hwang JM. Three-year surgical outcome of exotropia. J Korean Ophthalmol Soc. 2012; 53:1674–9.
crossref
11. Roh JH, Paik HJ. Clinical study on factors associated with recurrence and reoperation in intermittent exotropia. J Korean Ophthalmol Soc. 2008; 49:1114–9.
crossref
12. Ko BW, Shin SY. The clinical features of patients with early recurrence and with orthophoria after intermittent exotropia surgery. J Korean Ophthalmol Soc. 2008; 49:1108–13.
crossref
13. Pineles SL, Ela-Dalman N, Zvansky AG, et al. Long-term results of the surgical management of intermittent exotropia. J AAPOS. 2010; 14:298–304.
crossref
14. Burian HM, Spivey BE. The surgical management of exodeviations. Am J Ophthalmol. 1965; 59:603–20.
15. Lim SH, Hong JS, Kim MM. Prognostic factors for recurrence with unilateral recess-resect procedure in patients with intermittent exotropia. Eye (Lond). 2011; 25:449–54.
crossref
16. Koo NK, Lee YC, Lee SY. Clinical study for the undercorrection factor in intermittent exotropia. Korean J Ophthalmol. 2006; 20:182–7.
crossref
17. Beneish R, Flanders M. The role of stereopsis and early postoperative alignment in long-term surgical results of intermittent exotropia. Can J Ophthalmol. 1994; 29:119–24.
18. Jeoung JW, Lee MJ, Hwang JM. Bilateral lateral rectus recession versus unilateral recess-resect procedure for exotropia with a dominant eye. Am J Ophthalmol. 2006; 141:683–8.
crossref
19. Maruo T, Kubota N, Sakaue T, Usui C. Intermittent exotropia surgery in children: long term outcome regarding changes in binocular alignment. A study of 666 cases. Binocul Vis Strabismus Q. 2001; 16:265–70.
20. Kushner BJ. Selective surgery for intermittent exotropia based on distance/near differences. Arch Ophthalmol. 1998; 116:324–8.
crossref
21. Raab EL, Parks MM. Recession of the lateral recti. Early and late postoperative alignments. Arch Ophthalmol. 1969; 82:203–8.
22. Scott WE, Keech R, Mash AJ. The postoperative results and stability of exodeviations. Arch Ophthalmol. 1981; 99:1814–8.
crossref
23. von Noorden GK, Campos EC. Exodeviations. In : Campos EC, editor. Binocular Vision and Ocular Motility: Theory and Management of Strabismus. 6th ed.St Louis: Mosby;2002. chap. 17.
24. Leow PL, Ko ST, Wu PK, Chan CW. Exotropic drift and ocular alignment after surgical correction for intermittent exotropia. J Pediatr Ophthalmol Strabismus. 2010; 47:12–6.
crossref
25. Choi J, Kim SJ, Yu YS. Initial postoperative deviation as a predictor of long-term outcome after surgery for intermittent exotropia. J AAPOS. 2011; 15:224–9.
crossref
26. Ekdawi NS, Nusz KJ, Diehl NN, Mohney BG. Postoperative out- comes in children with intermittent exotropia from a population-based cohort. J AAPOS. 2009; 13:4–7.
27. Kim WJ, Kim MM. The clinical course of recurrent intermittent exotropia after previous unilateral recess-resection surgery. J Korean Ophthalmol Soc. 2009; 50:1386–91.
crossref

Table 1.
Criteria for surgical success
Surgical result Good Fair Poor
Motor criteria (deviation at the last postop visit) 0-8 PD X (T) ≤4 PD ET or >4 PD ET or
9-15 PD X (T) >15 PD X (T)
Sensory criteria (stereoacuity by Titmus test) ≤100 arc sec ≤100 arc sec >100 arc sec

Postop = postoperative; PD = prism diopter; X (T) = intermittent exotropia; ET = esotropia.

Table 2.
Comparisons of factors according to the motor success
Factors Good (n = 32) Fair (n = 14) Poor (n = 8) p-value
Age at surgery (years) 7.22 ± 7.48 9.29 ± 6.18 6.38 ± 1.60 0.54*
Sex (F/M) 20/12 9/5 7/1 0.4†
Age at diagnosis (years) 5.34 ± 7.72 5.93 ± 6.70 4.13 ± 2.23 0.61*
Time from diagnosis to surgery (years) 1.34 ± 1.47 2.86 ± 2.48 1.88 ± 2.23 0.28*
Time since first surgery (years) 4.91 ± 1.38 4.79 ± 1.37 4.33 ± 0.52 0.34*
Preoperative stereoacuity (log arc sec) 2.00 ± 0.36 1.92 ± 0.35 1.74 ± 0.16 0.23*
Preoperative distant deviation (PD) 28.84 ± 6.29 27.71 ± 9.29 29.38 ± 7.29 0.61*
Preoperative near deviation (PD) 27.55 ± 6.60 29.29 ± 9.97 26.88 ± 9.23 0.83*
PO 1 day distant deviation (PD) -0.94 ± 6.82 -0.71 ± 3.38 -4.00 ± 6.93 0.2*
PO 1 week distant deviation (PD) -1.11 ± 7.74 1.62 ± 6.05 -6.00 ± 6.50 0.78*
PO 1 month distant deviation (PD) 2.55 ± 8.79 8.00 ± 6.23 2.00 ± 4.28 0.51*
PO stereoacuity at the last follow up (log arc sec) 1.84 ± 0.22 1.75 ± 1.92 1.90 ± 0.32 0.30*
Mean follow up period (months) 65.5 ± 15.4 64.5 ± 16.8 66.1 ± 15.0 0.97*
Type of exotropia (%) 0.14†
  Basic 26 (81.3) 11 (78.6) 7 (87.5)
  Convergence insufficiency 0 (0) 0 (0) 0 (0)
  Divergence excess 0 (0) 0 (0) 1 (12.5)
  Pseudodivergence excess 6 (18.8) 3 (21.4) 0 (0)
Anisometropia (%) 3 (9.4) 0 (0) 0 (0) 0.34†
Amblyopia (%) 10 (31.3) 1 (7.1) 2 (25.0) 0.21†
First surgery type (%) 0.03†
  R&R 32 (100.0) 12 (85.7) 6 (75.0)
  BLR recession 0 (0) 2 (14.3) 2 (25.0)
Presence of DVD (%) 1 (3.1) 0 (0) 0 (0) 0.71†
Reoperation (%) 22 (68.8) 3 (21.4) 3 (37.5) 0.009†

Values are presented as mean ± SD; Minus values in deviation means esodeviation: plus values means exodeviation.

PD = prism diopter; PO = postoperative; R&R = resection and recession; BLR recession = bilateral lateral rectus recession; DVD = dissociated vertical deviation.

* p-value by one-way ANOVA;

† p-value by Fisher's exact test.

Table 3.
Comparisons of factors according to the functional success
Factor Good (n = 28) Fair (n = 12) Poor (n = 14) p-value
Age at surgery (years) 5.96 ± 2.50 9.58 ± 6.64 9.29 ± 10.7 0.16*
Sex (F/M) 17/11 8/4 11/3 0.51†
Age at diagnosis (years) 4.04 ± 2.13 6.08 ± 7.26 7.21 ± 11.4 0.34*
Time from diagnosis to surgery (years) 1.36 ± 1.50 3.00 ± 2.66 1.71 ± 1.82 0.48*
Time since first surgery (years) 4.96 ± 1.29 4.58 ± 1.31 4.67 ± 1.37 0.64*
Preoperative stereoacuity (log arc sec) 1.94 ± 0.34 1.89 ± 0.37 1.92 ± 0.34 0.96*
Preoperative distant deviation (PD) 28.68 ± 6.58 28.58 ± 9.75 28.57 ± 6.33 0.99*
Preoperative near deviation (PD) 27.37 ± 6.73 29.58 ± 10.8 27.50 ± 7.53 0.72*
PO 1 day distant deviation (PD) -1.71 ± 6.04 -1.00 ± 2.89 -0.86 ± 8.37 0.90*
PO 1 week distant deviation (PD) -1.88 ± 7.06 2.64 ± 5.77 -3.00 ± 8.51 0.14*
PO 1 month distant deviation (PD) 1.63 ± 6.86 7.33 ± 6.34 6.07 ± 10.1 0.65*
PO stereoacuity at the last follow up (log arc sec) 1.78 ± 0.17 1.72 ± 0.16 2.02 ± 0.29 0.01*
Mean follow up period (months) 66.6 ± 14.8 62.2 ± 15.1 65.6 ± 16.1 0.70*
Type of exotropia (%) 0.17†
  Basic 22 (78.6) 9 (75.0) 13 (92.9)
  Convergence insufficiency 0 (0) 0 (0) 0 (0)
  Divergence excess 0 (0) 0 (0) 1 (7.1)
  Pseudodivergence excess 6 (21.4) 3 (25.0) 0 (0) 0.66†
Anisometropia (%) 2 (7.1) 0 (0) 1 (7.1)
Amblyopia (%) 7 (25.0) 1 (8.3) 4 (28.6) 0.59†
First surgery type (%) 0.044†
  R&R 28 (100) 11 (91.7) 11 (78.6)
  BLR recession 0 (0) 1 (8.3) 3 (21.4)
Presence of DVD (%) 0 (0) 0 (0) 1 (7.1) 0.23†
Reoperation (%) 21 (75.0) 3 (25.0) 4 (28.6) 0.02†

Values are presented as mean ± SD; Minus values in deviation means esodeviation; plus values means exodeviation.

PD = prism diopter; PO = postoperative; R&R = resection and recession; BLR recession = bilateral lateral rectus recession; DVD = dissociated vertical deviation.

* p-value by one-way ANOVA;

† p-value by Fisher's exact test.

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