The Minimal Postoperative Follow-Up Period to Determine Secondary Surgery in Patients with Intermittent Exotropia

Dae Heon Han; Hae Jung Paik

doi:10.3341/jkos.2014.55.5.711

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Han and Paik: The Minimal Postoperative Follow-Up Period to Determine Secondary Surgery in Patients with Intermittent Exotropia

Original Article

J Korean Ophthalmol Soc 201;55(5):711-718.

Published online: 30 August 2014

DOI: https://doi.org/10.3341/jkos.2014.55.5.711

The Minimal Postoperative Follow-Up Period to Determine Secondary Surgery in Patients with Intermittent Exotropia

Dae Heon Han, MD, Hae Jung Paik, MD, PhD

Department of Ophthalmology, Gachon University Gil Hospital, Incheon, Korea

Address reprint requests to Hae Jung Paik, MD, PhD Department of Ophthalmology, Gachon University Gil Hospital, #21 Namdong-daero 774beon-gil, Namdong-gu, Incheon, 405-760, Korea, Tel: 82-32-460-3364, Fax: 82-32-460-3358 E-mail: hjpaik@gilhospital.com

Received 26 October 2013 Revised 12 November 2013 Accepted 15 April 2014

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

We investigated the recommended minimum postoperative follow-up period for the determination of secondary corrective surgery for the consecutive esotropia (ET) and recurrent exotropia (XT) after the first intermittent XT surgery.

Methods

The medical records of 728 patients who underwent surgical treatment for intermittent XT between 2004 and 2009 with a minimum postoperative follow-up of 1 year were retrospectively reviewed. Each patient underwent a detailed sensory and motor examination, including measurements of near and distance stereoacuity, alternating-cover test, and extraocular muscle function testing. Consecutive ET was defined as esodeviation over 15 prism diopter (PD) at distance persisting for more than 6 months after surgery despite medical treatment. Recurrent XT was defined as exodeviation over 15 PD at distance after surgery despite medical treatment.

Results

The mean age of the 728 patients at first surgery was 7.5 years (range, 22 months - 30 years). When only the motor outcome was considered, 663 patients (91.1%) had an orthrotropia at the final follow-up and 44 patients (6.0%) among consecutive ET patients and 21 patients (2.9%) who had a recurrent XT underwent secondary surgical correction. Binocularity decreased postoperatively in patients with consecutive ET (p < 0.001), whereas the other patients demonstrated improved stereopsis postoperatively (p = 0.041, 0.021). Patients with consecutive ET showed esodeviation over 10 PD when compared with orthotropia after 2 months postoperatively (p = 0.005). At 6 months postoperatively, 17 (81.0%) of 21 patients with recurrent XT showed or- thotropia with an exodeviation over 11 PD after 18 months postoperatively.

Conclusions

The success rate of surgical correction for intermittent XT showed a favorable outcome. However, careful concern for consecutive ET and recurrent XT are required in postoperative follow-up periods. Over-corrected or consecutive ETs need early surgical correction because no further improvement of ocular alignment will occur after 2 months postoperatively and delayed correction can result in poor sensory binocularity. Under-corrected or recurrent XT should be observed for an extended period because of the exotropic drift after surgery, thus requiring periodic long term follow-up for secondary surgery at least for 18 months postoperatively.

Keywords: Consecutive esotropia, Intermittent exotropia, Postoperative follow-up, Recurrent exotropia, Secondary surgery

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Figure 1.

Postoperative deviation after first surgery among “Consecutive ET”,“Orthotropia”, and “Recurrent XT”. ET = esotropia; XT = exotropia. *^,†Statistically significant different.

Figure 2.

Postoperative deviation at distance after first surgery between “Orthotropia” and “Recurrent XT”. XT = exotropia.

Table 1.

Demographics and preoperative characteristics of the 728 patient who underwent surgery for intermittent exotropia

Demographics
Mean age in years at diagnosis (range)	6.6 (1-24)
Mean length of follow-up in months (range)	47.2 (13-75)
Mean age at surgery in years (range)	7.5 (2-30)
Sex (male/female)	306(42.0%) : 422 (58.0%)
Ocular characteristics
Mean cycloplegic refraction (spherical equivalent, diopter, range)	-0.73 (-12.00∼2.50)
Mean distance horizontal deviation at surgery (prism diopter, range)	26.6 (18-50)
Mean near horizontal deviation at surgery (prism diopter, range)	25.3 (5-50)
Number within 60 arc sec or better preoperatively	534 (73.4%)
Type of XT
Basic	666(91.5%)
Divergence excess	15 (2.1%)
Convergence insufficiency	11 (1.5%)
Pseudo-divergence excess	36 (4.9%)
Number with amblyopia	48 (6.6%)
Number with anisometropia	39 (5.4%)
Associated strabismus
Number with dissociated vertical deviation	34 (4.7%)
Number with inferior oblique overaction	183 (25.1%)
Number with vertical deviation	27(3.7%)
Number with A or V pattern	113 (15.5%)

XT = exotropia.

^* Data includes 721 of 728 patients.

Table 2.

Comparison of clinical characteristics of patients with intermittent exotropia according to postoperative deviation

	Postoperative deviation			p-value
	Consecutive ET (n = 44)	Orthotropia (n = 617)	Recurrent XT (n = 21)	p-value
Demographics
Mean age in years at diagnosis (range)	6.0 (1-8)	6.8 (1-24)	5.9 (1-8)	0.391^§
Mean age at surgery in years (range)	6.9 (2-9)	7.7 (2-30)	7.1 (2-9)	0.413^§
Sex (male/female)	19:25	260:357	7:14	0.381^π
Ocular characteristics
Mean cycloplegic refraction (spherical equivalent, diopter, range)	-0.59 (-3.50∼1.25)	-0.77 (-12.00∼2.50)	-0.49 (-2.25∼1.25)	0.705^§
Mean distance horizontal deviation at surgery (prism diopter, range)	28.7 (20-40)	26.4 (18-50)	29.5 (25-35)	0.120^§
Mean near horizontal deviation at surgery (prism diopter, range)	27.5 (14-40)	25.1 (14-50)	26.3 (16-40)	0.186^§
Number within 60 arc sec or better preoperatively (%)	30 (71.4)^*	465 (75.7)^†	15 (78.9)^‡	0.603^π
Number with amblyopia (%)	3 (6.8)	43 (7.0)	1 (4.8)	0.249^π
Number with anisometropia (%)	2 (4.5)	29 (4.7)	1 (4.8)	0.805^π
Type of XT (%)				0.683^π
Basic	41 (93.2)	573 (92.9)	18 (85.6)
Divergence excess	0 (0)	15 (2.4)	1 (4.8)
Convergence insufficiency	0 (0)	6 (0.9)	0 (0)
Pseudo-divergence excess	3 (6.8)	23 (3.8)	2 (9.6)
Associated strabismus (%)				0.782^π
Number with dissociated vertical deviation	3 (6.8)	29 (4.7)	1 (4.8)
Number with inferior oblique overaction	10 (22.7)	155 (25.1)	6 (28.6)
Number with vertical deviation	2 (4.5)	24 (3.9)	0 (0)
Number with A or V pattern	6 (13.6)	99 (16.0)	4 (19.0)
Method of surgery (%)				0.260^π
BLR recession	32 (72.8)	462 (74.9)	16 (76.1)
R&R	10 (22.7)	100 (16.2)	3 (14.3)
RLR or LLR recession	2 (4.5)	43 (7.0)	1 (4.8)
BMR resection	0(0)	15 (2.4)	1 (4.8)

ET = esotropia; XT = exotropia; BLR = bilateral lateral rectus; R & R = recess/resect procedure; RLR = right lateral rectus; LLR = left lateral rectus; BMR = dilateral medial rectus.

^* Data includes 42 of 44 patients;

^† Data includes 614 of 617 patients;

^‡ Data includes 19 of 21 patients;

^§ One-way ANOVA among “Consecutive ET” group, “Orthotropia” group and “Recurrent XT” group;

^π Chi-square test between among “Consecutive ET” group, “Orthotropia” group and “Recurrent XT” group.

Table 3.

Number within successful outcome of patients with intermittent exotropia according to postoperative deviation

Postop	Postoperative deviation at distance				Postoperative deviation at near
Postop	Consecutive ET (n = 44)	Orthotropia (n = 617)	Recurrent XT (n = 21)	p-value	Consecutive ET (n = 44)	Orthotropia (n = 617)	Recurrent XT (n = 21)	p-value
1 day	4 (9.1%)	500 (81.0%)	17(81.0%)	<0.001^* 0.528^†	5 (11.4%)	538 (87.2%)	16 (76.2%)	<0.001^* 0.682^†
1 week	9 (20.5%)	542 (87.8%)	21 (100%)	<0.001^* 0.440^†	10 (22.7%)	558 (90.4%)	21 (100%)	<0.001^* 0.702^†
1 month	21 (47.7%)	579(93.8%)	21 (100%)	<0.001^* 0.671^†	19 (43.2%)	600 (97.2%)	20(95.2%)	<0.001^* 0.812^†
2 months	7 (15.9%)	584 (94.7%)	10 (47.6%)	<0.001^* <0.031^†	5 (11.4%)	610 (98.9%)	11 (52.4%)	<0.001^* <0.043^†
3 months	3 (6.8%)	591 (95.8%)	17(81.0%)	<0.001^* 0.049^†	2(4.5%)	615 (99.8%)	17 (81.0%)	<0.001^* 0.049^†
6 months	0 (0%)	605 (98.1%)	17 (81.0%)	<0.001^* 0.027^†	1 (2.3%)	617 (100%)	17 (81.0%)	<0.001^* 0.032^†
12 months	-	610 (98.9%)	5 (23.8%)	<0.001^†	-	617 (100%)	16 (76.2%)	0.029^†
18 months	-	617 (100%)	0 (0%)	<0.001^†	-	617 (100%)	0 (0%)	<0.001^†
24 months	-	617 (100%)	0 (0%)	<0.001^†	-	617 (100%)	0 (0%)	<0.001^†

Success was defined as distant alignment in primary position, with correction if necessary, of esotropia/phoria <6 PD or exotropia/phoria <10 PD. ET = esotropia; XT = exotropia.

^* 2 proportions test between “Consecutive ET group and “Orthotropia” group;

^† Fisher's exact probability test between “Orthotropia” group and “Recurrent XT” group.

Table 4.

Distribution of pre-op & post-op stereopsis of patients with intermittent exotropia according to postoperative deviation

	Number within 60 arc sec or better		p-value
	Pre-op	Post-op	p-value
Consecutive ET (n = 44)	30 (71.4%)^*	7 (16.7%)^*	<0.001^§
Orthotropia (n = 617)	465 (75.7%)^†	561 (90.9%)^†	0.041^§
Recurrent XT (n = 21)	13 (68.4%)^‡	18 (94.7%)^‡	0.021^π

ET = esotropia; XT = exotropia; Pre-op = preoperative; Post-op = postoperative.

^* Data includes 42 of 44 patients;

^† Data includes 614 of 617 patients;

^‡ Data includes 19 of 21 patients;

^§ 2 proportions test;

^π Fisher's exact probability test.

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