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Major Articles

The Surgical ManagementConsecutive Exotrop

Mark J. Donaldson, MBBS(Hons),a Michael P. Forrest, MBBS, BMedSci,b andGlen A. Gole, MD, FRANZCO, FRACSa,c

Purpose: To review the results and techniques of surgical treatment of consecutive exotropia. Methodperformed a retrospective chart review of all patients who underwent surgery for consecutive exotropipediatric ophthalmology practice between 1992 and 2001. Patients were excluded if follow-up lasted � 6 wor if exotropia was caused by other ocular disorders such as previous trauma or congenital cataracts. ReFifty-nine patients were identified. The procedure performed in the majority of cases was unilateral lateral rrecession and medial rectus advancement to the original insertion. Seven patients underwent bilateral lrectus recession, and 6 underwent lateral rectus recession combined with medial rectus resection. Theinterval between original surgery and surgery for consecutive exotropia was 14.1 years (range 4 months tyears). The mean preoperative distance exodeviation was 31.7 prism diopters (PD). Satisfactory alignmewithin 10 PD of orthophoria) was achieved in 36 patients (61%) at week 1 and 42 patients (71%) at final folloMean follow up was 16.0 months. Thirty-nine patients (66%) demonstrated an exodrift after surgery (mean 7.Conclusion: Consecutive exotropia may occur many years, even decades, after esotropia surgery. Lateral rrecession with advancement of the previously recessed medial rectus is an effective treatment. An exotropioccurs after consecutive exotropia surgery, usually within the first 6 weeks. A suitable ocular aligimmediately after surgery for consecutive exotropia is a small-angle esotropia of 5 to 10 PD. (J AAPOS 2230-236)

opia tropict forl patieher in.7,8

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exotropias on the

patientsbetween-surgeonreviouslyantile oriagnosedrs or theacquiredesotropialasted �r if exo-as previ-

te exam-ents in-1% cy-s exami-ing looseze, rightve lensesldren toodistance.distance

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C onsecutive exotropia is a manifest exotrdevelops spontaneously in a formerly esottient or after optical or surgical treatmen

otropia. It has been reported in 3% to 29% of alafter surgical treatment of esotropia1-6 with higdences reported in studies with longer follow-upMost investigators have studied the results fro

of patients who underwent surgery for esotropiaattempted to identify causative factors among theended up with an overcorrection. These factoramblyopia,4,5,9 presence of A- or V-patterns,6

mental delay,10 early-onset esotropia,7,11 esotropibefore 6 months of age,7 and multiple previous stsurgeries.12

When consecutive exotropia does occur, howbe managed? Little is known about how patieconsecutive exotropia respond to surgery. We r

From the Department of Ophthalmology, Royal Children’s Hospital,a Brisbathe Department of Ophthalmology, Mater Children’s Hospital,b Brisbane, Athe Department of Pediatrics and Child Health, University of QueenslanBrisbane, Australia.Submitted October 28, 2003.Revision accepted January 8, 2004.Reprint requests: Glen A. Gole MD, Department of Pediatrics and ChildChildren’s Hospital, Herston Rd, Brisbane, Queensland 4029, Australia.Copyright © 2004 by the American Association for Pediatric OphthStrabismus.1091-8531/2004/$35.00 � 0doi:10.1016/j.jaapos.2004.01.001

230 June 2004

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results of a series of patients with consecutivemanaged surgically and make recommendationmanagement of such patients.

SUBJECTS AND METHODS

We retrospectively reviewed the records of allwho underwent surgery for consecutive exotropiaApril 1, 1992 and March 31, 2001, in a singlepediatric ophthalmic practice. All patients had pundergone at least 1 surgical procedure for infacquired esotropia. Infantile esotropia had been din 42 patients either by one of the investigatoreferring ophthalmologist. Eight patients hadesotropia, and in 9 patients the previous type ofwas unclear. Patients were excluded if follow-up6 weeks, if exotropia developed spontaneously, otropia was caused by other ocular disorders suchous ocular trauma or congenital cataracts.All patients were assessed at 2 or more separa

inations before surgery was performed. Assessmcluded visual acuity, cycloplegic refraction (usingclopentolate), ocular deviation, and dilated fundunation. Preoperative deviations were measured usprisms at distance and near fixation and left gagaze, upgaze, and downgaze gaze with correctiwhen required. The Krimsky test was used for chiyoung for accurate alternate-prism cover tests atThe angle was measured for near at 33 cm and for

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Journal of AAPOS

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pia weret follow-.7 years;l [CI] �Twenty-e female.ent their

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re avail-s: 26 pa-n, 6 un-nilateralteral me-even pa-surgerytion withesotropiahese pa-aries re-f surgicalave onlyair).was 37.7I � 7.6,on com-acquirediginal es-became7%) un-resentingcant dif-ts with a

y and theI� 3.7)54, dataan � 8.3ia devel-of thesewithin 1

leven ofmblyopiahad hy-rated on. Only 1patients

nts wereal rectus

Journal of AAPOSVolume 8 Number 3 June 2004 Donaldson, Forrest, and Gole 231

at a target at approximately 40 m through an odow. Amblyopia was defined as (1) a differencethe two eyes � 2 lines of best-corrected visual acua lack of central, steady, maintained fixation inAmblyopia was treated with patching in all patiyears until no further improvement was observeconsecutive months.The indication for surgery was most common

metically obvious exotropia � 15 prism diopterssurgery was performed with the patient underanesthesia. Lateral rectus recession was performa standard technique by way of limbal inThe muscle was reinserted at a fixed point from ttion for nonadjustable sutures or hung backinsertion in the case of adjustable sutures. Adjusrequired, was performed between 2 and 8 hosurgery with the patient under topical anesthmedial rectus advancement, 2 double-armed 6-(Polyglactin 910; Ethicon, Somerville, NJ) sutuinserted with locking bites, and the muscle was diand advanced to the original insertion. Medial rsection was performed using a standard tecTenonectomy was not routinely performed. Thetiva was closed without recession using 8-0 VicryConjunctival resection was not performed in casmuscle surgery would be necessary. Topical aand mild topical steroids were applied for 1 wsurgery.The specific surgical procedure was chosen to

ize any abnormal ductions. For example, where tlimitation of adduction or convergence insufficiaffected medial rectus was strengthened. Conswas given to the type and amount of previous suavoid over-recession or resection of previouslymuscles. Unilateral surgery was performed pon the amblyopic eye. The extent of recession,ment or resection was determined using a standdeveloped by Parks.14 The general principle adoto advance the medial rectus back to the originalif the amount of advancement was equivalent withto the amount of resection advised from Park’sthat angle of deviation. If the amount of posvancement back to the original insertion was grethe resection amount advised from the table, thwas positioned behind the original insertion byble-armed hang-back sutures so that the musclevanced by the advised amount. If the amount ofadvancement to the original insertion was lessresection amount advised, the muscle was advancoriginal insertion and the difference resected befsertion. The amount of lateral rectus recession wmined according to the same tables. In patients wangles (� 50 PD), additional lateral rectus recmedial rectus advancement was performed intralateral eye.

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RESULTS

Sixty-four patients treated for consecutive exotroidentified; 5 were excluded because of insufficienup. Patient ages ranged from 11.5 months to 62the mean was 21 years (95% confidence interva4.3), and the median was 15.1 years (SD � 16.7).five patients were male (42%), and 34 (58%) werForty-four of the 59 patients (74.6%) underwinitial surgery elsewhere.Mean follow-up was 16.0 months (range 6 wee

years). Many of those with good results were diafter 6 months to the care of the referring ophthafor further follow up.For those patients whose original records we

able, previous surgical procedures were as followtients underwent bilateral medial rectus recessioderwent bilateral medial rectus recession with ulateral rectus resection, and 12 underwent uniladial rectus recession/lateral rectus resection. Stients had previously undergone inferior obliqueeither as an independent procedure or in combinahorizontal rectus surgery. Details of the originalsurgery were not available for 15 patients. In ttients, either correspondence or discharge summcorded examination findings but not the details oprocedures performed or the surgical notes glimited details (eg, esotropia–2-muscle squint repThe mean age at original surgery for esotropia

months (n � 54, data unavailable for 5 patients, CSD � 29.9, median � 26.). The study populatiprised a mixture of patients with infantile andesotropia, and many patients underwent their orotropia surgery at a time before early surgerystandard management. Twenty-eight patients (4derwent � 2 operations for esotropia before pwith consecutive exotropia. There was no signifiference in final outcome or drift between patienhistory of infantile or acquired esotropia.The mean interval between the original surger

surgery for consecutive exotropia was 14.1 years (Cand ranged from 4 months to 47.5 years. (n �unavailable for 5 patients, SD � 13.6 years, mediyears). In 16 patients (27%), consecutive exotropoped within 6 months of esotropia surgery. Sevenpatients had onset of consecutive exotropiamonth of the second or third operation.Amblyopia was present in 12 patients (20%). E

these patients were � 10 years old, and further atherapy was not attempted. Nine patients (15%)peropia � � 2.50 D. These patients were opeaccording to their angle when wearing glassespatient (1.7 %) had myopia � �2.50 D. Four(6.7%) had anisometropia � 1.0 D.Surgical procedures performed for the 59 patie

as follows: 42 patients (71%) underwent later

R adv(BLRd melargegerie(bilateRc/Mdepicsion pd varnt lattablegery,5 mmctusto 8 mrgerygery.mus1 patiwhootendlengPDand 35). Npatt

e), antropiiningof e

lar aliery aareho we per

tionsentfor bts (61

nd in 42ad satis-an addi-

10 PDd under-ndercor-showed

nificantlypatientsnificantlylignmenttients are

0 PD forere over-overcor-overcor-y, 2 weree, 1 wasremainedho werellow-up.ent afterrison be-nd thosee in themount ofo obtainand thatift.r serioustent dip-d a tem-ients re-folds at 2he dellen

cedures.ection, 1rrection,n. All 5the addi-rgery for

patientsns—43.1red withpatientsmblyopian fact, oftory finalwithoutent. Theose with

mentsepreseesode

Journal of AAPOSVolume 8 Number 3 June 2004232 Donaldson, Forrest, and Gole

recession and medial rectus advancement (LRc/M(12 %) underwent bilateral lateral rectus recessionand 6 (10 %) underwent lateral rectus recession anrectus resection (LRc/MRs). Four patients withviations (� 50 PD) underwent three muscle surpatient each (1.7 %) underwent LRc/BMR advmedial rectus advancement), BLRc/MR adv, BLor BLRc/BMR adv. (These four patients are notin Figure 1). The amount of lateral rectus recesformed before adjustment) averaged 6.5 mm anfrom 5 to 8 mm. Thirty-three patients underwerectus recession performed with hang-back adjustures. Of these, 15 required adjustment after surin those patients the average adjustment was 3.muscle advancement. The amount of medial revancement averaged 5.5 mm and ranged from 3.5Seventeen patients (29%) underwent oblique sucombination with their consecutive exotropia surpatients were found to have lost muscles requiringtransfer procedures. Of particular interest waswith �2 (of 4) defective adduction preoperativelyfound at surgery to have a medial rectus pseudcomposed of scar tissue that measured 11 mm inMean exodeviation before surgery was 31.7

distance, (CI � 3.3, SD � 13.0, range 15 to 65)PD for near (CI � 3.7, SD � 14.4, range 10 to 7patients (15%) had convergence-insufficiency(exotropia � 10 PD greater at near than distanc(10%) patients had divergence-excess pattern (exo10 PD greater at distance than near). The remapatients (75%) had measurements within 10 PDother for distance and near.The mean preoperative and postoperative ocu

ments are depicted in Figure 1. Results of surgweek, 6 weeks, 6 months, and final follow-uptailed in Table 1. The number of patients worthotropic, esotropic, or exotropic at each timare described.Figure 2 shows the distribution of overcorrec

undercorrections over time. Satisfactory alignmdefined as alignment within 10 PD of orthophoriadistance and near. This was achieved in 36 patien

Fig 1. Mean preoperative and postoperative ocular aligneach surgical procedure (horizontal bars). Vertical lines rSD on either side of the mean. Positive values representtions, and negative values represent exodeviations.

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andwasoth%)

at 1 week1, in 40 patients (68%) at 6 weeks, apatients (71%) at final follow-up. Five patients hfactory alignment at final follow-up but requiredtional procedure to accomplish this.Undercorrection was defined as exotropia of �

for distance or near. Only five patients (8%) hacorrections in our series. Two of these were urected at 1 week, whereas the other 3 patientssatisfactory alignment at 1 week but were sigundercorrected at the second visit. One of these 5drifted straight, and the other 4 remained sigundercorrected. One patient had satisfactory aafter an additional procedure, and the other 3 paconsidering further surgery.Overcorrection was defined as esotropia � 1

distance or near. Twenty-one patients (36%) wcorrected at 1 week, and 14 patients (24%) wererected at 6 weeks. Of the 21 patients who wererected at 1 week, 11 drifted straight spontaneouslstraightened after a further surgical procedurstraightened with Botulinum toxin injections, and 7overcorrected at final analysis. Two patients wstraight at 1 week became overcorrected by final foWe also assessed the drift in the ocular alignm

surgery. Results are detailed in Table 2. Compatween patients with satisfactory final alignment awith poor final alignment showed no differencamount of correction (39.1 vs 38.6 PD) or the apostoperative drift. This suggests that patients wha poor result demonstrate this soon after surgerythe poor result is not related to postoperative drNo patient developed slipped muscles or othe

complications. Four patients experienced intermitlopia after surgery. Four adult patients developeporary corneal dellen nasally. Two of these patquired resection of redundant nasal conjunctivaland 4 months after surgery, respectively, before tresolved.Five patients (8%) required additional pro

Three patients underwent surgery for an overcorrreceived Botulinum toxin injections for an overcoand 1 underwent surgery for an undercorrectiopatients had satisfactory final alignments aftertional procedure. One patient is still awaiting suan undercorrection.Amblyopia was present in 12 patients. These

had significantly larger preoperative exodeviatioPD for distance and 40.2 PD for near—compa28.8 PD for distance and 30.0 PD for near forwithout amblyopia (P � 0.002). Patients with awere no more likely to have a poor final result. Ithe 12 patients with amblyopia, 10 had a satisfacalignment compared with 36 of the 46 patientsamblyopia who had a final satisfactory alignmamount of postoperative exodrift was similar in thand without amblyopia.

fornt 1via-

cedefficultpia a

this in-ients and(n� 38).7 years.

llow-up‡

EsotropiaSD � 9.6)(14)(54)

7.3-20(24)

0.9-16

ment. †Threenal deviation

alignmentunderwent


DISCUSSIONThis study highlights the long delay that may predevelopment of consecutive exotropia. It was diestimate the time of onset of consecutive exotro

TABLE 1. Results of SurgeryResults 1 Week

Mean deviation 7.0 PD Esotropia(CI � 2.4, SD � 0.5) (n

No. (%) orthophoria 5 (8)No. (%) Esotropia 49 (83)

Mean esodeviation (PD) 9.9Range (PD) 4-25

No. (%) Exotropia 5 (8)Mean exodeviation (PD) 12.2Range (PD) 4-35

CI: confidence interval; PD: prism diopters.*Two patients (3%) missed their 6-week visit but returned later, and 1patients (5%) required a second procedure by 6 months, and 12 patiecalculations because their final deviation was measured after a secon

Fig 2. Distributions of overcorrections and undercorrectiogroup at final follow-up required an additional proceduresurgery for an undercorrection, and 1 received Botulinu

thetofter

the most recent procedure for esotropia becauseformation was not remembered accurately by patoften not recorded in referral letters. For patientswith accurate information, the mean delay was 4

6 Weeks* 6 Months† Final fo

PD EsotropiaI � 2.4, SD � 9.2)

3.1 PD Esotropia(n � 44, CI � 3.3, SD � 11.2)

1.5 PD(CI � 2.6,

4 (7) 6 (10) 833 (56) 30 (51) 32

8.8 8.84-20 4-25 4

19 (32) 8 (14) 147.5 15.8 1

4-25 8-30 4

(1.7%) was treated with Botulinum toxin injections just before the 6-week appoint) did not return for their 6-month visit. ‡Five patients (8%) were excluded from fi

tion.

week, 6 weeks, and final follow-up. *Five patients in the satisfactoryhieve this outcome (3 underwent surgery for an overcorrection, 1

injections for an overcorrection).

2.7� 56, C

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y againstould at-peration.ver, willay have.a includejections,include

ng minusions, thery,18 and

ding me-ncementombina-produc-xotropia.is appro-ination,previousction orhould beminimizecing theamountamountf there isd behindang-back

teral rec-consecu-al medialtory finalstudy. Itr adduc-advance-al,18 whop to thebeyondPD; and

No Drift

No. (%)Patients

9 (15)9 (15)

12 (20)

ed from drifts because of-to-6 months


These figures reinforce the trend to increased pof consecutive exotropia in studies of infantilewith longer follow-up.8 It is therefore important tto parents of a child with infantile esotropia thatexodeviation may occur even decades later.Amblyopia has been considered to be a con

factor in the development of consecutive exotrAmblyopia was present in 12 patients (20.3%series. This number is lower than that in seveseries2,11,16 and lower than the reported incidencblyopia in infantile esotropia of 35% to 41%.17

blyopic patients were no more likely to have a presult than those without amblyopia. Similaamount of postoperative exodrift was similar intients with and without amblyopia. The presencsence of amblyopia therefore does not seem tothe final result or the amount of postoperativeafter consecutive exotropia surgery.Twenty-eight patients (47%) underwent � 1 o

before developing consecutive exotropia. This agother series of consecutive exotropia in which a hmultiple surgeries was a frequent finding.8,12 It iswhether multiple surgeries lead to an increasedeveloping consecutive exotropia or whether abinocular fusion leads to both failure of initial surlater development of consecutive exotropia. Risfor consecutive exotropia after surgery for undercesotropia include medial rectus limitation6 andence of an exodeviation in the upgaze and downsitions.11 These findings should serve as a cautiosider performing lesser degrees of surgery in ttients.Details of initial esotropia surgery were unava

15 patients (25%) despite the fact that we wropatients’ previous ophthalmologists and requestedcharts. We believe the potential for delayed onsesecutive exotropia means that hospitals andshould preserve operative notes of all patients whwent surgery for childhood strabismus, for severaif not indefinitely, so that details of the original suavailable for planning subsequent procedures.proposed that surgeons should assess patients wsecutive exotropia as though there had been no

TABLE 2. Postoperative Drift*

Time Period Overall Drift (PD)No. (Patie

1 to 6 weeks �4.1 (CI � 1.7, SD � 6.8) 39 (661 week to final result �5.1 (CI � 2.5, SD � 9.4) 33 (566 weeks to 6 months �0.5 (CI � 1.9, SD � 6.2) 13 (22CI: confidence interval; PD: prism diopters.*Negative values represent exodrift, and positive values represent escalculations so that the effects of the second procedure were not attlack of data. Five patients (8.5%) were excluded from drift calculaticalculations because of either a second procedure or a lack of follow

ncepialainyed

ing4,5,9

ourherm-m-nalthepa-ab-ncerift

ionithofearofofandorstedes-po-on-pa-

fortheitalon-onser-desareer1

on-ous

surgery (Cooper’s dictum) and argued eloquentlthe notion that consecutive exotropia surgery shtempt to “undo what was done” at the first oKnowing details of previous procedures, howehelp avoid attempts to operate on muscles that malready undergone maximum amounts of surgeryManagement options for consecutive exotropi

observation, optical therapy, Botulinum toxin inand surgical correction. Optical treatment maydecreasing the hyperopic correction or prescribilenses for emmetropic patients. For large deviatresults of optical treatment may be only temporasurgical correction is usually indicated.2

A number of different surgical options—includial rectus advancement,19,20 medial rectus advaand resection,2 lateral rectus recession,1,2,21 or ctions of these techniques—have been described asing good results for patients with consecutive eThe decision regarding which surgical procedurepriate should be made after a thorough examproper consideration of the type and amount ofsurgery, and the presence of limitation of adduconvergence insufficiency. Unilateral surgery sperformed, if possible, on the amblyopic eye tothe risk to the better eye. We recommend advanmedial rectus back to the original insertion if theof advancement is equivalent within 1 mm to theof resection advised for that angle of deviation. Ia large discrepancy, the muscle can be positionethe original insertion by two double-armed hsutures.Medial rectus advancement combined with la

tus recession is indicated for those patients withtive exotropia with limited adduction after bilaterrectus recession. This technique achieved satisfacalignment in 29 of 42 patients (69%) in ourshould be performed on the eye with weaketion19,20 or on the amblyopic eye. Medial rectusment alone has been well described by Biedner etsuggested a grading system of advancement uoriginal insertion for deviations � 25 PD; to 2mmthe original insertion for deviations from 30 to 35

Exodrift Esodrift

Amount (PD)No. (%)Patients Amount

�7.6 (CI � 1.5, SD � 4.9) 10 (17) �6.0 (CI � 1.7, SD � 2.7)�10.5 (CI � 2.8, SD � 8.2) 12 (20) �5.8 (CI � 3.3, SD � 2.6)�5.5 (CI � 4.1, SD � 7.5) 19 (32) �5.1 (CI � 1.0, SD � 2.1)

atients who required a second operation or Botulinum toxin injections were excludto drift. One patient (1.7%) was excluded from drift calculations from 1 to 6 week

1 week to final result, and 16 patients (27%) were excluded from the 6 weeksmonths.

%)nts

)))

odrift. Pributedons from-up to 6

gery

tisfacties. Tvergetus fuitationthe prates mdvancus rec

d a mimilarPD)al19 (2nitionmmohner0 PDluatethata beia is b

eviatiostopexotrokhofial recpatielted iexodtent ergery

t in 6nsecualler eereasas mcted at of thngle edrift olmosteks aks anstudyexotro

t witexotroowevundeumbe

cause ofwas nopia. It islly over-ft toward

res thoseer of in-sensoryor in thelthoughtive andnsecutiveith ade-study byacquiredions, butional po-

result ofny yearsction ofty of pa-not delaynumberf consec-ommendd medialere is an, most ofery. Weediatelyall-angle

opia. Trans

ercorrected-9.1965;2:15-

corrections.tudy of itsement. Am

trospectiveus 1993;30:

consecutivecession for94;31:147-

Strabismus

ion in high

Pinto GL.in develop-


concomitant resection or additional muscle surdeviations � 35 PD.Bilateral lateral rectus recessions achieved sa

final results in 6 of 7 patients (86%) in our serprocedure is indicated for those patients with diexcess or basic exotropia with normal medial rection, but it should be avoided in patients with limadduction. According to Kushner and Fisher,22

ence of even mild convergence insufficiency indicdial rectus underaction, which warrants either athe medial recti or performing extra lateral rectsion.Fifty-nine patients underwent surgery and ha

correction of 34.3 PD for distance. This is sresults obtained by Biedner et al18 (mean 24 to 36slightly greater than that obtained by Ohtsuki etPD for distance and 32.1 PD for near). The defisuccessful alignment is controversial. It is most cotaken as being within 10 PD of orthophoria. KusFisher23 argued that alignment within 8 to 1orthotropia should not be the standard to evaoutcome of strabismus surgery. He demonstratedter surgery for infantile esotropia, orthotropia isoutcome than small-angle esotropia, and esotropter than small-angle exotropia.When anticipating the postoperative ocular d

surgeons must take into account the most likely pative drift pattern. Exodrift after consecutivesurgery was first noted in the literature by KerHoutman,15 who described it after bilateral medresection. In their series, almost all of the 18demonstrated exodrift, and in 9 patients it resurecurrence of exotropia. A similar postoperativewas shown in patients after surgery for intermittropia24,25 and in patients overcorrected after suinfantile esotropia.8,26,27

Our results demonstrated a significant exodrifof patients in the first 6 weeks after surgery for coexotropia. This exodrift averaged 7.6 PD. A smdrift of 6.0 PD was found in 10 patients (15%), whdrift occurred in 9 patients (15%). The exodrift wprominent in those patients who were overcorreweek. Although numbers were small (n� 6), mospatients who were undercorrected, with a small-atropia (0 to 10 PD) at 1 week, showed either noslight esodrift in the first 6 weeks after surgery. Aof the exodrift occurred within the first 6 wesurgery with little drift occurring between 6 weemonths. As far as we know, this is the firstquantify exodrift after surgery for consecutive(as distinct from intermittent exotropia).This exodrift suggests that the ideal alignmen

the first week after surgery for consecutiveshould be a small-angle esotropia of 5 to 10 PD. Han alignment � 10 PD of esotropia at 1 week isable and would result in a large increase in the n

for

oryhisncenc-ofes-e-inges-

eantoand4.0ofnlyandoftheaf-tteret-

on,er-piaandtusntsn ariftxo-for

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hinpiaer,sir-r of

patients with long-standing overcorrection. Thethe postoperative exodrift is not known. Thereevidence in this study that it is related to amblyomore prominent in those patients who are initiacorrected to esotropia, therefore resulting in a driorthotropia in these patients.This was a retrospective study and as such sha

limitations common to any such study. A numbvestigators have argued that assessment of thestate is not important in the decision to operate,planning of surgery, for manifest strabismus.28 Awe did not record data regarding the preoperapostoperative sensory states, overcorrection of coexotropia may only be appropriate for patients wquate fusional potential. This was the case in theDankner et al29 who showed that patients withesotropia achieved better results with overcorrectthis happened only in patients with adequate fustential.Consecutive exotropia is not an uncommon

esotropia surgery and may not appear until maafter infantile esotropia surgery. Surgical correconsecutive exotropia is successful in the majoritients, so a fear of consecutive exotropia shouldor discourage surgery for infantile esotropia.29 Aof surgical options are available for correction outive exotropia. Based on our experience, we reclateral rectus recession (� adjustable sutures) anrectus advancement as a suitable procedure. Thexotropic drift after consecutive exotropia surgerywhich occurs within the first 6 weeks after surgconclude that a suitable ocular alignment immafter surgery for consecutive exotropia is a smesotropia of 5 to 10 PD.

References1. Cooper EL. The surgical management of secondary exotrAm Acad Ophthalmol Otolaryngol 1961;65:595-608.

2. Mittleman D, Folk ER. The surgical treatment of ovesotropia. J Pediatr Ophthalmol Strabismus 1979;16:156

3. Arruga A. Surgical overcorrections. J Pediatr Ophthalmol22.

4. Bietti GB, Bagolini B. Problems related to surgical overin strabismus surgery. J Pediatr Ophthalmol 1965;2:11-4

5. Windsor CE. Surgically overcorrected esotropia: a scauses, sensory anomalies, fusional results and managOrthopt J 1966;16:8-15.

6. Bradbury JA, Doran RML. Secondary exotropia: a reanalysis of matched cases. J Pediatr Ophthalmol Strabism163-6.

7. Stager DR, Weakley DR, Everett M, Birch EE. Delayedexotropia following 7-millimeter bilateral medial rectus recongenital esotropia. J Pediatr Ophthalmol Strabismus 1950.

8. Yazawa K. Postoperative exotropia. J Pediatr Ophthalmol1981;18:58-64.

9. Rosenbaum AL, Jampolsky A, Scott AB. Bimedial recessAC/A esotropia. Arch Ophthalmol 1974;91:251-3.

10. Pickering JD, Simon JW, Lininger LL, Melsopp KB,Exaggerated effect of bilateral medial rectus recession

smus 1

a follow

conge

mus. P

Jaegerlphia (

tions.

theoryy; 199

theoryy; 199

tion ofrrected

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An Eye on the Arts – The Arts on the Eye

The two stood before Akbar, who was resting on his bed with his eyes open.Murtaza Beg whispered his praise for the emperor, then started to narrate astory—the story of an unpardonable crime. He told Akbar of an unfortunateartist, born of a master and himself a genius, who had displeased his emperor.But his crime was a strange one . . . Akbar stopped him with a raised hand. Heasked Bihzad to come forward. He approached with a few measured steps, andstarted to recite a prayer. Facing the bed, Bihzad prostrated himself with hisforehead touching the ground.The emperor rose from his bed. Holding Bihzad’s shoulder, he brought his

face close to his, staring at the patch over his eyes. In a swift move—one withwhich he’d sever a deer’s neck in a hunt—he flung open the blindfold.Bihzad saw the green jade cup full of Akbar’s blood. He saw the mole on

Akbar’s cheek, now a dried cherry. He started to cry.The emperor held his face, tears running down his hands. ‘You are not an

artist,’ Akbar told him. ‘You are a saint, Bihzad. Only a saint is truly blind,seeing none but the God inside him.’ He raised him from the floor, drew himtowards his bed, made him sit by his side. He kept on looking into his face fora long time. Then he spoke, still in the voice of the emperor.‘But I want you to turn into an artist for the last time.’—Kunal Basu (from The Miniaturist)

surgical manag exotropia

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