Effectiveness of medial rectus advancement alone or in combination with resection or lateral rectus recession in the management of consecutive exotropia Sundeep K. Kasi, MD, a Madhura A. Tamhankar, MD, b Maxwell Pistilli, MS, b and Nicholas J. Volpe, MD c PURPOSE To prospectively determine the long-term success of medial rectus advancement alone or in combination with other procedures in the management of consecutive exotropia. METHODS All patients with consecutive exotropia who underwent medial rectus advancement alone or in combination with medial rectus resection or lateral rectus recession or both, per- formed by a single surgeon between 1999 and 2010, were included. Initially, a retrospective review was performed. Patients were then recalled and examined by a masked observer. Good results were defined as final alignment within 10 D of orthotropia. RESULTS A total of 46 patients were enrolled in the study with a mean age of 43  15.5 years (range, 14-76) and a mean exotropia of 32  18 D (range, 10-90). Good results were achieved in 33 patients (72%) at a mean follow-up time of 2.5 years. Of the 21 patients returning for prospective examination, 15 (71%) had good alignment at an average follow-up of 4.2 years (range, 6.9 months to 8.6 years). Adduction deficits were improved in 30 of 33 (91%) patients at final follow-up. CONCLUSIONS In patients with consecutive exotropia, surgery including medial rectus advancement alone or in combination with resection or lateral rectus recession or both usually is effec- tive. ( J AAPOS 2013;17:465-470) C onsecutive exotropia often occurs years after sur- gery for primary esotropia, with an incidence ranging from 3% to 29%. 1-4 The primary surgery for esotropia usually involves bilateral medial rectus recession. Patients who have undergone prior esotropia surgery in childhood, may have a tendency toward an exotropic shift later in life because of age, prior medial rectus recession, or slipped medial rectus muscle, perhaps in conjunction with poor binocularity. 2-4 Treat- ment of consecutive exotropia involves advancement (with or without resection) of the previously recessed medial rectus muscle(s), recession of the lateral rectus muscle(s), or a combination of the two procedures. 2-5 Currently, there is no consensus on the optimal surgery, with multiple small series reporting equally successful results (60%-75%), defined as alignment within 10 D of orthotropia, with follow-up ranging from months to years. 1-5 Most authors advocate a combination approach and tailor surgery to the individual patient, based on number and timing of previous surgeries, coexistence of amblyopia, and ocular motility deficits. 6 Other variables purported to affect surgical outcomes include the presence or absence of binocularity, A- or V-pattern deviations, earlier onset of esotropia, and accompanying vertical deviations. 4,6 We assessed the effectiveness of medial rectus advancement alone or in combination with resection or lateral rectus recession or both in a sample of patients in whom longer follow-up data were prospectively obtained. Methods This study was approved by the University of Pennsylvania Insti- tutional Review Board, and informed consent was obtained according to the requirements of the US Health Insurance Porta- bility and Accountability Act of 1996. Consecutive patients who had undergone surgery for childhood esotropia at any age and subsequently underwent medial rectus advancement alone or in combination with medial rectus resection or lateral rectus reces- sion or both, performed by a single surgeon (NJV), between 1999 and 2010 for consecutive exotropia were included. Because our goal was to determine the role of medial rectus advancement in previously operated esotropic patients, we included all patients Author affiliations: a Department of Ophthalmology, University of California San Francisco, San Francisco, California; b Department of Ophthalmology, University of Pennsylvania, Philadelphia, Pennsylvania; c Department of Ophthalmology, Northwestern University, Chicago, Illinois This work was supported in part by an unrestricted grant from Research to Prevent Blindness. Submitted December 31, 2012. Revision accepted June 7, 2013. Correspondence: Madhura A. Tamhankar, MD, 51 N. 39th Street, Philadelphia, Pennsylvania 19104 (email: Madhura.Tamhankar@uphs.upenn.edu). Copyright Ó 2013 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2013.06.016 Journal of AAPOS 465