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AL - AZHAR ASSIUT MEDICAL JOURNAL VOL 13 , NO 1 , JANUREY 2015 44 | Page SURGICAL MANAGEMENT OF RESIDUAL AND RECURRENT EXOTROPIA. LONG TERM FOLLOW - UP Abdallh M A lamin Department of ophthalmology faculty of medicine Al Azhar university ــــــــــــــــــــــــ ـــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ ABSTRACT Aim: This prospective study evaluates the long term outcome of surgical management of residual and recurrent e xotr opia. Patients and methods : Seventeen patients were included in this study 11 patients having residual e x otropia, 6 patients were recurrent e x otropes . All patients failed to achieve good ocular alighetment by non surgical method. All patients were subjected to complete ophthalmologic examination . Every case was managed and reoperated individually according to its specific crit eria. Results : At the final follow - up period after reoperation, 10 patients ( 58 .8 3 %) maintained surgical success without recurrence. Among the 7 patients ( 41 . 17 %) who showed recurrent intermittent exotropia again after the reoperation . Conclusion : In this s tudy, the recurrence rate after reoperation for recurrent and residual exotropia was 41 . 17 % The success rate deteriorated with increasing follow - up duration. P ostoperative esodeviation at 1 week was found to be the predictor for response to strabismus su rgery and was the only discriminate factor for a successful surgical outcome in reoperation for recurrent and residual exotropia. Keywords Residual e x otropia, recurrent e x otropia . INTRODUCTION T here is no agreement on the best type of exotropia surgery. The principal difficulty with surgery is the relatively high incidence of over and undercorrections . 1 The results of surgical correction fort exotropia have been reported to deteriorate with time. 2 , 3 As expected, the recurrence rate increases with lengt hening follow - up after operation. It has been reported that the overcorrection immediately after operation of intermittent exotropia is associated with satisfactory long - term results, 4 but also that the deviation immediately after surgical correction of in termittent exotropia did not affect the final surgical results. 5 However, the clinical course after surgical correction of recurrent exotropia is unclear. There are small number of previous studies that documented the clinical course after reoperation for residual and recurrent exotropia. The purpose of this study is to evaluate long term follow up after surgical management for residual and recurrent exotropia. PATIENTS AND METHODS Seventeen patients were included in this study 11 patients having residu al e x otropia, 6 patients were recurrent e x otropes . All patient s failed to achieve good ocular alighetment by non surgical method. All patients were subjected to complete ophthalmologic examination the angle determined by using the Hirschbe

rg test, cover te st, and Krimsky prism test for near and distance vision. Visual acuity was examined using a Snellen acuity chart . Cycloplegic refraction was performed to exclude the accommodative component. Ocular motility, duction, and version movements were examined. V ertical incompliance (V or A pattern), oblique muscle overaction, and dissociated strabismus were recorded. Principal of reoperation : General anesthesia was used for all patients, with use of the surgical microscope to avoid complications which are more c ommon due to much scaring which might obscures normal anatomy. Forced duction test then s ubconjunctival saline injection to demonstrate the sites of conjunctival adhesion. The limbal conjunctival incision with two radial relaxing incisions gave a wider vi ew and allowed accurate measurements from the limbus and proper dissection of adhesions. Every case was managed individually according to its specific criteria. The presence of records served as to which muscles were available to be operated on. Follow - u p visits were conducted at 1 and 2 weeks; and 1, 3, 6 months and every 6 months for 2 4months postoperatively. Krimsky prism test as well as eye movement were assessed during follow - up examinations. Surgical success was defined as a final distance deviation of less than 10 PD at primary position, and recurrence, Moussa A. Hussein and Ibrahim S. Ibrahim VOL 13 , NO 1 , JANUREY 2015 45 | Page or an undesirable outcome as a final ocular misalignment of greater than 10 PD. RESULTS Seventeen patients were included in this study 1 1 patients having residual e x otropia and 6 patients were recu rrent es x tropes . Ten patients were females ( 64 %) and seven were males ( 36 %) The refraction of the patients (spherical equivalent) was ranging from – 1 2.0 to + 3 .0 Patients age range between ( 5 - 30 ) years with a mean of ± S.D 4 . 0 3± 7 . 6 7years. The preope rative near angle of deviation ranged from 25 - 8 0Δ with a mean of ± S.D 5 9 . 3 5 ± 1 9 . 6 2 the distance deviation range from 30 - 90Δ with a mean of ± S.D 6 7 . 5 2 ± 1 8 . 35 . Table (1) The age at initial surgery ranged from 2 .5 to 1 6 years with a mean of ± S.D 5 .5 3 ± 2 . 87 The time interval between first and second procedures ranged from 6 months to 1 0 years with a mean of ± S.D 4 . 4 7 ± 3 . 1 9 . Table (1): Patients data as regard age, sex , preoperative , postoperative angle and type of deviation. Types of Recurre nce Angle after treatment ∆ Angle before treatment ∆ Refracti on Spheric al equivale nt Age [yea rs] Se x Ca se No. Dis t. Nea r Dis t. Nea r Lt Rt Recurre nt 1 5 XT 10 XT 90 XT 80 XT - 10. 0 - 12. 0 17 1 Residual 1 5 XT 1 5 XT 60 XT 60 XT + 1.0 + 3.0 30 2 Residual 10 XT 5X T 50 XT 40 XT - 1.0 + 1.0 6.5 3 Residual 2 5 XT 15 XT 50 XT 35 XT - 1.0 + 3.0 11 4 Recurre nt 10 XT 5X T 90 XT 70 XT - 2.0 - 3.0 5 5 Recurre nt 30 XT 20 XT 90 XT 90 XT - 1.0 - 2.0 15 6 Recurre nt Ort ho Ort ho 70 XT 70 XT + 3.0 + 3.0 21 7 Residual 5E T 5E T 35 XT 25 XT + 1.0 + 2.0 1

1 8 Residual 1 0 E T 15E T 90 XT 70 XT - 4.0 - 2.0 9 9 Residual Ort ho Ort ho 50 XT 50 XT + 3.0 - 1.0 7 10 Residual 15 XT 10 XT 70 XT 60 XT - 1.0 - 2.0 25 11 Residual 10 XT 5X T 50 XT 30 XT + 2.0 + 2.0 22 12 Recurre nt 5E T 5E T 90 XT 80 XT - 2.0 - 5.0 10 13 Re sidual 5E T 5E T 60 XT 60 XT - 5.0 - 3.0 9 14 Residual Ort ho Ort ho 30 XT 30 XT + 2.0 - 1.0 6 15 Residual 15E T 15E T 60 XT 50 XT - 3.0 - 1.0 7.5 16 Recurre nt 10 XT 5X T 90 XT 70 XT - 2.0 - 3.0 12 17 Amblyopic was present in 1 0 patients (6 4 %). Inferior obl ique muscle overaction was present in 5patients ( 2 9 . 41 % ) . A pattern was present in3 patients (1 7 .6 4 %) V pattern was present in2 patients (11. 76 %) Limitation of movements was present in 6 patients ( 35 . 29 %) . Normal movements were present in ( 64.70 %) . S urgical procedures T he most commonly used procedures were recession - resection of 2 muscles (monocular surgery). These were used in 7 patients ( 41.17 %) with preoperative angle 50 Δ - 70 Δ . This procedure could be used in patients of residual, and recurrent exotropia with previous monocular surgery and the exploration revealed sufficient amount of surgery with score of forced duction test was ( 0 - 1). Planned overcorrections (1 5Δ) were applied in 5 patients (29.41%) with deep amblyopia to allow for the postoperative drift commonly encountered in these cases Favorable outcome was achieved in 6 patients ( 35.29 %). Bilateral medial rectus resections were done in 4 patients (2 2 . 52 % ) with preoperative angle 70 Δ - 80 Δ , this procedure could be used in patients of residual and recurrent exotropia with previous bilateral lateral rectus recession and the exploration revealed sufficient amount of recession with score of forced ductio n test was ( 0 - 1). The amount of resection ranged from 6 to 7 mm. Favorable outcome was achieved in 2 patients ( 11.76 %). Reoperation of 3 muscles (surgery on both eyes) was used in 2 patients with preoperative angle ranged from 80 Δ - 90 Δ . The AL - AZHAR ASSIUT MEDICAL JOURNAL VOL 13 , NO 1 , JANUREY 2015 46 | Page procedure was one lateral rectus rerecession with resection of both medial recti (3 muscles surgery on both eyes). Favorable outcome was achieved in 1 patients ( 5.88 %). Bilateral lateral rectus rerecession were used in 2 patients (1 1 . 76 %) the preoperative angle ran ged from 30 Δ to 40 Δ the amount of rerecession ranged from 3 to 5 mm. This procedure could be successful in residual exotropia with insufficient recession in primary surgery with score of forced duction test was ( 2 - 3). One mm of rerecession was found to correct u p to 4 Δ of deviation. Favorable outcome w as achieved in 1 patient (5 .88 %) One lateral rectus muscle recession 10 mm was used in 2 patient ( 11 . 64 %) with small residual angle 30 Δ . There was statistical significant difference between those who had two muscl es surgery and those who had three muscles surgery after 24 months. P atients with three muscles surgery were associated with less favorabl

e outcome. Score of forced duction test was zero in 7 patients ( 41 %) ; score 1 in 3 patients (1 7 .6 4 %) ; score 2 in 3 p atients (1 7 . 6 %) ; score 3 in 2 patients (11. 76 %) ; and score 4 in 2 patients (11. 76 %) . Table ( 2 ) : Score of forced duction test. score Definition No. (%) Patients Favorable outcome 0 No restriction. 7 ( 41 %) 6 (35 %) 1 Minimal restriction terminally. 3 ( 17.6 4 %) 2 (11. 7 6 %) 2 Eyeball could move past midline. 3 (17.6 4 %) 1 (5. 88 %) 3 Eyeball could not be moved past midline. 2 (11. 7 6 %) 1 (5. 88 %) 4 Eyeball could not be moved. 2 (11. 7 6 %) 0 Score of adhesion was zero in 9 patients (5 2.94 %) score 1 in 4 pat ients (2 3.52 %) ; score 3 patients in 2 patients (1 1.76 %) ; and score 3 in 2 patients (1 1.76 %) . Table (3) ; Score of adhesion. score Definition No. (%) Patients Favorable outcome 0 No adhesion. 9 (5 2 . 94 %) 7 ( 41 . 17 %) 1 Filmy adhesions easily separable with blunt dissection. 4 (2 3 . 5 2%) 2 (1 1 . 7 6%) 2 Mild to moderate adhesions with freely dissectible plane. 2 (11. 76 %) 1(5 .88 %) 3 Moderate to dense adhesions with difficult dissection 2 (11. 76 %) 0% Inferior oblique muscle inclusion was f ound in tow patients w hich presents by vertical deviation after lateral rectus surgery (hypotropia in primary position). During exposure of the previously operated lateral rectus muscle marked fibrosis and adhesion was found around lateral rectus and inferior oblique muscles. The inferior oblique and lateral rectus muscle were separated, and the inferior oblique muscle was repositioned into its normal anatomic position. This patient s had unfavorable outcome due to marked adhesion and fibrosis (Figure 1) . Figure 1 : Case NO 6 recurrent exotropia with LT inferior oblique inclusion postoperative residual exotropia 20PD for near and 30PD for far. postoperatively 1 3 patients Moussa A. Hussein and Ibrahim S. Ibrahim VOL 13 , NO 1 , JANUREY 2015 47 | Page (7 6 . 4 7%) were favorable outcome (ocular alighenment within 10 prism diopter) after one month and the sam e after 3 and 6 months after 12months 11 patients ( 64 .7 0 %) were favorable outcome (ocular alighenment within 10 prism diopter) ) . At the final follow - up period (24months) after reoperation, 10 patients ( 58.82 ) maintained surgical success without recurrence. Among the 7 patients ( 41.17 %) who showed recurrent intermittent exotropia again after the reoperation . The change in angle of horizontal deviation during the follow - up 6.2±7.8 PD. Postoperative esodeviation at 1 week was found to be the predictor for r esponse to strabismus surgery and was the only discriminate factor for a successful surgical outcome in reoperation for recurrent and residual exotropia . DISCUSSION In this study e very case was managed individually according to its specific criteria. The presence of records served as to which muscles were available to be operated on. It helped to plan the surgery preoperatively. However, intraoperative plan was necessary. Among the 1 7 patients included in the study, 1 1 patients with residual e x otro pia and 6 pa

tients were recurrent e x otropes there was a higher percentage of females ( 64 %) and seven were males ( 36 %) Amblyopia was present in 10 patients (5 8.82 %) . Gomez De liano et al. 6 reported amblyopia in 53.3% of his patients and accused it as one of the most important factor in recurrent strabismus. Planned overcorrections (15Δ) were applied in 5 patients ( 2 9 . 41 % ) with deep amblyopia to allow for the postoperative drift commonly encountered in these cases which was also stated by Scott and colleagues . 7 Favorable outcome was achieved in 6 patients ( 35.29 %). s The patient's age greatly affected the surgical plan. In the older patients, 15 - 30 years old, deliberate undercorrections were applied in 4 cases (11.1%) . Hidaji and colleagues 8 advocated leaving the older patients with a deviation less than 1 5 Δ for a reduction of postoperative diplopia . postoperatively 1 3 patients (7 6 . 4 7%) were favorable outcome (ocular alighenment within 10 prism diopter) after one month and the same after 3 and 6 months after12months 11 patients ( 64 .7 0 %) were favorable out come (ocular alighenment within 10 prism diopter) ) . Patel and colleagues 9 reported a success rate of 65% in exotropia reoperations . The angle was relatively unstable in relation to the long follow up period the average postoperative drift outward shift of 5∆ to 10∆ over a 2 - year period . The exodrift after strabismic surgery has been studied by many authors. Kushner et al 10 demonstrated that 75% of exotropic patients presented postoperative exodrift, compared w ith 7.4% of esotropic patients. Rabb and Parks 6 reported that among 159 exotropic patients, 32% of the patients that were initially orthotropic or had small residual exotropia developed 10 PD undercorrection by the postoperative 8th week. Hahm et al 4 state d that exotropic drift after surgery for intermittent exotropia was more common during the first 2 years after surgery and then stabilized, whereas Scott et al 3 advocated that the exodrift stabilized after the 6th postoperative week and then became fairly constant during follow - up of two years. . Kushner et al 11 demonstrated that the preoperative deviation significantly influenced response in exotropic patients, that is, patients with larger preoperative deviations had a poorer chance of having a successful outcome, while Graf et al 12 asserted that there was no such influence. The lack of agreement in these studies may be due to the patients' variability in response to strabismus surgery. One factor creating the discrepancy may be the variability in the post operative exodrift encountered in exotropic patients. 13 There was no significant statistical difference in the favorable outcome between sexes, presence versus absence of records, AL - AZHAR ASSIUT MEDICAL JOURNAL VOL 13 , NO 1 , JANUREY 2015 48 | Page presence versus absence of amblyopia and patients with IOOA versus normal IO. There was significant difference in percentage of outcome in different scores of forced duction test and different scores of adhision . Higher scores ( 2 - 3 - 4) were associated with less favorable outcome. As regard complications in this study. Persistent conjunctival inject

ion was present in 5 patients ( 29 . 41 %). Diplopia was present in 4 ( 23 . 52 %) patients for more than 3 months postoperatively . Mild limitation of a b duction in 2 patient s ( 11.76 %) maybe due to excessive recession of the lateral re ctus . CO NCLUSION In this study, the recurrence rate after reoperation for recurrent and residual exotropia was 41.17 % The success rate deteriorated with increasing follow - up duration. P ostoperative esodeviation at 1 week was found to be the predictor f or response to strabismus surgery and was the only discriminate factor for a successful surgical outcome in reoperation for recurrent and residual exotropia REFERENCES 1. Friendly DS: Surgical and non - surgical management of intermittent exotropia. Op hthalmol. Clin. North Am. 1992;5(1):23 - 30. 2 . Jenkins RH. Demographic geographic variations in the prevalence and management of exotropia. Am Orthop J 1992;42:82 – 87 3 . Scott WE, Keech R, Marsh AJ. The postoperative results and stabil ity of exodeviations. Arch Ophthalmol 1981;99:1814 – 1818. 4 . Hahm KH, Shin MC, Sohn MA. The change in deviation angle with time course after surgical correction of intermittent exotropia. J Korean Op hthalmol Soc 2002;42:2220 – 2226. 5 . Rabb EL, Par ks MM. Recession of the lateral recti. Early and late postoperative alignments. Arch Ophthalmol 1969;82:203 – 208. 6 . Gomez De Liano SP, Ortega, Moreno GRB and Merino SP: Consecutive exotropia surgery. Arch. Soc. Esp. Oftalmol. Jun 2001;76(6):371 - 378. 7 . Scott WE, Keech R and Mask AJ: Postoperative results and stability of exodeviations. Arch. Ophthalmol. 1981;99:1814 - 1819. 8 . Hidaji F, Nelson LB and Olitsky SE: Exodeviations of childhood. Ophthalmology Clinics of North America 1996;9:1 85 - 197. 9 . Patel AS, Simon JW and Lininger LL: Bilateral lateral rectus recession for consecutive exotropia. J.AAPOS. 2000;Oct, 4(5):29 1 - 294. 1 0 . Kushner BJ, Fisher MR, Lucchese NJ, Morton GV. Factors influencing response to strabismus surgery. Arch Ophthalmol 1993;111:75 – 79. 1 1 . Kushner BJ, Lucchese NJ, Morton GV. The influence of axial length on the response to strabismus surgery. Arch Ophthalmol 1989;107:1616 – 1618 . 1 2 . Graf M, Krzizok T, Kaufmann H. The influence of axial length on the effect of horizontal strabismus surgery. Binocular Vision 1993;8:233 – 240. 1 3 . McNeer KW. Observations on the surgical overcorrection of childhood intermittent exotropia. Am Orthop J 1987;37:135 – 150 Moussa A. Hussein and Ibrahim S. Ibrahim VOL 13 , NO 1 , JANUREY 2015 49 | Page ًقبخملاو عجحرملا ًشحىلا لىحلا Ø«�اح ةزجانم ايحارج هليىط هدمل هعباخملا لىح هم نىواعي Ø«�اح تخسو عجحرم ًشحو لىح هم نىواعي ضيرم هرشϋ يدحا ضيرم هرشϋ تعبس ًلϋ هساردلا جمح ايحارج مهج�ϋ محو ًقبخم ًشحو لىحلا ةدىϋ تبسو جواكو ارهش نورشϋو هعبرا هدمل Ø«�احلا عيمج تعباخم جمح 41 س�ا ًف ًسوا لىح دىجو نا دجوو ωىب رارقخسا ددحي مهم Ϟماϋ هيلمعلا دعب لو�ا تيلمϋ لىحلا