Surgical management of superior oblique palsy with coexisting exotropia

To analyze the surgical results of patients treated for superior oblique palsy with coexisting exotropia.

The medical records of patients with superior oblique palsy and exotropia who underwent inferior oblique weakening and simultaneous lateral rectus recession by a single surgeon from 1996 to 2022 were reviewed retrospectively. Demographics, pre- and postoperative vertical and horizontal deviation, and presence of diplopia were recorded. Surgical success was defined as horizontal deviation <10^Δ and vertical deviation ≤4^Δ without overcorrection or diplopia. The decision to operate for the horizontal deviation was made based on fusion in free space when the vertical deviation was offset with a prism.

A total of 27 patients were included. Mean age was 26.1 ± 22 years (range, 26 months to 78 years). Preoperatively, mean vertical deviation was 15.2^Δ ± 7.5^Δ (range, 4^Δ-30^Δ); mean exodeviation, 17^Δ ± 5.5^Δ (range, 10^Δ-35^Δ). Of the 27 patients, 25 underwent unilateral and 2 underwent bilateral lateral rectus recession, according to the magnitude of the horizontal deviation. Mean follow-up was 3 ± 3.8 months (range, 2 weeks to 17 months). Postoperative mean vertical alignment was 3.0 ± 5.9, and horizontal alignment was 3.4^Δ ± 5.2^Δ (esotropia of 7^Δ to exotropia of 12^Δ; P < 0.0001). Nineteen patients (70%) had a successful result; 2 patients had residual exotropia of >10^Δ, 2 had vertical overcorrection (range, 3^Δ-4^Δ), and 6 had residual vertical deviation ≥4^Δ (range, 5^Δ-20^Δ). None had secondary esotropia >10^Δ. Horizontal deviation was corrected successfully with no consecutive esotropia in 25 patients.

In our study cohort, patients with superior oblique palsy and exotropia in whom fusion required both horizontal and vertical prism correction had a high likelihood of successful horizontal alignment after lateral rectus weakening in combination with inferior oblique surgery.