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Updated: May 29, 2026
Surgical Correction for Pediatric Epiblepharon and Trichiasis
Published on: July 8, 2025
Initial postoperative alignment versus long-term outcomes in intermittent exotropia surgery
Eric R Crouch, Jonathan M Holmes1, Rui Wu2
1University of Arizona-Tucson, Tucson Arizona.
Insights
Immediate postoperative esodeviation greater than 7 prism diopters after childhood intermittent exotropia surgery is linked to fewer recurrences. However, this may slightly increase the risk of problematic esotropia.
Area of Science:
- Ophthalmology
- Pediatric Strabismus Surgery
- Clinical Trial Analysis
Background:
- Childhood intermittent exotropia (IXT) is a common strabismus condition requiring surgical intervention.
- Surgical outcomes for IXT are typically assessed by long-term recurrence rates and binocular vision status.
- The immediate postoperative alignment following IXT surgery may predict long-term success.
Purpose of the Study:
- To determine if immediate postoperative esodeviation after IXT surgery is associated with superior long-term outcomes.
- To analyze the relationship between the degree of 1-week postoperative esodeviation and motor recurrence or problematic esotropia at 8 years.
Main Methods:
- A post hoc analysis of a randomized clinical trial involving 185 children (3 to <11 years) undergoing surgery for IXT.
- Participants were randomized to bilateral lateral rectus recession (BLRc) or unilateral lateral rectus recession with medial rectus resection (R&R).
- One-week postoperative distance deviation was categorized into five levels, and long-term outcomes (motor recurrence, problematic esotropia) were assessed up to 8 years.
Main Results:
- A 1-week postoperative esodeviation >15 prism diopters was associated with a significantly lower cumulative probability of motor recurrence by 8 years (5% vs. 54-57% for exodeviation/orthophoria).
- Esodeviation between 8-15 prism diopters also showed a reduced recurrence rate (28%) compared to orthophoria (57%).
- The lowest composite failure rate (15%) was observed with a 1-week postoperative esodeviation >15 prism diopters, despite a slight increase in problematic esotropia (12%).
Conclusions:
- A 1-week postoperative esodeviation greater than 7 prism diopters is associated with a reduced rate of motor recurrence in childhood intermittent exotropia surgery.
- While beneficial for recurrence rates, higher degrees of immediate postoperative esodeviation may be linked to a small increase in problematic esotropia.
- These findings suggest that optimizing immediate postoperative alignment may be crucial for achieving favorable long-term outcomes in IXT surgery.
Purpose:
To investigate whether immediate postoperative esodeviation is associated with superior long-term outcomes following surgery for childhood intermittent exotropia (IXT).
Methods:
We performed a post hoc analysis of randomized clinical trial data, where 185 children 3 to <11 years of age underwent surgery for IXT with a 1-week visit and at least one of the 6-month to 8-year visits. Participants had been randomized to bilateral lateral rectus recession (BLRc) or unilateral lateral rectus recession with medial rectus resection (R&R). One-week postoperative distance deviation by prism and alternate cover test (PACT) was analyzed according to 5 levels.
Results:
For 1-week postoperative distance exodeviation (n = 32), orthophoria (n = 30), 1Δ-7Δ esodeviation (n = 37), 8Δ-15Δ esodeviation (n = 45), and >15Δ esodeviation (n = 41), the cumulative probability of motor recurrence by 8 years was 54%, 57%, 35%, 28%, and 5%, respectively. The cumulative probability of problematic esotropia was 3%, 3%, 0%, 9%, and 12%, respectively. Compared with orthophoria, cumulative probability of motor recurrence by 8 years was lower with 1-week alignment of >15Δ esodeviation (difference, -52%; 95% CI, -77% to -27%) and 8Δ-15Δ esodeviation (difference, -29%; 95% CI, -57% to -1%) but not for 1Δ-7Δ esodeviation or exodeviation. Overall composite failure (recurrence or problematic esotropia) was lowest with an esodeviation >15Δ at 1 week (15% vs 53%, 55%, 31%, 40%, resp.).
Conclusions:
Using current surgical doses, a 1-week alignment of >7Δ esodeviation is associated with a reduced rate of motor recurrence, albeit with a small increase in problematic esotropia.