Comparative Efficacy of Medial Rectus Plication Versus Resection for Exotropia: A Systematic Review and Meta-Analysis

Medial rectus resection has long been regarded as the standard muscle-strengthening procedure for the surgical management of exotropia. More recently, medial rectus plication has emerged as a vessel-sparing alternative that preserves the anterior ciliary circulation and may offer additional surgical advantages. However, the comparative efficacy of these two procedures remains uncertain. This systematic review and meta-analysis was conducted to compare the short-term clinical outcomes of medial rectus plication and medial rectus resection in patients undergoing surgery for exotropia. The review protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) (#CRD420261326761). We performed a systematic search of electronic databases to identify randomized controlled trials directly comparing the two techniques. The primary outcomes were surgical success and postoperative change in deviation, while secondary outcomes included postoperative exodrift, operative time, surgical dose-response, and stereopsis. Six randomized controlled trials involving 352 patients were included, with 175 patients undergoing medial rectus plication and 177 patients undergoing medial rectus resection. No statistically significant difference was observed in surgical success (risk ratio: 0.86; 95% confidence interval: 0.66-1.14; p=0.22). Likewise, no significant difference was found in postoperative deviation change (mean difference 0.84 prism diopters, 95% confidence interval: -2.51 to 4.20; p=0.55). No statistically significant differences were observed between the two procedures with respect to postoperative exodrift, operative time, or stereopsis. Although a statistically significant difference was observed for surgical dose-response, its magnitude was small, and its clinical relevance remains uncertain. The certainty of evidence ranged from moderate to very low according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Overall, no statistically significant differences were identified between medial rectus plication and medial rectus resection across the evaluated short-term outcomes. Given its vessel-sparing nature and potential reversibility, medial rectus plication may represent a reasonable alternative to conventional medial rectus resection. Interpretation of these findings is limited by the small number of included trials, modest sample sizes, methodological limitations, and relatively short follow-up. Further large-scale, multicenter randomized controlled trials with longer follow-up are needed to confirm these findings and evaluate long-term surgical outcomes.