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  • Recession–Resection Is a Treatment Option for Pediatric Intermittent Exotropia

    Pediatric Ophth/Strabismus

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    Review of: Eight-year outcomes of bilateral lateral rectus recessions versus unilateral recession-resection in childhood basic-type intermittent exotropia

    Donahue S, Chandler D, Wu R, et al. Ophthalmology, January 2024

    Intermittent exotropia (IXT) treated with recession–resection (R&R) surgery had fewer reoperations over the long term compared with IXT treated with bilateral lateral rectus muscle recession (BLRc) surgery.

    Study Design

    This was an extension study of a 3-year randomized clinical trial comparing BLRc and R&R for correction of basic IXT in 197 children aged 3–11 years. The extension study enrolled 123 patients and continued for an additional 5 years. The primary end point was the number of participants with suboptimal surgical outcome after 8 years; a secondary end point was the 8-year cumulative proportion of reoperation.

    Outcomes

    At the 8-year follow-up point, 68% of patients in the BLRc group and 53% of patients in the R&R group were found to have suboptimal surgical outcome. The cumulative probability of reoperation was 30% with BLRc and 11% with R&R. No significant differences in self-reported exotropia-related quality of life or recent incidence of diplopia were found between the groups.

    Limitations

    Approximately 50% of children randomized to the initial study were followed to the 8-year end point. While this is not a high percentage, long-term follow-up in pediatric patients is challenging and this is the longest-term randomized IXT study discussed in the published literature. Randomization is also difficult in strabismus surgery, as different surgeons tend to prefer either bilateral or unilateral surgery for IXT and may deviate from usual practice when following the protocol. The strict success criteria also yielded suboptimal surgical outcome rates that appear elevated when compared with the typical experience of practicing strabismus surgeons.

    Clinical Significance

    The need for improved long-term results in IXT surgery is well known. Given the high number of IXT surgeries performed annually, even small improvements in long-term success rates would help a tremendous number of young people. While both BLRc and R&R are reasonable and effective options for treating IXT, surgeons who primarily perform BLRcs can choose to switch to R&R as a primary procedure for this common problem.

    Financial Disclosures: Dr. Jagger Koerner discloses no financial relationships.