Surgical management of intermittent exotropia with high AC/A ratio

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Abstract

Background: A subgroup of patients with intermittent exotropia have a high AC/A ratio, which places them at risk for esotropia at near after surgical treatment of their distance deviation. Methods: A retrospective review of six patients with intermittent exotropia and a high AC/A ratio who were simultaneously treated with lateral rectus recessions to fully correct their exotropia at distance and placement of posterior fixation sutures on both medial rectus muscles in hopes of preventing an esotropia at near after surgery. Results: Despite the persistence of a high postoperative AC/A ratio as assessed by the gradient method, five of six patients achieved stable postoperative alignment at distance and near without bifocals. One patient required postoperative bifocal correction for intermittent esotropia at near. Conclusion: In patients with intermittent exotropia and a high AC/A ratio, posterior fixation of the medial rectus muscles at the time of lateral rectus recessions enables the surgeon to fully correct the distance deviation and minimizes the risk of postoperative esotropia at near.

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    In fact, bilateral LRM recession has been reported to give better long-term outcomes than LRM recession with MRM resection with success rates close to 80% without any significant increase in overcorrection [18]. In case of high AC/A ratio, a faden procedure for MRM could be added to prevent postoperative overcorrection for near [19]. For the convergence insufficiency type, we performed a unilateral surgery of LRM recession with MRM plication, similar to the Kraft technique [20], which was more efficient than other procedures [21].

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    Rarely, intermittent exotropia can coexist with a high AC/A ratio, which does not change near deviation on the patch test, but after occlusion near deviation increases significantly when measured with +3.00 D lenses. This finding suggests that patients with a high AC/A ratio will be at high risk for postoperative esotropia at near fixation if the lateral rectus muscles are recessed adequately to correct the distance deviation, and subsequent bifocal treatment or further surgery may be necessary to correct consecutive esotropia at near.3,4 Brodsky and Fray4 have demonstrated successful correction in patients with divergence excess intermittent exotropia and a high AC/A ratio; posterior scleral fixation of the medial rectus muscle at the time of lateral rectus recession corrects the distance deviation and minimizes the risk of postoperative esotropia at near fixation.

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