Consecutive Exotropia Lionel Kowal Elaine Wong

CONSECUTIVE XT Any XT happening after previous ET [usually after ET surgery] Rare: spontaneous consecutive XT

CONSECUTIVE XT - WHY? 1. The ET correction doesn’t ‘grow’ with the pt Ciancia: perfect early alignment after Cong ET surgery  30% consec XT after 25y Recession MR : mechanical disadvantage

CONSECUTIVE XT - WHY? 2. Early consec XT: Wrong surgical dose Poor surgical technique Poor early healing

CONSECUTIVE XT - WHY? 3. Later consec XT: ‘Stretched scar’ - look for stretchmarks, healing of other surgical scars, …. Irene Ludwig : Scar remodelling & Scar migration Scar remodeling after strabismus surgery - very under recognised Ludwig IH, Chow AY., J AAPOS. 2000 Ludwig IH Trans Am Ophthalmol Soc. 1999 Need to use non- absorbable sutures if recognised

Consecutive XT Results of consecutive XT in LK’s practice over last 2 years 91 cases of consecutive XT Average time to XT ~ 8 years 58 had XT surgery by LK 32 with follow up >1 yr Number of surgeries: 1-4 Median: 1 Avg. no. of surgeries: 1.3 No. of Botox for ET : 4 (10%) No. of Adjustables: 19 (45%)

Pre-op: Range 6 – 66 XT; Avg 31XT Post-op: Range 18ET – 45XT; Avg 0

Spontaneous consec XT 2 cases of spontaneous consec XT Case 1 accounts for 2% of all consecutive XT Case 1 10 yo girl with infantile ET Noted XT at ~ 2 yo Now XT 10Δ with V pattern Hypermetropia R +8.75 L +7.00 R amblyopia 6/12 No surgical Rx

Spontaneous XT Case 2 30 yo female Infantile ET ? When noted XT RXT of 35Δ No obliques OA Hypermetropia R +7.50, L +4.50 R Amblyopia 6/45 RMMRs 5.5mm, RLMRc 7.5mm Post op – RET 7Δ

Conclusions Spontaneous consecutive XT – rare! Consecutive XT a difficult surgical problem 69% with good surgical results