Intraoperative Findings in Consecutive Exotropia with and without Adduction Deficit

Purpose Consecutive exotropia may be associated with limited adduction, which has been reported to be caused by 1 or more anatomic abnormalities of rectus muscles or their insertions. We studied the relative frequency of grades of adduction deficit and the relative frequency of abnormal anatomic findings. Design Retrospective cohort study. Participants Patients undergoing surgery for consecutive exotropia. Methods Preoperative duction deficits were graded on a −5 (severe limitation) to 0 (normal) scale. Operative reports were reviewed to classify intraoperative factors: (1) medial rectus muscle attachment type (normal, abnormal [slipped or stretched scar], attached to pulley, behind pulley, or mixed [a tenuous normal attachment, but with muscle fibers also attached to the pulley or behind the pulley]), (2) medial rectus muscle distal fiber location (millimeters from original insertion), and (3) lateral rectus muscle tightness (normal, mild restriction, moderate restriction). Main Outcome Measures Relationship of grade of adduction deficit to each intraoperative factor. Results Of 143 eyes, 124 (87%) had an adduction deficit. Eyes with abnormal (n = 23), pulley (n = 9), behind pulley (n = 8), or mixed (n = 7) attachments had worse adduction deficits than normal attachments (n = 96; P < 0.02). There was a significant correlation between distal medial rectus muscle fiber location (0–19.5 mm recessed) and grade of adduction deficit (P < 0.0001). Eyes with mild or moderate lateral rectus muscle tightness on forced duction testing (n = 48/143 eyes) had worse adduction deficits than eyes without tightness (P < 0.001). Nevertheless, despite overall correlation, there was considerable individual variability. For example, for −1 and −2 adduction deficits, medial rectus muscle attachment could be at the pulley, behind the pulley, or include the pulley (19/87 eyes [22%]), and the lateral rectus muscle was tight in 36 of 87 eyes (41%). Conclusions Adduction deficits are common in patients with consecutive exotropia. Overall, more severe preoperative adduction deficits are associated with medial rectus muscle insertion abnormalities and abnormal forced ductions, but frequently there are exceptions. Severe medial rectus muscle insertion abnormalities, including lost muscles, may be found despite mild preoperative adduction deficits.