Exotropia Surgery (Strabismus or Eye Muscle Surgery): What to Expect

Exotropia surgery corrects an outward turning of the eyes. 

Generally, nonsurgical interventions are first attempted. If those are not successful, eye muscle surgery is performed to correct the issue. 

What Is Exotropia?

Exotropia is a condition in which the eyes turn outward instead of remaining aligned centered.

Exotropia is a form of strabismus, which is a condition in which the eyes do not line up with one another. This particular type of strabismus accounts for up to a quarter of all ocular misalignment in early childhood. 

In some cases, exotropia can resolve spontaneously and without treatment. In other cases, surgical intervention is necessary.

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Types of Exotropia

The following types of exotropia have been identified:

• Consecutive exotropia: A manifest exotropia that develops spontaneously or post-surgery when a patient has esotropia (a condition in which one or both eyes turn inward). This occurs in approximately 4 to 27 percent of patients who have received surgery for esotropia. 
• Exophoria: A condition of the eyes in which binocular vision is affected due to one eye drifting outward. People with this condition will have difficulty coordinating the function of both eyes. 
• Sensory exotropia: This involves a poorly seeing or blind eye drifting outward. This commonly occurs in infancy when an eye is blind or doesn’t see well. With children older than 2 to 4 years old and adults, the eye will become exotropic. 
• Convergence insufficiency: This is a condition of the eyes that impacts the manner in which the eyes function together. Convergence insufficiency may cause double vision or blurriness when examining objects at close distances. 
• Congenital exotropia or infantile exotropia: This is an outward turning of the eyes that occurs at birth or in early infancy. 
• Pseudoexotropia: This involves morphological characteristics in the face that give the appearance of exotropia, but these are not actually related to an outward turning of the eyes. 
• Intermittent exotropia: This is an occasional and undeliberate outward turning of one or both eyes. This is common in infancy but often resolves on its own.

Who Is a Candidate for Exotropia Surgery?

Surgery for this condition is most commonly indicated in the following instances: 

• Your exotropia is persistent (not of the intermittent variety).
• You are experiencing significant impairment of vision, such as double vision, blurriness, squinting, or strain. 
• You are losing binocular vision. 

In some (rare) cases, surgery may be recommended in cases of intermittent exotropia. This will depend on your specific case. 

Surgery is not generally recommended if symptoms are controllable via corrective lenses or noninvasive intervention. Surgery is generally considered a last resort after less invasive measures prove ineffective.

The Procedure

The surgical intervention that is implemented to correct the condition depends on the type of exotropia present. 

The procedure may include a bilateral muscle recession, unilateral lateral rectus recession with resection of the medial rectus, resection of each medial rectus muscle, or a single muscle surgery. The eye is never removed during surgery. 

A small incision is made on the membrane that covers the white part of one or both eyes. Via the incision, surgery is then performed on the eye surface to eliminate the issue causing exotropia. 

Recovery From Eye Muscle Surgery

Following surgical intervention for exotropia, you will most likely notice a pinkish tint to your eyes on the first day. Some reddish tears may also appear. This pinkish or reddish tint may be present for up to one week following surgery. 

You may also experience some mild pain and inflammation around the eye. This pain will most likely discontinue after a few days. 

Additionally, it is recommended that you follow these tips after surgery:

• Avoid irritants like shampoo from entering the eyes for two to four days after the procedure.
• Adhere to all medication guidance from your doctor, including the use of eye drops.
• Attend all follow-up appointments with your doctor. 
• Avoid swimming for at least one week after the procedure. 
• Apply ice packs if you experience any pain or inflammation. 
• Do not wear contact lenses for at least one week. 

Following these recommendations will promote a full recovery and reduce the risk of complications. 

Outcomes of Exotropia Surgery

The success rate of surgical intervention varies based on the type of exotropia. For example, one study showed that the final surgical success rate of pseudoexotropia was 70.2 percent, though general intermittent exotropia was associated with a 46.3 percent success rate. True exotropia had an even lower success rate at 28.6 percent. 

Reoperation for recurrent exotropia was performed in nearly a third of all general cases: 17 percent of cases involving pseudoexotropia and 35.7 percent of true exotropia cases. Patients with pseudoexotropia demonstrated a significantly lower recurrence than those with general and true exotropia as well. 

Since success is not guaranteed with surgery, it is important to consider alternative treatments if symptoms are not severe.

Alternative Treatments for Exotropia

For patients who are hesitant to receive surgical intervention, alternative treatments are available. One example is optometric vision therapy. Alternative approaches generally involve treatments that are specifically designed to augment vergence flexibility, fusional stability, and fusional ranges. 

Additionally, optometric vision therapy can increase convergence and accommodative relationships between the eyes as well as enhance near point of convergence. Eye exercises can be performed to improve control of the eyes.

Eye drops can provide some alleviation of symptoms of alternating exotropia. Eyeglasses can help to stimulate convergence. 

Additional alternative therapies include the following:

• Patch therapy: This involves covering one eye to bolster the strength and coordination of the other eye. 
• Prism therapy: This therapy uses prism lenses to facilitate augmentation of binocular vision. 
• Overcorrecting minus lens therapy: This involves the stimulation of accommodate convergence with additional minus power lenses. This is primarily used for intermittent exotropia.

Orthoptic sessions: These exercises are specifically tailored to improve functioning of the muscles within and surrounding the eyes. One example is pleoptics, which is designed to improve vision that is impaired when no organic eye diseases are detected.

References

1. Risk Factors Analysis of Consecutive Exotropia. (December 2016). Medicine.

2. Surgical Outcomes of Intermittent Exotropia According to Exotropia Type Based on Disease / Near Differences. (March 2019). PLOS ONE.

3. What Is Exotropia? (2022). University of Michigan Health.

4. Indications and Results of Exotropia Surgical Management. (May 2021). Journal of the Tunisian Society of Medical Sciences.