Major Article
Surgical management of clinically significant hypertropia associated with exotropia

Presented at the 35th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus, April 17-21, 2009, San Francisco, California.
https://doi.org/10.1016/j.jaapos.2010.01.016Get rights and content

Purpose

To report the surgical treatment of hypertropia coexisting with exotropia, with either vertical offset surgery or additional vertical muscle surgery simultaneous to correction of the exotropia.

Methods

A total of 35 patients with exotropia and hypertropia who underwent a horizontal muscle surgery for exotropia were included. To determine efficacy in resolving a vertical deviation in patients with exotropia, 28 patients were compared in 2 groups: those who underwent horizontal muscle surgery with vertical offset and those who underwent horizontal muscle surgery with additional vertical muscle surgery. An additional 7 patients who had exotropia and hypertropia but did not undergo vertically corrective surgery were included for comparison.

Results

Vertical offset of horizontal rectus muscles (4 mm) resulted in 8Δ correction of the distance hypertropia. Vertical rectus muscle recession used in the treatment of larger hypertropic deviations with exotropia had a 3Δ correction per 1 mm of recession. Success rates for hypertropia correction were similar between groups, 63% vertical offset and 71% vertical muscle groups; overcorrections occurred in 29% of the vertical muscle group. The vertical correction in both groups was stable in 88% over 6 months postoperatively.

Conclusions

Vertical offset of the horizontal muscles simultaneous with exotropia correction has a beneficial effect in small-angle hypertropia (<14Δ). Vertical rectus muscle surgery in patients with hypertropia greater than 10Δ had equivalent success; however, in intermittent exotropia the hypertropia was prone to overcorrection.

Section snippets

Methods

A retrospective case cohort series was conducted of 35 patients obtained from the patient registry at the University of Wisconsin–Madison. Patients were included in the study if they were diagnosed with exotropia (including intermittent exotropia) and a hypertropia and underwent a vertical offset of the horizontal muscles or horizontal surgery in combination with vertical rectus muscle surgery. Seven of these patients were diagnosed with exotropia and hypertropia but did not undergo vertical

Results

Charts of 35 patients were available for analysis, and 6-month postoperative data were available in 29 patients (83%) and, in the remaining 6 patients, the 5-week postoperative data were used. Patient age ranged from 1 to 84 years.

Of the 35 patients with exotropia, 10 patients carried the diagnosis of intermittent exotropia, 2 of these 10 had convergence insufficiency type, 18 patients had consecutive exotropia, 4 patients had constant exotropia, 2 had congenital exotropia, and 1 had cerebral

Discussion

The treatment of a constant small-angle vertical tropia associated with exotropia and unrelated to oblique dysfunction, paretic muscle, or DVD has been enigmatic. Pratt-Johnson and Tillson10 have stated that there is no advantage in eliminating a vertical component of 5Δ or less. Moore and Stockbridge's study11 described the coincidental finding of spontaneous resolution of the vertical tropia during prism adaptation for the horizontal deviation alone in intermittent exotropes. The potential

Literature Search

The National Library of Medicine's database was searched through PubMed and MEDLINE for all years with the search terms: vertical transposition of horizontal recti; vertical offset of horizontal recti, exotropia AND vertical; exotropia (all) AND hypertropia (title and abstract). Additionally the core clinical journals for human literature were searched for exotropia AND hypertropia AND NOT superior oblique palsy. Additional sources included the identical search terms in the database of the

References (11)

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Cited by (14)

  • Resolution of hypertropia with correction of consecutive horizontal deviation

    2017, Journal of the Chinese Medical Association
    Citation Excerpt :

    Only if hypertropia does not resolve should vertical alignment be undertaken. Our study confirms that horizontal muscle surgery alone can lead to resolution of hypertropia in association with consecutive horizontal strabismus.9 MRI was not used in this study, but may be helpful in future studies to find a probable mechanism for our findings.

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