Surgical management of superior oblique palsy with coexisting exotropia

Purpose: To analyze the surgical results of patients treated for superior oblique palsy with coexisting exotropia.Methods: The medical records of patients with superior oblique palsy and exotropia who underwent inferior oblique weakening and simultaneous lateral rectus recession by a single surgeon from 1996 to 2022 were reviewed retrospectively. Demographics, pre- and postoperative vertical and horizontal deviation, and presence of diplopia were recorded. Surgical success was defined as horizontal deviation <10(Delta) and vertical deviation <= 4(Delta) without overcorrection or diplopia. The decision to operate for the horizontal deviation was made based on fusion in free space when the vertical deviation was offset with a prism.Results: A total of 27 patients were included. Mean age was 26.1 +/- 22 years (range, 26 months to 78 years). Preoperatively, mean vertical deviation was 15.2(Delta) +/- 7.5(Delta) (range, 4(Delta)-30(Delta)); mean exodeviation, 17(Delta) +/- 5.5(Delta) (range, 10(Delta)-35(Delta)). Of the 27 patients, 25 underwent unilateral and 2 underwent bilateral lateral rectus recession, according to the magnitude of the horizontal deviation. Mean follow-up was 3 +/- 3.8 months (range, 2 weeks to 17 months). Postoperative mean vertical alignment was 3.0 +/- 5.9, and horizontal alignment was 3.4(Delta) +/- 5.2(Delta) (esotropia of 7(Delta) to exotropia of 12(Delta); P < 0.0001). Nineteen patients (70%) had a successful result; 2 patients had residual exotropia of >10(Delta), 2 had vertical overcorrection (range, 3(Delta)-4(Delta)), and 6 had residual vertical deviation >= 4(Delta) (range, 5(Delta)-20(Delta)). None had secondary esotropia >10(Delta). Horizontal deviation was corrected successfully with no consecutive esotropia in 25 patients.Conclusions: In our study cohort, patients with superior oblique palsy and exotropia in whom fusion required both horizontal and vertical prism correction had a high likelihood of successful horizontal alignment after lateral rectus weakening in combination with inferior oblique surgery.