Outcomes of nasal vertical rectus belly transposition and lateral rectus recession for large exotropia after medial rectus transection.

Purpose

To evaluate the long-term outcomes of nasal vertical rectus belly transposition (VRBT) and lateral rectus recession for secondary large-angle exotropia following medial rectus transection, and to assess factors associated with postoperative exotropic drift.

Design

Retrospective interventional case series.

Methods

We reviewed patients who underwent nasal VRBT combined with lateral rectus recession for secondary exotropia due to medial rectus transection between 2018 and 2025. Main outcomes included the surgical results and its stability. Factors associated with postoperative exotropic drift were analyzed. ​Surgical success was defined as a postoperative deviation within 10 prism diopters (PD). Minimum follow-up was 6 months.

Results

Fourteen patients (mean age 40.2 years) were included (10 after endoscopic sinus surgery [ESS], 4 after orbital tumor resection [OTR]). Mean follow-up was 26.3 months. Mean lateral rectus recession was 10.9 mm. Preoperative exotropia was reduced from 70.7 ± 15.4 PD (range, 50 to 100 PD) to 9.8 ± 10.5 PD (range, 0 to 30 PD) at 1 month and 13.9 ± 13.1 PD (range, 0 to 40 PD) at final follow-up (both P<0.001), with a mean exotropic drift of 4.1 PD (range, -5 to 15 PD; P=0.016). Surgical success was 57%. The ESS group achieved greater correction (60.0 ± 16.8 vs 45.0 ± 5.0; P=0.031) and less clinically significant residual exotropia (10% vs 75%; P=0.041) than the OTR group. Exotropic drift was greater in the OTR group (-8.8 PD vs -2.3 PD; P=0.048). Diplopia in the primary position resolved in 79% of patients, and 50% regained stereopsis. No serious complications occurred.

Conclusions

Nasal VRBT with lateral rectus recession is a safe and effective procedure for large-angle exotropia secondary to medial rectus transection. Outcomes are more favorable following ESS than OTR.