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To evaluate the clinical safety and efficacy of the novel Wright hang-back recession with fibrin glue for the treatment of horizontal strabismus.Retrospective, case-controlled clinical study comparing surgical outcomes of the Wright hang-back rectus recession with fibrin glue (WHBG) versus standard fixed suture rectus recession (SFR).Medical records of all patients who underwent strabismus surgery by one strabismus surgeon between 2016 and 2018 for horizontal deviations only, including cases of WHBG (group 1) or SFR (group 2), were reviewed. Good surgical outcome was defined as a postoperative deviation ≤10 prism diopters (PD) at a minimum 2 months of follow-up.32 eyes of 17 patients underwent WHBG and 32 eyes of 17 patients underwent SFR; in each group, 35% had esotropia and 65% had exotropia. Mean preoperative deviations between groups were similar: esotropia 25.5 PD and exotropia 26.6 PD in WHBG; esotropia 28.3 PD and exotropia 23.8 PD in SFR. The mean postoperative deviation was7 PD for both groups. Good surgical outcomes were similar between groups, 16/17 (94%) in WHBG and 15/17 (88%) in SFR, with no complications.WHBG was safe and effective with postoperative results similar to SFR. WHBG has an important advantage, eliminating the complication of retinal perforation that can occur with SFR while avoiding under- or overcorrection that can occur with traditional hang-back recession. This technique increases patient safety without sacrificing surgical outcomes and is especially useful in patients with thin sclera such as patients with high myopia or with difficult posterior exposure.

Standard rectus muscle recessions require suturing muscle to sclera posterior to the insertion, which is dangerous as the sclera is thin. Extraocular muscle hang-back recession can avoid the posterior scleral needle pass but has been reported to be unstable. The purpose of this study is to assess the use of N-butyl-2-cyanoacrylate to aid reattachment of rectus muscle to sclera during hang-back recession.2 Phase Study: Phase 1 was a wet lab animal study; Phase 2 was a small case series.Phase 1, 14 frozen bank rabbit heads; Phase 2, 4 human adult patients with myopia and large exotropia.Phase 1: Frozen bank rabbit heads were used to simulate human hang-back rectus muscle recession. Fourteen rectus muscles were recessed by hang-back and glued to sclera with either cyanoacrylate glue alone (group 1) or glue over prolene mesh for greater stability (group 2). Primary outcome was muscle detachment force measured at 20, 30, and 40 seconds. Phase 2: Four patients with myopia and large exotropia who underwent bilateral hang-back lateral rectus recessions with cyanoacrylate glue were retrospectively studied.Phase 1: Group 1 mean detachment force measured at 30 seconds was 172.07 g versus 376.5 g in group 2 (p0.01). Phase 2: All patients had excellent postoperative alignment within 5 PD of orthophoria and no overcorrections. Two patients had unilateral glue extrusion at 1 month requiring in-office removal under topical anaesthesia.Cyanoacrylate glue with or without mesh resulted in adequate muscle-to-sclera adhesion with a detachment force at least 2 times the force of a normal rectus muscle contraction. Patients undergoing hang-back lateral rectus recession with cyanoacrylate glue had excellent stable postoperative alignment; however, half had the complication of late extrusion of glue foreign body.

Retinopathy of prematurity (ROP) is a vasoproliferative disease occurring in premature infants that affects the blood vessels of the developing retina. ROP results in the development of vascular shunts, neovascularization, and in its most severe form tractional retinal detachment. The development of retinal vascular shunts and neovascularization in ROP is related to local ischemia in the immature and incompletely vascularized retina. Understanding the pathophysiology of ROP helps physicians both in the prevention and treatment of ROP and will be discussed in this review article. The role of oxygen in the pathophysiology of ROP will be reviewed with recent studies discussed.

The fourth edition provides primary care physicians with must-know information on eye examinations, eye disorders, vision screening, strabismus, dyslexia, ocular trauma, genetic syndromes, and all pediatric-specific eye issues likely to be encountered in primary care. Available for purchase at https://shop.aap.org/pediatric-ophthalmology-for-primary-care-paperback/

Follicular lymphoma (FL) is the most common type of B cell non-Hodgkin lymphoma in Western counties. FL is usually seen in adults and is very uncommon in pediatric population. Pediatric follicular lymphoma (PFL) is a rare indolent lymphoma characteristically seen in pediatric population, usually involving cervical lymph nodes, Waldeyer ring, and testis. They pose significant diagnostic challenges due to morphologic overlap with much more common florid follicular hyperplasia and lack of typical t(14;18)IgH/BCL2 fusion and BCL-2 protein expression. We present the case of a 10-year-old male with bilateral conjunctival nodules, showing characteristic morphologic and immunophenotypic features of PFL with demonstrated clonal B cell immunoglobulin heavy chain gene rearrangement. Of note, the neoplastic cells expressed MUM1, MYC, and IgM, suggestive of a different disease pathogenesis from adult FL.

Purpose Wright central plication is a minimally invasive tightening procedure described for the first time by Wright and colleagues in 2012. We compare outcomes of lateral rectus central plication (LRCP) to medial rectus recession (MRR) in the treatment of adult divergence insufficiency esotropia (ADIE). Methods A retrospective chart review of 30 consecutive patients with ADIE, who underwent either LRCP or MRR between 2010 and 2015 was performed. Inclusion criteria: age ≥45 years, LRCP or MRR surgery fixed suture technique, esotropia (ET) at least 10Δ greater at distance than at near, subjective diplopia at distance, fusion at near fixation, follow-up of at least 6 months. Primary outcome was postoperative single binocular vision. Secondary outcome was postoperative deviation of Results A total of 28 patients (15 females) met inclusion criteria: 15 had LRCP and 13 MRR. Primary outcome of no diplopia was not significantly different between LRCP and MRR group having a success rate of 93.3% versus 92.3%, respectively (P ≤ 0.01). Secondary outcome of a deviation of ≤5Δ at distance was better in the LRCP group than the MRR group (15/15 vs 11/13 [P ≥ 0.01]). One patient in LRCP group had an early overcorrection corrected by in-office suture lysis. Conclusions Both procedures had excellent primary outcomes eliminating diplopia in over 90% of cases. The LRCP group had statistically better postoperative alignment of

Purpose To demonstrate the validity of a new 3D-printed silicone model for practicing strabismus surgery, compared with the rabbit head, in terms of simulator fidelity. Methods In this multicenter study, a validated questionnaire was developed to assess fidelity of the model and rabbit head. Participants were asked to rate overall globe, conjunctiva, muscle, and scleral fidelity using a 5-point scale. The survey instrument was disseminated at three strabismus instruction courses: at two meetings, participants practiced on the model and rabbit head prior to completing the questionnaire; at the third, instructors demonstrated advanced surgical skills using only the model and then completed the questionnaire. Repeated measures analysis of variance compared ratings. Pearson's or Spearman's correlation evaluated correlation between years of experience to participants' responses. Qualitative data were coded into themes. Results A total of 47 participants completed the questionnaire. The model rated 18% higher than rabbit head for anatomical accuracy (mean difference, 0.667; P = 0.001) and 25% higher for position of eyes within the head (mean difference, 0.867; P = 0.006). More experienced participants were more likely to strongly agree that the silicone conjunctiva effectively mimics real conjunctiva (ρ = 0.337; P = 0.036) and that scleral tissue effectively mimics real sclera (ρ = 0.298, P = 0.042). Qualitative data supported the model. Conclusions This study demonstrated the validity of the surgical model in terms of fidelity compared to the rabbit head.

Adenoid cystic carcinoma (ACC) of the lacrimal gland is the most common primary malignant tumor of the lacrimal gland. It typically affects patients in the fifth decade of life and presents with rapid progression of pain, ptosis, motility disturbances, and sensory deficits of less than 1 year's duration. ACC is rare in children. Due to early, aggressive perineural and bony spread, there is a high risk of intracranial extension. Additionally, due to frequent hematogenous and lymphatic spread, there is a high rate of distant metastases even after treatment, which can occur late up to a decade or more. The currently accepted treatment for ACC is radical exenteration with orbitotomy and adjuvant chemotherapy and/or radiation therapy. Recently, intra-arterial cytoreductive chemotherapy (IACC) has been investigated as a neoadjuvant treatment modality. It has the advantage of increasing local concentration at the target tissue and decreasing systemic distribution. We report the first known pediatric case of ACC treated with IACC, followed by exenteration, radiation, and adjuvant intravenous chemotherapy. The patient was followed for 4 years, with no recurrence and no known complications.

A c.57 C > T mutation in the seed region of MIR184 located at the 15q25.1 chromosomal region has been independently associated with autosomal dominant keratoconus with early-onset anterior polar cataract in the Northern Irish family and with autosomal dominant EDICT (Endothelial Dystrophy, Iris hypoplasia, Congenital cataracts, and stromal Thinning) syndrome. In this study we report a five-generation family originating in Galicia, Spain with early onset cataracts and variable corneal abnormalities which include non-ectatic corneal thinning and severe early-onset keratoconus. We identified a heterozygous c.57 C > T mutation in miR-184 in the proband and two additional affected relatives on the maternal side. This finding represents a third independent occurrence of this mutation in familiar ocular disease thus strengthening the link between miR-184 abnormalities and inherited eye defects.

Background Mini-plication is a new rectus muscle tightening procedure for the correction of small-angle strabismus that can be performed under topical anesthesia. The purpose of this study was to report the outcomes of mini-rectus muscle plication. Methods We retrospectively reviewed the medical records of patients who underwent mini-plication. In this procedure, 6-0 polyglactin 910 suture was secured to the central 3 to 4 mm of the muscle belly 5 mm posterior to the insertion and was then passed through the sclera just anterior to the muscle insertion to plicate the central portion of the muscle. This differs from the standard procedure, in which the entire width of the muscle is plicated. Two groups were analyzed: those who underwent mini-plication alone and those who underwent mini-plication after prior antagonist muscle–weakening surgery. Results Our review identified nine patients aged 5 to 78 years. Topical anesthesia was used for all adults, who experienced no local or systemic complications. Mini-plication reduced vertical and horizontal deviations an average (± SD) of 6.7 Δ ± 3.5 Δ . The mini-plication–only group (3 patients) had an average postoperative correction of 5.5 Δ ± 2.6 Δ ; the prior surgery group (6 patients), an average of 9 Δ ± 2.7 Δ . Diplopia was noted in 50% of the adults preoperatively and none postoperatively. All patients experienced a decrease in strabismus, with an average outcome of Δ of postoperative deviation. Conclusions Mini-plication, which can be performed under topical anesthesia, corrected small deviations and was especially useful for adult strabismus patients with diplopia.

The clinical features of superior oblique paresis vary widely depending on the type. Common features include an ipsilateral hypertropia that increases on contralateral gaze, and a positive head tilt test with the hypertropia increasing on head tilt to the side of the hypertropia. Congenital superior oblique paresis is commonly associated with ipsilateral inferior oblique overaction and relatively less superior oblique underaction. Acquired superior oblique paresis, on the other hand, has relatively normal versions and minimal inferior oblique overaction, but significant extorsional diplopia. The head tilt test can help to differentiate primary inferior oblique overaction from inferior oblique overaction secondary to superior oblique paresis. A positive head tilt test indicates a superior oblique paresis, and a negative head tilt test suggests primary inferior oblique overaction.

Minimally invasive strabismus surgery provides a valuable option for our strabismus patients with small deviations, and offers an additional or alternative treatment option to the use of prism glasses. The techniques described below can be performed in the office under topical anesthesia, are less invasive than standard strabismus muscle surgeries, and preserve the integrity of the muscle insertion, presumably sparing the anterior ciliary vessels.

The superior oblique tendon can be functionally divided into the anterior one third, which is responsible for intorsion, and the posterior two thirds, which is responsible for depression and abduction (Fig. 18.1). Superior oblique tightening procedures are based on this physiologic division and either tighten the whole tendon (i.e., full tendon tuck) or tighten the anterior tendon fibers (i.e., the Harada-Ito procedure).

Prior to strabismus surgery, an important and seemingly obvious question should be asked: “Why are we operating?” Is our treatment goal to establish binocular fusion, eliminate diplopia, expand the field of binocular vision, correct a compensatory head posture, or simply to improve cosmetic appearance? Establishing the goals prior to surgery helps us clarify indications for surgery, and formulate a logical treatment plan. The plan that is made should be the one that is best for the patient—not just the plan that is best for correcting the angle of deviation.

The faden operation, also termed posterior fixation suture, is used to weaken the rotational force of a rectus muscle when the eye rotates towards the faden muscle. Faden is the German word for suture, so it is inappropriate to call the procedure “faden suture” (i.e., suture-suture).

Transposition surgery is based on changing the location of the muscle insertion so the muscle pulls the eye in a different direction (i.e., changes the vector of forces). Transposition surgeries can be used to treat a rectus muscle paresis, a lost muscle, A and V patterns ( Chap. 15), small vertical tropias ( Chap. 15), and torsion ( Chap. 15). Three transposition procedures are described in this chapter: Knapp, Jensen, and Hummelsheim.

The two most useful rectus muscle tightening procedures are the rectus muscle resection and the rectus muscle plication. Rectus muscle tucking has not proven reliable, as it tends to loosen over time. A tuck is a muscle-to-muscle union. Because the muscle fibers are longitudinal and the transverse fibers are weak, the sutures tend to pull out and slip. The rectus muscle plication, however, involves securing posterior muscle to sclera, and this procedure is as stable as a resection.

Superior oblique tendon weakening procedures are used in the management of various types of strabismus, including superior oblique overaction, inferior oblique palsy, and Brown’s syndrome (see Chap. 7). Most procedures weaken the superior oblique muscle by slackening the tendon. Uncontrolled procedures include tenotomy and tenectomy, in which the tendon is cut and the cut ends are free to widely separate or scar back together. These uncontrolled procedures should not be used in patients with binocular fusion, as the incidence of consecutive superior oblique palsy is more than 50 %.

Historically, inferior oblique surgery was considered extremely difficult and was fraught with complications such as fat adherence, ciliary nerve damage with pupillary dilatation, and intraoperative hemorrhage. More recently, however, the management of inferior oblique overaction has improved substantially. The late Dr. Marshall Parks pioneered meticulous techniques that all but eliminated these complications. Another important advance has been the anteriorization procedure.

This chapter gives a detailed description of the rectus muscle recession procedure. Two conjunctival approaches are presented: fornix and limbal.

Torticollis comes from the Latin word torti, meaning twisted, and collis, meaning neck. Simply speaking, we can consider two types of torticollis: musculoskeletal and ocular. Musculoskeletal torticollis is caused by tight neck muscles (usually the sternocleidomastoid) or a skeletal deformity. With musculoskeletal torticollis, the neck will resist passive flexion with the eyes open or closed, and these patients maintain their head posturing even during sleep. In contrast, ocular torticollis is a compensatory mechanism to achieve optimal vision in patients with nystagmus or incomitant strabismus. A face turn or head tilt is adopted to place the eyes in a position that either reduces nystagmus or improves eye alignment. Ocular torticollis may be horizontal (face turn), vertical (chin up or down), torsional (head tilt right or left), or a combination of the three. The best way to identify the presence of a face turn or chin posturing is by looking at the position of the eyes. A gaze preference indicates a face turn. For example, does the patient in Fig. 6.1 have a face turn?

Vertical transposition of horizontal muscle insertions is an effective means of collapsing an A or V pattern (Fig. 15.1), but only if there is no significant oblique overaction. If oblique overaction is present, appropriate oblique muscle surgery should be performed.

Topical anesthesia strabismus surgery reduces the systemic risk associated with general anesthesia, as well as the postoperative nausea and vomiting. It also eliminates the risk of globe perforation, optic nerve damage, and myotoxicity that is associated with retrobulbar injection. Topical anesthesia can be especially useful in senior citizens who have medical issues that make general anesthesia dangerous.

Adequate surgical exposure is the key to any operation. Good exposure starts with proper positioning of the patient. The top of the head should be positioned at the very end of the surgical table, placing the neck in an extended position so the chin is higher than the forehead (Fig. 10.1). Extending the neck lowers the superior orbital rim and eyebrow, improving exposure of the eye.

Objective. A wide variability in the inci- dence of severe retinopathy of prematurity (ROP) is re- ported by different centers. The altered regulation of vascular endothelial growth factor from repeated epi- sodes of hyperoxia and hypoxia is 1 important factor in the pathogenesis of ROP. Strict management of O2 de- livery and monitoring to minimize these episodes may be associated with decreased rates of ROP. The objective of this study was to compare the incidence of and need for surgery for severe ROP (stages >3) in infants of 500 to 1500 g birth weight before and after the implementation of a new clinical practice of O2 management in a large level 3 neonatal intensive care unit (NICU). Methods. An oxygen management policy that in- cluded strict guidelines in the practices of increasing and weaning of fraction of inspired oxygen (FIO2) and the monitoring of O2 saturation parameters in the delivery room, during in-house transport of infants to the NICU, and throughout hospitalization was implemented in April 1998. The main objectives were to monitor oxygen- ation levels more precisely and to avoid hyperoxia and repeated episodes of hypoxia-hyperoxia in very low birth weight infants. Included in the policy were equipment for monitoring, initiation of monitoring at birth, avoid- ance of repeated increases and decreases of the FIO2, minimization of "titration" of FIO2, modification of pre- viously used alarm limits, and others. After an educa- tional process, each staff member signed an agreement stating understanding of and future compliance with the guidelines. Examinations were performed by experi- enced ophthalmologists following international classifi- cation and American Academy of Pediatrics recommen- dations. ROP data from January 1997 to December 2002 for infants of 500 to 1500 g were analyzed as usual and also have been reported to Vermont Oxford Network since 1998. Results. The incidence of ROP 3 to 4 at this center decreased consistently in a 5-year period from 12.5% in 1997 to 2.5% in 2001. The need for ROP laser treatment decreased from 4.5% in 1997 to 0% in the last 3 years. Conclusion. We observed a significant decrease in the rate of severe ROP in very low birth weight infants in association with an educational program provided to all NICU staff and the implementation and enforcement of clinical practices of O2 management and monitoring. Al- though several confounders cannot be excluded, it is likely that differences in these clinical practices may be, at least in part, responsible for the documented inter- center variability in rates of ROP. Pediatrics 2003;111: 339 -345; retinopathy of prematurity, oxygen, pulse oxim- etry, very low birth weight.

Purpose: To determine the prognostic implication of compensatory head posturing in patients with unilateral or asymmetric congenital ptosis. Methods: A retrospective review of 80 consecutive patients with unilateral or asymmetric congenital ptosis was performed. The presence of documented compensatory head posturing, age of onset, age of presentation, visual acuity, refraction, and amblyopia were recorded, and binocularity was tested. Results: Five of seven (71%), patients with unilateral or asymmetric congenital ptosis and compensatory head posturing had amblyopia. All of these patients had straight eyes and four of the five amblyopic patients had anisometropia of less than 2 diopters (D). Conclusion: The high incidence of amblyopia in this group can occur in the absence of significant anisometropia and strabismus. This unusually high incidence of amblyopia in this subgroup of patients with unilateral or asymmetric congenital ptosis and compensatory head posturing warrants compulsive examination and prophylactic part-time occlusion therapy of the nonptotic eye until reliable vision testing can be performed. Journal of Pediatric Ophthalmology & Strabismus 1999; 36:74-77.

Purpose: The present study addresses the natural history ocular alignment in infantile esotropia that presents at 2 to 4 months of age. Methods: Eye alignment during the first 6 months of life was evaluated in two cohorts of healthy infants who initially had esotropia at 2 to 4 months of age; 80 infants were enrolled in a prospective study at the Retina Foundation of the Southwest (RFSW), and 41 infants were reviewed retrospectively as a pilot study for the Early Surgery for Congenital Esotropia (ESCET) multicenter trial. In addition, 79 of the 80 children in the RFSW cohort were reexamined at 4.5 years of age or older for ocular alignment and stereopsis. Results: Among infants who initially had constant esotropia ≥40 PD, 0 of 45 children in the RFSW cohort and 0 of 21 children in the ESCET cohort showed resolution to orthophoria. In addition, only 2 infants showed a reduction in angle of deviation below 40 PD (one to 35 PD and one to 20 PD). Resolution to orthophoria was noted in a few infants who initially had small angle or variable angle esotropia. On follow-up at 4.5 years of age or greater, 91% of the children in the RFSW cohort had alignment within 8 PD of orthoposition and 30% had stereoacuity of 3000″ to 60″. Children who underwent surgical alignment at 6 months of age had a higher prevalence of coarse stereopsis than children who underwent alignment at 7 to 15 months of age. Conclusions: Taken together, these results suggest that infants who present at 2 to 4 months of age with constant esotropia of 40 PD or greater are valid candidates for surgical treatment. In addition, data from long-term follow-up support the hypothesis that early surgical alignment may promote the development of at least coarse stereopsis in these infants.

In the past three decades there has been a gradual move toward performing congenital esotropia surgery at earlier ages. The best time to perform surgery is still not established. Surgery as early as four months of age may provide improved results and this will be tested in an NIH funded prospective study.

We report the ocular findings in a 2.5-year-old girl with a history of congenital erosive and vesicular dermatosis at birth. We highlight the complexity of the associated nasolacrimal duct obstruction with canalicular scarring and review the ocular manifestations of this rare disease.

Objective: Children with congenital esotropia, amblyopia, or early visual deprivation have persistent asymmetric monocular pursuit, as measured by optokinetic nystagmus (OKN), and favor targets moving in a temporal to nasal direction. Previous studies suggest that binocular visual development is necessary for the development of symmetric monocular OKN. We recently treated patients with congenital esotropia with unconventionally early surgery to establish good binocularity. We wished to determine if mature symmetric OKN responses could develop in patients with congenital esotropia following the acquisition of good stereopsis. Methods: Electro-oculographic recordings documented horizontal eye movements in response to an electronic OKN stimulus. Patients: The recordings of three patients with congenital esotropia that had been surgically aligned before age 20 weeks and who had achieved high-grade stereopsis with random dot and Titmus stereographic testing were studied. We compared this group of children with groups of age-matched controls, including the following: (1) three patients with congenital esotropia who underwent surgical alignment after age 6 months and who had no amblyopia but poor stereopsis; (2) three children with accommodative esotropia, good ocular alignment when wearing spectacles, and good stereopsis; and (3) three normal children. Results: The normal children and those with accommodative esotropia demonstrated normal symmetrical OKN. The patients with congenital esotropia showed poor nasal to temporal OKN regardless of the degree of stereopsis or timing of surgery. Conclusions: Our results indicate that good binocularity, as measured by stereopsis, is not sufficient for the development of symmetric OKN in patients with congenital esotropia.

Strabismus after retina surgery and glaucoma surgery involving drainage explants is associated with secondary strabismus. The most frequent causes of strabismus after retina surgery include scarrin...

Patients with unilateral congenital ptosis often adopt chin elevation to maintain fusion. This compensatory head posturing has been considered a sign of fusion, thus indicating a low risk for amblyopia. To evaluate this sign, we reviewed the charts of 11 preverbal children with unilateral congenital ptosis who had straight eyes and appropriate compensatory head posturing to maintain binocular vision. Four additional patients with unilateral ptosis and no compensatory head posturing were tested for comparison. All patients had undergone an examination and had been tested by pattern Visual Evoked Potential (VEP) under chloral hydrate sedation. Five of the 11 patients with compensatory head posturing were found to be amblyopic, three moderately so and two severely affected. The four patients without compensatory head posturing were amblyopic. It is our hypothesis that compensatory head posturing allows peripheral fusion even when significant amblyopia is present. Additionally, the clinical sign of a compensatory head turn to maintain binocular vision does not rule out the presence of significant amblyopia.

Historically, surgical formulas for the management of accommodative esotropia have been based on the residual deviation with full hypermetropic correction. This "standard surgery" has resulted in a high incidence of undercorrection. In response to the large number of undercorrections with standard surgery, the authors have devised a formula for augmenting the amount of rectus recession based on the average of the near deviation with and without correction. In this study, we compare augmented surgery to standard surgery in patients who underwent bilateral medial rectus recessions for residual esotropia after prescribing full hypermetropic spectacle correction. Seventy patients with acquired esotropia after 6 months of age, and hypermetropia of +3.00 or more, were retrospectively studied. Thirty of these patients had undergone standard surgery, while 40 had augmented surgery. The follow up on each group was at least 1 year. Of the 30 patients in the nonaugmented group, 22 (74%) had postoperative deviations of 10 prism diopters or less with 8 (26%) showing a significant undercorrection. Of the 40 patients who received augmented surgery, 35 (88%) had postoperative deviations of 10 δ or less and 5 (12%) were exotropic while wearing full hypermetropic correction. Of the 5 patients with a consecutive exodeviation while wearing full hypermetropic correction, 2 corrected to orthotropia by reducing the spectacle correction by +1.50 diopters and +1.25 D (93% success), 2 were converted to orthotropia by removing +3.00 spectacle correction (97% success), and 1 continued to have an intermittent exodeviation even after removing spectacle correction. This brought the overall success rate for augmented surgery to 98%. Fusion results, as measured by Worth Four Dot (W4D) or Titmus Stereo Acuity, showed 10 of the 30 patients with standard surgery (33%) achieved at least peripheral fusion, whereas 26 of 40 (65%) in the augmented group had postoperative fusion. Our conclusion is that augmented surgery provides better postoperative alignment and fusion than standard surgery. We recommend surgical recessions based on the average of the near deviation with correction and near deviation without correction.