Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts.
Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.
JAMA Ophthalmol. 2024 Jan 1;142(1):48-52. doi: 10.1001/jamaophthalmol.2023.5288.
IMPORTANCE: There is no consensus on the optimal surgical treatment for children with intermittent exotropia (IXT). OBJECTIVE: To compare the 5-year reoperation rates for children with IXT treated with horizontal muscle strabismus surgery using bilateral lateral rectus recession (BLR) vs unilateral lateral rectus recession with medial rectus resection (RR). DESIGN, SETTING, AND PARTICIPANTS: This cohort study examined data obtained from the Intelligent Research in Sight (IRIS) Registry on 7482 children (age, <18 years) with IXT who underwent horizontal eye muscle strabismus surgery between January 1, 2013, and December 31, 2017. Children undergoing initial surgeries involving 3 or more horizontal muscles, vertical muscles, or reoperations were excluded. MAIN OUTCOMES AND MEASURES: The primary outcome was the adjusted cumulative incidence of repeat horizontal muscle surgery within 5 years after the initial surgery. Reoperation risk was analyzed using adjusted hazard ratios (AHRs) derived from multivariable Cox regression models, adjusting for individual demographic and surgical factors (age, sex, race and ethnicity, US Census region, and surgeon subspecialty). Data were analyzed between January 16 and September 20, 2023. RESULTS: The study included 7482 children (median [IQR] age at initial surgery, 6 [4-9] years; 3945 females [53%]) with IXT treated with horizontal muscle strabismus surgery. Bilateral lateral rectus recession was performed more frequently than RR (85.3% vs 14.7%, P < .001), especially in younger children (rates of BLR vs RR by age: age 0 to ≤4 years, 88.4% vs 11.6%; age 5 to ≤11 years, 84.7% vs 15.3%; age 12 to ≤17 years, 78.1% vs 21.9%; P < 0.001). After data adjustment, the 5-year cumulative incidence of reoperation was 21.3% (95% CI, 20.1%-22.5%). The adjusted 5-year cumulative incidence of reoperation was higher for BLR than for RR (22.2% vs 17.2%; difference, 4.9%; 95% CI, 1.9%-8.0%). Unilateral lateral rectus recession with medial rectus resection was associated with a lower 5-year reoperation risk compared with BLR (AHR, 0.77; 95% CI, 0.64-0.93). Younger age at time of initial surgery was associated with a higher reoperation risk (AHR per 1-year decrease, 1.09; 95% CI, 1.07-1.11) after adjusting for all other covariates. CONCLUSIONS AND RELEVANCE: In this nationwide registry, approximately 1 in 5 children with IXT underwent reoperation within 5 years after the initial surgery. Children treated with RR were less likely to require a reoperation within 5 years compared with those treated with BLR. Further efforts to identify modifiable risk factors for reoperation are needed to reduce the surgical burden and improve outcomes for children with IXT.
重要性：间歇性外斜视 (IXT) 患儿的最佳手术治疗方法尚无共识。
目的：比较双侧外直肌后退术 (BLR) 与单侧外直肌后退联合内直肌切除术 (RR) 治疗间歇性外斜视患儿的 5 年再手术率。
设计、设置和参与者：本队列研究对 2013 年 1 月 1 日至 2017 年 12 月 31 日期间在智能眼视光研究 (IRIS) 注册中心接受水平眼外肌斜视手术的 7482 名间歇性外斜视患儿 (年龄<18 岁) 的数据进行了检查。排除了接受涉及 3 个或更多水平肌肉、垂直肌肉或初次手术的患儿。
主要结果和测量指标：主要结局是初次手术后 5 年内再次行水平肌肉手术的调整后累积发生率。使用多变量 Cox 回归模型得出的调整后危险比 (AHR) 分析再手术风险，调整了个体人口统计学和手术因素(年龄、性别、种族和民族、美国人口普查区和外科医生专业)。数据于 2023 年 1 月 16 日至 9 月 20 日之间进行分析。
结果：这项研究纳入了 7482 名间歇性外斜视患儿(初次手术时的中位[IQR]年龄为 6[4-9]岁；3945 名女性[53%])，接受了水平肌肉斜视手术。双侧外直肌后退术的应用频率高于 RR(85.3%比 14.7%，P<.001)，尤其是在年幼的患儿中(按年龄比较 BLR 与 RR 的比例：0 至≤4 岁年龄组，88.4%比 11.6%；5 至≤11 岁年龄组，84.7%比 15.3%；12 至≤17 岁年龄组，78.1%比 21.9%；P<.001)。数据调整后，5 年累积再手术发生率为 21.3%(95%CI，20.1%-22.5%)。BLR 5 年累积再手术发生率高于 RR(22.2%比 17.2%；差值为 4.9%；95%CI，1.9%-8.0%)。与 BLR 相比，单侧外直肌后退联合内直肌切除术的 5 年再手术风险较低(AHR，0.77；95%CI，0.64-0.93)。初次手术时年龄较小与调整所有其他协变量后再手术风险较高相关(AHR 每增加 1 岁为 1.09；95%CI，1.07-1.11)。
结论和相关性：在这项全国性的注册研究中，约 1/5 的间歇性外斜视患儿在初次手术后 5 年内需要再次手术。与 BLR 相比，RR 治疗的患儿 5 年内再手术的可能性较小。为了降低手术负担并改善间歇性外斜视患儿的治疗效果，需要进一步努力识别可改变的再手术风险因素。
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