eMedicine Specialties > Ophthalmology > Extraocular Muscles

Esotropia and Exotropia, V-patterns

Neepa Thacker, MBBS, MS, DNB, FRCS, Consulting Staff, Department of Pediatric Ophthalmology and Strabismus, Breach Candy Hospital, Mumbai, India
Arthur L Rosenbaum, MD, Chief, Division of Pediatric Ophthalmology, Professor, Vice Chairman, Department of Ophthalmology, University of California at Los Angeles School of Medicine; Frederico G Velez, MD, Assistant Clinical Professor, Department of Ophthalmology, Division of Pediatric Ophthalmology and Strabismus, University of California at Los Angeles School of Medicine

Updated: Sep 26, 2006

Introduction

Background

Duane first described V-pattern strabismus in 1897. Other investigators also studied these phenomena, contributing to the understanding of them. In 1944, Costenbader and colleagues recommended measuring the horizontal deviations in upgaze and downgaze as part of all routine motility examinations.

Two types of V-patterns can occur. V-pattern esotropia is an esodeviation with greater esotropia in downgaze than in upgaze. V-pattern exotropia is an exodeviation with greater exotropia in upgaze than in downgaze. See Images 1-2.

Comitant horizontal deviations are those in which the angle of deviation is the same in all gaze positions. Incomitant horizontal deviations are those in which the angle of deviation varies in different gaze positions. Horizontal deviations may have lateral incomitances and vertical incomitances. In lateral incomitances, significant differences exist in the amount of horizontal deviation in primary gaze versus side gaze, whereas, in vertical incomitances, significant differences exist in the amount of horizontal deviation in upgaze versus downgaze.

When the eyes diverge more than 10 prism diopters (PD) from upgaze to downgaze, an A-pattern is present; when the eyes converge more than 15 PD from upgaze to downgaze, a V-pattern is present.

Other types of vertical incomitances, which are less common, include X, Y, and lambda patterns. This discussion is limited to V-pattern strabismus.

Pathophysiology

Multiple factors may be responsible for V-pattern strabismus, and, in a given individual, one or more factors may contribute toward its cause.

Inferior oblique muscle overaction

The most widely accepted mechanism contributing to the causation of V-pattern strabismus is associated with inferior oblique muscle overaction and/or relative underaction of the superior oblique muscles. Inferior oblique muscle overaction produces significant horizontal deviation in upgaze. In upgaze, the horizontal action of the inferior oblique muscles is abduction; therefore, inferior oblique muscle overaction produces relative divergence in elevation. A V-pattern results in greater exotropia (or less esotropia) in upgaze and greater esotropia (or less exotropia) in downgaze. Not all V-pattern strabismus is associated with oblique muscle dysfunction. See Images 7-8.

Facial and orbital configuration

An association exists between individuals with hypoplasia of the malar bones, anti-Mongoloid lid slants, and S-shaped contours of the lower lid, and overaction of the inferior oblique muscles and V-pattern strabismus. Patients with craniosynostosis have shallow orbits, and the angle between the visual axis and the insertion of the inferior oblique muscle is increased. This increased angle increases the abduction ability of the inferior oblique muscles in upgaze, resulting in a V-pattern. Contributing to this condition is the complex interplay of these factors with excyclotorsion of the globe.

Effect of the pulley systems

Upward displacement of the pulley systems around the lateral rectus muscle may cause V-pattern strabismus.

Horizontal muscle overaction

Initially, this theory was believed to be responsible for V-pattern strabismus, but no convincing evidence supports it. In V-pattern esotropia, the medial rectus muscle was believed to overact, thereby increasing esotropia in downgaze, and, in V-pattern exotropia, the lateral rectus muscle overaction was responsible for increased exotropia in upgaze.

Vertical rectus muscle imbalance

One theory states that V-pattern strabismus occurs because of underacting superior recti muscles and corresponding overacting inferior oblique muscles. This hypothesis was applied when nasal and temporal displacements were used to treat A- and V-patterns. This theory has been abandoned.

Abnormal oblique muscle insertions

Alterations of the angle of the insertion of the oblique muscle with the visual axis can reduce cyclorotation and abduction forces and increase the vertical function of the oblique muscle.

Anomalous horizontal rectus muscle insertions

Among the suggested causes of V-pattern strabismus are anomalies of the horizontal rectus scleral insertions. They may be inserted above or below the usual positions.

Acquired form

V-patterns are acquired after superior oblique muscle palsy and are a prominent feature of bilateral superior oblique muscle palsies.

Frequency

United States

Although the exact prevalence of V-pattern strabismus in a given population is not known, 12.5-50% of patients with horizontal strabismus have an associated A- or V-pattern. V-pattern esotropia is not as commonly seen as V-pattern exotropia.

Mortality/Morbidity

Patients may experience diplopia that affects their everyday activities, such as driving and reading. In addition, the inability of patients to fuse in different gaze positions can interfere with other activities, including sports and recreation. The cosmetic appearance of V-pattern strabismus coupled with its social implications may be bothersome to patients. Over time, the associated anomalous head position could lead to secondary neck pain and similar problems.

Race

No racial predilection exists.

Sex

No sexual predilection exists.

Age

No age predilection exists.

Clinical

History

The most common presenting signs of V-pattern strabismus are as follows:

Inward or outward deviation of the eyes
Abnormal eye movements in different gazes
Asthenopia (eyestrain)
Abnormal head posture, chin down in V-pattern exotropia and chin up in V-pattern esotropia
Diplopia in older children and adults

Physical

The physical examination includes a general eye examination combined with a detailed ocular motility examination. The ocular motility examination, performed with the refractive error corrected, consists of the following:

Note any abnormal head position.
Perform cover tests with prisms in the primary position, 30° upgaze and 30° downgaze at near and at distance.
With ocular rotations, look for associated underaction or overaction of oblique muscles.
Perform a head tilt test if V-pattern strabismus is noted in patients with suspected bilateral superior oblique palsy.
Measure torsion in patients with suspected inferior oblique muscle overaction to check for excyclotorsion.
When required, perform sensory testing, including distance and near stereoacuity, and other tests.

Causes

See Pathophysiology.

Differential Diagnoses

Esotropia and Exotropia, A-patterns

Workup

Laboratory Studies

Laboratory tests are not required, except for those routinely performed prior to surgery.

Imaging Studies

Imaging studies are not required routinely, although they may be beneficial in patients with certain conditions (eg, craniosynostosis) or in patients where abnormalities of the pulley systems are suspected.

Treatment

Medical Care

In mild cases, no treatment may be required.

In intermittent deviations, which are exotropic in nature, overcorrection with minus lenses (-2 to –4 D) can be tried. The rationale is that the minus lenses stimulate accommodative convergence and reduce the exodeviation angle; however, this does not address the vertical incomitance.
For small comitant deviations, prisms can be tried to control the deviation and to relieve asthenopic symptoms. Base-in prisms are used for exotropia; base-out prisms are used for esotropia.

Surgical Care

Indications for surgery include the following: to correct the underlying deviation and to enable fusion, to achieve and regain comfortable binocular single vision, and to correct abnormal head posture when present.

In both esotropia and exotropia, the V-pattern incomitance is considered surgically significant when the difference between horizontal deviations in upgaze and downgaze is equal to or greater than 15 PD. Prior to surgery, determine if the V-pattern is associated with oblique muscle dysfunction. The most common pattern encountered is inferior oblique muscle overaction and relative superior oblique muscle underaction or overelevation and underdepression in adduction.

Surgical treatment of V-pattern strabismus with oblique muscle dysfunction
- These patients usually require appropriate horizontal rectus muscle surgery that is combined with inferior oblique muscle weakening procedures. For V-pattern esotropia, medial rectus muscle recessions (and/or lateral rectus muscle resections) along with inferior oblique muscle weakening (or superior oblique muscle tucks) are performed. For V-pattern exotropia, lateral rectus muscle recessions (and/or medial rectus muscle resections) and inferior oblique muscle weakening are performed. Inferior oblique muscle weakening procedures should be performed equally on both eyes.
- Several studies have confirmed the role of and reported surgical success with inferior oblique muscle weakening (recessions) in both V-pattern esotropia and V-pattern exotropia. In one study, the stereoscopic function improved in 33.3% of patients, and, in another study, a significant improvement in fusional status was noted postoperatively after a combination of horizontal rectus muscle surgery and inferior oblique muscle weakening.
- Inferior oblique muscle weakening procedures include inferior oblique muscle recession, anteriorization, myotomy, and myectomy. The degree of inferior oblique muscle overaction determines the procedure of choice. For mild-to-moderate inferior oblique muscle overactions, recessions are preferred. Depending on the severity of the inferior oblique muscle overaction, graded recessions can be performed.
- Quantification (grading) of the inferior oblique muscle recession for V-pattern strabismus was studied by a group of investigators. These investigators recessed the inferior oblique muscle from 8 mm for a V-pattern of 12 PD with +1 inferior oblique muscle overaction to 12 mm for a V-pattern of 30 PD with +3 inferior oblique muscle overaction. A satisfactory outcome was observed in 75% of patients with a preoperative V-pattern of less than 20 PD. A success rate of 57% was noted in patients with a preoperative V-pattern of more than 29 PD. Undercorrections were common, hence their recommendation that increased amounts of surgery be done.
- For severe inferior oblique muscle overaction, the anteriorization procedure is sometimes preferred. A study compared graded recession to anterior transposition of the inferior oblique muscle for V-pattern strabismus and concluded that anterior transposition is as effective as graded recession.
- Inferior oblique muscle myotomy or myectomy also can be performed. If a reoperation is required following inferior oblique muscle myectomy, localizing the muscle may be difficult. Inferior oblique muscle weakening procedures have very little, if any, effect on the horizontal deviation in the primary gaze.
Surgical treatment of V-pattern strabismus without oblique muscle dysfunction
- Vertical displacement of horizontal rectus muscle insertions: Introduced by Knapp, this technique shows favorable results in patients with mild-to-moderate V-patterns with no apparent oblique muscle dysfunction.
- In determining the direction of displacement, the authors follow a general rule wherein the medial rectus muscle insertion is always moved toward the closed end of the V (downward) and the lateral rectus muscle insertion is always moved toward the open end of the V (upward), as outlined below. See Image 3.
  - V-pattern esotropia - Bilateral medial rectus muscle recessions with downshift
  - V-pattern esotropia - Bilateral lateral rectus muscle resections with upshift
  - V-pattern exotropia - Bilateral lateral rectus muscle recessions with upshift
  - V-pattern exotropia - Bilateral medial rectus muscle resections with downshift
- The amount of displacement depends on the difference in the amount of deviation in upgaze and downgaze. A half tendon width displacement corresponds to a 5-mm vertical shift of the insertion, and a full tendon width displacement corresponds to a 10-mm vertical shift of the insertion. While performing the vertical displacement, maintaining the relationship between the original insertion of the muscles and the sclerocorneal limbus is important. See Image 4.
- Slanting the horizontal rectus muscle insertions with or without recessions: For a V-pattern, selective recession of the superior fibers of the medial rectus muscle or the inferior fibers of the lateral rectus muscle can be performed. The amount of correction from this type of surgery is minimal. A recent observational case study evaluated the therapeutic effects of surgically slanting the muscle insertions on the effect of the V-pattern in patients with exotropia. A slanting surgical reinsertion line with a 3- to 4-mm difference between the upper and lower corners of the muscles was created. The study showed that the mean amount of reduction in the V-pattern was 10.3 PD in the primary position and 29.8 PD in upgaze. This procedure can be combined with recessions and/or vertical rectus muscle displacement of the horizontal rectus muscle insertions. See Image 5.
- Horizontal transpositions of the vertical recti muscles: The vertical recti muscles are secondary adductors. By altering their site of insertion, the adducting forces can be modified. In V-pattern esotropia, the inferior recti muscles can be moved temporally. In V-pattern exotropia, the superior recti muscles can be moved nasally.
- This procedure is not commonly preferred because of the following:
  - The results are difficult to predict.
  - If fusion is present, the horizontal, vertical, and torsional component change that results from the transposition may change the sensory status.
  - Usually, a horizontal deviation occurs that requires surgery. In this case, additional surgery on the vertical recti muscles may increase the risk of anterior segment ischemia.
- This procedure may be considered as an option in patients where the inferior oblique muscles have been maximally weakened and are not overacting, and a residual V-pattern persists.
- Monocular surgery: When considering monocular surgery with an associated V-pattern and planning a recess-resect procedure, the medial rectus muscle is displaced downward and the lateral rectus muscle is displaced upward in the same eye. Goldstein reported that an 8-mm displacement of the horizontal recti muscles monocularly corrects V-patterns as large as 30 PD. See Image 6.

Medication

No effective medical treatments exist.

Follow-up

Further Inpatient Care

Surgery for the patient with strabismus usually is performed as an outpatient procedure.

Further Outpatient Care

Although regimens vary among surgeons, regular follow-up visits are necessary to determine if the eyes are well aligned and if fusional abilities are present and stable.

Complications

If left untreated, loss of fusion and stereopsis could occur. If the patient freely alternates, the chance of amblyopia is reduced.
Complications associated with surgery include undercorrection and overcorrection and/or residual or new oblique muscle dysfunction.
Postoperative complications include residual A- or V-pattern strabismus, diplopia, and undercorrection or overcorrection of the horizontal deviation.

Prognosis

The prognosis for patients with this condition is good. Only one surgery is required to correct the deviation in 80-85% of patients; 10-15% of patients may need a second or third procedure for good alignment.
Success for binocularity depends on the patient's age, the time of presentation, and any previous amblyopia.

Miscellaneous

Medicolegal Pitfalls

Failure to detect and appropriately treat this condition could result in loss of binocularity and possibly amblyopia.

Multimedia

Media file 1: V-pattern exotropia.

Media file 2: V-pattern esotropia.

Media file 3: Esotropia and exotropia, V-pattern. In Image 3a, lateral rectus muscle insertion moved toward the open end of V. In Image 3b, medial rectus muscle insertion moved toward the closed end of V.

Media file 4: Esotropia and exotropia, V-pattern. In Image 4a, half tendon width vertical shift of muscle insertion. In Image 4b, full tendon width vertical shift of muscle insertion.

Media file 5: Esotropia and exotropia, V-pattern. In Image 5a, slanting of rectus muscle insertion. In Image 5b, recession and slanting of rectus muscle insertion.

Media file 6: Esotropia and exotropia, V-pattern. Recess-resect procedure in same eye.

Media file 7: Patient with V-pattern exotropia and inferior oblique muscle overaction.

Media file 8: Patient with V-pattern esotropia and inferior oblique muscle overaction.

References

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Keywords

V-pattern strabismus, vertically incomitant horizontal deviations, A-pattern, V-pattern, horizontal deviation, upgaze, downgaze, angle of deviation, V-pattern esotropia, V-pattern exotropia

Contributor Information and Disclosures

Author

Neepa Thacker, MBBS, MS, DNB, FRCS, Consulting Staff, Department of Pediatric Ophthalmology and Strabismus, Breach Candy Hospital, Mumbai, India
Disclosure: Nothing to disclose.

Coauthor(s)

Arthur L Rosenbaum, MD, Chief, Division of Pediatric Ophthalmology, Professor, Vice Chairman, Department of Ophthalmology, University of California at Los Angeles School of Medicine
Arthur L Rosenbaum, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Frederico G Velez, MD, Assistant Clinical Professor, Department of Ophthalmology, Division of Pediatric Ophthalmology and Strabismus, University of California at Los Angeles School of Medicine
Frederico G Velez, MD is a member of the following medical societies: American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Medical Editor

Michael J Bartiss, OD, MD, Medical Director, Ophthalmology, Family Eye Care of the Carolinas
Michael J Bartiss, OD, MD is a member of the following medical societies: American Academy of Ophthalmology, American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, and North Carolina Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Ralph Garzia, OD, Assistant Dean for Clinical Programs, Associate Professor, School of Optometry, University of Missouri at St Louis
Ralph Garzia, OD is a member of the following medical societies: American Academy of Optometry and American Optometric Association
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

Further Reading