We appreciate Dr Bhambhwani’s interest in our study and the opportunity to reply to his comments. This was a retrospective study, and the patient population was indeed somewhat heterogeneous.

With regard to Dr Bhambhwani’s questions regarding clinical findings, 7 patients were treated for amblyopia and treatment was successful in 5 patients. Five patients were less than 1 year of age when exotropia was first noted, and 3 had their first surgery before 1 year of age. One of these patients had constant exotropia and the others were intermittent. All of the patients in the study had either basic or pseudo-divergence excess types of exotropia. Although the number of patients was large in comparison to similar studies, it was not large enough to allow for meaningful statistical analysis of these subgroups.

With regard to surgical technique, all of the procedures were performed through inferotemporal fornix incisions. When inferior oblique procedures were performed concurrently, the surgery on the inferior oblique muscle was performed through the same incision. Indeed, it was the ability to combine inferior oblique muscle weakening and lateral rectus muscle re-recession through the same incision that led to this procedure being adopted in the first place. The good results led to re-recession of the lateral rectus muscle becoming our first choice for the majority of patients with recurrent exotropia. It is our practice in general not to adjust the amount of horizontal surgery when inferior oblique muscles are performed concurrently, and we did not do so for the patients in this study.

With regard to intraoperative findings, all patients had either minimal or moderate restriction (none were markedly restricted). Mild to moderate scar tissue was usually present, which did not interfere with the ability to successfully re-recess the lateral rectus muscles. As the surgeries were performed through fornix incisions, recession of the conjunctiva was not performed concurrently, and none of the patients had conjunctival scarring to the extent that it created significant restriction. In general, we found that re-recessing the muscle from approximately 6 mm to 10 mm from the original insertion corrected about 18–20 prism diopters of exotropia.

One specific surgical finding deserves mention. The inferior oblique muscle is normally found along the inferior border of the lateral rectus muscle posteriorly. When re-recessing the lateral rectus muscle, one must pay careful attention to identifying these 2 structures and separating them, so that the inferior oblique muscle isn’t inadvertently damaged.

As Dr Bhambhwani notes, there are a number of factors to consider when making preoperative and intraoperative decisions for correction of strabismus. We are pleased with our outcomes, and hope that this information proves useful for those considering similar procedures.