Unilateral four-muscle surgery for large-angle exotropia.

Eight patients with large-angle exotropia and unimprovable poor vision in one eye were treated with conventional maximum horizontal rectus recession/resection plus weakening of both obliques of the poorly seeing eye. This appears to be a useful alternative to "supermaximal" recession/resection procedures, which are more likely to lead to deficient or restricted rotations. The effect is probably due to the release of additional sites of contracture that occur in the oblique muscles. The principal disadvantage is a small postsurgical hypertropia of the operated eye, for which routine infraplacement of both horizontal recti can compensate adequately.