V-pattern and accommodative convergence/accommodation ratio in consecutive esotropia after surgery for intermittent exotropia: A comparison of bilateral lateral rectus recession and unilateral recession–resection

Objective To delineate a clinically actionable phenotype of consecutive esotropia with V-pattern following surgery for intermittent exotropia and to determine whether the initial surgical approach—bilateral lateral rectus recession versus unilateral recession–resection—is associated with differential patterns of V-pattern presentation and accommodative convergence/accommodation behavior among patients who develop consecutive esotropia. Clarifying these associations may inform postoperative surveillance and the selection of secondary surgical strategies in consecutive esotropia complicated by pattern deviation. Methods We retrospectively reviewed patients who developed consecutive esotropia after surgery for intermittent exotropia and were evaluated/managed at our center between 2016 and 2024. Thirty-four patients with consecutive esotropia had previously undergone bilateral lateral rectus recession (bilateral lateral rectus recession group), and twenty-six had previously undergone recession–resection (recession–resection group). Intermittent exotropia stage and consecutive esotropia clinical data were extracted, including ocular motility (with emphasis on abduction limitation), refractive status, presence and magnitude of V-pattern, and accommodative convergence/accommodation ratio measured using the gradient method. Comparisons were performed between groups at each stage and within individuals across the intermittent exotropia-to-consecutive esotropia transition. Results Baseline distance exodeviation was comparable between groups (bilateral lateral rectus recession: 38.92 ± 12.78 Δ at 6 m and 36.47 ± 13.47 Δ at 33 cm; recession–resection: 39.04 ± 12.91 Δ at 6 m and 40.60 ± 10.54 Δ at 33 cm), whereas near exodeviation was greater in the recession–resection group than in the bilateral lateral rectus recession group. No patient demonstrated a preoperative pattern deviation. Among consecutive esotropia cases, V-pattern was observed more frequently in the bilateral lateral rectus recession–derived consecutive esotropia cohort than in the recession–resection–derived cohort (15/34 vs. 3/26). During intermittent exotropia stage, accommodative convergence/accommodation ratios did not differ between groups; however, accommodative convergence/accommodation ratios increased after consecutive esotropia onset and were higher in the bilateral lateral rectus recession–derived consecutive esotropia cohort than in the recession–resection–derived cohort. These findings indicate that, once consecutive esotropia develops, the postoperative phenotype may vary according to initial procedure, with a stronger association between bilateral lateral rectus recession–derived consecutive esotropia and both V-pattern presentation and elevated accommodative convergence/accommodation. Conclusions Among patients who developed consecutive esotropia after intermittent exotropia surgery, bilateral lateral rectus recession–derived consecutive esotropia was more commonly accompanied by V-pattern and a higher accommodative convergence/accommodation ratio than recession–resection–derived consecutive esotropia. The increase in accommodative convergence/accommodation from the intermittent exotropia stage to the consecutive esotropia stage suggests that accommodative mechanisms may contribute to the consecutive esotropia-with-pattern phenotype and should be assessed when planning postoperative monitoring and secondary correction. Importantly, this study characterizes phenotypic differences among consecutive esotropia cases and does not estimate the incidence of consecutive esotropia or V-pattern consecutive esotropia after bilateral lateral rectus recession or recession–resection.