Combined bilateral lateral rectus recession and medial rectus Faden procedure in true divergence excess exotropia: a case report

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True divergence excess, a subtype of intermittent exotropia, presents with a greater exodeviation at distance than at nearby. Its management often requires tailored surgical strategies to address both distance and near deviations. A 9-year-old Saudi girl presented with intermittent right-eye exotropia. Prism and alternate cover test measurements revealed 30 prism diopters (PD) of exodeviation at distance and 12 PD at nearby. Cycloplegic refraction showed mild hyperopia. The accommodative convergence to accommodation ratio was within normal limits. No significant ocular or systemic comorbidities were present. The patient underwent bilateral lateral rectus recession (7 mm) to correct the distance deviation, combined with bilateral medial rectus Faden procedures to control near deviation. The surgery proceeded without complication. On postoperative Day 1, the patient achieved orthophoria at both distance and near. At the 3- and 6-month follow-ups, ocular alignment remained stable, with only a mild residual exotropia of 5 PD at distance without glasses. No diplopia or motility restrictions were reported. A combined surgical approach of bilateral lateral rectus recession and medial rectus Faden procedure can effectively manage true divergence excess in intermittent exotropia, yielding stable postoperative alignment. Individualized surgical planning remains essential for optimizing outcomes.