V-pattern with diplopia following bilateral lateral rectus recession in intermittent exotropia

Purpose To report a case series of patients presenting with diplopia, V-pattern with esotropia/esophoria, and chin-down head position after bilateral lateral rectus recession (BLR) for the treatment of intermittent exotropia (IXT). Methods The historical data of patients were recorded, in addition to variables of routine ophthalmological evaluation, including age at onset of IXT; age at BLR; preoperative deviation; magnitude of recessions; postoperative deviation and stereoacuity; ductions and versions; onset and degree of alphabet pattern, diplopia, and chin-down/abnormal head position (AHP); time between the initial BLR and second surgery (inferior displacement of the medial rectus muscles); and degree of correction of the V-pattern, AHP, and diplopia. Results Six patients were identified. After BLR, two patients had small-angle esotropia, and four had esophoria. The time between surgery and V-pattern development/chin-down position ranged from 2 months to 2 years. Diplopia occurred in five patients. We did not observe inferior oblique overaction, but small subjective excyclotorsion (3°–5°) was detected in four of the six patients. The second surgery occurred around the age of 7 years, except in one patient aged 28 years. The V-pattern and abnormal head position were corrected after medial rectus infraplacement. Orthophoria was observed in five patients and esophoria of 4 prism diopters (PD) in one patient. Subjective torsion was neutralized in only one patient. Conclusion V-pattern and chin-down position with diplopia may occur after BLR for IXT. We describe successful surgical correction of diplopia and V-pattern/abnormal head position by infraplacement of medial rectus muscles.