Double Vision and V-Pattern Can Follow Surgery for Intermittent Exotropia

Some patients who undergo surgery for intermittent exotropia, a common eye misalignment in which the eyes drift outward, go on to develop an unexpected combination of problems: double vision, a V-shaped deviation of the eyes and a chin-down head posture. That is the finding of a case series by Jaime Tejedor of the Autonomous University of Madrid and Hospital Universitario Ramón y Cajal and Francisco J. Gutiérrez-Carmona of the Instituto Ramón Castroviejo de Investigación Oftalmológica, published in Frontiers in Ophthalmology in its Pediatric Ophthalmology and Strabismus section. The report documents six patients who developed these features after bilateral lateral rectus recession, the operation in which both outer eye muscles are recessed to treat an outward-drifting eye alignment.

The authors recorded historical clinical data alongside variables from routine ophthalmological evaluation for each patient. These included the age at onset of the intermittent exotropia, the age at which bilateral lateral rectus recession was performed, the preoperative deviation, the magnitude of the recessions, and the postoperative deviation and stereoacuity. The team also tracked ductions and versions, the onset and degree of the alphabet pattern, the appearance and severity of diplopia and of a chin-down abnormal head position, the time between the initial surgery and a second operation, and the degree to which the V-pattern, the abnormal head position and the diplopia were ultimately corrected.

Six patients were identified. After the initial surgery, two had a small-angle esotropia, a measurable inward turn of the eyes, and four had esophoria, a tendency of the eyes to drift inward that is held in check by fusion. The interval between surgery and the development of the V-pattern and chin-down position ranged from two months to two years. Diplopia occurred in five of the six patients. The authors did not observe overaction of the inferior oblique muscles, but small subjective excyclotorsion, an outward rotational displacement of the perceived visual world measuring three to five degrees, was detected in four of the six patients.

The second operation consisted of inferior displacement, or infraplacement, of the medial rectus muscles, the inner eye muscles, on the globe. It took place around the age of seven years in most cases, with one patient undergoing the procedure at age 28. The outcomes were consistent across the series: the V-pattern and the abnormal head position were corrected after medial rectus infraplacement. Five patients achieved orthophoria, in which the eyes are aligned without residual drift, and one patient retained esophoria of four prism diopters. Subjective torsion, however, was neutralized in only one patient, so most retained a residual rotational component even after the horizontal and postural problems had been addressed.

The authors conclude that a V-pattern, chin-down position and diplopia may occur after bilateral lateral rectus recession for intermittent exotropia, and that infraplacement of the medial rectus muscles successfully corrected the diplopia and the V-pattern and abnormal head position in their series. The report also documents the small degrees of subjective excyclotorsion found in most of these patients, a rotational finding that persisted after surgery in all but one case.

The scope of the evidence carries clear limits. This was a retrospective case series drawing on historical records, not a prospective study of an unselected cohort, so it does not establish how frequently these complications occur after the operation. With only six patients, and one adult among an otherwise pediatric group, the findings describe what can happen after bilateral lateral rectus recession and how the resulting V-pattern, abnormal head position and diplopia were surgically corrected in these cases, rather than measuring risk for surgical candidates in general. The final formatted version of the article is pending publication, and, as the journal’s disclaimer notes, all claims expressed in the article are solely those of the authors and do not necessarily represent those of their affiliated organizations, the publisher, the editors or the reviewers.

Subject of Research: Complications of bilateral lateral rectus recession in intermittent exotropia

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

Article References: Tejedor, J., & Gutiérrez-Carmona, F. J. (2026). V-pattern with diplopia following bilateral lateral rectus recession in intermittent exotropia. Frontiers in Ophthalmology, 6, Article 1982180. https://doi.org/10.3389/fopht.2026.1982180

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DOI: 10.3389/fopht.2026.1982180

Keywords: strabismus, intermittent exotropia, diplopia, V-pattern, lateral rectus recession, medial rectus infraplacement, abnormal head position, pediatric ophthalmology, case series, torsion, esophoria, excyclotorsion