Strabismus pp 305-310 | Cite as


  • Burton J. Kushner


Every discussion about strabismus reoperations usually begins with a mention of Cooper’s dictum [1]. Cooper is quoted as stating that then when doing a reoperation, you should approach it as a fresh case; for example, do not make allowances for what was done previously. In my opinion this is bad advice in many situations. However, in Cooper’s defense, his words are really taken out of context. Cooper made his pronouncement as part of a discussion of a narrowly defined scenario. At the time a common precept was that if a patient has a consecutive exotropia (XT), one should always undo the prior operation (e.g., advance the medial rectus muscles [MRs]) and do a greater amount of surgery than had previously been done. Cooper, in fact, said, “Whenever an overcorrection results from extraocular muscle surgery, the case should be re-evaluated based on the diagnostic findings determined following the last operation. It is inadvisable to assume the attitude that one should undo some of the surgery which has previously been done. .. The idea that that surgery for secondary XT should always (emphasis added) undo what was previously done should be rejected.” On the other hand, Cooper specifically advised that, if a consecutive XT has a convergence insufficiency pattern, the MRs should be advanced. It is only if there is a divergence excess pattern that the lateral rectus muscles (LRs) should be recessed. It is noteworthy that Cooper published these guidelines in 1961, when strabismus surgical formulae recommended much smaller recessions that they do now. In fact, Cooper advised that the MRs should never be recessed more than 3.5–4 mm. I imagine that if he were treating patients with consecutive XT who had undergone MR recessions of 6.5 or 7 mm, as is often done currently, he would have more frequently recommended advancing the previously recessed muscles. How Cooper’s dictum became misconstrued to the reductionist idea that all reoperations should be treated as fresh cases is inexplicable to me. I imagine Cooper would have been greatly distressed to know that his words would become so misconstrued by so many people for so many years. There are countless scenarios in which treating a reoperation as a fresh case would be unwise. Certainly, if there are limitations of rotation, they must be addressed.


Cooper’s dictum Elongated scars Pseudotendon Reoperations Reverse leash Slipped muscles Spring-back testing String sign 


  1. 1.
    Cooper EL. The surgical management of secondary exotropia. Trans Am Acad Ophthalmol Otolaryngol. 1961;65:595–608.PubMedGoogle Scholar
  2. 2.
    Kushner BJ. Surgical pearls for the management of exotropia. Am Orthoptic J. 1992;42:65–71.CrossRefGoogle Scholar
  3. 3.
    Jampolsky A. Spring-back balance test in strabismus. In: Transactions of the New Orleans Academy of Opththalmology. St Louis: Mosby; 1978. p. 104–11.Google Scholar
  4. 4.
    Jampolsky A. Strategies in strabismus surgery. In: Pediatric ophthalmology and strabismus transactions of the New Orleans Academy of Ophthalmology. New York: Raven Press; 1985. p. 363–8.Google Scholar
  5. 5.
    Repka MX, Fishman PJ, Guyton DL. The site of reattachment of the extraocular muscle following hang-back recession. J Pediatr Ophthalmol Strabismus. 1990;27:286–90.PubMedGoogle Scholar

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© Springer International Publishing AG 2017

Authors and Affiliations

  • Burton J. Kushner
    • 1
  1. 1.Department of Ophthalmology and Visual SciencesUniversity of Wisconsin-MadisonMadisonUSA

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