To evaluate the clinical analysis of intermittent exotropia patients who required more than three reoperations and to investigate the factors leading to situations that require more than three reoperations.

We retrospectively analyzed the results of 13 patients who underwent more than three reoperations for recurrence after the second operation, as well as for 29 patients who had successful results for operation at least 1 year after the second operation. We investigated the factors associated with surgical outcomes of the second operation using multiple logistic regression analysis, which included; onset of symptom, primary, secondary, tertiary, and fourth ages of surgery, stereopsis before and after surgery, distance and near deviation before and after surgery, and constancy of exotropia.

There were more cases in which symptoms occurred before 1 year of age ( p = 0.011) and which had constant exotropia ( p = 0.023), with a large deviation at first operation ( p = 0.003) after more than three operations compared to patients who only had two operations. There were less cases that achieved initial overcorrection after first operation ( p = 0.003) and successful postoperative stereopsis after second operation ( p = 0.043) in the three operations group than in the two operations group. Among these factors, the most important factor affecting reoperation and success after second operation was related to successful recovery of stereopsis using multiple regression analysis (odds ratio [OR] = 50.00, 95% confidence interval [CI] = 4.392–569.224, p = 0.002).

In cases of intermittent exotropia occurring before 1 year of age, constant exotropia with a large deviation at first operation, and insufficient initial overcorrection after operation, it may be necessary for patients to receive more than three operations because of recurrence. Further, recovery of postoperative stereopsis after the second operation was the most important predictor for postoperative results.