Abstract
Background
This study aimed to investigate whether the blood supply associated with the rectus muscles may influence corneal and conjunctival temperature by comparing the changes in ocular surface temperature, estimated by infrared thermography, before and after strabismus surgery.
Methods
This retrospective study included 38 eyes of 19 patients with intermittent exotropia who underwent bilateral lateral rectus recession. Body temperature, noninvasive tear breakup time, corneal temperature, and nasal and temporal conjunctival temperature were measured at baseline, 1 week, and 4 weeks after surgery.
Results
No significant change was observed in body temperature, noninvasive tear breakup time, and corneal temperature over time. Conjunctival temperatures were analyzed separately for the nasal (non-operated site) and temporal (operated site) conjunctiva. While a significant time effect was observed (p = 0.04), neither the conjunctival site nor the time × site interaction showed statistical significance.
Conclusions
The results suggest that ocular surface temperature is not significantly affected by hemodynamic changes resulting from lateral rectus muscle recession.
Keywords: Ocular surface temperature, Bilateral rectus recession, Conjunctival temperature, Infrared thermography
Background
Ocular surface temperature (OST) estimated by infrared thermography, which was first reported by Mapstone [1, 2] in 1968, has been considered a possible indicator for disease severity confirmation, treatment response [3], and pathologic mechanism identification in various ocular surface diseases including infectious keratitis [4], pterygium [5], and dry eye disease (DES) [6]. Infrared thermography is a non-invasive and easily applicable method for monitoring anterior segment temperature and assessing the effects of various ocular pathologies on OST [1]. Using this technique, increased OST has been observed in bacterial corneal ulcers, and dynamic thermography may provide new options for monitoring ocular surface alterations [4]. In DES, corneal temperature (CT) decreases due to tear film break-up [6]. Gonnermann et al. also reported that eyes with pterygium and DES show a significant reduction in OST, suggesting its potential for objective assessment of dry eye symptoms in these patients [5].
In healthy subjects, OST shows a consistent pattern, with the highest temperature at the nasal canthus and the lowest at the central cornea, and is primarily influenced by age, forehead skin temperature, and laboratory temperature [7]. However, it remains unclear how vascular changes in the anterior segment affect ocular surface temperature.
Strabismus is a condition in which the visual axes of the two eyes are not parallel [8] and strabismus surgery loosens or tightens extraocular muscles, changing the alignment of the eyes. During this procedure, the anterior ciliary arteries, which course along the rectus muscles, are commonly compromised. Anatomically, each eye has seven anterior ciliary arteries that provide 70–80% of the blood supply to the anterior segment [9]. They originate from the ophthalmic artery and accompany the horizontal rectus muscles, and are transected during strabismus surgery [8]. As with the peripheral tissue cooling observed in response to peripheral vasoconstriction, alterations in the anterior vascular structure may influence OST [10]. Thus, strabismus surgery may influence OST through multiple mechanisms, including damage to the anterior ciliary arteries, iatrogenic inflammation at the conjunctival incision site, and postoperative dry eye symptoms [11].
To the best of our knowledge, it has not been reported about changes in OST after strabismus surgery. The aim of this study is to investigate whether the blood supply associated with the rectus muscles may influence corneal and conjunctival temperature (Conj-T) by comparing the changes in OST, estimated by infrared thermography, before and after strabismus surgery.
Methods
Ethics statement
This retrospective study was approved by the Institutional Review Board of Daegu Catholic University College of Medicine, Daegu, Republic of Korea (IRB no.2025-06-027) and was conducted in accordance with the tenets outlined in the Declaration of Helsinki. Medical records were accessed for research purposes between 13 August 2025 and 30 November 2025. During data collection and analysis, the authors had access to identifiable patient information, which was used solely for research purposes and was anonymized prior to analysis.
Inclusion and exclusion criteria
This study included patients who were diagnosed with intermittent exotropia (IXT) and underwent bilateral rectus muscle recession (BLR Rc) from August 2023 to February 2024. The patients were followed up for at least 1 month after surgery.
To prevent postoperative infection and inflammation, all patients were instructed to administer 0.5% levofloxacin (Cravit®; Santen Pharmaceutical Co., Ltd., Osaka, Japan) eye drops and 0.1% fluorometholone (Ocumetholone®; Samil, Seoul, Korea) eye drops four times daily for two weeks, and neomycin sulfate combined with dexamethasone oint (Neodex®; Hanlim Pharmaceutical Co., Seoul, Korea) one time daily for two weeks in the operated eye.
The exclusion criteria were as follows: (i) patients with any ocular disease at that time, such as glaucoma and ischemic retinal disease; (ii) patients with any ocular surface inflammatory disease at that time, such as allergic or viral conjunctivitis; (iii) patients who underwent ocular procedures except strabismus surgery, within the previous 6 months; (iv) patients with a previous history of contact lens; (v) patients using other eye drops apart from the postoperative medications mentioned above.
Ophthalmologic examinations
All patients underwent ophthalmological examinations including measurement of best-corrected visual acuity (BCVA), refractive error assessment, intraocular pressure (IOP), body temperature (BT), OST, noninvasive tear breakup time (NIBUT), ocular motility testing, and slit lamp examination preoperatively and at the 1-week, 1-month follow-up after surgery. The refractive error was measured using an autorefractor (Huvitz HRK-7000 A, Huvitz Co Ltd, Gunpo, Gyeonggi-do, South Korea) 30 min after instillation of cyclopentolate 1% 3 times at 5-minute intervals, and the results were converted to spherical equivalent. The IOP was measured using a non-contact tonometer (Canon TX-20, Canon Inc.,Tokyo, Japan). BT that might affect OST was checked using ear thermometers.
NIBUT was measured using ocular surface analyzer (OSA). Before measuring NIBUT using the OSA (IDRA, SBM sistemi, Inc., Torino, Italy), the examination was performed after a rest period of at least 10 min to minimize its impact on NIBUT. IDRA measured the time from the full blink to the presence of the first disruption of the reflected image on the cornea using the projected ring patterns from a Placido’s disc onto the cornea [12].
The angles of deviation at distance fixation (6 m) and near fixation (33 cm) were measured using the alternate prism cover test in the refractive error-corrected state.
Surgical techniques
All surgeries were performed by one surgeon (DL) under general anesthesia using the fornix approach. The patients included in the study underwent BLR Rc. In the process of BLR Rc, the LR muscle was dissected and separated, the anterior ciliary artery accompanying the muscle was also disconnected. Detached LR muscle was reattached directly to the sclera with 6 − 0 Vicryl sutures. As the last process, conjunctiva was closed through 8–0 absorbable polyglactin sutures.
Ocular surface temperature
The assessments on OST were conducted in the sequence described as follows. During the study period, ocular surface temperature measurements were performed according to a standardized protocol in patients undergoing strabismus surgery. Before measuring OST, the examination was performed after a rest period of at least 10 min to minimize its impact on OST. All measurements were conducted between 8:30 A.M and 5:30 P.M in a clinical room by one person (YSH) using infrared thermography (FLIR E5 XT, FLIR Systems, Oregon, U.S.A) like previous studies including our reports [3, 7, 13]. FLIR E5 XT had a focal plane resolution size of 160 × 120 pixels and an image frequency of 9 Hz with ± 2% accuracy. Thermal sensitivity and noise equivalent temperature difference (NETD) were < 0.10˚C / <100 mK. The room temperature and humidity were between 24˚C and 26˚C and 20% and 30%, respectively. The measurement points included the central cornea, as well as the nasal and temporal conjunctiva in the region between the limbus and the canthus. All participants were instructed to blink several times, and measurements were performed immediately after opening the eye.
Statistical analysis
Statistical analyses were performed using SPSS software (version 25.0, IBM Corporation) and data are expressed as the mean ± standard deviation. Changes between baseline and 4 weeks were analyzed by paired t-test. Longitudinal changes in parameters after surgery were analyzed using linear mixed-effects models, with time included as a fixed effect and subject included as a random effect to account for repeated measurements within individuals.
BT, CT, and NIBUT were analyzed using models including time as the sole fixed effect. For Conj-T analysis, conjunctival site was additionally included as a fixed effect, and a time × site interaction term was incorporated to evaluate whether postoperative Conj-T changes differed between nasal (non-operated) and temporal (operated) conjunctiva. Baseline differences in ocular surface temperature among the cornea, nasal conjunctiva, and temporal conjunctiva were assessed using paired t-tests with Bonferroni correction. P-value < 0.05 was considered statistically significant.
Results
Thirty-eight eyes of 19 patients (14 males and 5 females) were analyzed retrospectively. The mean age at surgery was 8.53 ± 2.04 years and mean preoperative exodeviations were 22.21 ± 3.65 prism diopters (PD) at distance and 24.95 ± 6.19 PD at near. Mean preoperative BT was 36.77 ± 0.41 °C without fever and NIBUT was 5.78 ± 2.00 s. Ocular surface temperature was measured at three sites: CT, nasal and temporal Conj-T. CT was the lowest, followed by temporal and nasal Conj-T. Bonferroni-corrected paired t-tests demonstrated statistically significant differences between all pairs. Baseline characteristics are shown in Table 1.
Table 1.
Baseline characteristics of enrolled 19 patients with intermittent exotropia
| Parameters | Values | Range |
|---|---|---|
| Sex, n (male: female) | 14: 5 | - |
| Mean age at surgery (years) | 8.53 ± 2.04 | 6 to 15 |
| BT (°C) | 36.77 ± 0.41 | 36.0 to 37.4 |
|
Mean refractive errors (spherical equivalents, D) |
-2.88 ± 1.90 | -6.125 to + 0.25 |
| Mean angle of preoperative exodeviation (PD) | ||
| Distance | 22.21 ± 3.65 | 18 to 30 |
| Near | 24.95 ± 6.19 | 12 to 35 |
| NIBUT (seconds) | 5.78 ± 2.00 | 4.5 to 13.3 |
| CT (°C) | 35.74 ± 0.90 | 33.3 to 37.1 |
| Nasal Conj-T (°C) | 36.32 ± 0.70 | 35.60 to 37.60 |
| Temporal Conj-T (°C) | 36.16 ± 0.80 | 34.80 to 37.60 |
Baseline regional differences in ocular surface temperature were significant among the cornea, nasal conjunctiva, and temporal conjunctiva (all p < 0.001)
D = diopter, PD = prism diopter, BT = body temperature, CT = Corneal temperature, NIBUT = noninvasive tear breakup time, Nasal Conj-T = nasal conjunctival temperature, Temporal Conj-T = temporal conjunctival temperature
No surgical complications, including IXT recurrence, anterior ischemic syndrome, conjunctival wound dehiscence, infection, severe subconjunctival hemorrhage, or corneal abrasion, were observed in any patient during the follow-up period. No residual polyglactin sutures were observed in any patient.
Postoperative changes in BT, non-invasive tear breakup time, and ocular surface temperature are summarized in Table 2; Figs. 1 and 2. There was no significant change between baseline and 4 weeks in BT, NIBUT, CT, and nasal/temporal Conj-T (all p > 0.05). BT, NIBUT, and CT did not show significant changes over time (all p > 0.05). Mean BT remained stable throughout the follow-up period with no postoperative fever observed, and similarly, no significant temporal trends were identified in NIBUT or CT.
Table 2.
Postoperative changes in body temperature, non-invasive tear film breakup time, corneal temperature
| Parameters | Baseline | 1 week | 4 weeks | p-value | |||
|---|---|---|---|---|---|---|---|
| Between baseline and 4 weeks | Time | ||||||
| BT (°C) | 36.77 ± 0.41 | 36.92 ± 0.25 | 36.91 ± 0.29 | 0.320 | 0.082 | ||
| NIBUT (seconds) | 5.55 ± 1.54 | 5.30 ± 0.53 | 5.20 ± 0.40 | 0.896 | 0.286 | ||
| CT (°C) | 35.74 ± 0.90 | 35.85 ± 0.66 | 35.55 ± 1.11 | 0.321 | 0.332 | ||
| Time | site | Time x site | |||||
| Nasal Conj-T (°C) | 36.32 ± 0.70 | 36.21 ± 0.61 | 36.03 ± 0.82 | 0.132 | 0.04 | 0.786 | 0.265 |
| Temporal Conj-T (°C) | 36.16 ± 0.80 | 36.44 ± 0.58 | 36.04 ± 0.80 | 0.090 | |||
BT = body temperature, CT = Corneal temperature, NIBUT = noninvasive tear breakup time, Nasal Conj-T = nasal conjunctival temperature, Temporal Conj-T = temporal conjunctival temperature
Linear mixed-effects models were used. Time was included as a fixed effect for body temperature, corneal temperature, and NIBUT, and conjunctival site and a time × site interaction were additionally included for conjunctival temperature
Fig. 1.
The changes of body temperature, noninvasive tear breakup time, and corneal temperature of all patients over time. All parameters were analyzed using models including time as the sole fixed effect. (A) The change over time in body temperature. There was no significant change over time (p = 0.082). (B) The change over time in noninvasive tear breakup time. There was no significant change over time (p = 0.286). (C) The change over time in corneal temperature. There was no significant change over time (p = 0.332)
Fig. 2.
The changes of conjunctival temperature over time. Conjunctival temperature was analyzed using linear mixed-effects models to account for within-eye correlations, with time and conjunctival site included as fixed effects. A significant time effect was observed (p = 0.04), indicating a temporal change in conjunctival temperature. No significant site or time × site interaction effects were observed (p > 0.05), suggesting no difference between nasal and temporal conjunctiva and similar patterns of change over time
Conj-T was analyzed using linear mixed-effects models to account for within-eye correlations, with time and conjunctival site included as fixed effects. A significant time effect was observed (p = 0.04), whereas neither the site effect nor the time × site interaction was significant (p = 0.786 and p = 0.265, respectively).
Discussion
Ocular surface temperature (OST) has been proposed as a potential indicator in various ocular surface diseases since Mapstone’s initial report [1–6]. In healthy individuals, the highest OST has been reported at the nasal canthus and the lowest at the central cornea, which is thought to result from the greater vascularization of the conjunctiva compared to the cornea [7]. Consistent with previous reports, our results also showed that BT was the highest, followed by nasal conjunctival, temporal conjunctival, and CT in decreasing order. Previous studies have prospectively evaluated ocular surface and tear film changes after lateral rectus recession [14]. However, to the best of our knowledge, no studies have investigated how ocular surface temperature, measured using infrared thermography, is affected by hemodynamic changes in the anterior segment, particularly in the conjunctiva, which receives direct blood supply, and the cornea, an avascular tissue.
Despite conjunctival and lateral rectus muscle surgery, no significant changes in CT or non-invasive tear breakup time were observed over time. These findings indicate that surgical manipulation of the conjunctiva and extraocular muscles does not result in measurable alterations in corneal surface temperature or tear film stability during the postoperative period. Anatomically, each rectus muscle is typically accompanied by one or two anterior ciliary arteries, and the remaining extraocular muscles continue to contribute to anterior segment perfusion [9]. The anterior ciliary artery (ACA), a branch of the ophthalmic artery, supplies blood to the ciliary body, iris, sclera, episclera, and conjunctiva. The bulbar conjunctiva receives its blood supply from the ACA as well as from the posterior conjunctival artery, which branches off from the peripheral tarsal arcade [15]. The anterior ciliary artery, which runs alongside the horizontal rectus muscle, is inevitably transected during surgery for intermittent exotropia [8]. The corneal surface temperature appears to be relatively independent of changes in blood supply from the ACAs. The bulbar conjunctiva also receives blood from sources other than the ACAs, which may account for the absence of sustained postoperative temperature changes. Taken together, these anatomical considerations may explain why transection of a single lateral rectus muscle did not lead to measurable changes in CT in the present study.
In contrast to CT, Conj-T exhibited a different postoperative pattern. Conj-T analysis using linear mixed-effects models demonstrated a significant effect of time, whereas neither the conjunctival site nor the time × site interaction was statistically significant, suggesting similar temporal patterns between the operated (temporal) and non-operated (nasal) conjunctiva. Although temporal Conj-T was significantly lower than nasal Conj-T at baseline, a descriptive reversal of the mean values was observed at one week postoperatively, with the temporal site appearing slightly warmer than the nasal site, as illustrated in Fig. 2. However, this difference did not reach statistical significance. This observation may be associated with transient postoperative changes on the ocular surface, including inflammatory responses related to surgical wound healing [2, 4, 16, 17]. In a previous study, an increase in ocular surface temperature (OST) has been reported following conjunctival stimulation with capsaicin, which induces an increase in blood flow [18]. Therefore, rather than concluding that no postoperative changes in ocular surface temperature occur, it may be reasonable to speculate that transient temperature elevations related to conjunctival wound healing and repair processes can be detected.
OST is known to be influenced by factors such as age, forehead skin temperature, and ambient temperature [7]. It has also been reported to increase with shorter tear film break-up time (TBUT) and a thicker tear film lipid layer [19]. In the present study, ocular surface temperature measurements were conducted in the same clinical environment, where ambient temperature and humidity did not show abrupt fluctuations, thereby minimizing the potential influence of external environmental factors. In addition, considering that no significant changes were observed in NIBUT, the ocular surface temperature measurements obtained in this study can be considered reliable. Postoperative topical medications, especially corticosteroids, may have modulated inflammatory responses at the surgical conjunctival site [20]. Although the distribution of topical medications across the ocular surface cannot be assumed to be uniform, the nasal conjunctiva was likely also exposed to their effects through tear film spread [21].
This study was conducted to evaluate the effects of anterior segment vascular alterations on ocular surface temperature. The findings suggest that injury to the anterior ciliary arteries associated with the lateral rectus muscle has a limited impact on ocular surface temperature, whereas inflammatory responses at the conjunctival incision site may play a more prominent role. These findings suggest that ocular surface temperature may have limited utility as a clinical indicator of hemodynamic changes and may reflect transient postoperative ocular surface changes, although direct inflammatory markers were not assessed in this study. However, the effects of procedures involving more than one extraocular muscle in a single eye were not evaluated in this study. Therefore, further studies are needed to clarify this issue.
This study was conducted retrospectively and has several limitations, including the absence of a control group consisting of non-operated patients whose ocular surface temperature was measured under identical conditions. As this study included only pediatric patients, the findings may not be generalizable to adults due to potential age-related differences in ocular surface physiology and vascular responses. Moreover, as inflammatory biomarkers such as MMP-9 were not assessed, this study does not offer direct evidence supporting an association between changes in conjunctival surface temperature and inflammatory responses.
Conclusion
The findings of this study suggest that OST is not significantly affected by hemodynamic changes following lateral rectus muscle surgery. These results indicate that disruption of a limited number of anterior ciliary arteries may not produce measurable alterations in corneal surface temperature. However, Conj-T may be influenced by transient postoperative inflammatory responses on the ocular surface.
Acknowledgements
The authors have no acknowledgments to declare.
Author contributions
Conceptualization: Sook Hyun Yoon. Formal analysis: Donghun Lee, Geun Woo Lee. Investigation: Geun Woo Lee. Writing-original draft: Donghun Lee. Writing-review and editing: Sook Hyun Yoon.
Funding
The authors received no specific funding for this work.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This retrospective study was approved by the Institutional Review Board of Daegu Catholic University College of Medicine, Daegu, Republic of Korea (IRB no.2025-06-027) and was conducted in accordance with the tenets outlined in the Declaration of Helsinki. The requirement for informed consent was waived by the Institutional Review Board of Daegu Catholic University College of Medicine due to the retrospective nature of the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.