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PubMed1994

The outcome of strabismus surgery in childhood exotropia.

The results of squint surgery in 42 children with primary, non-paralytic, childhood exotropia are analysed. A 'favourable outcome', defined as a final alignment for near and distance within +/- 10 dioptres of straight, or within +/- 20 dioptres of straight with evidence of binocular single vision, was achieved in 39 (93%) children. The factors affecting the final outcome are discussed, including age of onset, age at the time of surgery, preoperative and post-operative amblyopia, refractive error, anisometropia, the surgical procedures used, and postoperative ocular alignment.

Age Factors↗
PubMed2003

Surgical correction of large-angle exotropia in adults.

AIM: A retrospective and longitudinal review of the outcome of strabismus surgery for adults with large- and very-large-angle manifest exodeviations, using two-, three- and four muscle horizontal recti surgery with adjustable sutures. METHODS: A total of 26 consecutive adult patients undergoing surgery for socially noticeable strabismus comprising five primary, 16 consecutive, and five secondary constant exotropias with a mean near deviation of 58 prism dioptres and a mean distance deviation of 55Delta were evaluated preoperatively and at various time intervals postoperatively. Surgery involved two muscles in seven cases, three muscles in 13 cases, and four muscles in six cases; and 25 of 26 had adjustable sutures. There was a horizontal preoperative ocular movement deficit in 17 that was asymmetrical in four cases. RESULTS: Binocularity was restored in eight patients (31%), 20 (77%) were within 10Delta of orthotropia, and 24 (92%) were happy with their cosmesis. Two had symptomatic asymmetrical ocular motility deficits postoperatively following a two-muscle procedure and one required reoperation. A total of 19 patients undergoing three- or four-muscle surgery were asymptomatic postoperatively. A total of 22 patients had follow-up of 8 months or more. CONCLUSION: In adults with large-angle manifest exodeviations, adjustable suture surgery involving three or more horizontal recti successfully restores primary position alignment, a high degree of patient satisfaction, and can be expected to be associated with a low incidence of symptomatic postoperative asymmetrical ocular movement deficits.

Adolescent↗
PubMed2005

The long-term result of slanted medial rectus resection in exotropia of the convergence insufficiency type.

PURPOSE: To evaluate the long-term results of slanted medial rectus (MR) resection for intermittent exotropia (X(T)) of the convergence insufficiency type. METHODS: In all, 10 patients with an X(T) greater at near than at distance by 10 prism diopters (PD) or more were included in this prospective study. Patients received slanted bilateral MR resection. The upper edge of the MR was resected according to the distance exodeviation and the lower edge of the MR was resected according to near exodeviation. The postoperative follow-up period was between 6 and 62 months with a mean of 38.9 months. The paired t-test was used to compare: mean distance angle of deviation preoperatively and postoperatively; mean near angle of deviation preoperatively and postoperatively; and mean near-distance exodeviation difference preoperatively and postoperatively. RESULTS: Bilateral slanted MR resections reduced mean exodeviation at distance from 23.0+/-7.2 to 16.3+/-5.4 PD (P=0.03); mean exodeviation at near from 34.3+/-7.7 to 24.6+/-6.9 PD (P=0.01); and mean near-distance difference from 11.4+/-2.6 to 8.3+/-3.5 PD (P=0.04). At the final follow-up examination, all patients demonstrated an exodeviation of 10 PD or more at distance and near, and the exodeviation difference between distance and near deviation was within 10 PD in five of the 10 patients. Three patients had an esodeviation at distance after surgery, but all resolved within 4 weeks. CONCLUSIONS: Bilateral slanted MR resections in patients with X(T) of the convergence insufficiency type resulted in undercorrection in all patients.

Adolescent↗
PubMed2006

[Management of consecutive exotropia -- operative therapy and diplopia testing].

PURPOSE: The aim of this study was to investigate the diagnostic value of preoperative sensory testing on postoperative diplopia and to evaluate the dose-effect relations of medial rectus muscle or unilateral recess/resect advancement procedures and their constancy. METHODS: A retrospective evaluation of 62 operative cases of consecutive exotropia performed from 2001 to 2003 was carried out. Diplopia after prismatic correction and after converging by minus glasses was tested. In 47 cases a unilateral recess/resect procedure and in 15 cases an advancement of the medial rectus muscle were performed. The postoperative results were controlled one week and three months after operation by measuring the angle of squint by a prism cover test looking in five metres and in 33 cm. RESULTS: 22 patients (36 %) had neither diplopia after prismatic correction of angle of squint nor after operation. The other 40 patients (64 %) experienced diplopia, but were not troubled by it. In all patients the whole amount of angle of squint was operated. Immediately after operation, 14 patients (23 %) experienced diplopia temporarily, which remained after 3 months in 9 patients, but all of them were not disturbed by it. In all patients the mean preoperative angle of - 19 degrees was corrected by a mean operative amount of 11 mm, the mean postoperative angles were + 1.5 degrees after one week and - 2.6 degrees after three months with considerable variations of the results (standard deviations were about 5 degrees ). In 15 cases with advancement of the medial rectus muscle the dose-effect relation was 2 degrees per mm operative amount. After three months these patients become more divergent, the mean value was - 6 degrees , the dose-effect relation was reduced to 1.4 degrees /mm. The unilateral recess/resect operations were more constant: these became more divergent of 2.5 degrees only and their dose-effect relation remained more constant (after one week: 1.9 degrees /mm, after 3 months: 1.7 degrees /mm). CONCLUSIONS: The diagnostic value of preoperative prismatic correction of the deviation is very limited. Even if diplopia can be provoked, the chance of disturbing diplopia is very low. Nevertheless, some guidelines for pre- and postoperative care are necessary to prevent double vision. The postoperative outcome is favourable for the patient after one operation. In cases of relapsing divergence a second operation is easily possible.

Adolescent↗
PubMed2000

Transient exotropia after posterior spinal fusion in a child: a new case.

Ocular complications after spinal surgery are rare, although ischemic optic neuropathy, occipital lobe infarcts, and central retinal vein thrombosis have been reported. Our purpose is to report a case of an acute, comitant, postoperative exotropia that rapidly and spontaneously resolved. This case is particularly interesting in that it may indirectly shed some light on mechanisms of vergence control.

Child↗
PubMed2001

Long-term outcome of uncomplicated infantile exotropia.

PURPOSE: The term congenital exotropia (XT) is typically reserved for patients presenting in the first year with a large, constant angle, however, no published study provides a rationale for this restrictive definition. In this study, the present classification system for XT was evaluated and differences between infants with constant versus intermittent XT at presentation were characterized. METHODS: Medical records of all patients diagnosed with XT before 12 months of age between 1980 and 1994 were identified by computer search. Exclusion criteria included previous eye muscle surgery, resolution of the XT by 3 months of age, and concomitant systemic or ocular disease. Patients were separated into intermittent XT and constant XT groups. The clinical characteristics and outcomes of these two groups were compared. RESULTS: Of 2018 patients examined on our service during the first year of life for all causes, 23 (1.1 %) met the inclusion criteria. Follow-up data of more than 1 year was available for 13 patients, and of these, 46% had constant XT. The 2 groups had similar clinical features at presentation except for a larger initial angle in the constant XT group (P =.02). Average follow-up was 58 months (range: 13-158 months). Twelve patients (92%) required surgery. The reoperation rate was 27%, and 82% had final horizontal deviations of less than 10 PD. The incidence of A/V-patterns (38%), dissociated vertical deviation (46%), and binocularity (70%) was similar between groups. CONCLUSION: Half of infantile XT patients may present with intermittent XT, with similar clinical outcomes regardless of presentation. Surgical intervention resulted in successful alignment in most cases. More than half the patients developed measurable stereopsis, but none achieved bifixation.

Depth Perception↗
PubMed1992

Treatment options in intermittent exotropia: a critical appraisal.

Clinical opinions regarding treatment of intermittent exotropia (IXT) vary widely and there is controversy as to which treatment modality is most successful. This paper reviews the clinical literature related to five different treatment modalities used for IXT: overminus lens therapy, prism therapy, occlusion therapy, extraocular muscle surgery, and orthoptic vision therapy. Based upon review of 59 studies of treatment of IXT, and using each author's stated criteria for success, the following pooled success rates were revealed: over-minus lens therapy (N = 215), 28%; prism therapy (N = 201), 28%; occlusion therapy (N = 170), 37%; extraocular muscle surgery (N = 2530), 46%; and orthoptic vision therapy (N = 740), 59%. Success rates for IXT surgery differed depending upon whether a functional (43%) or cosmetic (61%) criterion was used to evaluate treatment success. These pooled success rates must be viewed carefully because nearly all the studies suffer from serious scientific flaws such as small sample sizes, selection bias, inadequately defined treatments and success criteria, absence of statistical analysis, and results reported in a manner that makes interpretation difficult. These problems indicate the need for a careful, circumscribed, and well controlled clinical trial to study the efficacy of different treatment modalities in remediating IXT.

Contact Lenses↗
PubMed1997

A case-comparison of intermittent exotropia and quality of life measurements.

A Vision Quality of Life Questionnaire that combines the SF-20 and a Vision Quality Scale developed by the authors was pilot tested in a case-comparison of extreme groups, patients with intermittent exotropia (IXT) and those with no vision problems (Non-IXT), at the University of Houston (UH) Optometry Clinic. The purposes of the study were to measure the internal consistency reliability and examine the validity-related evidence of vision function associated with the instrument. The pilot study involved mailing the instrument to 52 patients in each group (IXT and Non-IXT patients). IXT patients were then frequency-matched by age and separately by sex, to control for confounding variables, to Non-IXT group patients. The Cronbach's Alpha internal consistency reliability of both scales was acceptable at > 0.70 for both the IXT and Non-IXT groups. The Wilcoxon signed ranks test was used to determine validity-related evidence. The differences between groups on the SF-20 (p = 0.0276) and Vision Function Scale (VFS) (p = 0.0385) confirm that the scales discriminate between IXT and Non-IXT populations. Two conclusions can be drawn from the pretesting and pilot testing of the SF-20 and the VFS: (1) both have acceptable internal consistency reliability scores, and (2) both show validity-related evidence that they can discriminate vision function between IXT and Non-IXT patient populations.

Adolescent↗
PubMed2000

Field expansion for homonymous hemianopia by optically induced peripheral exotropia.

PURPOSE: To describe a novel method for prism correction of hemianopia that provides field-of-view expansion in a convenient and functional format and to evaluate initial clinical application. METHOD: To expand the upper quadrant of the field, a high power prism segment (30-40delta) is placed base-out across the upper part of the spectacle lens, on the side of the loss, at about the level of the limbus. A similar prism segment at the lower part of the lens is used to treat the lower field. The peripheral location of the prisms causes peripheral exotropia. As a result a scene segment as high as the vertical span of the prism is shifted laterally by 15 to 20 degrees relative to the view of the other eye. At the edge of the hemianopic field loss, objects that would fall in the scotoma of one eye are seen through the prism in the other eye, providing a simultaneous awareness of details within the otherwise absent field-of-view. An approach for fitting the system to patients with abnormal binocular vision (strabismus and amblyopia, with or without diplopia) is discussed as well. The effect of the prisms was evaluated in a noncomparative case series (12 patients). RESULTS: The field expansion is provided at any position of lateral gaze, including gaze away from the side of the scotoma. The effect of this technique on field expansion was demonstrated using standard binocular perimetry. Most patients reported substantial improvement in function and in obstacle avoidance. CONCLUSION: A novel method for the optical treatment of hemianopia was developed and tested. It was found to be effective in expanding the field and helping patients' mobility.

Adaptation, Ocular↗
PubMed1997

Comparison of surgical results of responders and non-responders to the prism adaptation test in intermittent exotropia.

The data for 94 consecutive patients with intermittent exotropia of basic type, ranging from 20 to 40 prism diopters (delta), who preoperatively wore neutralizing prisms for 3 to 5 days, were studied retrospectively. The surgery in 43 patients in whom the amount of increase of angle was 4delta or less was based on the original angle (Group A), while that in 51 patients in whom the magnitude of increase was 5delta or more was based on the increased angle of deviation (Group B). Patients with initial deviation less than 30delta and patients younger than 7 years of age showed an increase of deviation with prism correction. There were no significant differences in surgical results between the two groups at 1 year, and at 3 years; although at 3 years satisfactory motor alignment and binocular function for single vision at distance was higher in Group B than that in Group A.

Adaptation, Ocular↗
PubMed2004

The Newcastle Control Score: a new method of grading the severity of intermittent distance exotropia.

AIM: To describe the development and application of a novel scoring system for grading the severity of intermittent distance exotropia (IDEX) and its potential application as an intervention criterion for surgical intervention. METHODS: The Newcastle Control Score (NCS) for IDEX was developed by incorporating both subjective (home control) and objective (clinic control) criteria into a scale to grade severity. The score structure described was evaluated for interobserver and test-retest reliability. To determine an optimal score threshold for surgical intervention, 170 cases of IDEX were scored retrospectively. Cure rates for surgical and non-surgical cases were then compared according to preoperative or presenting scores. RESULTS: Interobserver and test-test reliability were good (r = 0.82 and r = 0.89 respectively). Total cure rate with surgery was 54% and without surgery 18% (chi(2) = 23.093, df = 1, p<0.001). Significantly fewer patients with NCS >/=3 achieved cure without surgery than those with NCS 2 (chi(2) = 3.362, df = 1, p<0.047). CONCLUSIONS: The NCS is a reliable method for grading the severity of IDEX and aids decisions regarding intervention. Patients with a score of 3 or more are unlikely to attain a cure without surgery.

Child↗
PubMed2006

The use of the Newcastle Control Score in the management of intermittent exotropia.

AIM: To evaluate the use of the Newcastle Control Score (NCS) in the management of intermittent exotropia (X(T)). PARTICIPANTS AND METHODS: Children aged <11 years with X(T) had an assessment of NCS as part of routine management. Other data collected included visual acuity, near and distance alignment with alternating prism cover test and near (Frisby test) and distance stereoacuity (Frisby Davis Distance Stereotest (FD2TM)). Analysis involved correlation between baseline NCS, angle and stereoacuity, examination of change over time and logistic regression to determine predictors of surgery. RESULTS: Baseline data were obtained on 272 children and follow-up data on 157. Mean (SD) age was 4 (1.9) years. Complete NCSs were obtained for all except one child at baseline, and all children at follow-up. At baseline, total NCS and the home control component were correlated with near stereo (r = -0.22, p<0.01 and r = -0.19, p<0.02, respectively), near alignment (r = 0.34, p<0.001 and r = 0.19, p<0.02) and distance alignment (r = 0.30, p<0.001 and r = 0.26, p<0.001). The clinic near control component was correlated with near alignment (r = 0.39, p<0.001), but not near stereoacuity, and the clinic distance control with near alignment (r = 0.16, p<0.02), distance alignment (r = 0.27, p<0.001) and distance stereoacuity (r = -0.25, p<0.03). A high (poor) NCS (> or =4) at the latest follow-up predicted surgery (p<0.001, OR 29.3, 95% CI 6.2 to 138.7). CONCLUSION: The NCS is a useful measure of the clinical severity of X(T), can be used to serially assess improvement or deterioration and is a useful tool for the management of these patients.

Child↗
PubMed1986

The magician's forceps phenomenon in exotropia under general anaesthesia.

Prifinium bromide was administered for eight weeks to three patients with exotropia. Under general anaesthesia active discharges from the lateral rectus muscles were demonstrated by electromyography. When a slight adductive force was applied to the straight or the master eye, active discharge from the lateral rectus of the associate eye disappeared in all patients, and this eye moved in the direction of orthophorisation. The discharge reappeared when the master eye was released from the forced adduction. From these results the authors concluded that proprioception is involved in the magician's forceps phenomenon discovered by Mitsui in exotropic patients in 1978.

Adolescent↗
PubMed1996

Results of surgery for paralytic exotropia due to oculomotor palsy.

In 138 cases of paralytic exotropia due to oculomotor palsy, transposition of the superior oblique muscle and resection of the medial rectus muscle were carried out. Surgery was performed with or without recession of the lateral rectus muscle. The long-term prognosis for 4 years or more was observed in 35 cases. We found that the same results could be obtained by selecting transposition of the superior oblique muscle in cases of complete palsy and resection of the medical rectus muscle in cases of incomplete palsy. There was no benefit in combining resection of the medial rectus muscle when performing the transposition of the superior oblique muscle. Regardless of which method was used, a combination with recession of the lateral rectus muscle greatly improved the effectiveness of the procedure.

Adolescent↗
PubMed2006

Clinical study for the undercorrection factor in intermittent exotropia.

PURPOSE: The surgical technique for intermittent exotropia [X(T)] is quite simple. However, in many cases, the condition recurs due to any one of a number of causes, including undercorrection. This study examined the factors associated with undercorrection on X(T) patients. METHODS: The study examined 199 X(T) patients who underwent bilateral recession of the lateral rectus muscle or unilateral recession of the lateral rectus muscle and resection of the medial rectus muscle, and who were followed-up for more than a year. Patients whose near and far distance angles of deviation were 9 prism diopters (PD) or more at one year after surgery were designated as group 1. Those whose PD was 8 or below or who had orthophoria were assigned to group 2. Various factors were compared and analyzed. RESULTS: One day after surgery, group 1 showed an average overcorrection of 1.9 and 4.1 PD at near and far, respectively, and group 2 showed an average overcorrection of 6.3 and 7.6 PD at near and far, respectively. A statistically significant difference was observed between the two groups (p < 0.05). Factors such as the age of onset of strabismus, age at the time of surgery, the interval from the onset of strabismus to surgery, the preoperative angle of deviation, the dissociated vertical deviation, amblyopia, anisometropia and vertical strabismus had no influence on the undercorrection of X(T) patients (p > 0.05). CONCLUSIONS: Of the many factors that might influence the surgical results of X(T) patients, the angle of deviation during the initial postoperative period is the most important factor.

Child, Preschool↗
PubMedDate not supplied

Episodic exotropia from lateral rectus neuromyotonia--appearance and remission after radiation therapy for a thalamic glioma.

Sixteen months after radiation therapy for a moderately anaplastic astrocytoma of the thalamus, a 7-year-old boy developed spontaneous episodic contractions in his left lateral rectus muscle. During these episodes, lasting 10 to 30 seconds and occurring 20 or more times a day, he had exotropia, limitation of adduction, and retraction of the left globe. This phenomenon peaked in duration and frequency at 14 months and gradually disappeared after 22 months. As this case confirms, radiation injury to the abducens nerve can cause ocular neuromyotonia, resulting in episodic strabismus. Our case also illustrates that this condition can disappear completely after many months.

Abducens Nerve↗
PubMedDate not supplied

Advancement of medial rectus muscle to the original insertion for consecutive exotropia.

Twenty-four patients who underwent surgery to correct consecutive exotropia that developed iatrogenically after surgical overcorrection were studied retrospectively. All patients underwent single or bilateral advancement of the medial rectus muscle to the original muscle insertion. The mean preoperative exodeviation was 26.7 prism diopters at distance and 35.2 delta at near. Postoperatively, in cases receiving advancement of a single medial rectus, the mean amount of correction was 23.2 delta at distance and 29.6 delta at near. In cases receiving bilateral medial rectus advancement, the mean amount of postoperative correction was 26.3 delta at distance and 39.8 delta at near. Adduction deficiency was normalized in five patients (71%), while convergence insufficiency was improved in only nine patients (45%) after surgery. Twelve (50%) patients had binocular single vision at distance on a normal or abnormal basis as determined by the Bagolini lens test.

Adolescent↗
PubMedDate not supplied

Unilateral surgery for exotropia with convergence weakness.

We prospectively studied 14 patients whom we treated surgically for exotropia (XT) with convergence weakness measuring at least 8 delta for distance (6 m) that increased at least 8 delta at near (1/3 m). Surgery involved lateral rectus recessions and medial rectus strengthenings (advancements or resections) to eliminate distance and near deviations and simultaneously collapse near-distance differences. The medial rectus was strengthened more than the lateral rectus was recessed; amounts were based on the near deviation. Minimum follow-up was 6 months after surgery. Preoperatively, the mean XT at distance was 18.3 delta (range, 8 to 35 delta) and at near 30.1 delta (range, 16 to 50 delta). At latest follow-up evaluations the mean distance deviation was 0.1 delta XT and at near 1.8 delta XT. The near-distance differences were reduced by a mean of 10.2 delta; the mean postoperative difference was 1.7 delta. Unilateral surgery for XT with convergence weakness biased to medial rectus strengthening and geared to near deviation can successfully collapse the near-distance differences while satisfactorily aligning both distance and near fixation. This surgery has low risk of creating long-term postoperative esodeviations at distance.

Adolescent↗