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In a retrospective study of 89 patients with exotropia, the authors investigated the influence of active convergence exercises in the postoperative angle of deviation and found that convergence exercises do not increase the incidence or the size of the esodeviation post-operatively.
Eight patients with large-angle exotropia and unimprovable poor vision in one eye were treated with conventional maximum horizontal rectus recession/resection plus weakening of both obliques of the poorly seeing eye. This appears to be a useful alternative to "supermaximal" recession/resection procedures, which are more likely to lead to deficient or restricted rotations. The effect is probably due to the release of additional sites of contracture that occur in the oblique muscles. The principal disadvantage is a small postsurgical hypertropia of the operated eye, for which routine infraplacement of both horizontal recti can compensate adequately.
"Forced elimination" of anomalous correspondence in a patient with constant exotropia is discussed. Therapy was similar to classic visual therapy for esotropia: presenting targets at the angle of strabismus (Angle H) using a troposcope. Home therapy methods using anaglyphic techniques and after-images are described.
Objective infrared recording devices were used to measure simultaneously and continuously both accommodation and accommodative vergence to near stimuli in 4 subjects with intermittent exotropia of the divergence-excess type (2 simulated and 2 true). In addition standard clinically determined stimulus accommodative convergence to accommodation (AC/A) ratios were measured. Results showed the mean group response AC/C ratio to be 5.9/1 (range 4.5-8.0/1) with no differences between true and simulated divergence-excess. Similar AC/A ratios were found after 45 minutes of monocular occlusion. Our results clearly demonstrate relatively normal response AC/A ratios in these subjects. Thus, contrary to what is believed by many clinicians, the reduced ocular deviation at near compared with distance vision cannot be attributed primarily to an abnormally high AC/A ratio. We believe than fusional convergence after-effects and/or proximal convergence effects contribute to inflate the clinically determined stimulus AC/A ratios.
In summary, 22 patients have been presented who have undergone lateral rectus recessions ranging from 8 to 14 millimeters. The overall cosmetic success rate (plus or minus 15 diopters of orthophoria) was 77%. Eight of these patients had unilateral recession-resection procedures. Surgically created incomitance ranged from 3 millimeters to 6 millimeters and correlated only poorly with the amount of surgery performed. None of the patients complained of cosmetic or symptomatic effects of the lateral incomitancy induced. We have restricted surgery of the large angle exotrope to a single, two-muscle procedure, thereby decreasing patient morbidity. It is therefore our recommendation that surgery for large angle exotropia be restricted to two horizontal muscles.
Twenty-five patients with intermittent exotropia and suppression were prescribed prisms which neutralised their maximum deviation. Thirteen patients failed to wear their prisms properly and served as controls and none were cured. Eight of the 12 patients who wore their corrective prisms more than half the time they were awake were cured.
The most decisive factors for surgical intervention in intermittent exotropia are the frequency of manifest deviation, the motor disturbancies and the degree of binocular functions present. The disturbance of binocular function may be characterised primarily by the extent to which binocular vision is convergence-dependent. We prescribe increasingly strong correcting prisms preoperatively. The aim is to attain and stabilise the divergent position of rest, to approximate the near and distant angles in cases of pseudodivergenceexcess, and to eliminate convergence-dependency of binocular vision.
Among 78 children who had undergone surgery for intermittent exotropia, undercorrection was found in 39, an acceptable result in 33 and overcorrection in 6. A review conducted to determine what factors might explain the high frequency of undercorrection showed that the average age of the patients was higher than usual, and this was a significant prognostic factor. The presence or absence of associated hypertropias, lateral incomitance and A or V patterns was not of prognostic importance. Purposeful overcorrection of the exodeviation by 10 to 15 prism diopters tended to ensure a more satisfactory result.
Four cases of large angle exotropia secondary to third nerve palsy are presented. An effective technique involving recession of the lateral rectus and splitting and advancement of the medial rectus is presented.
Selected patients with blepharoptosis and exotropia with aberrant regeneration of the oculomotor nerve can achieve acceptable cosmesis by simple strabismus surgery. Patients with good lid position on attempted contralateral gaze are candidates for this new approach. With aberrant regeneration of the oculomotor nerve, the affected levator frequently becomes pathologically yoked to the contralateral lateral rectus muscle. In these cases, the ecotropia is corrected by a recess-resect procedure primarily or exclusively on the contralateral fixing eye such that postoperatively. The fixing eye is "abducted" by the patient to the primary position, and the ptotic lid elevates simultaneously.
Sensory and motor anomalies of the intermittent exotropia, the divergence excess type, have been described by various authors. However, previous theories of etiology fail to incorporate all the sensory motor anomalies typically found. The present paper attempts to develop a theory of etiology based upon sensory-motor findings and to offer a treatment plan consistent with those findings.
Intermittent exotropia is classified according to the AC/A ratio. Convergence amplitude measured on a light includes accommodative convergence. Amplitude measured while maintaining clear, single, binocular vision on 20/30 print utilizes only true fusional convergence.
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