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PubMed2002

[Study on the near, middle and long distance stereopsis of normal and children with intermittent exotropia].

OBJECTIVE: To study the pre- and post-operative changes of stereopsis at different distances in normal and children with divergence in excess type of intermittent exotropia. METHODS: TNO and new stereo tests (NST) and the middle and long distance stereotest were used for the evaluation of stereoacuity at 40 cm - 5 m in 844 normal and 35 children aged 4 - 12 years with divergence excess type of intermittent exotropia undergoing operative correction of strabismus. RESULT: (1) Normal subjects: The TNO test showed that the near distance stereoacuity </= 60" was in 98% subjects aged 4 - 8 years. The stereoacuity was increased with the increase of age, the correlation being linear. The stereoacuity in children aged 10 - 11 years was the lowest. In the comparison of stereoacuity between children aged 4 - 8 years and 9 - 12 years, the difference in distribution was very significant (P < 0.01). The NST test showed that the near stereoacuity >/= 40" was in 97% subjects. The mean stereoacuity was 40" - 42" in children various in age. The middle and far distance stereoacuity was the greatest in children aged 4 years, along with the increase of age, it was gradually declined and at 9 - 10 years it was the lowest. (2) Divergence excess type of intermittent extropia: There was no significant difference between the pre- and post-operative near stereoacuity examined by TNO and NST (P > 0.05) The pre-operative middle and long distance stereoacuities were greater than that in the normal children, the difference being significant (P < 0.05). The post-operative middle distance stereoacuity was improved and approximately normal in comparison with that before the surgery, and the far distance stereoacuity was improved mildly. CONCLUSIONS: (1) In the normal group, the development of stereopsis at different distances begins at 4 years, keeping on developing with the increase of age, and the stereoacuity is elevated after 8 years and in 9 - 11 years well developed. (2) In the group of divergence excess type of intermittent exotropia, the pre-operative near stereoacuity is well, but the middle and far distance stereoacuities are poor and the middle stereoacuity improves significantly after the surgery. The recovery of middle distance stereoacuity seems to be an objective criterion of the operative therapeutic effect.

Age Factors↗
PubMed1992

[A case of hemi-hyperhidrosis and non-paralytic pontine exotropia due to brainstem infarction].

A case of hemihyperhidrosis and non-paralytic pontine exotropia due to brainstem infarction is reported. A 55-year-old hypertensive man developed right hemiparesis with slight dysarthria and nausea upon awaking. The right side of his face and right upper limb and trunk to the level of the Th8-9 territory showed hyperhidrosis, which disappeared in a week. Ocular motor examination revealed that during forward gaze with the left eye fixing, the right eye deviated outward. The patient was able to adduct the right eye to midposition with the right eye fixing. Rightward gaze elicited full abduction and right-beating nystagmus of the right eye, but the left eye did not adduct. When he attempted to gaze leftward, both eyes made the full excursion, but saccades were slow in that direction. Convergence was intact. Vertical gaze was full, and he did not show Horner's sign. This ocular sign, non-paralytic pontine exotropia, disappeared three days later. T2-weighted spin echo magnetic resonance imaging disclosed a small lesion with high intensity in the inner side of the left middle pons. This hyperhidrosis was thought to be caused by destruction of inhibitory fibers thermoregulating sweating. These findings suggest that at the level of the middle pons inhibitory fibers descend along the inner side of facilitatory fibers thermoregulating sweating, which are speculated to descend the dorso-lateral part of the pontine tegmentum. These findings also suggest that lesions of non-paralytic pontine exotropia may be located in the paramedian pontine reticular formation rostral to the abducens nucleus with ipsilateral medial longitudinal fasciculus lesion, but further investigation is necessary.

Brain Stem↗
PubMed2003

Outcome of 5 mm resection of one medial rectus extraocular muscle for recurrent exotropia.

PURPOSE: To evaluate the success rate of 5 mm resection of one medial rectus (MR) as the second surgery for intermittent exotropia of childhood after bilateral lateral rectus recessions and after unilateral lateral rectus recessions, and to propose a theory of how this surgery works. CASES: The author performed a retrospective chart review of 10 years experience of routinely performing a 5 mm resection of one medial rectus as the second surgery for exotropia recurrent after unilateral or bilateral lateral rectus (LR) recession. A total of 45 cases of children receiving a second surgery for recurrent exotropia, a 5 mm resection of one medial rectus in all cases, were identified. Ten of the second surgeries were performed with the first surgery having been a large unilateral LR recession. Thirty-five had received bilateral LR recessions as the first procedure. Only those cases needing a third surgery prior to 2 years or with at least two years followup with continued good binocular alignment were included. OUTCOME: Residual deviations of 8 XT to 10 ET, inclusive, (or less) were considered surgical "successes". RESULTS: Of the 10 whose first surgery had been a unilateral LR recession (8-9 mm for 9 of the 10), the two year failure rate was 4/10. Of the 35 whose first surgery had been a bilateral LR recession (4.5 to 8.2 mm), the two year failure rate was 4/35. The time to failure after resection of one MR averaged 27 months for the 6/10 failures of the unilateral LR recession group; the time to failure after resection of one MR for the 14/35 failures of the bilateral LR recession group averaged 42 months. CONCLUSIONS: The more rapid failure of resection of one MR for those whose first surgery was a unilateral instead of a bilateral LR recession suggests that recession of the other LR may yield a higher success rate for the unilateral LR recession group in the future. Resection may work for a long time due to removal of embryonic myosin responsible for restoration of normal linear sarcomeric density.

Child, Preschool↗
PubMed2003

When the patient says no. Management of exotropia with hemianopic visual field defects.

BACKGROUND: A homonymous hemianopia can be compensated for by an exotropia in the direction of the visual field defect. CASE REPORTS (AND LITERATURE REVIEW): Two young males with visual field defects and exotropia are reported. Both refused surgery when they were advised of the risk of reduction of their binocular visual field with the alignment of their eyes. CONCLUSION: Mapping of the binocular visual field is mandatory in patients with exotropia and neurological involvement to search for this rare combination which could produce a disappointing surgical outcome.

Adult↗
PubMed1991

[Intermittent exotropia associated with accommodative esotropia].

Intermittent exotropia associated with accommodative esotropia is a rare particular type of strabismus. 8 cases of XT-ET were presented here. The clinical features of them were summarized as follows: 1. The age of onset was early. 2. The initial symptom was esotropia, exotropia was observed by doctor. 3. The most patients (6/8) associated high or medium hyperopia. 4. The AC/A rate were normal or lower than normal. 5. The angle of deviation varied with the examination, exotropia 30 degrees-15 degrees<-->orthophoria<-->esotropia 15 degrees-30 degrees. 6. The esotropia can be corrected with spectacles. The visual-vestibular interaction examination for eye movement were examined in 3 cases, but have no regular expression yet. Finally, the incidence (0.4%, 8/21 58) and treatment for this disease were discussed.

Accommodation, Ocular↗
PubMed1990

[A case of non-paralytic pontine exotropia due to pontine tegmentum lesion confirmed by magnetic resonance imaging and electronystagmography].

A case with non-paralytic pontine exotropia (NPPE) due to brainstem infarction is reported. A 77-year-old hypertensive man suddenly developed dizziness, double vision, dysarthria, and right ataxic hemiparesis. Oculomotor findings on admission consisted of: (1) full right exotropia in the primary position; (2) complete adductive paralysis of the left eye with slight preservation of convergence; (3) tonic deviation of the right eye to the full abducting position with right-beating nystagmus after an immediate forward gaze. The leftward saccades showed multiple saccades with slow velocity on electronystagmography (ENG). The right exotropia disappeared and the slight adductive paresis of the left eye remained with right monocular nystagmus seven weeks after the onset. Magnetic resonance imaging (MRI), which was performed nine weeks after the onset, disclosed a small lesion with high intensity involving the left medial longitudinal fasciculus (MLF) on T2-weighted spin echo image. The leftward saccades showed multiple saccades with normal velocity eleven weeks after the onset. The hypofunction of unilateral PPRF with ipsilateral MLF lesion probably causes the contralateral NPPE.

Aged↗
PubMedDate not supplied

[Personal experience with consecutive exotropia].

This article presents a detailed analysis of sensor and surgical exotropias. Of the 669 operated esotropias 20 patients (2.98%) had surgical consecutive exotropia. Of the 1264 esotropias treated conservatively throughout several years, 7 patients (0.55%) showed sensor consecutive exodeviation. In both groups exotropia appeared in more than 60% of children after the age of 10 years. In 45% of the cases, surgical exodeviation appeared within 6 months of surgical treatment what suggests a wrong estimation of the situation. In the age from 2 to 5 years, 75% of the children were surgically treated. In 65% of the operated patients, several factors were present at the same time, such as amblyopia, anisometropia and vertical component.

Child↗
PubMed1989

[Postoperative secondary divergent strabismus. Statistical analysis of 160 consecutive exotropias].

Exotropias secondary to convergent squint surgery are fully different from primary exotropias. Their frequency appears to be largely variable according to the operative procedures. The computerized analysis of 160 consecutive exotropias reveals the compound nature of their motor impairments. In each case it is necessary to carry out a careful check up of various causal parameters, but the authors find they are not bound by simple correlations. In all cases an elongation reducing one or several muscles is noticed. Such anomalies are much more frequent and heavy than those observed in primary esotropias. Their iatrogenic origin is unquestionable. In 37% of the cases heavy capsular scars have been observed; their consequences on passive forces are obvious, but it is difficult to carry out their exact evaluation by the usual clinical tests. In that series the resulting surgical planning was made according to the various abnormal parameters had allowed the achievement of a good motor result in 89% of the cases. In 86% of the cases, only one additional operative procedure was necessary.

Esotropia↗
PubMed1983

[Paralytic and non-paralytic pontine exotropia].

Paralytic pontine exotropia is a form of the one-and-a half syndrome of Fisher, in which an acute lesion of the paramedian pontine reticular formation (PPRF) is present. We compared such a case with a case of pontine exotropia without lateral gaze palsy, but in which the alteration of the ipsilateral saccades suggested a partial lesion of the PPRF. We suggest to call this oculomotor disturbance "non paralytic pontine exotropia".

Aged↗
PubMed1995

[Surgical and botulinum toxin treatment in two cases of abnormal retinal correspondence-exotropia with congenital homonymous hemianopsia].

We report 2 unusual cases of congenital occipital hemianopsia associated with abnormal retinal correspondence (ARC)-exotropia. Two Japanese males, 25 and 28 years of age, visited our hospital for surgical correction of manifest exotropia with dissociated vertical deviation and overaction of the superior oblique muscle. Visual field examination demonstrated homonymous hemianopsia with approximately 5 to 10 degrees of macular sparing. Visually evoked potential examination showed small amplitude similar to dissociated vertical deviation patients in all half-field stimulation. Electrooculogram examination demonstrated defective pursuit to the ipsilateral side. Some investigators have speculated that progressive exotropia compensates for homonymous hemianopsia and is a rare contraindication for strabismus surgery. To confirm the deterioration of motor and visual functions before surgery in these patients, we tried injections of botulinum A type toxin into the lateral rectus muscle ipsilateral to the hemianopsia. Contrary to the hypothesis, our patients had no change in their binocular visual fields and visual function. Finally, we performed recession of the lateral rectus muscle, so that both patients were satisfied with their ocular alignment, with no marked change of visual behavior.

Adult↗
PubMed1994

[Binocularity after treatment for constant exotropia].

We studied the binocularity of cured chronic exotropic patients and discussed the critical period of gross stereopsis and its vulnerability. An infant, developing chronic exotropia associated with myasthenia gravis at the age of 17 months, returned to exophoria 10 months later and showed a stereo-acuity of 800 sec. This clinical finding suggests that the critical period for gross stereopsis is before the age of 18 months and the function is recoverable even when it is suppressed for several months after that period. Of the 18 patients with chronic exotropia who had undergone surgery after school age. 16 patients (83.3%) recovered stereoacuity of 3,000 sec or better, which suggests that gross stereopsis once established will never vanish. Patients with chronic exotropia with poor central vision also recovered gross stereopsis and stable eye position after strabismus surgery, indicating that gross stereopsis with peripheral fusion is significant for the stabilization of the eye position.

Adolescent↗
PubMed1998

Comparison between adjustable and non-adjustable hang-back muscle recession for concomitant exotropia.

We compared the results of strabismus surgery using adjustable and non-adjustable hang-back muscle recessions in 38 patients having concomitant exotropia. The two groups were matched for age of the patient, type of concomitant exotropia, amount of deviation, and type and amount of muscle surgery. At 6 months follow-up, 18 of the 19 patients (95%) in the adjustable hang-back recession group and 17 of the 19 patients (90%) in the non-adjustable hang-back recession group had ocular alignment within 10 prism diopters (PD) of orthophoria. At the most recent follow-up (mean 3.4 years), 12 of the 13 patients (92%) in adjustable hang-back recession group and 12 of the 14 patients (86%) in non-adjustable hang-back recession group had ocular alignment within 10 PD of orthophoria. There was no statistically significant difference in success rates between the two groups at 6 months postoperatively and at the most recent follow-up. This preliminary study suggests that non-adjustable hang-back muscle recession can be considered for routine concomitant exotropia.

Adolescent↗
PubMed1998

Results of large (8-9 mm) bilateral lateral rectus muscle recessions for exotropia.

PURPOSE: Commonly recommended maximum lateral rectus muscle recession for exotropia ranges from as little as 7 mm to as much as 11 mm. Published studies on recessions of 8 mm or more are scarce. Many ophthalmic surgeons still avoid recessions larger than 7 mm because of the fear of creating abduction deficits and surgical overcorrections. Therefore, we sought to determine the incidence of clinically detectable abduction deficits and their correlation with early surgical overcorrection in exotropic patients who had undergone large 8 to 9 mm lateral rectus muscle recessions. SUBJECTS AND METHODS: A retrospective chart review identified 30 patients with exotropia ranging from 35delta to 65delta who were treated with 8 to 9 mm recessions of both lateral rectus muscles. Patients with concurrent oblique muscle surgery were included. Mean followup time was 15 months (range 3-30 mos). RESULTS: Twenty-four patients (80%) required only one operation. The remaining 6 patients (20%) required a second operation, four for overcorrection and two for undercorrection. Nine patients (30%) had mild but persistent abduction deficits postoperatively. However, abduction deficits were not predictive of poor outcome (p=0.959). Other variables that did not significantly affect outcome included age (p=0.894), systemic anomalies (p=0.127), size of preoperative exotropia (p=0.987) and amount of rectus muscle recession (p=0.480). However, concurrent oblique muscle surgery was associated with a higher risk of a poor result. CONCLUSIONS: 8-9 mm lateral rectus recessions are not associated with a poor outcome, except in association with concurrent oblique muscle surgery.

Adolescent↗
PubMed1980

Multiple regression analysis predictor models in exotropia surgery.

We developed a statistical model based on multiple regression analysis from a sample population of 30 patients with intermittent exotropia who underwent bilateral recession of the lateral recti muscles. We also identified predictor variables, which accounted for most of the change in deviation per millimeter of surgery performed. The application of multiple regression analysis to the problem of exotropia may be limited by variation in predictor variables according to sample population, multicollinearity, measurement unreliability, and the unproven assumption that the preoperative calculation of effect per millimeter correlates well with postoperative clinical success. Controlled clinical trials are needed to determine the value of multiple regression analysis in exotropia surgery. Discriminant analysis may represent an alternative statistical technique with application to this particular problem.

Humans↗
PubMedDate not supplied

Postoperative exotropia.

One hundred fifty-four cases of infantile esotropia and acquired esotropia surgically treated before the age of seven were followed for a minimum of five years. We found 44% of infantile esotropia and 60% of acquired esotropia were converted to phoria with 20% having postoperative exotropia. Eight to 10 years of age seemed to be the turning point from esotropia to exotropia. Spontaneous decrease of accommodative convergence with age seemed to be the most important causative factor in relation to secondary exotropia. Long-term follow-up revealed the residual angle of deviation decreased with time and undercorrected esotropia resolved spontaneously. Therefore, it is the responsibility of the surgeon to encourage his patients to return regularly for follow-up visits even ten years after surgery for possible spontaneous change of deviation.

Adolescent↗
PubMed1998

Distance/near differences in intermittent exotropia.

BACKGROUND: Burian's classification of exotropia based on the difference between the distance deviation and near deviation (distance/near differences) leaves some questions unanswered. Controversy exists concerning whether the divergence excess pattern is caused by an excess of divergence or by excessive accommodative convergence. Much of the literature on this subject has been confusing because investigators did not eliminate tenacious proximal fusion as an artifact in calculating the ratio of accommodative convergence to accommodation (AC/A ratio). Previously, one of us (B.J.K.) proposed a classification system that respected this artifact and subdivided the classification system proposed by Burian. METHODS: A total of 202 consecutive patients with an exotropia underwent a series of measurements to determine the respective role of accommodative convergence and tenacious proximal fusion as a cause for their distance/near differences. In addition, the value obtained by a rapid prism adaptation test as a possible substitute for 1 hour of monocular occlusion was studied. RESULTS: In 98 patients, the initial distance deviation exceeded the near deviation. In 10 patients, the distance/near differences were caused by a high AC/A ratio, which would have been mislabeled by Burian's classification system. Brown's recommendation of using +3.00-diopter lenses at near to diagnose simulated divergence excess would have led to the misdiagnosis of a high AC/A ratio in 61 of these patients. In 26 patients, the near deviation exceeded the distance deviation. Burian's classification would have incorrectly labeled 2 patients as having convergence insufficiency when, in fact, they had pseudoconvergence insufficiency. The new proposed classification system proved 100% sensitive and 100% specific (6 of 6 patients for both parameters) for identifying preoperatively exotropic patients who postoperatively developed an esotropia at near with a high AC/A ratio. Rapid prism adaptation tests at near proved useful for identifying the presence of tenacious proximal fusion, but were not accurate in its quantification. CONCLUSIONS: The validity and utility of the new classification system was confirmed. Identification of exotropic patients with a high AC/A ratio and consideration of nonsurgical treatment is important. The rapid prism adaptation test is qualitatively, but not quantitatively, the same as 1 hour of monocular occlusion.

Accommodation, Ocular↗
PubMed1997

Exotropia secondary to vitreous hemorrhage.

BACKGROUND: Diplopia after cataract surgery has been reported by several authors, but diplopia after recovery from vitreous hemorrhage (VH) has not been described. METHODS: We examined eight patients with manifest exotropia and binocular diplopia after recovery from dense VH by vitreous surgery. VH was bilateral in three patients and unilateral in five, and lasted for an average of 7.7 years. RESULTS: Visual acuity before vitrectomy ranged from 20/200 to light perception; that after vitrectomy ranged from 20/20 to 20/60. Exotropia was present in all patients after vitrectomy. Additionally, seven out of eight patients had vertical strabismus with an average deviation of 6 prism diopters (delta). Fusion was confirmed in four patients with an average amplitude of 13 delta. Four patients underwent horizontal strabismus surgery. Fusion was present in two before strabismus surgery and in all four after surgery; however, unstable diplopia persisted in three of the four after surgery. CONCLUSION: Diplopia after vitrectomy for longstanding VH may occur due to fusion impairment comparable to that occasionally seen after surgery for traumatic cataract.

Adolescent↗
PubMed1966

The surgical treatment of intermittent exotropia.

A group of 38 cases of intermittent exotropia was examined. All operations were performed by the same surgeon. The follow-up period averaged 21 months. These patients were evaluated and treated, when necessary, by preoperative orthoptics. The records were analyzed for such characteristics as onset, duration, family history, visual acuity and refraction. These patients were classified into the following types of exotropia: primary (divergence excess), convergence insufficiency, and combined. The basic physiology of this condition is discussed. The progressive nature of this entity is demonstrated. The choice of operation depended upon the presence or absence of a significant deviation at near. In the postoperative evaluation, the absence of a tropia was the criteria for adequate surgical correction. Only 26 patients (68%) were adequately corrected.

Exotropia↗