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PubMed1995

Excess cyclovergence in patients with intermittent exotropia.

Recently, we developed a model of binocular fixation. This model predicts the amount of cyclovergence as a function of target elevation and horizontal target vergence. The prediction derives from the assumption that version and vergence add linearly and that the eye positions are constrained in three respects: (1) the foveae of the two eyes are directed towards the target, (2) the version component follows Listing's law, i.e. cycloversion, and horizontal and vertical version are not independent, (3) the vergence component is restricted to a plane approximately perpendicular to Listing's plane, i.e. horizontal, vertical and torsional vergence are not independent. The version and the vergence components are characterized by a common primary direction for the two eyes. We applied this model to data of patients with intermittent exotropia. In two patients with an amblyopic eye we found that the common primary direction rotates towards the amblyopic eye. In the third patient, not suffering from amblyopia, the common primary direction was practically straight ahead. In all three patients, cyclovergence angles were larger than those found in normal subjects. We found that the increased cyclovergence was compatible with our model for normal subjects if an offset on the horizontal vergence was given. This offset represents the additional convergence effort required in these patients to overcome the exodeviation of the eyes. According to our model the increased horizontal vergence effort results in excess cyclovergence. The relation between horizontal vergence and cyclovergence offers a new method for measuring the angle of exotropia.

Adult↗
PubMed2001

Prism adaptation response is useful for predicting surgical outcome in selected types of intermittent exotropia.

PURPOSE: To evaluate the prevalence of prism adaptation response in Japanese patients with intermittent exotropia (X [T]) using the prism adaptation test and to assess whether patients with selected types of X [T] benefit from surgical outcome to which prism adaptation response may contribute. METHODS: In a prospective study, 128 consecutive patients with X [T] between 1990 and 1995 were enrolled. The prism adaptation test was conducted by neutralizing the angle of deviation for 2 to 3 hours. Patients who showed an increase in exodeviation by 10triangle up or more with the prism adaptation test were defined as having a prism adaptation response. For classification of the pattern of X [T], we chose a value of 15triangle up as the difference between the distance and near measurements. RESULTS: The percentage of patients in whom the prism adaptation response was observed at near fixation was significantly larger than those at distance fixation [35 (27%) patients versus 10 (8%) patients, P <.05]. Of 35 patients shown to have a prism adaptation response at near fixation, 21 patients (83%) had the basic type of exotropia. Fourteen patients (17%) with the basic type were changed to convergence insufficiency type because of an increase in near deviation and were defined as pseudo basic type. Patients with pseudo basic type had a significantly better surgical outcome compared with that of true basic type, whereas in the convergence insufficiency type, no definite tendency was found between the two subtypes, true and pseudo types. CONCLUSION: Patients with the pseudo basic type of X [T] in whom a prism adaptation response was demonstrated had a more favorable surgical outcome.

Adaptation, Ocular↗
PubMedDate not supplied

Relationship between motor alignment at postoperative day 1 and at year 1 after symmetric and asymmetric surgery in intermittent exotropia.

PURPOSE: To evaluate the relationship between the motor alignment at postoperative day 1 and at year 1 following bilateral lateral rectus recession (BLR, symmetric surgery) and unilateral lateral rectus recession-medial rectus resection (R&R, asymmetric surgery) for the treatment of intermittent exotropia, X(T). METHODS: Forty-six patients with basic or pseudo-divergence excess type of X(T) underwent BLR and 57 patients underwent R&R. The motor alignment at postoperative day 1 was classified as overcorrected by 11-20 prism diopters (PD), overcorrected by 1-10 PD, orthotropic, or undercorrected by 1-10 PD of exotropia. RESULTS: There was a statistically significant relationship between the alignment at postoperative day 1 and at year 1 following both R&R and BLR surgery (r = 0.74, r = 0.51, respectively, P <.05). Patients overcorrected by 1-20 PD had a significantly higher success rate than those undercorrected by 1-10 PD on postoperative day 1 (P <.05). For R&R, a postoperative day 1 alignment of 1-10 PD resulted in the highest success rate of 73.7%. For BLR, a postoperative day 1 alignment of 11-20 PD showed the highest success rate of 76.9%. There were no significant differences in the success, undercorrection and overcorrection rates between the two surgical procedures after a 1-year postoperative period. CONCLUSIONS: The alignment at postoperative day 1 can be a predictive factor of the surgical outcome in X(T). A postoperative day 1 overcorrection of 11-20 PD following BLR surgery and an overcorrection of 1-10 PD following R&R can lead to good results.

Adolescent↗
PubMed1983

The surgical management of intermittent exotropia in adults.

Most studies of intermittent exotropia deal primarily with children. However, the manifestations of this disorder in adults differ considerably from those in children. The case records of 44 adults (ages 15-70) who underwent surgery for intermittent exotropia were analyzed. These patients experienced a variety of preoperative symptoms including diplopia, headache, difficulty with reading, and ocular fatigue or pain. Cosmesis was a rare presenting complaint. The authors recommend that surgery in adults be conservative, aiming at slight undercorrection. Surgical management was successful in 41 of 44 patients. All patients with postoperative exodeviations under 15 delta had complete resolution of symptoms. Most patients with larger residual exodeviations did not improve symptomatically; patients with postoperative exodeviations tended to experience persistent diplopia.

Adolescent↗
PubMed2001

Intermittent exotropia.

The ideal approach to the management of intermittent exotropia remains unclear. Well designed, prospective studies are limited. Furthermore, the criteria for success vary among health care professionals. Long-term outcomes of surgical intervention are not known, and the role of non-surgical treatment modalities has not been agreed upon. A multicenter study comparing surgical and nonsurgical treatment method has been proposed. If carried out, a study of this nature would greatly benefit many individuals affected by this common condition. Until then, intermittent exotropia will continue to be one of the most difficult problems to treat.

Child, Preschool↗
PubMed1999

Role of botulinum toxin A in surgically overcorrected exotropia.

PURPOSE: The purpose of this study was to define the role of botulinum toxin type A (BTXA) in surgically overcorrected exotropia. METHODS: A retrospective review was performed using the BTXA clinic database of more than 3500 patients to identify patients with a consecutive esotropia. RESULTS: Sixty patients met the inclusion criteria; the patients' ages ranged from 5 to 80 years. Before toxin treatment, an average of 1.8 operations had been performed per patient. The mean distance deviation was 17 PD base out and near deviation was 18 PD base out. The time from the last operation to an injection of BTXA averaged 28.3 months. We divided our patient population into 2 groups: those with fusion potential and those with no expected fusion potential. Of the 36 patients with fusion potential, 15 patients achieved and maintained good ocular alignment and resolution of their diplopia with an injection of BTXA. In the 24 patients with no expected fusion potential, 4 patients (17%) achieved and maintained good alignment with an injection of BTXA. Although they were not cured, 10 additional patients chose to have repeated BTXA injections to maintain their ocular alignment, whereas only 2 patients required occlusive methods to eradicate intractable diplopia. Five patients had additional surgery, of which 3 patients obtained a functional result. CONCLUSIONS: BTXA has a role in surgically overcorrected exotropia for patients in whom a functional result may be obtained. BTXA is of less value for patients with poor binocular function. It has proved especially useful as a treatment given only once for 42% of patients who could regain high-quality stereopsis. The safety and ease of administration of this treatment add to its merit.

Adolescent↗
PubMed2005

Interventions for intermittent distance exotropia: review.

PURPOSE: Management decisions in intermittent distance exotropia vary and lack well-defined clinical guidelines. We undertook a systematic review in an attempt to clarify the effects of various surgical and nonsurgical treatments and to establish the significance of factors such as age with respect to outcome. The review was undertaken in collaboration with the Cochrane Eyes and Vision Group. METHODS: Electronic and manual searches were undertaken to identify randomised controlled trials of surgical or nonsurgical treatments for intermittent distance exotropia. We also contacted researchers active in this field for information about further published or unpublished studies. There were no language restrictions. Study abstracts identified from the searches were analysed independently by the two reviewers (SR and LG) and marked for inclusion, exclusion, or consideration. Reviewer analysis was compared and full papers for appropriate studies were requested. RESULTS: No randomised controlled trials were found that met our selection criteria. CONCLUSIONS: The current literature consists mainly of retrospective reviews. These are difficult to compare and analyse due to variations in definition, intervention criteria, and outcome measures. However, there appears to be an agreement that the nonsurgical treatment is more appropriate in small-angle deviations or as a supplement to surgery. Studies supporting both early and late surgical intervention were found, so the optimal timing of surgical intervention could not be concluded. There is a need for robust clinical trials to improve the evidence base for the management of this condition.

Child↗
PubMed2006

[How useful is the prescription of glasses in intermittent exotropia and decompensating exophoria?].

BACKGROUND: The aim of this study was to investigate the effect of full correction of the retinoscopic measurements done in cycloplegia in two groups of patients with intermittent exotropia (IE) and decompensating exophoria (DE), respectively. PATIENTS AND METHODS: 58 patients (n = 29 each of IE and DE) fulfilled the inclusion criteria: retinoscopy in cycloplegia, follow-up of at least 6 weeks, age more than 2.5 years and reliable visual acuity. Exclusion criteria were all forms of secondary and constant exotropia, A-V incomitance of high amount and eyes with amblyopia (visual acuity in far distance < 0.5). The age median of refractometry was not higher in patients with IE compared to those with DE: 7.4 (3.10; 47.8) vs. 7.3 (3.8; 40.11) years, p = 0.33. Glasses were prescribed in any case of myopia and astigmatism as well as in hyperopia of > + 0.5 dpt. RESULTS: Mean refraction of both eyes (mean value of spherical equivalent of both eyes) was higher for IE compared to DE: 0.7 +/- 1.8 (- 5.13; + 4.75) vs. 0.1 +/- 1.7 (- 5.25; + 2.5) dpt, p = 0.9. Visual acuity improved in both groups significantly: median of visual acuity in IE: 0.9 (0.3; 1.25) vs. 1.1 (0.5; 1.25), p = 0.02; in DE: 1.0 (0.4: 1.25) vs. 1.0 (0.6; 1.25), p = 0.03. Considering only patients aged over 7 years the difference stayed significant only in the group of DE: IE: median 1.0 (0.5; 1.25) to 1.0 (0.5; 1.25), p = 0.2; DE: median 1.0 (0.8; 1.25 to 1.0 (0.8; 1.25): visual acuity was nearly always 1.0 and better, p = 0.009. In hyperopic patients a significant improvement of visual acuity could be seen: in IE from median 0.9 (0.3; 1.25) to 1.1 (0.5; 1.25), p = 0.02 , in DE visual acuity: median 1.0 (0.4; 1.25) to 1.1 (0.6: 1.25), p = 0.02, as well as stereoacuity improved significantly: median 60 (30; 240)'' vs. 60 (15; 240)'', p = 0.03. In patients aged over 7 years the improvement was no longer significant in IE: p = 0.7, but stayed significant in DE: p = 0.03. There was no significant change of the angle deviation in both groups. CONCLUSIONS: According to the results of this study, full correction of refractive errors in IE and DE leads to an improvement of the visual acuity mainly due to correction of myopia and astigmatism, but not to a better compensation of the angle deviation.

Child, Preschool↗
PubMed2002

Surgical results in large-angle exotropia.

PURPOSE: This study examines the surgical results of correcting large angle exodeviations in adults who may lack bifixation. The expected results in adults are not to achieve improved fusion but, rather, to construct the alignment. METHODS: A retrospective chart review was conducted of all patients with comitant exodeviation greater than 35 Delta examined and treated by 1 pediatric ophthalmologist between January 1994 and May 1999. Any patients with large A or V patterns, nystagmus, history of botulinum toxin injections for strabismus, paralytic or mechanical cause for strabismus, or use of adjustable sutures were excluded. Charts were reviewed for postoperative alignment. Postoperative results were separated into 3 categories: exodeviation greater than 10 Delta, successful outcome (esotropia<10 Delta, orthotropia, or exodeviation <10 Delta), or esotropia greater than 10 Delta. RESULTS: Sixty-three patients met the inclusion criteria. Their median age at the time of surgery was 18, with a standard deviation of 20. The majority of them had intermittent exotropia that had deteriorated into constant exotropia. Fifty-two patients had bilateral lateral rectus recessions, and 11 patients had recess/resect procedures. Sixty-two percent (39 of 63) had successful outcomes overall. Only 2 patients had overcorrection (esotropia>10 Delta). In patients with deviations greater than 50 Delta, 82% (9 of 11) were undercorrected (exodeviation >10 Delta). CONCLUSIONS: Large-angle exodeviations can be successfully approached with bilateral lateral rectus recessions or recess/resect procedures in preoperative deviations up to and including 50 Delta with a success rate of 71%. In larger deviations, 2-muscle surgery was not as successful (18%, or 2 of 11).

Adolescent↗
PubMed2002

A case of paradoxical diplopia in large-angle consecutive exotropia.

PURPOSE: To describe the investigation and subsequent management of paradoxical diplopia in unsightly exotropia. A 32-year-old lady requested surgical correction of a large manifest consecutive exotropia which, on initial correction with any base-in prism, was accompanied by paradoxical diplopia. METHODS: Botulinum toxin to the right lateral rectus reduced the deviation to 30 delta over a one-week period. The residual deviation was corrected with base-in Fresnel prisms which the patient wore constantly for another two weeks. Although there was demonstrable diplopia initially, it disappeared after 3-4 days of prism wear. Surgery was carried out comprising right lateral rectus recession (6 mm) and right medial rectus advancement from 12 mm to 6 mm posterior to the limbus. RESULTS: There was no diplopia following the surgery and the residual exodeviation measured 6 delta for near and 16 delta for distance (fixing OD). The patient remains symptom-free and cosmetically excellent. CONCLUSION: A gradual progressive reduction in the deviation using a combination of Botulinum toxin and prisms allowed a more informative conclusion to be made regarding the potential post-operative sensory status in this patient, by allowing her to slowly adjust to an altered ocular alignment. In patients with non-functional strabismus who may be at risk from post-operative diplopia, a trial with prisms over a few weeks with or without the addition of Botulinum toxin is advocated.

Adult↗
PubMed2002

Alternating ptosis associated with intermittent exotropia.

A unique case of alternating, poorly controlled, intermittent strabismus that improved after repair of bilateral, alternating congenital ptosis is described. A 7-year-old boy with bilateral, alternating congenital ptosis and poorly controlled, intermittent exotropia underwent bilateral frontalis suspensions. After surgery, the patient demonstrated improved control of his exotropia. We conclude that an alternating ptosis may lead to sensory deprivation of the occluded eye and decreased fusion, causing an intermittent strabismus to be poorly controlled. Repair of the ptosis to a sufficient eyelid height bilaterally may improve control of the strabismus, obviating strabismus surgery.

Blepharoplasty↗
PubMed1986

Orthophorization after occlusion-induced exotropia.

A 36-year-old male had been constantly wearing a patch to avoid diplopia since an operation on the right parietal area of the brain. Postsurgical visual field evaluation indicated a complete bilateral left hemianopia with macular splitting. The patient had a constant alternating comitant exotropia with no suppression. By terminating the patching, establishing the appropriate fixing eye, and applying relieving prisms, diplopia was removed. Once binocularity was thus established, it was found (over the course of 7 months) that binocular function was possible with diminishing amounts of prism power. During this 7-month period, measurements of the patient's heterophoria, motor fusion, and sensory fusion revealed that he adapted from his occlusion-induced exotropia toward an habitual heterophoria. Such vergence adaptation has been defined as orthophorization. The occurrence of vergence adaptation after sensory fusion indicates that sensory fusion plays an important role in the etiology of prism adaptation.

Adaptation, Physiological↗
PubMed2006

Intermittent exotropia: comparison of treatments.

PURPOSE: To identify the best treatment option for intermittent exotropia. METHODS: A retrospective analysis of the progress of 150 treated intermittent exotropia patients was performed. Treatment forms considered are: (i) surgery combined with orthoptic/occlusion therapy; (ii) surgery; (iii) orthoptic/occlusion therapy; and (iv) observation. Pearson's chi(2)-analysis of association of therapy form with success was performed. Reduction of exodeviation in prism dioptres between groups and subgroups were compared at 6 months, 1, 2 and 5 years follow up and the "within group" variations were compared. Exodeviation reduction in prism dioptres per millimetre of horizontal rectus surgery performed in the "surgery with orthoptic/occlusion therapy" and "surgery only" groups were compared. RESULTS: Chi(2)-analysis revealed a significantly highest (P < 0.001) association with success in the "surgery with orthoptic/occlusion therapy" group at follow up. ANOVA analysis revealed that surgery with orthoptic/occlusion therapy resulted significantly (P < 0.001) in the highest reduction of exodeviation as compared with the other three treatment modalities at each follow up. Reduction of exodeviation in prism dioptres per millimetre of horizontal rectus surgery performed was significantly higher (P < 0.05) in the surgery with orthoptic/occlusion therapy group as compared with surgery only at all follow ups. Chi(2)-test revealed no significant association of success with the magnitude of initial exodeviation (P > 0.05). CONCLUSION: Surgery with preoperative orthoptic/occlusion therapy had the highest success rates. Surgery with orthoptic/occlusion therapy was more effective in reducing exodeviation (prism dioptres per millimetre of horizontal rectus surgery), compared with surgery only.

Child↗
PubMed1984

Accommodative disfacility presenting as intermittent exotropia.

Accommodative disfacility and intermittent exotropia are two common clinically-observed ocular abnormalities. However, records of individual system dynamics are rare and mechanisms for possible interactive effects between the accommodation and the vergence system remain obscure in cases of system dysfunction. We present objective, quantitative, static and dynamic records of accommodation, vergence and related system responses in a symptomatic patient having accommodation disfacility and intermittent exotropia and propose that these two conditions worked in a pathogenic symbiotic manner.

Accommodation, Ocular↗
PubMed1983

[Surgical indication and results in exotropia with divergence excess].

4 patients with primary exotropia of divergent excess type and 6 patients suffering from secondary exotropia and raised AC/A ratio have been operated with combined external rectus recession interal rectus 'Fadenoperation' and, if necessary, internal rectus resection. In all patients, the far-/near angle difference has been diminished, and in most of them microstrabism was achieved. Lateral gaze incomitance or a significant reduction of the motility of the globe did not occur. Thus, this kind of operation can be recommended for both groups of patients.

Adolescent↗
PubMed2005

Sensory exotropia subsequent to senile cataract.

To evaluate the phacoemulsification and intraocular lens implantation in patients with sensory exotropia subsequent to senile cataract. The authors prospectively studied the role of phacoemulsification and intraocular lens implantation on 25 patients by observing visual acuity, ocular alignment, binocular vision and diplopia pre-, 1 month post- and 3 months post-operation. The patients underwent follow-up for three months. Postoperatively, one patient had a corrected visual acuity of 20/50, and 24 patients had 20/40 or better. The ocular alignment, binocular vision and diplopia were resolved spontaneously. Phacoemulsification and intraocular lens implantation performed together is effective on sensory exotropia subsequent to senile cataract.

Aged↗
PubMed1992

Binocularity and photophobia in intermittent exotropia.

The relationship between photophobia and binocular function in intermittent exotropia was examined in 42 subjects (21 patients and 21 controls). In all subjects fusional amplitude and strength of binocular sensory status were tested before and during exposure to bright light. An explanation of photophobia in intermittent exotropia was suggested as impairment in binocular cooperation, since the indicators of binocular function were significantly altered in the patients, particularly during light exposure.

Adolescent↗
PubMed1988

Infantile exotropia in healthy children.

Constant exotropia is uncommon during the first year of life. We retrospectively identified 13 patients with large, constant exotropia during the first year of life which required surgery. Bilateral lateral rectus muscle recessions were done in all 13 cases. Only two patients have required reoperation. The clinical characteristics and management of this unusual condition are similar to those of infantile esotropia.

Exotropia↗