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PubMed1997

Initial versus subsequent postoperative motor alignment in intermittent exotropia.

BACKGROUND: Although initial overcorrection is believed to be important after bilateral lateral rectus muscle recessions for intermittent exotropia, not all patients with desirable amounts of initial overcorrection have good final outcomes. The purpose of this study is to evaluate the relationship between initial postoperative and subsequent postoperative motor outcomes in a group of patients operated on for intermittent exotropia. METHODS: All patients on whom I performed bilateral lateral rectus muscle recessions as the initial surgical procedure for intermittent exotropia and who had at least 6 months of postoperative follow-up were included in this study. RESULTS: Of the 60 patients in this study, 38 (63%) had good outcomes (< or = 10 PD exophoria or < or = 5 PD esophoria), 15 (25%) had undercorrection (> 10 PD exodeviation), and seven (12%) had overcorrection (> 5 PD esodeviation). The chance of a good outcome was highest with initial postoperative alignment between orthotropia and 9 PD of esotropia, but 22% of patients with alignment in this range after the operation ended up overcorrected or undercorrected. Most patients had an exotropic drift after the operation, but seven patients had a drift in an esotropic direction. CONCLUSIONS: Although an initial alignment within the range of orthotropia to 9 PD of esotropia during the first few days after the operation is desirable for patients with intermittent exotropia, alignment within this range does not guarantee a good final outcome, nor does alignment outside this range guarantee a bad outcome. Little predictability exists with respect to the amount and occasionally even the direction of postoperative drift. This unpredictability may in part reflect the artifactual nature of the initial postoperative measurement.

Adolescent↗

PubMed1998

Surgical management of intermittent exotropia with high AC/A ratio.

BACKGROUND: A subgroup of patients with intermittent exotropia have a high AC/A ratio, which places them at risk for esotropia at near after surgical treatment of their distance deviation. METHODS: A retrospective review of six patients with intermittent exotropia and a high AC/A ratio who were simultaneously treated with lateral rectus recessions to fully correct their exotropia at distance and placement of posterior fixation sutures on both medial rectus muscles in hopes of preventing an esotropia at near after surgery. RESULTS: Despite the persistence of a high postoperative AC/A ratio as assessed by the gradient method, five of six patients achieved stable postoperative alignment at distance and near without bifocals. One patient required postoperative bifocal correction for intermittent esotropia at near. CONCLUSION: In patients with intermittent exotropia and a high AC/A ratio, posterior fixation of the medial rectus muscles at the time of lateral rectus recessions enables the surgeon to fully correct the distance deviation and minimizes the risk of postoperative esotropia at near.

Accommodation, Ocular↗

PubMed1998

Long-term results of botulinum toxin in consecutive and secondary exotropia: outcome in patients initially treated with botulinum toxin.

INTRODUCTION: Long-term ocular alignment can be difficult to achieve in patients with consecutive and secondary (sensory) exotropia, and botulinum neurotoxin A (BTXA) is a recognized alternative to surgery in this group. PATIENTS AND METHODS: We reviewed the results of 44 patients aged 15 to 77 years (mean 31 years) who underwent their first BTXA injections from 1989 to 1990. In 30% of cases the choice of toxin treatment was made by the patient. In the remainder BTXA was recommended by the clinician to assess the risk of postoperative diplopia. Thirty-three patients (75%) were consecutively exotropic and 68% of patients had had previous strabismus surgery. The mean preinjection deviation was 41 delta of exotropia (range 12 to 85 delta exotropia) and the minimum mean angle change after 1 injection was 27 delta (range 0 to 57 delta). The average number of injections was 3 (range 1 to 17). RESULTS: Of the patient group, 59% went on to strabismus surgery, 14% continued to attend for maintenance treatment, and 9% were discharged with a small, stable deviation. The remainder were either followed up elsewhere or failed to reattend. CONCLUSIONS: Botulinum toxin appears to be a satisfactory treatment for constant exotropia in patients at risk of postoperative diplopia who have undergone multiple operations but, because more than half the group went on to surgery, surgery as a first therapy may be preferable in uncomplicated cases.

Adolescent↗

PubMed2005

Unilateral recession-resection in children with exotropia of the convergence insufficiency type.

PURPOSE: The surgical success rates for intermittent exotropia of the convergence insufficiency type have been reported to be variable, and most were studied retrospectively in adults. The purpose of this study was to evaluate prospectively the long-term surgical results of unilateral lateral rectus (LR) muscle recession and medial rectus (MR) muscle resection in children with intermittent exotropia of the convergence insufficiency type. METHODS: A total of 14 children with intermittent exotropia greater at near than at distance by 10 prism diopters (PD) or more were included in this prospective study. The amounts of resection and recession were based on near and distance deviation, respectively. Minimum follow-up was 1 year (mean 26.6 months; range, 12-68 months) after surgery. The paired t-test was used to compare preoperative and postoperative measurements of the angle of deviation at distance and near, near-distance difference. RESULTS: Significant postoperative reduction was achieved in terms of mean distance exodeviation, from 22.5 PD to 9.1 PD (P=0.000), and mean near exodeviation from 33.8 PD to 13.6 PD (P=0.000). Mean near-distance difference reduced from 11.3 PD preoperatively to 4.6 PD postoperatively (P=0.000). Fresnel prism was used temporarily to treat postoperative esotropia in only one patient for postoperative 6 months. CONCLUSIONS: Unilateral surgery biased to MR strengthening more than LR weakening in children with intermittent exotropia of the convergence insufficiency type, was found to successfully reduce both distance and near deviation and to collapse near-distance differences with a low risk of long-term postoperative esotropia.

Child↗

PubMed2006

An office-based scale for assessing control in intermittent exotropia.

INTRODUCTION: Although intermittent exotropia may deteriorate with time, there are no widely accepted criteria for measuring progression in this disorder. The purpose of this study was to prospectively evaluate a new scale for assessing the level of control in children with intermittent exotropia. METHODS: Thirty consecutive pediatric patients (< 14 years) with intermittent exotropia were prospectively evaluated from July 1, 2004 through June 30, 2005 using a new scale to assess the level of control for both distance and near fixation. The distance score (0 to 5) was combined with the near score (0 to 5) to yield an overall control score from 0 to 10. RESULTS: The 30 patients were examined at a median age of 72 months (range, 15 months to 13 years). The level of control at distance was worse than or equal to the near level of control in all 30 patients. The control scores ranged from 0 to 5 for distance and 0 to 4 for near, with an overall control score ranging from 0 to 8 (median of 3). CONCLUSIONS: This new scale for assessing control in children with intermittent exotropia can be easily applied in the office setting and characterizes the wide range of control in this disorder.

Adolescent↗

PubMed1983

Consecutive exotropia following surgery.

We studied 250 patients with consecutive exotropia. The interval between the surgical procedure and the onset of the consecutive exotropia may take many years. Consecutive exotropia occurred with all types of corrective esotropia surgery that we studied. Amblyopia and medial rectus limitation postoperatively seemed to be common factors associated with consecutive exotropia.

Amblyopia↗

PubMed2002

Clinical effect of early surgery in infantile exotropia.

To evaluate the effects of early surgical intervention in infantile exotropia on the motor and sensory functions, we reviewed the records of 17 subjects diagnosed with exotropia before the age of 12 months, receiving surgery before the age of 24 months, with a follow-up period greater than one year, between 1996 and 2000. Of the 17 subjects (6 intermittent, 11 constant), 14 (82%) (6 intermittent, 8 constant) had a final horizontal deviation of <10 PD, with 3 (18%) needing a re-operation. Fusion and gross binocularity were developed in 7 (4 intermittent, 3 constant), and 11 (6 intermittent, 5 constant) subjects, respectively. Seven subjects developed stereopsis of 200 seconds or better, and 5 of the 6 with intermittent exotropia (83%) being involved. In conclusion, over 80% of the successful alignments were obtained with surgery before the age of 24 months in infantile exotropia, which was similar to previous studies. Furthermore, early surgical intervention, particularly in the intermittent phase, resulted in more effective sensory function.

Age Factors↗

PubMed2005

The clinical course of recurrent exotropia after reoperation for exodeviation.

PURPOSE: To determine the clinical course of recurrent exotropia after a secondary operation for exotropia. METHODS: The surgical results in 58 patients who had undergone reoperation for recurrent exotropia (reoperation group) were retrospectively investigated and compared with those of 100 patients who had undergone primary strabismus surgery only (primary operation group) using survival analysis. RESULTS: In the reoperation group, recurrence occurred in 19 of the 58 patients (33%). Survival analysis revealed that the recurrence rates in the reoperation group were significantly lower than those in the primary operation group at the same follow-up period after the corresponding strabismus surgery (p=0.018). The distant esodeviation at the postoperative 1st week after reoperation was the only significant factor associated with the recurrence after reoperation (p=0.01). CONCLUSIONS: Exotropia did recur after a secondary operation, although the recurrence rate was lower than that after a primary operation only.

Child↗

PubMedDate not supplied

Long-term results of unilateral lateral rectus recession in intermittent exotropia.

PURPOSE: Unilateral lateral rectus recession is an alternative procedure in the treatment of moderate angle intermittent exotropia. However, long-term results of unilateral lateral rectus recession have not yet been studied. The aim of this study was to determine the long-term stability of alignment following unilateral lateral rectus recession in patients with intermittent exotropia with a deviation of 25 to 30 PD. PATIENTS AND METHODS: Thirty-two patients with intermittent exotropia with a deviation of 25 to 30 PD were included in this study. All patients underwent 8-mm unilateral lateral rectus recession by conventional techniques. RESULTS: Satisfactory results (+/- 5 PD of orthophoria) were obtained in 77.7% of the patients after a 3-year follow-up period. The mean correction achieved was 22.9 PD. CONCLUSION: Our results indicate that 8-mm unilateral lateral rectus recession is an attractive alternative procedure in the treatment of intermittent exotropia with a deviation of 25 to 30 PD.

Child, Preschool↗

PubMedDate not supplied

Adjustable medial rectus muscle resection in adult exotropia.

PURPOSE: To describe the success of a unilateral recess/resect procedure incorporating an adjustable medial rectus muscle resection in the treatment of adult exotropia. METHODS: The charts of 60 consecutive adult patients with exotropia undergoing lateral rectus muscle recession and adjustable medial rectus muscle resection from November 1998 to August 2003 were reviewed. RESULTS: In 56 (93%) patients, postoperative alignment was within 10 prism diopters of orthophoria. Using adjustable suture technique, a small esodeviation was consistently created in the field of gaze away from the resected medial rectus muscle, and this may guard against recurrence of exotropia. CONCLUSIONS: The use of adjustable medial rectus muscle resection is an alternative, successful, and reliable procedure for the management of adult exotropia.

Adolescent↗

PubMed2001

Intermittent exotropia surgery in children: long term outcome regarding changes in binocular alignment. A study of 666 cases.

PURPOSE: To review and determine the long term outcome of surgery for intermittent exotropia in children. CASES: A total of 666 cases were reviewed. They were 15 years old or younger and underwent surgery for intermittent exotropia during the preceding 22 years. Bilateral recession of the lateral rectus muscles was performed in 349 cases. Unilateral recession of the lateral rectus and resection of the medial rectus muscles was performed in 298 cases. One and four muscle procedures were performed in 19 cases. The outcome was evaluated at 1 month and 4 years after surgery. RESULTS: Orthotropia or mini-microtropia was achieved in 401 patients (60.2%) one month after surgery. Bilateral recession of the lateral rectus muscles was more effective than unilateral recession- resection. Out of these 401 patients, half, 199 patients (49.6%) showed orthotropia or mini-microtropia 4 years after surgery while the other half, 202 (50.4%), became exotropic. Bilateral recession of the lateral rectus muscles was also more effective in producing orthotropia or mini-microtropia on a long term basis than unilateral recession-resection. The rate of orthotropia or mini- microtropia was higher when the patients were operated before 3 years and after 11 years of age. CONCLUSIONS: There was a strong tendency for intermittent exotropia to recurr and drift into permanent exotropia during 4 or more years following surgery. It is advocated to aim at orthotropia during the immediate post- surgical period and to avoid overcorrection. Early surgery is not necessary when the patient is over 4 years of age. Bilateral lateral rectus recession is the preferred surgical procedure.

Adolescent↗

PubMed2002

[A clinical observation on variation of crossed disparity and uncrossed disparity in intermittent exotropia].

OBJECTIVE: To understand the clinical variety of crossed disparity and uncrossed disparity in intermittent exotropia. METHODS: Zero disparity stereo-acuity, crossed disparity and uncrossed disparity stereo-acuity of 55 cases with intermittent exotropia were examined with stereogram designed by Yan Shaoming before surgery. RESULTS: In group 1 consisting of 25 cases, the zero disparity stereo-acuity of normal persons was 48%, the values of crossed disparity and uncrossed disparity stereoacuity were not in the normal range, and the crossed disparity was larger than the uncrossed disparity stereo-acuity (t = 843.5, P < 0.000 1). In group 2 including 26 cases, the zero disparity stereo-acuity of normal person was 30.8%, the value of crossed disparity was abnormal, and the uncrossed disparity was not found. In group 3 consisting of 4 cases, only the abnormal zero disparity stereo-acuity was found. In the 55 cases, there was no coexistence of zero disparity and uncrossed disparity, no existence of only crossed disparity or only uncrossed disparity, and no coexistence of crossed and uncrossed disparity. CONCLUSIONS: (1) In the cases with intermittent exotropia, the zero disparity stereoacuity, the crossed disparity and uncrossed disparity stereoacuities are abnormal. (2) The sequential damage of stereopsis in intermittent exotropia is uncrossed disparity, crossed disparity and zero disparity. (3) It is proved in the clinic that the binocular temporal retinae correspond to the crossed disparity and the binocular nasal retinae correspond to the uncrossed disparity.

Adolescent↗

PubMed2004

Outcome of a surgical treatment protocol for late consecutive exotropia following bilateral medial rectus recession for esotropia.

PURPOSE: To describe a specific protocol for the surgical treatment of Late Consecutive Exotropia (LCXT) following bilateral medial rectus (MR) recessions, and to report the results of surgery, performed according to this protocol, in a series of 119 children followed 6 months to 15 years after surgery for consecutive exotropia. METHOD: The senior author (JLM) performed a retrospective chart review of 15 years of his experience following a specific protocol for the surgical treatment of LCXT. In individual cases, following this protocol led to recessions of the overacting inferior oblique (IO) with anterior transposition if dissociated vertical deviation (DVD) was also present, weakening of the overacting superior oblique (SO) with simultaneous 10 mm recessions of the superior rectus (SR) with 3 mm of nasal transposition (to ameliorate DVD which might be aggravated by SO tenotomies), graded recessions of one lateral rectus (LR) 7.0 to 8.5 mm if the distance deviation was equal to or less than 23 prism diopters (PD) of XT, and advancement of one previously recessed MR to the insertion if the distance deviation was equal to or greater than 24 PD XT. RESULTS: "Success" was defined as 8 PD ET to 6 PD XT, with both distance and near fixation. Among 14 patients receiving SR recessions, SO tenotomies, and recession of one LR, 12 of the 14 were "successes" at 6 months postop' and 10 of 14 at an average of 3 years postop'. Among 26 receiving advancement of one MR, "successes" were 23 of 26 at 6 months postop' and 20/26 at two years after surgery. Among 22 receiving IO recession with anterior transposition if DVD was present, "successes" were 18 of 22 at 6 months and 12 of 22 at 3.6 years. Among 57 receiving only recession of one LR, 53 of 57 were "successes" at 6 months postop' and 45 of 57 at 4 years postop'. The overall "success" rate for this protocol for these 119 patients was 89% at 6 months and 74% at 2 to 4 years postop'. Treatment of simultaneous IO overaction and LCXT was associated with the highest long term "failure" rate in this protocol. CONCLUSION: This specific surgical protocol for treatment of late consecutive exotropia is reasonably safe and effective and comparable to the few other reported protocols of various surgical treatments for consecutive exotropia.

Adolescent↗

PubMed1992

Optometric management of optically induced consecutive exotropia.

A 5-1/2 year old black female initially presenting with a moderate angle esotropia and latent hyperopia developed a large angle constant exotropia 2 years after final correction of her refractive error. The occurrence of consecutive exotropia as a result of optical correction of hyperopia has been documented infrequently in the ophthalmologic literature and has rarely been mentioned in the optometric literature. While the overall risk for occurrence of this complication from correction of hyperopia may be small, it is a problem which may occur and can be avoided. Unfortunately, there is only limited information about the various risk factors that should be monitored to avoid the occurrence of an optically induced consecutive exotropia. What is available with regard to evaluation and management is scant, and there are no case reports emphasizing optometric management which includes the use of lenses, occlusion and vision therapy. The purpose of this paper is to present a case report of optically induced consecutive exotropia followed by a summary of the available information from the optometric and ophthalmologic literature. This combined information will aid optometrists managing these patients to avoid the occurrence of this problem and better understand the various management aspects when it does occur.

Accommodation, Ocular↗

PubMed2006

[Clinical study on crossed disparity and uncrossed disparity in intermittent exotropia before and after surgery].

OBJECTIVE: To understand the clinical variety of zero disparity, crossed disparity and uncrossed disparity in intermittent exotropia before and after strabismus surgery. METHODS: 100 cases of intermittent exotropia were involved in the study. Before and after surgery, zero disparity stereo-acuity, crossed disparity and uncrossed disparity stereo-acuity were examined with stereogram designed by Yan Shaoming, distance fusion range and distance stereo-acuity were examined with traditional and random dot synoptophore stereogram. The patients were divided into four groups based on the results of the stereogram examination before surgery. RESULTS: In the 100 cases, there was no coexistence of zero disparity and uncrossed disparity, no coexistence of crossed and uncrossed disparity, and no existence of only crossed disparity or only uncrossed disparity. Postoperative zero disparity, crossed disparity, uncrossed disparity, distance fusion range and distance stereo-acuity improved significantly compared with the preoperative results for each group (P < 0.01). The comparison of distance fusion range was not prominent before and after strabismus surgery in the 4 groups (P > 0.05). The distribution of distance stereo-acuity was prominent after strabismus surgery in the 4 groups (P < 0.01). Distance stereo-acuity rebuilding after surgery in group 1 and group 2 was better than that in group 3 and group 4. CONCLUSIONS: (1) In the cases with intermittent exotropia, zero disparity stereo-acuity, crossed disparity and uncrossed disparity stereo-acuity are abnormal. The sequential damage of stereopsis is uncrossed disparity, crossed disparity and zero disparity. The sequential rebuilding of stereopsis is zero disparity, crossed disparity and uncrossed disparity. (2) The serious damage or disappearance of uncrossed disparity stereo-acuity is the indication of intermittent exotropia surgery for perfect binocular vision rebuilding.

Adolescent↗

PubMed1987

Exotropia associated with defective accommodation.

Despite the close association of convergence and accommodation, accommodative dysfunction is not often associated etiologically with exotropia. We studied 13 adolescent and young adults having intermittent exotropia and severely reduced accommodative function. Most patients had a prolonged history of visual symptoms that had not responded to therapy in the past. Clinical testing indicated that the patients had severely reduced amplitudes of accommodation and difficulty sustaining accommodation. Exotropia was manifest when the accommodative response was inadequate; relative orthophoria existed when the accommodative response was adequate. Treatment of the accommodative defect as well as the strabismus was successful for some patients. We recommend careful evaluation of accommodation for adolescent and young adults with exotropia to rule out an accommodative defect as a contributing cause.

Accommodation, Ocular↗

PubMed1994

[Intermittent exotropia: evaluation of results on the basis of different treatments].

The aim of the study is to evaluate the results obtained in treatment of Intermittent Exotropia with the therapeutic programme applied at the Orthoptic Centre of Sassari Oculist Clinic. 250 patients were considered; 176 completed treatment. The patients were divided into four groups according to the kind of treatment adopted: orthoptic exercises, surgery (double recession of lateral rectus), exercises and surgery, no therapy. Results were evaluated by measuring the acquired state of orthophoria or residual exotropia: less than 10 prismatic diopters (excellent result); residual exotropia between 11 and 20 prismatic diopters (unsatisfactory result); residual exotropia > 20. The highest percentage of excellent results was found in those patients who underwent surgery but only among those who completed the therapy with cycles of orthoptic exercises. Conversely, the worst results were evident in patients who followed no therapeutic programme.

Adolescent↗

PubMed1995

[A study of eight patients with non-paralytic pontine exotropia].

We reported 8 patients with non-paralytic pontine exotropia (NPPE): 7 men and 1 woman aged from 56 to 79 years (mean: 67.8 years). From 1991 to 1994, 402 patients with acute infratentrial cerebrovascular diseases other than subarachnoid hemorrhage were admitted to our hospital within 7 days after the ouset of their stroke. NPPE was observed in 2% of these patients. NPPE was noted on admission in 6 of them, while it developed during the hospital stay in 2 others with paralytic pontine exotropia and bilateral median longitudinal fasciculus (MLF) syndrome, respectively. Abnormal convergence and alternating exotropia were noted in 6 and 2 patients respectively. The duration of NPPE was 0.5 to 4 days (mean; 2 days), and the ocular movement disorder was transient in all patients. When MRI was performed to detect the causative lesion, a small infarct was found in the upper, middle, and lower pons in 1, 3, and 4 patients, respectively. NPPE is generally considered to develop when the MLF and the paramedian pontine reticular formation (PPRF) are completely and incompletely destroyed respectively. In the present study, however, the pathophysiological features of the NPPE patients with alternating exotropia could not be explained by this mechanism, and severe MLF damage was considered to be a contributory factor.

Aged↗