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PubMed1979

Monofixational intermittent exotropia.

The surgical correction of intermittent exotropia occasionally results in a monofixational sensory pattern. Stereopsis as a measure of bifixation was studied preoperatively and postoperatively in 39 cases of intermittent exotropia. Of 26 patients with bifixation, 25 remained so after surgery. Of 13 patients with monofixation, 11 remained unchanged by surgery, one improved, and one lost all binocularity. The presence of preoperative monofixational intermittent exotropia, to explain a monofixation result from intermittent exotropia surgery, is proposed.

Adolescent↗

PubMed1988

Monocular eye closure in intermittent exotropia.

Monocular eye closure in bright illumination is a common occurrence in intermittent exotropia. In a series of patients with intermittent exotropia with normal retinal correspondence and stereopsis while the eyes were in the straight position, monocular eye closure occurred in 90% of patients with normal retinal correspondence while exotropic and in only 35% of patients with abnormal retinal correspondence while exotropic. Monocular eye closure occurs in people with intermittent exotropia to avoid diplopia and visual confusion even though these are not usual complaints. The cortical adaptation of anomalous retinal correspondence prevents diplopia and visual confusion and obviates the need to close one eye in bright sunlight.

Exotropia↗

PubMed2006

Recession-resection combined with intraoperative botulinum toxin A chemodenervation for exotropia following subtotal ruptured of medial rectus muscle.

BACKGROUND: Ruptured extraocular muscle loses its function and shows severe restriction of eye movement even after muscle-to-muscle anastomosis or muscle transposition surgery. We present the case of a patient who developed a large exotropia after near-total rupture of the medial rectus muscle following a blowout fracture. METHODS: Case report. RESULTS: A 12-year-old girl presented at our clinic with 45 prism diopters' exotropia after a blunt trauma. A forced duction test was unrestricted, and orbital computed tomography showed a medial orbital wall fracture and an impinged medial rectus muscle. Upon surgical exploration, an almost totally ruptured medial rectus muscle was found. The median margin of the ruptured muscle was 6.0 mm from its insertion, and the distal end that we could examine was 15.0 mm from the limbus. Recession-resection surgery combined with intraoperative botulinum toxin A chemodenervation to the ipsilateral lateral rectus muscle achieved a good primary alignment and binocular single visual field, even at a 9-month follow-up. CONCLUSIONS: Recession-resection surgery augmented by intraoperative botulinum toxin A chemodenervation to the ipsilateral rectus muscle appears to be highly effective in the treatment of a large exotropia produced by subtotal rectus muscle rupture following orbital wall fracture, with a lower risk of anterior segment ischemia.

Botulinum Toxins, Type A↗

PubMed2005

Female predominance in intermittent exotropia.

PURPOSE: To evaluate gender differences among children diagnosed with intermittent exotropia. DESIGN: Retrospective, population-based cohort study. METHODS: The medical records of all Olmsted County, Minnesota residents younger than 19 years diagnosed with intermittent exotropia from January 1, 1975, through December 31, 1994, were reviewed. RESULTS: One hundred eighteen (64.1%) of the 184 study patients were girls with an age-adjusted incidence rate of 38.3 (95% CI: 31.4-45.2) per 100,000 compared to 20.8 (95% CI: 15.7-25.8) per 100,000 for boys (P < .0001). There were no significant differences between girls and boys in their family history of strabismus, birth weight, prevalence of prematurity, age at diagnosis and surgery, refractive error, and initial angle of deviation. CONCLUSIONS: Intermittent exotropia was nearly twice as common in girls compared with boys in this defined population. There were, however, no significant historical or clinical differences between the genders.

Adolescent↗

PubMed2006

Re-recession of the lateral rectus muscles in patients with recurrent exotropia.

PURPOSE: We undertook a retrospective evaluation of changes in deviation and ocular motility after surgical rerecession of the lateral rectus (LR) muscles as a treatment for recurrent exotropia (XT). METHODS: We describe 16 consecutive patients (age 6 to 35 years; median, 10 years; 13 children and 3 adults) with an average amount of recurrent alignment, amount of rerecession, distance from insertion to the limbus, postoperative alignment, and versions. RESULTS: In most cases, bilateral LR muscles were rerecessed to a distance of 15 mm from the limbus, but in 5 cases with larger amount of deviation, these muscles were rerecessed to 17 mm from the limbus. A relation was found between the amount of rerecession and change in far alignment in prism diopters (r=0.46, P=0.07), but not for near deviation. The success rate (esotropia<or=10 PD or exotropia<or=8 PD) 1 to 7 days after surgery and in long-term follow-up (6-96 months; median, 25.5 months) was 100%. No significant underaction of the LR muscles was noted. CONCLUSIONS: The results support the notion that bilateral LR rerecession to 17 mm from the limbus successfully corrects recurrent exotropia up to 33 PD and that it is particularly effective in children and adults without producing significant limitation of abduction.

Adolescent↗

PubMed2006

The natural history of surgically untreated intermittent exotropia-looking into the distant future.

PURPOSE: We studied patients with distance intermittent exotropia with at least 5 years follow-up before any surgical therapy, to determine how often amblyopia developed, whether there was progressive worsening in the angle or control of the exodeviation, whether there was deterioration in binocular vision, and other parameters. METHODS: Retrospective review of charts of patients with exodeviations examined consecutively over 17 years. RESULTS: There were 109 patients followed for a mean of 9 years (range 5 to 25). Amblyopia was mild (20/25 in 33, 20/30 in 15, and 20/40 in 2). There was no significant change in the mean exoangle from initial to final visit (20.6 to 20.9 PD), but the initial to final exoangle decreased by more than 10 PD in 19%, remained stable in 58%, and increased by more than 10 PD in 23%. There was no statistically significant trend for worsening or improving when serial measurements were plotted and the aggregate slopes were analyzed. Change in control in the distance from initial to final visit was favorable in 26%, showed no change in 51%, and was unfavorable in 23%, with 17% deteriorating to a constant distance exotropia. Mean near stereoacuity at the final visit was 88 seconds of arc. Strabismus surgery was performed in 14% of patients from 5 to 18 years (mean 9) after their initial visit. CONCLUSIONS: Visual acuity and near stereoacuity were generally good. There was little change in the mean angle of deviation from initial to final visit for the group, with a nearly chance occurrence for the distance deviation to progressively worsen or improve, perhaps explaining why strabismologists have had difficulty definitively prognosticating about the long-term stability of intermittent exotropia.

Adolescent↗

PubMed2006

The course of intermittent exotropia in a population-based cohort.

PURPOSE: To evaluate the change in the angle of deviation in an incidence cohort of pediatric patients diagnosed with intermittent exotropia during a 20-year period. DESIGN: Retrospective, population-based observational study. PARTICIPANTS: All pediatric (<19 years old) residents of Olmsted County, Minnesota diagnosed with intermittent exotropia (> or =10 prism diopters) from January 1, 1975 through December 31, 1994. METHODS: The medical records of all potential patients identified by the resources of the Rochester Epidemiology Project were reviewed. MAIN OUTCOME MEASURES: The change in the angle of deviation and its association with treatment were reviewed for each patient. RESULTS: A total of 184 pediatric patients were diagnosed during the study period, of which 138 patients (75.0%) had > or =2 examinations. The deviation resolved in 5 of the 138 patients (3.6%) during a median follow-up of 9.2 years, while the Kaplan-Meier rate of increasing by 10 or more prism diopters (PD) was 23.1% at 5 years and 52.8% at 20 years. The distance deviation increased by a median of 5 PD during the preoperative period in the 55 patients who underwent surgery during a mean follow-up of 3.2 years compared with a zero PD median change in the 83 patients who avoided surgery during a mean follow-up of 7.1 years. The Kaplan-Meier probability of undergoing surgery within 20 years after diagnosis was 74.0% in this population. We were unable to detect a significant association between nonsurgical treatments and a change in the angle of deviation. CONCLUSIONS: In this population-based cohort of pediatric patients with intermittent exotropia, the deviation resolved in 4%, and more than half of the patients were expected to have an increase of 10 or more PD within 20 years of their diagnosis. Children who received surgery in this population were significantly more likely to have demonstrated an increase in their deviation during the preoperative period.

Adolescent↗

PubMed1993

Children with exotropia responsive to spectacle correction of hyperopia.

A series of seven exotropic children (aged 2 to 10 years) had resolution of exotropia after spectacle correction of hyperopia. Their hyperopic correction ranged from 3.00 to 7.00 diopters. Six had intermittent exotropia, which became small-angle esophoria after spectacle correction. In one patient with apparently no fusion, spectacle correction converted constant exotropia to small esotropia in the monofixational range. In all patients, Worth 4-dot and Titmus Stereo Test results, when obtainable, indicated an improvement in binocular sensory status after correction of the hyperopia. We conclude that a trial of spectacle correction is warranted in exotropic children with severe hyperopia and in those with moderate hyperopia and a low accommodative convergence/accommodation ratio or evidence of hypoaccommodation.

Child↗

PubMed1983

Overcorrecting minus lens therapy for treatment of intermittent exotropia.

The purpose of this paper is to determine the value of overcorrecting minus lenses in treating children with intermittent exotropia. The aim with this therapy is to secure an increase in the quality of fusion and to induce a quantitative decrease in the angle of strabismus. Thirty-five children were treated with 2.00 to 4.00 diopters of overcorrecting minus lenses for a median of 18 months duration. Of these, 46% had an improved quality of fusion during therapy; 26% had an improved quality of fusion and also had a quantitative decrease in their angle of deviation; and 28% had an inadequate improvement in their quality of fusion and decrease in the angle of their deviation with this therapy. Two children went from intermittent exotropia to esotropia while wearing their minus lenses--both had high accommodative-convergence/accommodation ratios (11.5 delta/1D and 10.7 delta/1D). Seventy percent of good responders who were followed for at least 1 year after discontinuing the therapy maintained a qualitative or quantitative improvement in their intermittent exotropia.

Child↗

PubMed2005

Effects of unilateral lateral rectus recession according to the tendon width in intermittent exotropia.

PURPOSE: To verify the effect of unilateral lateral rectus recession for each millimeter according to the tendon width in intermittent exotropia. METHODS: A total of 37 patients (37 eyes) of 7 to 11 years of age with basic-type intermittent exotropia and a deviation of 16-25 Prism Diopters (PD) were included in this study. Under general anaesthesia, the tendon width of the lateral rectus of the deviating eye near insertion was measured with calipers, prior to dissection of the muscle tendon from the sclera. Patients underwent 6.5-10 mm unilateral lateral rectus recession. The effect of lateral recession for each millimeter was the absolute value of the angle of preoperative deviation plus postoperative deviation on the second day divided by the total amount of recession. RESULTS: Mean tendon width of the lateral rectus of a deviating eye was 8.3 mm (range: 6.5-9.5). The mean effect per millimeter of unilateral rectus recession in those 37 patient was 2.98+/-0.42 PD (range: 2.4-4.1). The effect of recession was larger in cases in which the tendon width of the lateral rectus was narrower (P=0.000, r=0.72). CONCLUSION: The tendon width of the lateral rectus muscle can be a useful indicator to estimate the effect of lateral rectus recession in intermittent exotropia.

Child↗

PubMed2006

Surgical outcomes of intermittent exotropia associated with concomitant hypertropia including simulated superior oblique palsy after horizontal muscles surgery only.

PURPOSE: To investigate the clinical features and obtain guideline of treatment in intermittent exotropia associated with hypertropia including simulated superior oblique palsy. METHODS: We retrospectively reviewed the charts of 93 patients of intermittent exotropia aligned with horizontal muscle surgery only, who showed hypertropia more than 2 PD in primary gaze before surgery and disappeared after surgery. They showed forveal extorsion and dysfunction of oblique muscles of 2+ or less and positive Bielschowsky head tilt test. The postoperative changes of deviation angle were analysed at postoperative 1 day, 6 months, and 1 year. RESULTS: Average amount of distant horizontal deviation in primary gaze was 32.3+/-9.58 (25-53) PD, hypertropia was 3.50+/-2.52 (2-14) PD. Average vertical deviation of ipsilateral (hypertropic eye) side was 8.8+/-4.63 PD and contralateral (hypotrophic eye) side was 4.0+/-4.77 PD in Bielschowsky head tilt test. Hypertropic eye was accorded with exotropic eye in 53.4%. After horizontal surgery, the amount of hypertropia was 1.2 PD at postoperative 1 day. On Bielschowsky head tilt test, hypertropia was almost eliminated showing 0.6 PD on the ipsilateral side and 0.2 PD on the contralateral eye at 1 month. This state was maintained up to postoperative 1 year. CONCLUSION: Small amount of hypertropia up to 14 PD in intermittent exotropia could be disappeared with horizontal muscle surgery only. However, careful examinations for head tilt history, fovea extorsion, oblique dysfunction, and Maddox rod test should be preceded to rule out true superior oblique palsy.

Adolescent↗

PubMed1992

[Congenital nystagmus and intermittent exotropia. Suppression of nystagmus by fusional convergence].

We report on a patient with a combination of congenital nystagmus and intermittent exotropia. When the exotropia became manifest, a gross nystagmus appeared. When, however, the exotropia was overcome by fusinal convergence, the nystagmus was largely suppressed. The angle of squint was surgically reduced by such an amount that the exodeviation was just compensated, and the fusional convergence required to overcome the remaining angle sufficed to suppress the nystagmus.

Convergence, Ocular↗

PubMed2001

Medial rectus resection(s) with adjustable suture for intermittent exotropia of the convergence insufficiency type.

BACKGROUND: The surgical results for intermittent exotropia of the convergence insufficiency type have been reported to be of varying success. The purpose of this study is to evaluate the surgical results of medial rectus muscle (MR) resection(s) with adjustable suture for this condition. METHODS: Twenty-one consecutive patients with intermittent exotropia of the convergence insufficiency type were included in this retrospective study. All patients had a history of prolonged difficulties at near work unrelieved by nonsurgical treatment. Unilateral or bilateral MR resection(s) were done with the adjustable suture, which was tied at the first postoperative day. The target angle was an esotropia of 10 to 20 PD at distance and an esotropia of 5 to 10 PD at near. Postoperatively Fresnel prisms were used temporarily in patients manifesting a consecutive esotropia with diplopia at distance. Postoperative follow-up period was between 6 months and 24 months with a mean of 9.1 months. RESULTS: MR resection(s) with the adjustable suture reduced the mean exodeviation at near from 25.7 to 3 PD. It also reduced the exodeviation at distance from 11.4 to -2 PD (esodeviation). The mean near-distance difference was collapsed from 14.3 PD preoperatively to 5 PD postoperatively. CONCLUSIONS: MR resection(s) with adjustable suture combined with intentional postoperative aggressive overcorrection and the use of Fresnel prisms is useful in intermittent exotropia of the convergence insufficiency type. The intentional overcorrection during the immediate postoperative period at distance and near is required to prevent long-term undercorrection.

Adolescent↗

PubMed2006

Timing of surgery for primary exotropia in children.

OBJECTIVE: To compare postoperative alignment and sensory functions in children with primary exotropia who were operated at an early age (< 7 years) with patients who were operated at an older age (> 7 years). METHODS: In a consecutive retrospective cohort study, 112 patients who had a surgical intervention for primary exotropia between 1997 and 2003 were evaluated for postoperative results. After applying criteria for eligibility, the group of patients was divided into two groups: those who had surgical intervention before the age of seven years (n = 24) and those who had surgery after the age of seven years (n = 36). Age at surgery, preoperative alignment and sensory functions were correlated with the postoperative status. The follow-up was at least one year (1.0 year to 7 years; median: 2.3 and 3.5 years, respectively). RESULTS: Children who had surgery before the age of seven had significantly better alignment and sensory functions. The univariate logistic regression model confirmed a statistically significant association between motor outcome (exodeviation less than 10 prism-diopters) and age at the time of surgery (before or after the age of seven; p = 0.002). In the multivariate model, the association between age at time of surgery and motor outcome was even stronger. The number of reoperations in the group operated before the age of 7 years was significantly less than in the group operated after the age of seven (2 versus 12, p = 0.023). CONCLUSION: The postoperative alignment and sensory functions in patients with primary exotropia who had surgical intervention before the age of seven years were, in this study, better than in patients who had surgery after the age of seven years.

Child↗

PubMed1986

Ten years follow-up of surgery for intermittent exotropia.

Ten years post-operative follow-up of 25 consecutive patients with intermittent exotropia have been performed. 13/25 patients are at follow-up fine, that is small and symptom-free exoforia, good sensorial binocular functions of normal type, sufficient although subnormal fusional amplitude and never exotropia. 8/25 patients are fair, that is only occasionally momentary occurrence of exotropia and binocular complaints. 4/25 patients are orthoptically poor (suppression on all tests), but without complaints. Eye position is on a whole unchanged for distance, whereas exodeviation has increased about 10 PD for near during the 10 years post-operative observation time (no orthoptic treatment in this period). 22/25 patients indicated spontaneously at the follow-up examination that they considered their squint cured. None of the patients had cosmetic or functional restrictions in jobs or studies.

Adolescent↗

PubMed2003

Clinical correlations of aggrecan in the resected medial rectus muscle of patients with intermittent exotropia.

The purpose of this study was to elucidate the role of extracellular matrix components such as aggrecan, fibronectin, and laminin in the extraocular muscle of patients with strabismus. Resected tissues of the medial rectus muscle of 47 patients with intermittent exotropia obtained during recession-resection surgery were frozen under liquid nitrogen and pulverized by a Freezer/Mill to solubilize the tissue for enzyme immunoassay. The total amounts of aggrecan, fibronectin, and laminin in the resected tissue were correlated with clinical data of patients such as age, exodeviation, and refractive error. The amount of aggrecan decreased significantly with the advance of age (P < 0.0001, Spearman rank correlation test), while the amount of laminin or fibronectin had no correlation with age. Patients with basic type intermittent exotropia showed larger, although not significantly, amounts of aggrecan than those with convergence insufficiency type (P = 0.0538, Mann-Whitney U-test). The amount of aggrecan may be related to motor aspects of intermittent exotropia.

Adolescent↗

PubMedDate not supplied

Early and late postoperative alignment following unilateral lateral rectus recession for intermittent exotropia.

PURPOSE: Bilateral lateral rectus recession is useful in the treatment of intermittent exotropia. A unilateral recession may be used in the treatment of small-to-moderate angle intermittent exotropia as well. An early overcorrection following bilateral surgery has been shown to carry the best prognosis for future alignment. The relationship between the early and late postoperative alignment following unilateral surgery is unknown. The current study was designed to establish this relationship. METHODS: Thirty-seven patients undergoing a unilateral lateral rectus recession for intermittent exotropia were prospectively evaluated to determine the relationship between early and late postoperative alignment. Patients were evaluated 1 week and 6 months following surgery. A satisfactory result was considered to be alignment within 8 prism diopters (delta). RESULTS: Of the 37 patients who underwent surgery, 35 completed the study. Overall, 77% of patients achieved a satisfactory result at the 6-month exam (27/35). Satisfactory alignment at 6 months was obtained in all patients who were orthophoric (14/14), 77% (10/13) of patients with an exodeviation less than 9 delta (10/13), and 60% (3/5) of patients with an exodeviation less than 9 delta at the 1-week postoperative exam. Twenty-nine percent of patients changed alignment status during this time period (10/35), and 29% of all patients became more divergent (10/35). The average divergent shift for the entire group was 1.6 delta and was not significant. Among those patients who experienced a divergent shift, the average amount was 6 delta. CONCLUSIONS: There is not a significant difference in early versus late alignment following unilateral lateral rectus recession. Surgeons performing this procedure should not expect a significant divergent shift from the first postoperative week. Unlike bilateral recessions where an early overcorrection is desirable, acceptable alignment in the first week following surgery carries the best prognosis for later alignment.

Adolescent↗

PubMedDate not supplied

Usefulness of the preoperative prism adaptation test in patients with intermittent exotropia.

PURPOSE: To investigate whether the preoperative prism adaptation test is useful in patients with intermittent exotropia. METHODS: Sixty-five consecutive patients with basic-type intermittent exotropia <40 prism diopters (PD) comprised the study population in this prospective study. Patients were divided into two groups based on the results of the prism adaptation test. Patients with a negative response comprised group 1 and patients with a positive response comprised group 2. Group 1 patients (n=26) underwent surgery according to the original angle, and group 2 patients (n=27) underwent surgery in accordance with the change in the angle of deviation with prisms. RESULTS: Satisfactory motor alignment (+/- 5 PD of orthophoria) was achieved in 14 (53.8%) group 1 patients and 24 (88.8%) group 2 patients (P=.01). Mean residual deviation was 9.8 PD in group 1 and 4.5 PD in group 2 (P < or = .05). CONCLUSION: The prism adaptation test may be helpful in achieving a favorable surgical outcome in intermittent exotropia.

Adaptation, Ocular↗