Olitsky SE. Simulated divergence excess type X(T) is designated when the near deviation angle increases with occlusion or on adding +3.00 lens [47]. Graeber CP, Hunter DG. [106] reported no difference in terms of surgical success before versus after 4 years of age at surgery. Cases of X(T) with a high AC/A ratio can be managed with BLR and posterior fixation sutures on BMR to prevent the postoperative overcorrection at near. The https:// ensures that you are connecting to the [32] also found higher cumulative success rates with divergence excess type compared to the basic type after augmented BLR. Another meta-analysis involving 967 patients from 10 studies found no differences in the success rates and overcorrection and/or undercorrection rates between BLR and RR [61]. Surgical management of convergence insufficiency. A meta-analysis concluded that RR showed a higher success rate and lower undercorrection than ULR for X(T) 20 PD. Kushner and Morton [50] classified divergence excess type X(T) as a high ratio of accommodative convergence (AC) to accommodation (A) ratio and proximal convergence. Intermittent exotropia is not present all the time. Differing surgical results have been associated with the changes in the preoperative deviation angle. Kim BH, Suh SY, Kim JH, et al. Operating on one muscle could spare other muscles for reoperation and could reduce the surgery time as well as the risks of scleral perforation or endophthalmitis.
Intermittent Exotropia Article - StatPearls Lee HJ, Kim SJ. Intermittent exotropia is the most common form of strabismus, characterized by an intermittent outward deviation of the eyes, affecting as much as 1% of the population. It is typically more noticeable when looking far away or daydreaming. Cho KH, Kim J, Choi DG, et al.
3 Eye Exercises for Strabismus | Healthline Lim SH, Hwang BS, Kim MM. The first study will explore the natural history of intermittent exotropia by comparing patching against no treatment. [103] reported that surgeries performed at <7 years of age could result in better motor (exodeviation of <10 PD) and sensory outcomes as well as fewer instances of reoperations. But a recent study in the British Journal of Ophthalmology(BJO)1 and an accompanying editorial2 call into question the notion that intermittent exotropia is straightforward or fully understood. The prism-weaned group showed a larger preoperative constant deviation and anisometropia, and higher exodrift. 1 Buck D et al. Bae SH, Lee YB, Rhiu S, et al.
Intermittent Exotropia - EyeWiki This topic will focus specifically on intermittent exotropia, which is the most common type of manifest exodeviation.
Interventions for intermittent exotropia - PMC It accounts for 25 percent of all ocular misalignment cases in young children. Kim H, Yang HK, Hwang JM. Lim SH, Hong JS, Kim MM. Bilateral lateral rectus recession versus unilateral recession resection for basic intermittent exotropia: a meta-analysis. Later, Sung et al. Intermittent Exotropia. [38] reported that preoperative hyperopia > +2.00 diopters was one of the risk factors of recurrence.
Is intermittent exotropia a curable condition? | Eye - Nature [54] evaluated the accommodative response with dynamic retinoscopy and found better results with RR (13 of 18, 72%) than with BLR (5 of 14, 36%) in 32 patients with unequal accommodation. Souza-Dias C, Uesugui CF. However, Arnoldi and Reynolds [43] suggested that diagnostic occlusion did not increase the angle of X(T) in cases with poor fusional capacities. Yang HK, Hwang JM. But Dr. Rosenbaum argued that a number of issues still needed to be explored. The overcorrection rate was still significantly higher with BMR resection (35% vs. 15%, p = 0.039).
Intermittent exotropia surgery: results in different age groups They found a decreased success rate with time and the amount of initial X(T) was significantly correlated with the final success rate. A lot of kids go through childhood having intermittent sessions of these conservative measures and dont require further treatment. Surgery at early versus late for intermittent exotropia: a meta-analysis and systematic review. Intermittent exotropia: In this type of strabismus, one eye will fixate (concentrate) on a target while the other eye points outward. Surgical dose-effect relationship in single muscle advancement in the treatment of consecutive strabismus. Four RCTs have previously compared BLR and RR [18,51,54,55], and three of them [18,51,54] demonstrated that RR could be more effective than BLR, especially with unequal accommodation or with a dominant eye. Five years later, the success rate (54% with BLR vs. 42% with RR) as well as the reoperation rate (24% with BLR vs. 34% with RR) was observed to be comparable. Your eye may turn outward when you're tired, sick or under stress. Seeking consensus. http://creativecommons.org/licenses/by-nc/4.0/. Comparison of different surgery procedures for convergence insufficiency-type intermittent exotropia in children. Kim KE, Yang HK, Hwang JM. Surgical correction of intermittent exotropia is a bread-and-butter procedure for many pediatric ophthalmologists. Yam JC, Chong GS, Wu PK, et al. It should not be confused with infantile esotropia. Kushner BJ. Department of Ophthalmology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, [89] performed a ULR of 11.5 to 12.0 mm on the nondominant eye in 10 patients with X(T) of 14 to 16 PD. Randomized controlled trials, comparative observational studies, and case series with a large number of patients as well as a long follow-up period of over a year were included. Lee SY, Hyun Kim J, Thacker NM. Gurlu VP, Erda N. Diagnostic occlusion test in intermittent exotropia. Hardesty HH, Boynton JR, Keenan JP. Kim et al. Surgical management of intermittent exotropia with high AC/A ratio. Some facts and fictions of the two clinical tests: occlusion of one eye and the use of +3.00 spherical lenses. They concluded that after BLR, consecutive esodeviation continuously decreased, and 82% of the patients were weaned off prism glasses after 3 years. [90] reported orthophoria in 51%, undercorrection in 44%, and overcorrection in 5% of 55 patients after 7 to 8 mm of ULR with a minimum follow-up of 6 months. Bilateral vs unilateral medial rectus resection for recurrent exotropia after bilateral lateral rectus recession. Maruo et al. Ekdawi NS, Nusz KJ, Diehl NN, et al. Brodsky MC, Fray KJ. Increasing the surgical dosage of MR resection by 1 mm improved the long-term surgical results compared to the original dosage without significant differences in overcorrection [34]. [26] also found lesser recurrence with older age at surgery after BLR. Abroms et al. Yang HK, Kim MJ, Hwang JM. Those are some of the questions we are trying to answer., More than meets the eye. Intermittent exotropia is a very common type of eye misalignment. Multivariate analysis revealed that initial postoperative esodeviation of 18 PD at 1 month after exotropia surgery was a predictor for success. Most of the kids who underwent surgery were losing vision or losing depth perception, but their eyes were not drifting out all the time., Dr. Epley added that the proportion of children in the study who had surgery was surprisingly low. He recommended that near measurements in exotropes must be performed after prolonged monocular occlusion. They found a worse outcome with X(T) of 20 to 25 PD than with X(T) less than 20 PD, and no overcorrection. In contrast, Lim et al. More than 200 children will be enrolled in these trials, which will be conducted at more than 50 designated study centers. By about 4 months of age, the eyes should be aligned and able to focus. Prismatic correction of consecutive esotropia in children after a unilateral recession and resection procedure. Hermann [78] performed BMR resection of 3.5 to 4.5 mm in 14 patients; the postoperative overcorrection in all the patients was managed with Fresnel prisms. New Research Sheds Light on Intermittent Exotropia, Instruction Courses and Skills Transfer Labs, Program Participant and Faculty Guidelines, LEO Continuing Education Recognition Award, What Practices Are Saying About the Registry, Provider Enrollment, Chain and Ownership System (PECOS), Subspecialty/Specialized Interest Society Directory, Subspecialty/Specialized Interest Society Meetings, Minority Ophthalmology Mentoring Campaign, Global Programs and Resources for National Societies, Dr. Richard Mills' Opinions, 2002 to 2016, International Society of Refractive Surgery. Distance/near differences in intermittent exotropia. Kim et al. Veronneau-Troutman S. Fresnel prism membrane in the treatment of strabismus. 14, 15 Currently, ther. Botulinum toxin injection without electromyographic guidance in consecutive esotropia. Parents of children who experience deterioration of control will have the option of enrolling their child in a surgical study designed to evaluate the recess-resect procedure versus bilateral recession. This entity is also named distance exotropia, divergent squint, periodic exotropia, or exotropia of inattention. 1 The treatment of intermittent exotropia includes watchful . In the context of this uncertainty, it is not unreasonable to ask whether childhood intermittent XT can be 'cured'. Before Awadein A, Eltanamly RM, Elshazly M. Intermittent exotropia: relation between age and surgical outcome: a change-point analysis. An official website of the United States government. Kushner BJ. [38] found that a larger exodeviation of >5 PD at near than at distance was one of the risk factors of recurrence in 560 children with basic type X(T) with an average follow-up of 9.5 years. Only one eye turns out at a time while the other eye points straight forward. Small exophorias are found in high frequency in adults. Leow PL, Ko ST, Wu PK, et al. Kim WJ, Kim MM. Comparison of long-term surgical outcomes of two-muscle surgery in basic-type intermittent exotropia: bilateral versus unilateral. Early and late postoperative alignment following unilateral lateral rectus recession for intermittent exotropia. Kim HJ, Choi DG. Lee S, Lee YC. [17] favored BLR rather than RR because of the higher overcorrection rate after RR in true divergence excess type X(T). Exotropia is defined as the outward deviation of either one or alternate eyes, which can be present intermittently or be persistent. No significant difference in terms of overcorrection rates was observed between BLR and RR [59]. At the last follow-up, the average angle of exotropia (esotropia 2 PD to exotropia 30 PD) was 6.8 PD at distance, and 6.2 PD (esotropia 9 PD to exotropia 30 PD) at near. Farid and Abdelbaset [71] prospectively compared three procedures of slanted BLR (upper horn based on distance deviation angle and lower horn based on near deviation angle in 22 patients), modified RR (LR recession based on distance deviation angle and MR resection based on near deviation angle in 23 patients), and augmented BLR based on near deviation in 22 patients. [25,26] found no relationship between the preoperative deviation angle and surgical outcome in both RR and BLR. Kim SH, Choi YJ. Treatment of X(T) includes occlusion, overminus lens, and surgery, of which, surgery is the mainstay of treatment. Surgical experiences with two-muscle surgery for the treatment of intermittent exotropia. Most of the studies are retrospective. Four patients (5.9%) needed a reoperation for consecutive esotropia. Surgical outcomes of three different surgical techniques for treatment of convergence insufficiency intermittent exotropia. At 5 years after surgery, the success rates were not significantly different between the BMR and UMR resection (57% vs. 62%); similar findings were observed in the recurrence rates. Predictive factors affecting the short term and long term exodrift in patients with intermittent exotropia after bilateral rectus muscle recession and its effect on surgical outcome. The undercorrection rate at distance was 23% with augmented BLR and slanted BLR, and 57% after modified RR. They concluded that large UMR resections could be safe and effective in treating recurrent exotropia 25 PD after BLR with significantly lower overcorrection rate than that with BMR resection. Overacting oblique muscles in exotropia: a mechanical explanation. This symptom may. Intermittent exotropia. Wilson ME, Hutchinson AK, Saunders RA. Medial rectus resection(s) with adjustable suture for intermittent exotropia of the convergence insufficiency type. Kim and Choi [98] reported a larger effect of ULR with a narrower tendon width of LR. Choi and Jung [85] reported that BLR and posterior fixation sutures on BMR achieved exodeviation of 8 PD at distance and at near, and a distance-near difference of 10 PD without bifocal glasses in five of the seven patients with X(T) and a high AC/A ratio, and esotropia at near managed with bifocal glasses in one patient. Comparison of bilateral lateral rectus recession and unilateral recession resection for basic type intermittent exotropia in children. They also found that recurrences were most common within postoperative 6 months, and continued to increase with RR, but not with BLR. Furthermore, it should be determined whether the surgical dose could be performed based on the largest angle ever measured or the most common or final angle measured, when preoperative angles of X(T) were inconsistent. [54], RR may be considered more beneficial than BLR, especially in patients with unequal accommodation. [32] found higher success rates with the divergence excess type X(T) compared to the basic type X(T) after BLR. The cumulative probabilities of success 2 years after augmented BLR versus modified RR were 61% versus 100% in the true convergence insufficiency, 58% versus 100% in the masked convergence insufficiency, and 77% versus 71% in the pseudoconvergence insufficiency type X(T). However, Hardesty et al. Comparison of surgical outcomes of slanted procedure for exotropia with convergence insufficiency according to their response to preoperative monocular occlusion. Notably, no patient lost stereopsis because of overcorrection. BLR is more likely to result in relapse within postoperative 1 year than RR (29.3% vs. 7.0%, p < 0.001). [108] found that a greater degree of myopia and smaller deviations contributed to higher success rates, and that hyperopia and larger deviations resulted in lower success rates. According to the American Academy of Ophthalmology, intermittent esotropia is normal up to 3 months after birth and resolves on its own. Lyu et al. Yang et al. [44] found that 1-day occlusion test increased distance deviation angle in 14% (26 of 185), and near deviation angle in 31% (57 of 185) of the cases, especially with hyperopia. Predictive factors affecting long-term outcome of unilateral lateral rectus recession. Intermittent exotropia (XT) is one of the most common types of childhood strabismus, occurring in 1% of children. Efficacy of diagnostic monocular occlusion in revealing the maximum angle of exodeviation. They concluded that the prismatic correction could lead to good motor outcomes while maintaining favorable sensory status in consecutive esotropia. Kushner [51] reported a satisfactory outcome after BLR in 80% (55 of 68) of patients with simulated divergence excess type X(T). Several studies have compared the relative efficacy of the two surgeries; however, there is no consensus regarding the more effective surgery. Ren M, Wang Q, Wang L. Slanted bilateral lateral rectus recession for convergence insufficiency-type intermittent exotropia: a retrospective study. Dr. Epley is a lecturer for Alcon.
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