|Year : 2020 | Volume
| Issue : 3 | Page : 217-225
Non-surgical management options of intermittent exotropia: A literature review
Samira Heydarian1, Hassan Hashemi2, Ebrahim Jafarzadehpour3, Amin Ostadi2, Abbasali Yekta4, Mohamadreza Aghamirsalim5, Nooshin Dadbin2, Hadi Ostadimoghaddam6, Fahimeh Khoshhal7, Mehdi Khabazkhoob8
1 Department of Rehabilitation Sciences, School of Allied Medical Sciences, Mazandaran University of Medical Sciences, Sari, Iran
2 Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
3 Department of Optometry, Iran University of Medical Sciences, Tehran, Iran
4 Department of Optometry, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
5 Eye Research Center, Tehran University of Medical Sciences, Tehran, Iran
6 Refractive Errors Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
7 Dezful University of Medical Sciences, Dezful, Iran
8 Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
|Date of Submission||03-Jun-2019|
|Date of Decision||24-Mar-2020|
|Date of Acceptance||01-Apr-2020|
|Date of Web Publication||04-Jul-2020|
Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran
Source of Support: None, Conflict of Interest: None
Purpose: To review current non-surgical management methods of intermittent exotropia (IXT) which is one of the most common types of childhood-onset exotropia.
Methods: A search strategy was developed using a combination of the words IXT, divergence excess, non-surgical management, observation, overcorrecting minus lens therapy, patch/occlusion therapy, orthoptics/binocular vision therapy, and prism therapy to identify all articles in four electronic databases (PubMed, Web of Science, Google Scholar, and Scopus). To find more articles and to ensure that the databases were thoroughly searched, the reference lists of the selected articles were also reviewed from inception to June 2018 with no restrictions and filters.
Results: IXT is treated when binocular vision is impaired, or the patient is symptomatic. There are different surgical and non-surgical management strategies. Non-surgical treatment of IXT includes patch therapy, prism therapy, orthoptic sessions, and overcorrecting minus lens therapy. The objective of these treatments is to reduce the symptoms and the frequency of manifest deviation by decreasing the angle of deviation or enhancing the ability to control it.
Conclusions: Evidence of the efficacy of non-surgical management options for IXT is not compelling. More comprehensive randomized controlled trial studies are required to evaluate the effectiveness of these procedures and detect the most effective strategy.
Keywords: Divergence excess, Intermittent exotropia, Non-surgical management
|How to cite this article:|
Heydarian S, Hashemi H, Jafarzadehpour E, Ostadi A, Yekta A, Aghamirsalim M, Dadbin N, Ostadimoghaddam H, Khoshhal F, Khabazkhoob M. Non-surgical management options of intermittent exotropia: A literature review. J Curr Ophthalmol 2020;32:217-25
|How to cite this URL:|
Heydarian S, Hashemi H, Jafarzadehpour E, Ostadi A, Yekta A, Aghamirsalim M, Dadbin N, Ostadimoghaddam H, Khoshhal F, Khabazkhoob M. Non-surgical management options of intermittent exotropia: A literature review. J Curr Ophthalmol [serial online] 2020 [cited 2023 Mar 29];32:217-25. Available from: http://www.jcurrophthalmol.org/text.asp?2020/32/3/217/288949
| Introduction|| |
Strabismus is one of the most frequent ocular problems among developmentally normal children. The prevalence of strabismus varies among different regions, ranging from 0.06% in Japan to 5.65% in China.,,,,,,, Exotropia is reported to be the most prevalent type of deviation in many of these studies.,,, About 48–92% of the exotropic patients have intermittent exotropia (IXT).,,, Jenkins reported that the prevalence of exodeviation was higher in countries near the Equator. Its prevalence is also higher in subequatorial Africa, the Middle East, and East Asia (where there is plenty of sunshine) in comparison to the USA and Central Europe.,
IXT is an outward deviation of the eye that is not constant and is intermittently controlled by fusional mechanisms. Unlike a pure phoria, IXT breaks down spontaneously into a manifest exotropia. It is one of the most frequent types of childhood-onset exotropia. In many subtypes of IXT, the deviation is more obvious on distance vision, which is the reason why it is also referred to as intermittent distance exotropia.,,, Since the deviation usually manifests when the person is tired, sick, or daydreaming, it is also known as periodic or inattention exotropia. The etiology of IXT is not clear, but many factors, including neuro-mechanical factors, insufficient fusion, a high accommodative convergence to accommodation ratio (AC/A),, refractive errors, and genetic factors, were cited in previous reports.
There are two classification systems for IXT: the Burian's classification and Kushner's classification. The Burian's system is based on the distance and near measurements of exodeviation. According to this system, IXT may occur during distance fixation (divergence excess [DE]), near fixation (convergence insufficiency [CI]), or both (basic exotropia [BE]). Therefore, limiting the use of IXT to DE is not correct, and each type of exodeviation can be latent, intermittent, or constant. DE IXT is also divided into true and simulated forms. A patient has true DE if there is no change in near deviation after the relaxation of proximal fusion and accommodation, while simulated DE is present if near measurements approach or exceed distance measurements in this situation [Table 1]. Kushner's classification system is more complex and is based on the effective mechanism of distance and near deviation disparity [Table 2].
It is unclear whether this type of deviation changes over time, and there are different hypotheses in this regard. A decompensated exophoria is sometimes converted to IXT, which ultimately becomes constant. Suppression, increased distance between the eyes, and decreased accommodation and tonic convergence with age are risk factors of IXT progression. However, studies have shown that not all IXT deviations are progressive as some of them remain constant for years, and a lower percentage of patients improve over time.,,, Examination of the magnitude of deviation, stereo-acuity, and the ability of the patients to control their deviation can help the examiner predict the severity of the deviation and the possibility of deterioration in future. However, quantification of its severity has been poorly standardized. Different scales are used to assess the ability to control the deviation based on the speed and recovery movements of the eyes from a dissociated state such as the Newcastle Control Score (NCS) [Table 3] and the Mohney and Holmes score [Table 4].
Management decisions in IXT patients still present a challenge to many clinicians. IXT is treated when binocular vision is impaired, or the patient is symptomatic. The objective of treatment is to reduce the symptoms and the frequency of manifest deviation by decreasing the angle of deviation or enhancing the ability to control it. There are different surgical and non-surgical management strategies. Non-surgical methods are non-invasive and can reduce the symptoms and postpone surgical interventions., Current non-surgical management strategies of IXT are discussed in this research.
| Methods|| |
A search strategy was developed using a combination of the words IXT, DE, non-surgical management, observation, overcorrecting minus lens therapy, patch/occlusion therapy, orthoptics/binocular vision therapy, and prism therapy to identify all articles in four electronic databases (PubMed, Web of Science, Google Scholar, and Scopus). Two authors (S.H. and A.O.) searched and extracted the articles. Then, they scanned the titles and abstracts of the retrieved articles for relevance. To find more articles and to ensure that the databases were thoroughly searched, the reference lists of the selected articles were also reviewed from inception to June 2018 with no restrictions and filters.
| Results|| |
Management decisions in IXT patients are presently guided by both the angle of deviation and the ability to control it. Although non-surgical management options are not very effective for the treatment of IXT, they are rarely associated with adverse outcomes. These options are believed to be more appropriate in many patients with a small angle of deviation (< 20 prism diopter [PD]). Moreover, these methods may be preferred in very young children who may become amblyopic or lose their binocular fixation due to the possibility of overcorrection in surgical procedures., A summary of some previous studies that investigate different non-surgical management strategies of IXT is reported in [Table 5].
|Table 5: Summary of some previous studies that investigate different non-surgical management strategies of intermittent exotropia|
Click here to view
Correction of refractive errors
According to the literature, one of the etiologies of IXT is high hyperopia and/or low-to-moderate myopia, which can cause deviation through decreased accommodative convergence.,,,, Anisometropia can also impair sensory fusion and thus result in deviation due to the relationship between sensory and motor fusion., Therefore, correction of these types of refractive errors may resolve the problem by improving the sensory and subsequently, the motor fusion and enhancing the ability to control the deviation. According to a recent study by Han et al., uncorrected refractive errors impair stereo-acuity, and since impaired stereo-acuity may worsen IXT in the long-term, its treatment may improve the patient's status over time.
In myopic cases, full correction is suggested due to its effect on accommodative convergence. In hyperopic patients, although some clinicians believe that hypermetropia will increase both the frequency and the angle of deviation, this is not always correct. Many patients with high hyperopia and IXT improve after optical correction. Age, degree of hyperopia, and amount of AC/A should be considered in prescribing this type of refractive error. In general, mild-to-moderate hyperopia is not usually corrected due to the possibility of accommodative convergence relaxation and worsening of the angle of deviation. However, in hyperopia >4 D or anisometropia >1.5 D, refractive error correction usually improves the deviation control. Moreover, in these cases, due to the lack of accommodative effort, the retinal image is blurry, and deviation becomes manifest; hence, correction of hyperopia can enhance the retinal image and improve deviation control.,
Chung et al. evaluated the changes of the angle of deviation after refractive correction in IXT patients and reported a mild increase in exodeviation following hyperopic correction (more than 10 PD in one-third of the hyperopic cases). By contrast, in their myopic cases, the angle of deviation remained constant or decreased following wearing spectacles for at least 6 months. The authors concluded that optical correction in cases with exotropia was useful before strabismus surgery, and considering a new angle of deviation after spectacle correction should produce better results.
Although findings related to the effect of refractive error correction on IXT are controversial, it is widely accepted that correcting even insignificant amounts of refractive error (especially astigmatism and myopia) may result in a better deviation control and should be considered prior to surgical intervention.
Studies in this field have reported different results that can be categorized into three groups: no change in deviation over time,,,, improvement in the course of time,, and deterioration of deviation over time.,
A study conducted by the Pediatric Eye Disease Investigator Group showed that observation did not result in IXT deterioration in the age range 12–35 months. Buck et al. indicated a very low risk of deterioration within 2 years after a diagnosis of IXT. However, these studies were conducted in children (<12 years) and followed the patients for a short period, while it is possible that IXT will deteriorate at older ages considering its risk factors and etiologies. There are no recent reports indicating IXT improvement with observation. However, symptoms (functional and cosmetic) are important factors in decision-making regarding the start of treatment. If the patient is able to control the deviation, the angle of deviation does not worsen on several follow-up visits, and the patient or parents are not concerned about functional or cosmetic issues, the patient may be followed at short intervals to start treatment interventions if deviation becomes worse.
There are different methods for occlusion therapy, also known as anti-suppression therapy, including monocular or alternate occlusion and part-time versus full-time occlusion. Monocular occlusion (patching the dominant eye) is applied if there is a dominancy relationship between the eyes, and alternate occlusion is done when there is no dominant eye. The aim of this approach is to eliminate visual adaptation (suppression), induce diplopia, and consequently motivate motor fusion. Nonetheless, diplopia may not be induced in all patients. It is also suggested that occlusion may reduce the amount of deviation and change the deviation from exotropia to exophoria. Some researchers believe that this method is useful in younger children and in patients who wish to postpone surgical treatment., Cotter et al. evaluated the effect of alternate occlusion for 3 h daily versus observation on the deterioration of deviation (worsening of stereopsis or deviation becoming more constant) in children aged 3–10 years who were not previously treated. The cases were randomly allocated to observation (no treatment) or intermittent occlusion. After 6 months, a low rate of deterioration was observed in both groups (6.1% in the observation group and 0.6% in the occlusion group). Although the deterioration rate was lower in the occlusion group, there was no significant difference between observation and patching.
Moreover, according to the results of the recent clinical trials conducted by the Pediatric Eye Disease Investigator Group to evaluate the effect of part-time occlusion in children aged 12––35 months, deterioration over 6 months was uncommon with or without patching treatment. In other words, there was insufficient evidence to recommend part-time patching for the treatment of IXT in children in this age group.,
Alkahmous and Al-Saleh conducted a study to assess the efficacy of occlusion therapy in controlling IXT and degree of deviation in children aged 4–10 years. In this study, three variables, including stereopsis, deviation size, and positive fusional vergence, were examined at far and near. Binocular visual acuity and the Mohney and Holmes control scale were also assessed. After about 6 h a day alternate occlusion for about 6 months, all variables improved markedly except for deviation angle at distance. The authors concluded that alternate occlusion improved the sensory status and strengthened the fusional amplitudes at near and distance. The authors reported that alternate patching could improve IXT control but did not improve the angle of deviation. Although there are no reports of the deviation angle improvement in the above studies, some earlier reports showed changes in the amount of deviation after occlusion therapy.,
Akbari et al. investigated the effect of 2 h of alternate occlusion on control of IXT in children 3–8 years old and found a significant improvement in control of deviation both in near and far.
In general, part-time occlusion for 2–6 h was recommended in previous studies. However, we could not find a clear rationale for the duration of patching recommended in these studies or sufficient evidence to support the optimum patch time for IXT treatment in different age groups of children. An important point to remember when using this method is that since fusion control improvement resulting from occlusion therapy is temporary, it should not be used alone for IXT treatment., In fact, this method is mostly used to postpone surgical treatment.
Overcorrecting minus lens therapy
In this method, the patient wears over-minus spectacles compared to their cycloplegic refraction at all times. The aim of this method is to improve deviation control and reduce the angle of deviation to delay surgical correction. This temporary method is also used when children are not old enough to start orthoptic therapies. Minus lens therapy is usually used in preschool children (aged 2–7 years old);, however, there are reports of its efficacy in older ages, too., It was previously believed that the minus lens was effective only in patients with a high AC/A; however, more recent evidence suggests otherwise.,,, On the other hand, recent studies found that a high AC/A ratio was not detrimental to a good outcome, and it appears that even children with low and normal AC/A ratios may respond well to overcorrecting minus lens therapy., It is reported that even a slight accommodative effort can trigger a surprisingly large vergence response that can be enough to permit the child to keep the exodeviation latent by using large fusional convergence amplitudes.
A widely held mechanism for the efficacy of a minus lens is that it stimulates accommodation, resulting in the stimulation of accommodative convergence and IXT reduction. Another theory that accounts well for the efficacy of minus lens therapy is the fusional convergence mechanism. Horwood and Riddell proposed that the use of “over-minus” lenses in IXT could eliminate blur that is secondary to excess accommodation resulting from disparity-driven convergence and thereby could promote fusional convergence at near. Moreover, many other investigators have discussed the role of disparity-induced vergence in controlling intermittent exodeviations.,,, Indeed, the use of fusional convergence to reduce the deviation angle results in the stimulation of convergence accommodation causing a distance blurred vision. Therefore, over-minus spectacles improve the distance vision and therefore, sensory fusion.
Two methods are used to determine the required overcorrection: (1) using a constant amount of over-minus lens according to the refractive error and age, and (2) using a primary lens and applying gradual additions until IXT control is achieved. The overcorrecting minus power is −0.5 D to −5.00 D in most studies (more routinely −1.00 to −3.00).,,,, Indeed, the minimum minus power that a child can tolerate and does not compromise the child's vision while providing the best control over the deviation at the same time is usually considered. The first minus lenses are placed in a trial frame starting at −0.50 D strength and working up in −0.50 D steps until the patient controls his/her deviation at near and distance fixation.
Chen et al. investigated the effectiveness of short-term minus therapy in children 3–6 years of age with IXT. In this study, IXT patients were randomly allocated to either observation or 2.5 D over-minus spectacles, and the results were compared after 8 weeks. The mean distance exotropia control score was better in the over-minus group compared to the observation group (2.0 vs. 2.8 points), and 59% of the patients in the over-minus group showed >1 point improvement in distance control (59% vs. 39%). Bayramlar et al. conducted a study to investigate the effectiveness of minus therapy in IXT. In this study, 2.00–4.00 D of overcorrecting minus power was added to the patient's cycloplegic refraction, considering the maximum tolerable lens to read 20/25 at near and distance. Two methods were used to assess the success of minus therapy: (1) a method described by Caltrider and Jampolsky and (2) the NCS method. In the first method, qualitative and quantitative changes were evaluated after treatment. Qualitative changes included improved ability to control the deviation from poor control to good control, and the quantitative change included a decrease of at least 15 PDs in the exodeviation on the alternate cover test. Qualitative and quantitative changes were considered if neither the parents nor the physician noticed any manifest deviation while the overcorrecting minus lenses were worn. A classification of no change was used if manifest exotropia persisted while wearing the minus lenses, even if the ability to control the deviation improved in that patient. After 1 year, the results showed that 84% of the children had an NCS score of 2 or less, indicating a significant improvement. According to the Caltrider and Jampolsky method, qualitative and quantitative improvement in the size of deviation was observed in 48% and 37% of the children, respectively. The authors found that overcorrecting minus therapy could decrease deviation and improve the patient's status and should be considered as the first line of treatment.
A very recent study of the effectiveness of minus therapy in IXT in 2018 showed that over-minus correction improved IXT control (lowers the NCS score) and decreased the angle of deviation at distance and near. However, it should be noted that the majority of these studies assessed the results of short-term minus therapy, and there is no sufficient information regarding the long-term effects of this treatment method after discontinuing the use of the minus lens. Moreover, because excessive accommodation has been implicated as a cause of myopia, there is a theoretical concern that overcorrecting minus lens therapy for exotropia may cause myopia. However, despite this concern, many previous studies found that this treatment did not seem to cause myopia.,,,
Moreover, over-minus therapy can cause esotropia in near. Hence, after beginning therapy, the first examination should be performed 3–4 weeks later to evaluate alignment in near.
Prism therapy is another intervention that can be applied either alone to neutralize the deviation or in combination with orthoptic therapy. Prism therapy is mainly used in patients with a deviation <20–25 PD. Higher prisms are required in higher deviations, resulting in increased weight of the spectacles and distortion. There are different strategies for prism prescription, including a neutralizing prism (a prism is prescribed according to the deviation magnitude to neutralize its angle), a relieving prism (a prism is prescribed to decrease the deviation to some extent in order to reduce the fusional vergence demand), and an overcorrection prism (used to induce diplopia and stimulate fusional convergence).
Some authors recently found the effectiveness of base-out prism addition, also known as inverse prism addition, for improving NCS in patients with basic IXT. Inverse prisms are used to increase fusional vergence ability since they increase the demand for controlling fusional vergence. Theoretically, base-out prisms increase the demand by shifting the image to where the eye is supposed to look. This shift will provoke diplopia, stimulate fusion, and encourage the visual system to improve sensory perception and motor control.
Coffey et al. reviewed the studies related to different IXT treatment modalities. The overall pooled success rate of different treatment modalities reviewed in this article was 28% for prism therapy, 28% for over-minus therapy, 59% for vision therapy, and 37% for occlusion therapy. It was suggested that a combination of relieving prism and orthoptic therapy may be more successful than most of the above strategies.
Orthoptics/binocular vision therapy
The main objective of binocular vision therapy/orthoptics is to remove suppression, stimulate diplopia awareness, improve sensory fusion and fusional reserve, and restore binocular vision. A combination of anti-suppression therapy and accommodation and vergence therapy is recommended. Vision training should initially address vergence skills by modifying fusional vergence amplitudes and vergence facility at near fixation for CI and at distance, intermediate, and near for DE and BE.
There is no consensus on the effectiveness of this treatment method. For example, Sanflippo and Clahane found that orthoptic therapy improved the deviation in 64% of the subjects. Hardesty reported improvement in 50% of the patients who underwent both surgical intervention and orthoptic therapy, while only 32% of the patients who only underwent surgery improved. In general, there are three opinions about binocular vision therapy: some studies suggest that it has no effect on the deviation, some have shown that binocular vision therapy/orthoptics alone can reduce deviation,, and some others have found that it should be accompanied by surgery.
According to Lavrich, binocular vision therapy/orthoptics is more effective in adults that are more cooperative and mostly suffer from CI, although, it also has some effects on other types of exodeviation as well. Asadi et al. found that the most frequent complaints of the patients were intermittent deviation in one eye (67.2%), eye strain (23%), and diplopia (9.8%). Of 74 patients, 43 (58.1%) had BE, 22 (29.7%) had CI, and 9 (12%) had DE exodeviation. The results showed improvement in the angle of deviation (at distance and near depending on the type of deviation) and symptoms in 88.3% of the patients with BE, 100% of the patients with CI, and 88.8% of the patients with DE. In this study, office and home-based training exercises including prism exercises, pencil push-ups, 3D stereogram tests, and suppression therapy like dominant eye occlusion were applied for 8 weeks. Researchers usually categorize vision therapies into some general categories for comparison, including home-based computer therapy, office-based therapy, and pencil push-up treatment. It has been shown that a combination of in-office and home-based therapy produces better results than does home-based therapy alone.,,
Peddle et al. found that binocular vision therapy/orthoptics could be even effective in adults who received no treatments for exodeviation at all. In their study, two adult patients with BE were subjected to weekly office-based and frequent home-based therapies for 30 weeks. At the end of treatment, exotropia at distance and near reduced, the patients achieved the required fusion at all distances, and their symptoms improved.
In general, it can be concluded that binocular vision therapy/orthoptics is very effective in children or even in adults who are cooperative and willing to do the therapies.
Studies have shown the effectiveness of botulinum toxin injection for the treatment of IXT.,, The therapeutic principle of botulinum toxin in IXT is to paralyze the injected muscle (lateral rectus muscle). According to the literature, it is at least as effective as surgery irrespective of the initial strabismus angle. Significant improvements in fusion control and improved stereovision have been reported 6 months after botulinum toxin injection to the lateral rectus muscles.
| Discussion|| |
The first step in the treatment of IXT patients is refractive correction to improve the sensory and subsequently, motor fusion and to enhance the ability to control the deviation., In the next step, other methods can be applied according to the patient's status, severity of the deviation, and age. According to the results of recent studies, observation does not result in improvement, and it is better to use observation together with other treatment interventions as an assessment method rather than applying it as a treatment option. Another point is that observation may be used as a temporizing measure in uncooperative children whose deviation is not severe.
Overcorrecting minus lens therapy is an appropriate method for patients with good accommodative power. It may be considered the first treatment option after refractive correction because it is more convenient and acceptable compared to other methods such as occlusion therapy and orthoptics.,,
Since occlusion therapy is used to achieve anti-suppression, it can be included in the category of binocular vision therapy/orthoptics and prescribed for children whose accommodative system is not yet normally established to improve deviation and prevent deterioration. However, it should always be remembered that occlusion therapy has short-term effects and should be accompanied by other methods.,,
In patients with <20–25 PD deviation, another intervention that can be applied is prism therapy. This technique can be used either alone to neutralize the deviation or in combination with orthoptic therapy.
Kushner in a study on the effect of combination therapy consisting of part-time alternate occlusion followed by over-minus spectacles with base-in prism in children 2–10 years of age with IXT found that this conservative management could delay or eliminate the need for surgery.
Binocular vision therapies, including fusion, accommodative, and anti-suppression therapies, can affect all systems involved in deviation and are therefore very useful. Another advantage of orthoptic therapy is that it can also be used in adult patients.,,
Another non-surgical temporary treatment method is botulinum toxin injection to paralyze the lateral rectus muscle. It is supposed that this method can be at least as effective as surgery irrespective of the initial strabismus angle.
In conclusion, evidence supporting the efficacy of non-surgical management options for IXT is not compelling. More comprehensive randomized controlled trial studies are required to evaluate the effectiveness of these procedures and identify the most effective strategy. Studies with longer follow-ups are also recommended to investigate the long-term effects of different treatment options, especially after the cessation of interventions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Donnelly UM, Stewart NM, Hollinger M. Prevalence and outcomes of childhood visual disorders. Ophthalmic Epidemiol 2005;12:243-50.
Grönlund MA, Andersson S, Aring E, Hård AL, Hellström A. Ophthalmological findings in a sample of Swedish children aged 4-15 years. Acta Ophthalmol Scand 2006;84:169-76.
Robaei D, Rose KA, Kifley A, Cosstick M, Ip JM, Mitchell P. Factors associated with childhood strabismus: Findings from a population-based study. Ophthalmology 2006;113:1146-53.
Matsuo T, Matsuo C, Matsuoka H, Kio K. Detection of strabismus and amblyopia in 1.5- and 3-year-old children by a preschool vision-screening program in Japan. Acta Med Okayama 2007;61:9-16.
Multi-ethnic Pediatric Eye Disease Study Group. Prevalence of amblyopia and strabismus in African American and Hispanic children ages 6 to 72 months the multi-ethnic pediatric eye disease study. Ophthalmology 2008;115:1229-360.
Chia A, Dirani M, Chan YH, Gazzard G, Au Eong KG, Selvaraj P, et al
. Prevalence of amblyopia and strabismus in young Singaporean Chinese children. Invest Ophthalmol Vis Sci 2010;51:3411-7.
Chen X, Fu Z, Yu J, Ding H, Bai J, Chen J, et al
. Prevalence of amblyopia and strabismus in Eastern China: Results from screening of preschool children aged 36-72months. Br J Ophthalmol 2016;100:515-9.
Hashemi H, Nabovati P, Yekta A, Ostadimoghaddam H, Behnia B, Khabazkhoob M. The prevalence of strabismus, heterophorias, and their associated factors in underserved rural areas of Iran. Strabismus 2017;25:60-6.
Schaal LF, Schellini SA, Pesci LT, Galindo A, Padovani CR, Corrente JE. The prevalence of strabismus and associated risk factors in a Southeastern region of Brazil. Semin Ophthalmol 2018;33:357-60.
Mohney BG, Huffaker RK. Common forms of childhood exotropia. Ophthalmology 2003;110:2093-6.
Chia A, Roy L, Seenyen L. Comitant horizontal strabismus: An Asian perspective. Br J Ophthalmol 2007;91:1337-40.
Khorrami-Nejad M, Akbari MR, Khosravi B. The prevalence of strabismus types in strabismic Iranian patients. Clin Optom (Auckl) 2018;10:19-24.
Jenkins RH. Demographics: Geographic variations in the prevalence and management of exotropia. Am Orthopt J 1992;42:82-7.
Eustace P, Wesson ME, Drury DJ. The effect of illumination of intermittent divergent squint of the divergence excess type. Trans Ophthalmol Soc U K 1973;93:559-70.
Graham PA. Epidemiology of strabismus. Br J Ophthalmol 1974;58:224-31.
Rutstein RP, Corliss DA. The clinical course of intermittent exotropia. Optom Vis Sci 2003;80:644-9.
Govindan M, Mohney BG, Diehl NN, Burke JP. Incidence and types of childhood exotropia: A population-based study. Ophthalmology 2005;112:104-8.
McKean-Cowdin R, Cotter SA, Tarczy-Hornoch K, Wen G, Kim J, Borchert M, et al
. Prevalence of amblyopia or strabismus in Asian and non-Hispanic white preschool children: Multi-ethnic pediatric eye disease study. Ophthalmology 2013;120:2117-24.
Buck D, Powell CJ, Rahi J, Cumberland P, Tiffin P, Taylor R, et al
. The improving outcomes in intermittent exotropia study: Outcomes at 2 years after diagnosis in an observational cohort. BMC Ophthalmol 2012;12:1.
Von Noorden GK, Campos EC. Binocular Vision and Ocular Motility: Theory and Management of Strabismus. St. Louis: Mosby; 2002.
Cooper J. Intermittent exotropia of the divergence excess type. J Am Optom Assoc 1977;48:1261-73.
Khawam E, Zein W, Haddad W, Haddad C, Allam S. Intermittent exotropia with high AC/A ratio: Is it a bane to surgical cure? Some facts and fictions of the two clinical tests: Occlusion of one eye and the use of +3.00 spherical lenses. Binocul Vis Strabismus Q 2003;18:209-16.
von Noorden GK, Avilla CW. Accommodative convergence in hypermetropia. Am J Ophthalmol 1990;110:287-92.
Matsuo T, Hayashi M, Fujiwara H, Yamane T, Ohtsuki H. Concordance of strabismic phenotypes in monozygotic versus multizygotic twins and other multiple births. Jpn J Ophthalmol 2002;46:59-64.
Burian HM. Exodeviations: Their classification, diagnosis and treatment. Am J Ophthalmol 1966;62:1161-6.
Kushner BJ. Exotropic deviations: A functional classification and approach to treatment. Am Orthopt J 1988;38:81-93.
Chia A, Seenyen L, Long QB. A retrospective review of 287 consecutive children in Singapore presenting with intermittent exotropia. J AAPOS 2005;9:257-63.
Nusz KJ, Mohney BG, Diehl NN. The course of intermittent exotropia in a population-based cohort. Ophthalmology 2006;113:1154-8.
Romanchuk KG, Dotchin SA, Zurevinsky J. The natural history of surgically untreated intermittent exotropia-looking into the distant future. J AAPOS 2006;10:225-31.
Haggerty H, Richardson S, Hrisos S, Strong NP, Clarke MP. The Newcastle Control Score: A new method of grading the severity of intermittent distance exotropia. Br J Ophthalmol 2004;88:233-5.
Mohney BG, Holmes JM. An office-based scale for assessing control in intermittent exotropia. Strabismus 2006;14:147-50.
Hutchinson AK. Intermittent exotropia. Ophthalmol Clin North Am 2001;14:399-406.
Rosenbaum AL, Santiago AP. Clinical Strabismus Management: Principles and Surgical Techniques. Philadelphia: David Hunter; 1999.
Joyce KE, Beyer F, Thomson RG, Clarke MP. A systematic review of the effectiveness of treatments in altering the natural history of intermittent exotropia. Br J Ophthalmol 2015;99:440-50.
Chung SA, Kim IS, Kim WK, Lee JB. Changes in exodeviation following hyperopic correction in patients with intermittent exotropia. J Pediatr Ophthalmol Strabismus 2011;48:278-84.
Pediatric Eye Disease Investigator Group, Mohney BG, Cotter SA, Chandler DL, Holmes JM, Chen AM, et al
. A randomized trial comparing part-time patching with observation for intermittent exotropia in children 12 to 35 months of age. Ophthalmology 2015;122:1718-25.
Pediatric Eye Disease Investigator Group, Chen AM, Holmes JM, Chandler DL, Patel RA, Gray ME, et al
. A randomized trial evaluating short-term effectiveness of overminus lenses in children 3 to 6 years of age with intermittent exotropia. Ophthalmology 2016;123:2127-36.
Pediatric Eye Disease Investigator Group, Cotter SA, Mohney BG, Chandler DL, Holmes JM, Repka MX, et al
. A randomized trial comparing part-time patching with observation for children 3 to 10 years of age with intermittent exotropia. Ophthalmology 2014;121:2299-310.
AlKahmous LS, Al-Saleh AA. Does occlusion therapy improve control in intermittent exotropia? Saudi J Ophthalmol 2016;30:240-3.
Bayramlar H, Gurturk AY, Sari U, Karadag R. Overcorrecting minus lens therapy in patients with intermittent exotropia: Should it be the first therapeutic choice? Int Ophthalmol 2017;37:385-90.
Mangad SE, Mohan L, Vijayalakshmi M, Krishnan P, Babu SP. Role of overminus therapy in intermittent exotropia. Kerala J Ophthalmol 2018;30:38-42. [Full text]
Samy El Gendy NM, Abdel Nabi E. Is inverse prism therapy comparable to conventional prism therapy for improving newcastle scores in patients with basic intermittent exotropia? Semin Ophthalmol 2019;34:497-503.
Hardesty HH, Boynton JR, Keenan JP. Treatment of intermittent exotropia. Arch Ophthalmol 1978;96:268-74.
Asadi R, Ghasemi-Falavarjani K, Sadighi N. Orthoptic treatment in the management of intermittent exotropia. Iran J Ophthalmol 2009;21:35-40.
Peddle A, Han E, Steiner A. Vision therapy for basic exotropia in adults: 2 case studies. Optometry 2011;82:467-74.
Spencer RF, Tucker MG, Choi RY, McNeer KW. Botulinum toxin management of childhood intermittent exotropia. Ophthalmology 1997;104:1762-7.
Etezad Razavi M, Sharifi M, Armanfar F. Efficacy of botulinum toxin in the treatment of intermittent exotropia. Strabismus 2014;22:176-81.
Irfan S. The impact of refractive errors on strabismus. Indian Journal Strabismology and Pediatric Ophthalmology 2018;2:21-32.
Donders FC. An Essay on the Nature and the Consequences of Anomalies of Refraction. Philadelphia: P. Blakiston's Son and Company; 1899.
Kang KT, Lee SY. Relationship between control grade, stereoacuity and surgical success in basic intermittent exotropia. Korean J Ophthalmol 2015;29:173-7.
Zhu H, Yu JJ, Yu RB, Ding H, Bai J, Chen J, et al
. Association between childhood strabismus and refractive error in Chinese preschool children. PloS One 2015;10:e0120720.
Brooks SE, Johnson D, Fischer N. Anisometropia and binocularity. Ophthalmology 1996;103:1139-43.
Tomaç S, Birdal E. Effects of anisometropia on binocularity. J Pediatr Ophthalmol Strabismus 2001;38:27-33.
Wagner RS. Correction of hyperopia in intermittent exotropia. J Pediatr Ophthalmol Strabismus 2011;48:267.
Han D, Jiang D, Zhang J, Pei T, Zhao Q. Clinical study of the effect of refractive status on stereopsis in children with intermittent exotropia. BMC Ophthalmol 2018;18:143.
Iacobucci IL, Archer SM, Giles CL. Children with exotropia responsive to spectacle correction of hyperopia. Am J Ophthalmol 1993;116:79-83.
Lavrich JB. Intermittent exotropia: Continued controversies and current management. Curr Opin Ophthalmol 2015;26:375-81.
Hiles DA, Davies GT, Costenbader FD. Long-term observations on unoperated intermittent exotropia. Arch Ophthalmol 1968;80:436-42.
Sainani A. Clinical ophthalmology-contemporary perspectives. Indian J Ophthalmol 2009;57:479. [Full text]
Buck D, Powell C, Cumberland P, Davis H, Dawson E, Rahi J, et al
. Presenting features and early management of childhood intermittent exotropia in the UK: Inception cohort study. Br J Ophthalmol 2009;93:1620-4.
Suh YW, Kim SH, Lee JY, Cho YA. Conversion of intermittent exotropia types subsequent to part-time occlusion therapy and its sustainability. Graefes Arch Clin Exp Ophthalmol 2006;244:705-8.
Freeman RS, Isenberg SJ. The use of part-time occlusion for early onset unilateral exotropia. J Pediatr Ophthalmol Strabismus 1989;26:94-6.
Park JY, Sohn HY, Cho YA. Is the nonsurgical treatment effective on intermittent exotropia in children of school-age? J Korean Ophthalmol Soc 1995;36:1561-7.
Akbari MR, Mirzajani A, Moeinitabar MR, Mirmohammadsadeghi A, Khorrami-Nejad M, Sharbatoghli L. The effect of alternate occlusion on control of intermittent exotropia in children. Eur J Ophthalmol 2020;30:275-9.
Pritchard C, Ellis GS Jr. Management of intermittent exotropia: For non-surgical therapy. Am Orthopt J 1998;48:21-4.
Figueira EC, Hing S. Intermittent exotropia: Comparison of treatments. Clin Exp Ophthalmol 2006;34:245-51.
Reynolds JD, Wackerhagen M, Olitsky SE. Overminus lens therapy for intermittent exotropia. Am Orthopt J 1994;44:86-91.
Watts P, Tippings E, Al-Madfai H. Intermittent exotropia, overcorrecting minus lenses, and the Newcastle scoring system. J Am Assoc Pediatr Ophthalmol Strabismus 2005;9:460-4.
Caltrider N, Jampolsky A. Overcorrecting minus lens therapy for treatment of intermittent exotropia. Ophthalmology 1983;90:1160-5.
Rowe F, Noonan C, Freeman G, DeBell J. Intervention for intermittent distance exotropia with overcorrecting minus lenses. Eye 2009;23:320-5.
Coffey B, Wick B, Cotter S, Scharre J, Horner D. Treatment options in intermittent exotropia: A critical appraisal. Optom Vis Sci 1992;69:386-404.
Brodsky MC, Horwood AM, Riddell PM. Intermittent exotropia: Are we underminusing by not overminusing? J Am Assoc Pediatr Ophthalmol Strabismus 2015;15:397-8.
Horwood AM, Riddell PM. Evidence that convergence rather than accommodation controls intermittent distance exotropia. Acta Ophthalmol 2012;90:e109-17.
Laird PW, Hatt SR, Leske DA, Holmes JM. Stereoacuity and binocular visual acuity in prism-induced exodeviation. J Am Assoc Pediatr Ophthalmol Strabismus 2007;11:362-6.
Laird PW, Hatt SR, Leske DA, Holmes JM. Distance stereoacuity in prism-induced convergence stress. J Am Assoc Pediatr Ophthalmol Strabismus 2008;12:370-4.
Ahn SJ, Yang HK, Hwang JM. Binocular visual acuity in intermittent exotropia: Role of accommodative convergence. Am J Ophthalmol 2012;154:981-6.e983.
Donaldson P, Kemp E. An initial study of the treatment of intermittent exotropia by minus overcorrection. Br Orthopt J 1991;48:41-3.
Kushner BJ. Does overcorrecting minus lens therapy for intermittent exotropia cause myopia? Arch Ophthalmol 1999;117:638-42.
Rutstein RP, Marsh-Tootle W, London R. Changes in refractive error for exotropes treated with overminus lenses. Optometry Vis Sci 1989;66:487-91.
Ekdawi NS, Nusz KJ, Diehl NN, Mohney BG. The development of myopia among children with intermittent exotropia. Am J Ophthalmol 2010;149:503-7.
Daum KM. Divergence excess: Characteristics and results of treatment with orthoptics. Ophthalm Physiol Optics 1984;4:15-24.
Veronneau-Troutman S, Shippman S, Clahane A. Prisms as an orthoptic tool in the management of primary exotropia. Orthoptics: Past, Present and Future. New York: Stratten Intercontinental; 1976. p. 195-201.
Jampolsky A. Characteristics of suppression in strabismus. AMA Arch Ophthalmol 1955;54:683-96.
Srinivasan G. Management of intermittent exotropia of the divergence excess type: A teaching case report. Optometr Educ 2017;42:43-52.
Evans BJ. Pickwell's Binocular Vision Anomalies: Investigation and Treatment. Philadelpia, USA: Elsevier Health Sciences; 2002.
Scheiman M, Wick B. Clinical Management of Binocular Vision: Heterophoric, Accommodative, and Eye Movement Disorders. Philadelpia, USA: Lippincott Williams and Wilkins; 2008.
Sanflippo S, Clahane AC, editors. The Immediate and Long Term Effects of Orthoptics in Exodeviations. Trans 1st
Int Congress of Orthoptists. St Louis: CV Mosby; 1968.
Velez G. Results in intermittent exotropia. J Pediatr Ophthalmol Strabismus 1975;12:160-1.
Chryssanthou G. Orthoptic management of intermittent exotropia. Am Orthopt J 1974;24:69-72.
Singh V, Roy S, Sinha S. Role of orthoptic treatment in the management of intermittent exotropia. Indian J Ophthalmol 1992;40:83-5.
] [Full text]
Birnbaum MH, Soden R, Cohen AH. Efficacy of vision therapy for convergence insufficiency in an adult male population. J Am Optometr Assoc 1999;70:225-32.
Scheiman M, Mitchell GL, Cotter S, Kulp MT, Cooper J, Rouse M, et al
. A randomized clinical trial of vision therapy/orthoptics versus pencil pushups for the treatment of convergence insufficiency in young adults. Optometry Vis Sci 2005;82:583-95.
Insuffi C. Randomized clinical trial of treatments for symptomatic convergence insufficiency in children. Arch Ophthalmol 2008;126:1336-49.
Li Y, Wu X. Observation of botulinum toxin A management in childhood with intermittent exotropia. Zhonghua Yan Ke Za Zhi 2008;44:967-71.
Kushner BJ. Conservative management of intermittent exotropia to defer or avoid surgery. J AAPOS 2019;23:256.e1-6.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|This article has been cited by|
||Vision Abnormalities in Children and Young Adults With Cerebral Palsy; A Systematic Review
| ||Samira Heydarian, Marziye Moradi Abbasabadi, Mehdi Khabazkhoob, Hosein Hoseini-Yazdi, Masoud Gharib |
| ||Seminars in Ophthalmology. 2022; : 1 |
|[Pubmed] | [DOI]|
||Analysis of Improvement Time and Influencing Factors of Diplopia after Intermittent Exotropia in Children
| ||Fei Wang, Haijing Cao, Yuan Zhang, Wenqi Wang, Rahim Khan |
| ||Journal of Healthcare Engineering. 2022; 2022: 1 |
|[Pubmed] | [DOI]|
||Comparison of alternate part-time patching and pencil push-up training for patients with intermittent exotropia
| ||Desheng Song, Ling Yin, Danni Chen, Jing Qian, Zhijun Chen |
| ||BMC Ophthalmology. 2022; 22(1) |
|[Pubmed] | [DOI]|
||Observation of Short-Term Outcomes of Perceptual Learning Based on Virtual Reality in Patients with Small-Angle Intermittent Exotropia
| ||? ? |
| ||Hans Journal of Ophthalmology. 2022; 11(02): 201 |
|[Pubmed] | [DOI]|
||Strabismus divergens intermittens: eine Herausforderung
| ||Santa Heede |
| ||Kompass Ophthalmologie. 2020; 6(4): 167 |
|[Pubmed] | [DOI]|