Intermittent Exotropia: Management

Options and Surgical Outcomes
Kelley Davis Dasinger, OD
Southern College of Optometry
Memphis, Tennessee

Background: This paper reflects an effort to recreate a modern analysis of a 1985 study on surgical outcomes of
intermittent exotropia. Post-surgical results are reported as functional, motor, cosmetic, and unsuccessful. Modern
optometric approaches to management of intermittent exotropia are also discussed.

Methods: A literature review of 17 acceptable papers (dating from 1990-2011) on the outcome of strabismus surgery
for intermittent exotropia was conducted. Search words included: intermittent exotropia, strabismus, strabismus
surgery, and strabismus surgical outcomes.

Results: No papers exactly fit the rigorous standards of the original 1985 study regarding surgical outcomes for in-
termittent exotropia. Some modern papers did not differentiate between exo deviations (exophoria versus exotropia)
or strabismic deviations (esotropia versus exotropia). Not one study reported an absence of post-surgical strabismus
and concomitant functional improvement. However, in papers citing functional results only, 62.3% of patients had
successful post- surgical outcomes.

Conclusions: Data from the 1985 study on surgical outcomes of intermittent exotropia is impossible to recreate in
2011. Interestingly, more surgeons/authors in modern studies show an interest in post-surgical functional vision
than in the 1985 version. Very few modern studies analyze the use of vision therapy concomitantly with strabismus
surgery. This is a potential area of future interest.

Key Words
exotropia, intermittent exotropia, strabismus surgical outcomes, strabismus surgery, vision therapy.

Introduction ways to calculate the appropriate amount of base-in prism nec-
It is estimated that strabismus affects 2% to 6% of the gen- essary for treatment, measuring the associated phoria is one of
eral population.1 One study suggests that 20.4% of strabismics the most common. Prism can be ground-in or applied to spec-
are exotropes.1 However, this number is likely an underesti- tacles (Fresnel) and is often combined with OVT to maximize
mate because of the typical intermittency seen in exotropia. success.
Among the most common treatment methods are minus lens- Occlusion therapy is the most common nonsurgical treat-
es, prism, occlusion, vision therapy, and surgical intervention. ment prescribed by ophthalmologists, and probably the least
A 1991 study by Coffey et al. 2 compared these five treatment common prescribed by optometrists. The basis of this treat-
options (Figure 1).The highest success rate (61%) was seen ment is to limit binocular stimulation to eliminate the need
in patients post-strabismus surgery, when only analyzing cos- for anomalous correspondence and/or suppression. Regi-
metic results. When post-surgical functional results were also mens vary greatly among clinicians, ranging from one hour
considered, the success rate dropped to 43%. Optometric Vi- of patching per day to full-time occlusion. Some practitioners
sion Therapy (OVT) had the highest rate of functional success alternate which eye is occluded, while others choose to patch
(59%). Occlusion therapy, with a wide range of applications, the dominant eye only. Eye care practitioner concerns include
was successful in managing 37% of cases. Both prism therapy iatrogenic amblyopia and disruption of fusion potential.
and minus lens therapy demonstrated a 28% success rate. OVT tends to be the most popular optometric treatment
Minus lens therapy is designed to take advantage of a high option for intermittent exotropia. Goals of an OVT program
accommodative convergence to accommodation (AC/A) often include increasing fusional vergence amplitudes and fa-
ratio. Glasses or contact lenses with extra minus power are cility, improving control of the exotropia, enhancing sensory
prescribed in order to stimulate accommodative convergence, fusion, eliminating suppression, and disrupting anomalous
thereby decreasing the exotropic deviation. Typical treatments correspondence. OVT is an active form of treatment.
involve -0.75 to -4.00 diopters of additional minus power
Strabismus surgery is often regarded as the treatment of
above the manifest refractive error. Visual acuity, alignment,
choice by ophthalmologists. Surgery is prescribed most com-
and comfort at near must be monitored regularly, as ample ac-
monly when non-surgical options have failed or in large angle,
commodative amplitude is required to clear additional minus.
high frequency exotropia. As previously mentioned, success
Prism therapy is a common management option that offers rates differ when considering cosmetic alignment versus func-
a high level of control for the doctor. While there are several tional vision enhancement.
Volume 23/2012/Number2/Page 44 Journal of Behavioral Optometry

 Motor alignment – post-surgically no tropia at any dis. Successful Management of Intermittent Exotropia. regardless of binocularity. the total was 1. functional and cosmetic success rates in strabismus surgery for rized surgical results of intermittent exotropia from 22 accept. and five included the reoperation rate. General guidelines for each category were:  Unsuccessful – post-surgically unchanged or worsened. no improvement in sensory fusion. Functional success was achieved in than 15 prism diopters. Of the very few papers that included a would be beneficial for eye care practitioners to know both the failure rate. and cessful at a functional level. normal motor fusion ranges at studies that combined other treatment options (such as OVT. distance by cover test. of patients had an unsuccessful outcome.9% (63 patients). It 42. 34. In this updated study. Figure 1.2% (388 patients) results.  Functional success – generally a presence of post-surgical The results of the original project were analyzed in three fusion.5% (157 patients). minus lenses. eight studies reported surgical failures. including esotropia. Methods The categories were functional success. (125 patients). therefore.8% (145 patients).9% circumstances. Flax and Selenow ad- opted four categories of criteria to allow for direct comparison. No mutually inclusive subgroups – eight studies reported func.2% (13 patients). Analysis Criteria tance by cover test. able papers into four levels of success.0% (386 patients). and reported sensory fusion. The only variable of interest  Functional success – post-surgically no tropia at any for this paper was strabismus surgery outcomes. In the group of papers that only reported nonfunctional Results data. not necessarily an improvement from baseline. 571 surgical  Cosmetically acceptable – post-surgical strabismus less patients were included. and surgical outcome was unsuccessful in 21. 919 surgical patients were included. they were not steadfast throughout the analysis. cosmetic alignment was – 12 included functional results. 1068 surgical out of 393 surgical patients. The criteria were often defined by each study. five included nonfunctional achieved in 15. Functional success was re- ported in 62. Journal of Behavioral Optometry Volume 23/2011/Number 2/Page 45 .3% (665 patients). and 42. A literature review of Pubmed and Visionet (Southern Col- metic acceptability.  Cosmetically acceptable – post-surgical strabismus less therefore.3% (196 patients). All results cited are in  Motor alignment – no tropia post-surgically. the categories were allowed leniency out of necessity. and unsuccessful outcome. study required an absence of tropia to be considered suc- tional results. intermittent exotropia. motor alignment was achieved in 27. distance and near using prisms or an amblyoscope. or prism) were not included.5% (454 patients).9% failure rate (69 patients) Among the papers that cited functional data. motor alignment. Among the papers that cited functional data. The definitions lege of Optometry’s internal search system) produced 17 ac- of the categories were: ceptable papers from 1990 to 2011 that assessed surgical out- comes of intermittent exotropia. patients were included (Table 1). than 15 prism diopters. Motor alignment Data was analyzed in three mutually inclusive subgroups was achieved in 42. accepted. Coffey et al2 Success Rates Treatment Options A study performed in 1985 by Flax and Selenow 3 catego. while cosmetic alignment was present in order to compare more modern data to the original data. all phorias accordance with the previously mentioned 1985 standards.3% (93  Unsuccessful – unable to extrapolate this data in most patients). cos. Motor alignment was achieved The purpose of this research was to recreate this study in in 5. cosmetic alignment was achieved in 16. 17 studies reported nonfunctional results. The papers that in- cluded surgical failures noted a 17.

a lack of applicable papers forced the “unsuccessful” to a questionably more positive “reoperation. The most While not the same by definition. making it impossible to differentiate be- modalities. as the authors found “a surprising number Because reporting methods differed with each paper. Reoperation Rates Author n= Motor Cosmetic Author n= Reoperation Rate Pineles 16 50 41 Baker 7 30 30% (9) Leow17 48 29 Ekdawi 11 61 19. and an extrapolated 25% of are more volatile. Arguing either side would be outside of the patients (84 patients) had an unsuccessful outcome. The number counted twice – once for sensory findings and once for mo- of necessary secondary surgical procedures ranged anywhere tor findings. Functional Success Measures Author n= Functional Motor Cosmetic Unsuccessful Hunter 4 6 4* 4 Saunders 5 12 4 5 4 3 Adams6 18 11 6 12 Baker7 30 19 * Dadeya8 27 17 21 Abroms 9 45 42 * Morrison 10 95 4 (improved) 6 (lost stereo) Ekdawi11 56 25 * 31 Maruo12 666 496 (simultaneous 355 (4 years perception) post-op) Yildirim13 26 17 18 O’Neal14 20 12 11 6 3 Beneish15 67 14 (improved) 41 (no XT vs. “unsuccessful” rates were extrapolated easily in the nonfunctional results by simply adding the percentage of mo- Discussion tor aligned and the percentage of cosmetic aligned and sub- The original intention was to include research from the years tracting from 100%. and combining multiple treatment operative stereopsis. 337 (defined by sensory fusion and absence of tropia).” 3 While there is recent literature supporting that both anes- The original goal of this study was to recreate the criteria thesia and strabismus surgery are relatively safe in pediatric exactly as they were in 1985. and the outcome Volume 23/2012/Number2/Page 46 Journal of Behavioral Optometry . That proved to be exceptionally populations. Motor alignment lead to potential debate – perhaps the original study require- was achieved in 32. Table 1. all group analysis is less meaningful than in the original study. from intermittent. cosmetic alignment was ments were too strenuous or perhaps today’s surgical outcomes achieved in 42.7% (12) Wang18 83 72 Hunter 4 5 40% (2) Ing19 52 32 Pineles 16 50 60% (30) Kushner20 104 79 Among the papers that cited only nonfunctional results. successful” rates.1% (142 patients). reoperation rates was published in an effort to maintain three ing esotropia from exotropia. The reoperation rates may be of particular interest (Table 3). One patient in the reviewed papers study analyzed met the 1985 definition of functional success underwent a total of five surgical procedures. Notice that the jargon has changed from 2000-2011. XP) 3 1 (lost stereo) * no mention of pre-operative stereopsis Table 2. using and comparing different types of sur- gical procedures (example – lateral rectus recession compared Another critique is that many studies failed to report pre- to medial rectus resection). The summation of the 2011 functional totals do not equal As analyzed in five papers.9% (111 patients). however. not a single cedures are appropriate. However. This could patients’ outcomes were analyzed (Table 2). unless specifically defined in the paper. there seems to be debate as to how many pro- challenging in the modern version. These complications seemed similar to challenges tween presence of stereopsis and improvement in stereopsis. ferentiate between phoria and tropia. patients requiring more than one 100%. Surprisingly. Because of this.” search to expand the inclusive years to 1990-2011. one cannot extrapolate the “un- from one additional procedure upwards to four additional pro. Motor Alignment Success Measures Table 3. not separating constant exotropia categories of analysis and as an interesting aside. in the original study. the serendipitous finding of common reasons that papers were excluded were: not separat. cedures. scope of this paper. the over- of papers… failed to state the criteria used… they failed to dif. This is due to the fact that some patients had to be strabismus surgery ranged from 19.7% to 60%.

Altinsoy HI. When referring a patient 6. cate for strabismus surgery or not. J AAPOS 2001. As optometrists. in intermittent exotropia. it is important to advise the patient and his/her tance stereoacuity following surgery for intermittent exotropia. Scharre J. possible indicator that modern surgeons have more regard for 13. Distance stereo acuity In conclusion. et al. Ellis FJ. Corresponding author: References Kelley Davis Dasinger. Timely surgery in make the most of any post-surgical outcome and offer appro. whether you are an advo.14:298- 304. This should not be used as a point of contention meant to jab 7. 16.62:100-4. Mohney BG. peripheral fusion and near and distance stereoacuity in intermittent exo- tropic patients before and after strabismus surgery. et al. Wick B.30:110-7. Morrison D. Rush DP. MO: Mosby. Stathacopoulos RA.7%) cited in mittent exotropia.47:12-6. at ophthalmologists. Dadeya S. Coffey B.116:324-8. Chen Y. the 1985 article included some type of functional data. functional vision analyses in the 12. see how the functional success rates compare in patients who 20. Intermittent exotropia surgery in modern papers ranged greatly from simultaneous perception children: Long term outcome regarding changes in binocular alignment. Daum KM. Selenow A. Selective surgery for intermittent exotropia based on distance/ near differences. Maruo T. The study is unattainable 15. Nonetheless. Cotter S. J Pediatr Ophthalmol Strabismus 2010. Hunter DG. surgical anguish. Arch Ophthalmol 1998.6%) included a functional in children with intermittent exotropia from a population-based cohort. Outcome study of bilateral lateral rectus controlled experiment. Nishimura J. Am J Optom Physiol Optics 1985. 10. Being educated 17.12:132-5. Outcome study of unilateral lateral rectus recession for small to moderate angle intermittent exotropia in children. tential goals and realistic outcomes of surgery. J AAPOS parents or guardians that multiple surgeries may be required. A to improved stereopsis. 1998:189. cession for intermittent exotropia operated before two years of age. Rosenbaum AL. the patient. Date accepted for publication: 30 November 2011 ADDITIONAL CONTENT AVAILABLE! The JBO Online version of this article features author interviews. Buffenn AN. Optom Vis Sci 1992. Memphis. Access JBO Online at: www. OD 1. sible to recreate using modern data. making intel.was still not positive by functional standards. one should be prepared to help 9. Usui C. priate post-surgical management options. Beneish R. Flax N. Wang L. Ing MR. Trivedi RH. and the surgeon from unnecessary post.16:265-70. Strabismus 2010. Results of surgical treatment of intermittent divergent kdasinger@sco. Leske DA. J Ophthalmol 1994. 69:386-404. Sensory results after lateral rectus muscle re- tant point for referring optometrists. Saunders RA. the results from 1985 research are impos. Rutstein RP. USA 38104 3. Okino L.oepf. Exotropic drift and ocular alignment and upfront with your patients before strabismus surgery can after surgical correction for intermittent exotropia. Long-term outcome of un. The role of stereopsis and early postoperative based on today’s available literature. participate in OVT with those who undergo strabismus sur- gery alone. Diehl NN.131:111-6. Kubota N. Tennessee. et al.and post-surgical OVT. 4. A J Ophthalmol 1999. but rather a well-documented truth that 8. Louis. 2008. 5. only five of 22 papers (22. Ophthalmic Surg Lasers both pre.29:119-24. J AA- POS 2008. 1245 Madison Avenue tent exotropia: A critical appraisal. Anomalies of Binocular Vision: Diagnosis and Management. Treatment options in intermit. O’Neal TD. Zvansky AG. Sakaue T. Long-term results of unilateral lateral rectus recession can help to prepare patients and families for the process ahead. However.47:242-7. Mutlu FM. Wu PK. As a co-managing optometrist.14:47-51. J Pediatr Ophthalmol Strabismus 1995. agement options with patients and their families. et al. Kelly JB. discussion 358. vision analysis. Donahue S. Leow PL. Long-term results of ligent surgical referrals when appropriate. or by scanning this QR code with your smartphone! Journal of Behavioral Optometry Volume 23/2011/Number 2/Page 47 . Chan CW. Canadian in strabismus surgery includes discussing all potential man. St. An area of future research related to this topic could be a strabismus. J AAPOS 2010. and discussing po. J AAPOS 2009. Ela-Dalman N. intermittent and constant exotropia for superior sensory outcome.5:352-6. 128:222-30. Twenty-year follow-up of surgery for intermittent exotropia. J AAPOS 2010. J Pediatr Ophthalmol Strabismus 2003.40:283-7. our role alignment in long-term surgical results of intermittent exotropia. Ko ST. It would be interesting to 1999. Nelson LB. Assessment of central and post-surgical binocular status. This is an impor. Mohney BG.13:4-7.247-70. Nusz KJ. Adams WE. Binocul Vis Strabismus Q 2001. Baker JD. Am J Ophthalmol 2001.12:227-32. Flanders M. in which the variable group receives recession for intermittent exotropia in children. Comparison of sensory outcomes in patients with monofixation versus bifoveal fusion after surgery for inter- On a positive note.12:141-4. Parks MM. Postoperative outcomes modern data. the surgical management of intermittent exotropia. Kamlesh. Hatt SR. Improvement in dis- for surgery. this paradigm could be a study of 666 cases. Mohney BG. Southern College of Optometry 2. Ekdawi NS. J AAPOS 2008. Yu F.32:353-7. Pineles SL. Date submitted for publication: 25 August 2011 complicated infantile exotropia. Yildirim C. J Pediatr Ophthalmol save you. Abroms AD. 12 of 17 papers (70. Conclusion 14. In the 11. Kushner BJ. improvement in intermittent exotropic patients following strabismus sur- gery. McSwain W.