The incidence of abscess formation as a result of pit
viper envenomation is 9%, and prophylactic antibiotics
are recommended.6 The infection rate of venomous snake-
bite in northern Taiwan is 6.2%.7 Although there is no
specific data for D acutus snakebite in the literature,
prophylactic systemic antibiotics were prescribed for our
patient, and his condition was not complicated by local
infection.
In summary, maintaining stable life signs and preven-
tion of infection remain the chief strategies of treatment
after venomous snakebite to the eye. In addition to
antivenom, early evisceration was our treatment of choice
for this patient’s blind eye.
REFERENCES
1. Gupta M, Sharma P, Jain A, Solanky J, Sharma KK, Basu S.
Unusual site of snake bite. Trop Doct 1995;25:134 –135.
2. Kleinman DM, Dunne EF, Taravella MJ. Boa constrictor bite
to the eye. Arch Ophthalmol 1998;116:949 –950.
3. Sheard RM, Smith GT. Penetrating eye injury following a
snake attack. Eye 2003;17:279 –280.
4. Brandao EO, de Bastos HC, Nishioka Sde A, Silveira PV.
Lance-headed viper (Bothrops moojeni) bite wounding the eye.
Rev Inst Med Trop Sao Paulo 1993;35:381–383.
5. Warrel DA. Injuries, envenoming, poisoning, and allergic
reactions caused by animals. In: Weatherall DA, Cox TM,
Firth JD, Benz EJ Jr, editors. Oxford textbook of medicine, 4th
ed. Oxford: Oxford University Press, 2003:923–946.
6. Kerrigan KR. Bacteriology of snakebite abscess. Trop Doct
1992;22:158 –160.
7. Chen JC, Liaw SJ, Bullard MJ, Chiu TF. Treatment of
poisonous snakebites in northern Taiwan. J Formos Med
Assoc 2000;99:135–139.
Female Predominance in Intermittent
Exotropia
Kevin J. Nusz, MD, Brian G. Mohney, MD,
and Nancy N. Diehl, BS
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 inci-
dence 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
546 AMERICAN JOURNAL
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 histori-
cal or clinical differences between the genders. (Am J
Ophthalmol 2005;140:546 –547. © 2005 by Elsevier
Inc. All rights reserved.)
I NTERMITTENT EXOTROPIA IS THE MOST COMMON FORM
of exodeviation and occurs more frequently than esotro-
pia in some populations.1 Although common, population-
based data on the epidemiology of this disorder are nearly
nonexistent. The primary objective of this study was to
determine whether there are differences between genders
in a population-based cohort of pediatric patients with
intermittent exotropia.
The medical records of all patients less than 19 years
of age who were residing in Olmsted County, Minnesota
and diagnosed by an ophthalmologist with intermittent
exotropia from January 1, 1975, through December 31,
1994, were retrospectively reviewed. Institutional Re-
view Board approval was obtained for this study and
only patients who provided research authorization were
included. Intermittent exotropia was defined in this
study as an acquired, intermittent exodeviation of 10 or
more prism diopters unassociated with other ocular,
paralytic, or neurologic defects. Potential cases of inter-
mittent exotropia were identified by means of the
resources of the Rochester Epidemiology Project, a
medical records linkage system designed to capture data
on any patient-physician encounter in Olmsted County,
Minnesota.2,3 Exotropic patients not residing in Olm-
sted County at the time of their diagnosis were ex-
cluded.
One hundred eighty-four new cases of childhood
intermittent exotropia were diagnosed in Olmsted
County, Minnesota during the 20-year study period.
Sixty-four percent of the 184 patients were female
during a period in which the population of Olmsted
County patients less than 19 years were nearly equally
divided between the genders (Table). The age-adjusted
incidence rate for intermittent exotropia in Olmsted
County, Minnesota was 38.3 per 100,000 for girls, which
is significantly greater than the 20.8 per 100,000 for
boys (P ⬍ .0001). There were, however, no significant
Accepted for publication Mar 2, 2005.
From the Department of Ophthalmology (K.J.N., B.G.M.) and Divi-
sion of Biostatistics (N.N.D.), Mayo Clinic and Mayo Foundation,
Rochester, Minnesota.
Supported in part by an unrestricted grant from Research to Prevent
Blindness, Inc, New York, New York.
Inquiries to Brian G. Mohney, MD, Mayo Clinic, Department of
Ophthalmology, 200 First Street Southwest, Rochester, MN, 55905; fax:
(507) 284-4612; e-mail: mohney@mayo.edu
OF OPHTHALMOLOGY SEPTEMBER 2005
 TABLE. Historical and Initial Clinical Characteristics of 184 Patients With Intermittent Exotropia Less Than 19 Years From
Olmsted County, Minnesota

Characteristic Females Males P Value

Incident cases (%) 118 (64.1%) 66 (35.9%) ⬍.0001

Age-adjusted incidence per 100,000 (95% confidence 38.3 (31.4–45.2) 20.8 (15.8–25.8) ⬍.0001
interval)
1990 Population of Olmsted County, MN, ages birth to 19 296, 201 (49%) 309, 316 (51%)
years (%)
Number with positive family history of strabismus (%) 41 (34.8) 20 (30.3%) .83
Number born at ⬍37 weeks gestational age (%) 6 (5.1%) 4 (6.1%) .72
Median birth weight in grams (range) 3374 (953–4620) 3382 (1640–4545) .76
Mean age at diagnosis in years (range) 6.2 (0.9–18.5) 6.5 (0.7–18.6) .92
Number with amblyopia at first examination (%) 2 (1.70%) 2 (3.0%) .62
Median angle of distance deviation in prism diopters (range) 20 (10–40) 20 (10–40) .86
Median angle of near deviation in prism diopters (range) 12 (0–45) 10 (0–45) .73
Median initial refractive error (range) ⫹0.50 (⫺3.25–⫹2.63) ⫹0.25 (⫺8.00–⫹3.13) .11
Number who underwent at least one surgery (%) 41 (34.8%) 18 (27.3%) .33
Mean age of first surgery in years (range) 7.2 (3.3–22.1) 8.5 (3.6–22.8) .42

historical or clinical differences between the genders
(Table).
No prior reports on strabismus have demonstrated a
predominance of girls among children with intermittent
exotropia.1,3– 6 Former studies of prevalence either failed
to distinguish between the intermittent variety and
other forms or exotropia,4 or reported no appreciable
difference between the genders.1,3,5,6 A recent study
from Olmsted County, surveying a period of 10 years, a
duration shorter than the current study, found that girls
tended to be more likely than boys to develop exotropia
during the first decade, whereas boys were more com-
monly exotropic during the teenage years (P ⫽ .10).3
However, they did not indicate gender for each of the
individual forms of exotropia.
Why intermittent exotropia may be more common
among females is unclear. The gender distribution in
this study suggests an X-linked dominant inheritance
that would affect females nearly twice as often as males.
However, an X-linked affected male would be expected
to transfer the trait to all his daughters and none of his
sons. This seems unlikely, although Lyonization, incom-
plete penetrance, and environmental factors could ex-
plain some of the discrepancies. Additionally, we
cannot discount the possibility that parents of exotropic
girls were more likely to seek medical attention for their
child than were the parents of boys with the same
condition.
This population-based study found that intermittent
exotropia is significantly more common among girls
than boys. Two of every three children diagnosed with
intermittent exotropia in this 20-year study were female.
In contrast, there were no historical or clinical differ-
ences between the genders. Further studies are needed
to validate the gender differences of this common form
of childhood strabismus.
REFERENCES
1. Yu CB, Fan DS, Wong VW, et al. Changing patterns of
strabismus: a decade of experience in Hong Kong. Br J
Ophthalmol 2002;86:854 – 856.
2. Kurland LT, Molgaard CA. The patient record in epidemiol-
ogy. Sci Am 1981;245:54 – 63.
3. Govindan M, Mohney BG, Diehl NN, Burke JP. Incidence
and types of childhood exotropia: a population-based study.
Ophthalmology 2005;112:104 –108.
4. Chew E, Remaley NA, Tamboli A, et al. Risk factors for
esotropia and exotropia. Arch Ophthalmol 1994;112:1349 –
1355.
5. Graham PA. Epidemiology of strabismus. Br J Ophthalmol
1974;58:224 –231.
6. Friedman Z, Neumann E, Hyams SW, Peleg B. Ophthalmic
screening of 38,000 children, age 1 to 2 and one half years, in
child welfare clinics. J Pediatr Ophthalmol Strabismus 1980;
17:261–267.

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