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76 Original article
A pilot randomized trial evaluating overminus spectacles versus
part-time occlusion for control of intermittent exotropia among
children 2–10 years of age
Merna G. Abdelfatah, Ahmed T.I Mahmoud, Abdelrahman G. Salman,
Marwa E. Elsebaay
Ophthalmology department, Ain Shams
university, Cairo, Egypt
Correspondence to Merna G. Abdelfatah,
MBBCh, 10th Abu bakr el sediq street,
heliopolis, Cairo, 11384, Egypt.
E-mail: mernagamalahmed@gmail.com
Received 30 December 2017
Accepted 3 February 2018
Journal of the Egyptian Ophthalmological
Society 2018, 111:76–81
Introduction
Intermittent exotropia [X(T)] is the most common
type of exodeviation in children [1,2]. It is an
exophoria (X) that intermittently breaks down to a
constant exotropia (XT) of one or both eyes, mostly
for distance at times of fatigue or inattention [3].
Approximately 80% of patients with X(T) will show
progressive loss of fusional control and an increase in
the X(T) over several months to years [4].
Although X(T) is a common condition, there is still a
debate about the efficacy and timing of different
treatment options whether surgical or nonsurgical,
particularly for young children who are not
cooperative for accurate measurements [5,6].
Nonsurgical treatment options such as overminus
spectacles or occlusion are used as a primary or a
© 2018 Journal of the Egyptian Ophthalmological Society | Published by Wolters Kluwer - Medknow
Purpose
The aim was to compare the short-term effectiveness of overminus spectacles
versus part-time occlusion (PTO) in improving control of intermittent exotropia
[X(T)].
Patients and methods
A total of 60 children with X(T), from 2 to 10 years of age, were included in the study.
Their distance office control score started from 2 or worse. This is a clinical,
randomized, prospective, pilot study. Children were randomly assigned to
overminus spectacles, PTO therapy, and observation for 4 months followed by
2 months without treatment.
Results
The mean distance exotropia control score after 4 months of treatment improved
significantly in the overminus spectacle and the PTO groups from 3.9 vs. 3.9 to 2.0
vs. 2.7, respectively. After stoppage of treatment for 2 months, the score
deteriorated significantly to 3.3 and 3, respectively. The observation group’s
score showed nonsignificant change all throughout the study period.
There was a significant improvement in both mean near and distance angles only in
the overminus spectacle group after 4 months of treatment and a significant
deterioration after 2 months without treatment. Both near and distance angles
showed nonsignificant change in both PTO and observation groups all throughout
the study period. There was also a significant correlation between the poor
compliance of the patients and their deterioration in the PTO group.
Conclusion
Overminus spectacle therapy has proved to be more effective in control of X(T) than
PTO therapy. Poor compliance in PTO therapy affects the treatment effectiveness.
It is suggested to work on a protocol of treatment cessation in further studies.
Keywords:
intermittent exotropia, overcorrecting minus spectacles, part-time occlusion
J Egypt Ophthalmol Soc 111:76–81
© 2018 Journal of the Egyptian Ophthalmological Society
2090-0686
temporary treatment to delay progression of X(T) or
to improve the sensory outcome after surgery [7].
Overminus spectacles are additional minus power over
the cycloplegic refraction, prescribed full time with
eventual weaning to a point at which the X(T) is
well controlled in the regular refractive correction
[6–8]. They work by stimulating the accommodative
convergence and thus facilitating fusion [9–11].
It has been also reported that part-time occlusion
(PTO) therapy has potential benefits in preservation
This is an open access journal, and articles are distributed under the terms
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DOI: 10.4103/ejos.ejos_8_18
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Overminus spectacles versus Part time occlusion for intermittent exotropia Abdelfatah et al
of the binocularity and reduction in the frequency or
magnitude of the exodeviation [12,13].
Patients and methods
The study was carried out in the Ophthalmology
Department, Ain Shams University, according to the
tenets of the Declaration of Helsinki. The protocol
was approved by the Ophthalmology Department and
Ethical Committee, Ain Shams University. Informed
consents were also given by the parents.
The study included children from 2 to 10 years with
best-corrected visual acuity not less than 20/100
and X(T) meeting the following criteria: (a) distance
angle at least 20 prism diopters (PD) measured by
prism alternate cover test for cooperative children or by
Krimisky test for uncooperative children; (b) near
deviation should not exceed the distance deviation
by greater than 10 PD; (c) prior treatment for
X(T) was not permitted preceding enrollment;
and (d) normal neurological status. Patients with
convergence insufficiency X(T), significant aniso-
metropic amblyopia more than 4 D, and significant
vertical deviations or patterns were excluded from our
study.
At the enrollment visit, control of the exodeviation
was assessed at distance (6 m) and near (1/3 m) using
the office control score, which ranges from 0 (X, best
control) to 5 (XT, worst control). After an initial
control assessment, the magnitude of exodeviation
was assessed at distance (6 m) whenever possible and
near (1/3 m). Photographs were taken whenever
possible after the consent of the parents.
Monocular distance best-corrected visual acuity
was measured using Snellen acuity chart for
cooperative children, and for younger children,
visual acuity(VA) was assessed by noticing the
monocular fixation to objects. In addition to the
clinical testing, the participant’s parents were
consulted about the treatment regimen and were
instructed to observe the home control of the X
(T). All the clinical assessment and prism alternate
cover test were performed by study-certified masked
pediatric ophthalmologists.
Patients were randomly assigned using a permuted
block design stratified by mean distance control
score with equal probability to overminus spectacles,
PTO, and observation groups. The test results were
statistically analyzed to assess the effectiveness of
the two treatment modalities versus observation
on X(T).
77
The 20 participants who were assigned to the
overminus spectacle group were all prescribed
spectacles with fixed −3.00 D added to the sphere
power of the cycloplegic refraction, which was for all
the waking hours for the whole 4 months, and no other
X(T) treatments were allowed during this time. The
cylindrical values were prescribed without changing.
The power of the spectacles was fixed during the 4
months of treatment and then stopped for 2 months
with prescription only of nonoverminus refraction
correction if needed.
The treatment regimen for PTO was to cover the eyes
alternately for 4 h daily whether continuous or
separated for 4 months and guaranteed that the
patches were completely closing the eyes so that the
children could not see through them.
Participants who were assigned to the observation group
received no treatment other than nonoverminus
refractive correction if needed.
Patients were followed-up at the first month, third
month, and fourth month, and then after stop of
treatment at the sixth month. In each visit, we
assessed the fusional control using the Office Control
Score and the near and far angles of deviation with and
without glasses. At each visit, the clinical assessment was
performed by a masked examiner.
Compliance was assessed for participants in the PTO
and overminus spectacle groups at each follow-up visit.
It was judged to be excellent (>75%), good (51–75%),
fair (26–50%), or poor (25%) based on discussions with
the parent and by reviewing study calendars on which
parents recorded the overall number of hours the child
patched or wore the glasses.
For the PTO group, the child was supposed to cover
the eye for 4 h daily, thus, around 480 h in the 4
months. Any of the parents was asked to the write
down the hours of PTO each day, so we could
calculate the percentage and thus judge the child
compliance.
Results
Between October 2016 and June 2017, 60 children
with X(T) were included in our study. Overall, 55%
(33/60) were females and 45% (27/60) were males, and
48.3% (29/60) were myopic and 51.7% (31/60) were
hypermetropic. Moreover, 55% (33/60) of them were
younger than 5 years. The demographic statistics are
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78 Journal of the Egyptian Ophthalmological Society, Vol. 111 No. 2, April-June 2018

summarized in Table 1. Most patients (66.66%, 40/60) months of treatment, 90% (18/20) of the patients in
had basic type X(T) and the minority (33.33%, 20/60) the overminus spectacle group showed improvement
had divergence excess X(T). in their control score; 30% (6/20) had one line of
improvement, 60% (12/20) of them showed
Of the 60 participants, 91.6% (55/60) of all the significant improvement, 5% (1/20) showed
participants completed until their fourth month deterioration, and 5% (1/20) showed no change in
follow-up visit. Among them were all the patients in their score. At the sixth-month follow-up after
the observation and overminus spectacle groups stoppage of the overminus spectacles, 88.8% (16/
whereas 75% (15/20) of the patients in the PTO group. 18) of the patients showed deterioration in their
control score, whereas 11% (2/18) remained with
The sixth-month follow-up after treatment stoppage the same score, but no one showed improvement
was completed by 78.3% (47/60). Among them were in the control score after removal of the overminus
70% (14/20) of the patients in the observation group, spectacles.
90% (18/20) of the patients in the overminus spectacle
group, and 75% (15/20) of the patients in the PTO At the fourth-month follow-up, 74% (11/15) in the
group. PTO group showed improvement; among them, 33%
(5/15) showed significant improvement, 20% (3/15)
Sixteen of the 20 (80%) patients in the overminus had the same score before and after treatment, and 6%
spectacle group were judged to have good (1/15) showed deterioration. After 2 months with no
compliance, whereas 27% (4/15) in the PTO therapy PTO therapy, 46.6% (7/15) of the patients showed
group were judged to have good compliance. The P deterioration in their control score. Among them,
value was significant in both groups (P=0.002) as 28.5% (2/7) of them showed poor compliance,
shown in Table 2 and Fig. 1. 28.5% (2/7) showed fair compliance, and 42.8% (3/
7) showed good compliance to the PTO therapy.
Improvement according to Office Control Score was Moreover, 53.4% (8/15) of patients in the PTO
defined as 1-point improvement in the distance group did not show any change in their control
control score, whereas significant improvement was score at the sixth-month visit. Among them, 50%
defined as 2 or more points improvement. After 4 (4/8) showed bad compliance to the treatment and
showed no improvement in the fourth month nor in
the sixth month, 37.5% (3/8) showed fair compliance,
Table 1 Demographic data and mean values of the patients in
the study and only one showed good compliance to the PTO
Descriptive statistics therapy.
Range Mean±SD
Age 2–10 4.675±2.553 Figure 1
SE OD −11–5 −0.728±3.537
SE OS −13.5–5 −0.608±3.608
Pretreatment near angle 15–50 27.717±12.106
Fourth-month near angle 5–50 19.827±12.441
Sixth-month near angle 5–50 22.805±11.729
Pretreatment distance angle 15–70 38.333±12.967
Fourth-month distance angle 10–60 30.240±11.885
Sixth-month distance angle 10–60 34.750±12.957
Pretreatment score 1–5 3.633±1.073
Fourth-month score 1–5 2.491±1.136
Comparison between compliance of patients with overminus specta-
Sixth-month score 1–5 3.085±1.060 cle therapy and part-time occlusion therapy.
SE, spherical equivilant. OD, right eye. OS: left eye.

Table 2 Compliance of patients in both treatment modalities (overminus spectacle vs. part-time occlusion groups)
Compliance Treatment modality [n (%)] χ2 P value
Patching Overminus Total
Poor 6 (40.00) 0 (0.00) 6 (17.14) 12.859 0.002*
Fair 5 (33.33) 4 (20.00) 9 (25.71)
Good 4 (26.67) 16 (80.00) 20 (57.14)
Total 15 (100.00) 20 (100.00) 35 (100.00)
*statistically significant.
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Overminus spectacles versus Part time occlusion for intermittent exotropia Abdelfatah et al 79

In the observation group, 20% (4/20) of the patients
showed deterioration in their control score in the
fourth month visit, 45% (9/20) of the patients did
not show any deterioration, and 35% (7/20) of them
showed improvement in their score. It was noticed that
most of the children who improved in the observation
group were prescribed minus glasses only for their
refractive error. Moreover, 92.8% (13/14) showed
the same control score at the sixth month follow-up,
and only one patient showed deterioration in the
control score at the sixth month.
The mean distance exotropia control score after 4
months of treatment improved significantly in the
overminus spectacle and the PTO groups to 2.0 and
2.68, respectively, whereas at the sixth month visit after
the treatment was stopped for 2 months, deteriorated
significantly to 3.3 and 3, respectively. The observation
group’s score showed nonsignificant change all
throughout the study period as shown in Fig. 2 and
Table 3.
There was a significant improvement in both mean
near and distance angles only in the overminus
spectacle group after 4 months of treatment from
Figure 2
Comparison between office control score in the three groups before
treatment, in the fourth month, and in the sixth month.
22.7 to 9 PD for near and 39 to 25.1 PD for far. At
the sixth month after 2 months without treatment,
there was a significant deterioration to 19.4 PD for
near and 37.7 PD for far in the overminus group. Both
near and distance angles did not show a significant
change in both PTO and observation group all
throughout the study period as shown in Figs 3 and 4.
When we further studied the compliance of the
patients who did not improve in the PTO group
after 4 months of treatment, it showed a significant
correlation between the poor compliance of the
patients and their deterioration as shown in Table 4.
When we further studied the measured angle, which
represented the quantitative improvement, and office
control score, which represented the qualitative
improvement, it showed a significant correlation
between the angle and the score improvement.
Discussion
Although nonsurgical treatment for X(T) is still
debatable. It has been reported that approximately
4–16% of patients improve spontaneously with
observation through the course of time [14,15].
Other clinical investigators have reported a range of
23–75% increase in the angle of deviation through a 5-
year period of follow-up [14,16]. Lee et al. [17]
reported that surgery for deterioration of angle of
deviation to 20 PD or greater is the final destination
of almost half of patients with small exodeviation.
Rowe et al. [10] recommended overminus lens
treatment as a primary treatment option for X(T).
After a comprehensive and systemic review of
the literature, we found no previous prospective
randomized trials comparing overminus spectacles
and PTO therapy with observation in children with

Table 3 Comparison between Office Control Score in the three groups before treatment, in the fourth month, and in the sixth
month
Scores Observation (mean±SD) Patching (mean±SD) Overminus (mean±SD) ANOVA (F) P value
Pretreatment 3.050±1.099 3.950±1.099 3.950±0.759 5.414 0.007*
Fourth month 2.700±1.342 2.688±1.078 2.000±0.745 2.530 0.089
Sixth month 2.786±1.424 3.067±0.961 3.333±0.767 1.057 0.356
Pr-P4
Differences 0.350±1.182 1.063±1.063 2.000±0.745
Paired test 0.201 0.001* <0.001*
Pr-P6
Differences 0.214±0.893 0.667±0.724 0.611±1.243
Paired test 0.385 0.003* 0.052*
P4-P6
Differences −0.143±0.363 −0.467±0.516 −1.333±1.188
Paired test 0.165 0.004* <0.001*
ANOVA, analysis of variance. *statistically significant.
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80 Journal of the Egyptian Ophthalmological Society, Vol. 111 No. 2, April-June 2018

Figure 3 deteriorated in the sixth month visit after 2 months

with no treatment. In comparison with our study, the
rate of deterioration according to Mohney et al. [18], 6
months after PTO therapy, was 2.2% in 90 patients
from 12 to 35 months of age and in the study by Cotter
et al. [6] was only 0.6% in 159 patients from 3 to 10
years of age. Most patients in the previously mentioned
studies [6,18] showed excellent or good compliance,
which was inconsistent with our study.

Comparison between the mean near angle (pretreatment, at the The mean distance and near angles in the PTO therapy
fourth month, and at the sixth-month follow-up) among the three
groups.
group did not show significant improvement at the
fourth month nor deterioration at the sixth month. In
comparison with our study, Alkhamous and AlSaleh
Figure 4 [13] proved that PTO therapy can improve the
deviation control but does not improve nor worsen
the angle of deviation. However, the assessment
methods were different. Mohney et al. [18] noticed
also no improvement in the angle of deviation despite
improvement in the control and thus proved that there
was not sufficient evidence to prescribe PTO for X(T).
In the overminus spectacle group, 5% of patients
deteriorated in their score whereas 90% showed
Comparison between the mean distance angle (pretreatment, at the improvement at the fourth month of treatment. At
fourth month, and at the sixth-month follow-up) among the three
groups. the sixth month follow-up after stoppage the
overminus spectacles, 88.8% of the patients
Table 4 Correlation between compliance of the patients in
deteriorated in their control score, whereas 11%
overminus spectacle and part-time occlusion groups and remain with the same score, but no one showed
their control score improvement in the control score after removal the
Mean±SD t-Test P value overminus spectacles. There was also a significant
Pretreatment score improvement in the angle for near and far in the
Poor 3.500±1.378 1.782 0.185 overminus spectacle group at the fourth-month
Fair 4.333±0.500 follow-up and a significant deterioration in the
Good 3.750±0.910
sixth-month visit after cessation of treatment.
Fourth-month score
Previous studies of the overminus spectacle therapy
Poor 3.000±1.265 6.110 0.006*
Fair 2.667±0.500
showed variable results and different assessment
Good 1.842±0.765 criteria [10,11,19]. Rowe et al. [10] results were
Sixth-month score based on New Castle Control Score system (NCCS)
Poor 3.333±1.211 0.117 0.890 and showed a 51% improvement rate in 21 patients
Fair 3.111±0.601 after 5 years of follow-up which was longer than the
Good 3.222±0.878 treatment duration in our study and that may explain
*statistically significant. the lower percentage of improvement in his study than
ours. Watts et al. [20] reported a 70.8% success rate in
X(T) in one study. There were also no previous studies 24 patients from 2 to 17 years within 4 months of
that assessed the effect of withdrawal of overminus treatment, which was same as the treatment period in
spectacles for 2 months after 4 months of treatment on our study, with the use of NCCS to assess the control
the control of X(T). Mohney et al. [18] assessed the of X(T). Huseyin et al. [21] retrospective study showed
control of exodeviation at the sixth month after 84% improvement in 19 patients with overminus
cessation of PTO therapy for 1 month following a spectacle therapy. However, with the use of NCCS
5-month treatment period with PTO. and Jampolsky’s assessment criteria in a median of 18
months, the study by Chen et al. [19] showed
The deterioration in the control score after 4 months improvement in the score more than 1 in 59% of
of treatment in our study occurred in 6% of the participants, which is almost similar to our study, as
participants in the PTO group whereas 46% among the 90% who improved were 60% who showed
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Overminus spectacles versus Part time occlusion for intermittent exotropia Abdelfatah et al
significant improvement. We both used the same
control score to assess the patients, although the
study duration was 8 weeks [19].
The small sample, the pilot design, and the study
duration are the most important limitations in our
study. On the contrary, it has a number of strength
points. First, we assessed the success of treatment after
2 months of withdrawal. Second, we compared the two
treatment modalities, overminus spectacles and PTO
therapy, in one study. We suggest working on a protocol
of treatment and treatment cessation in further studies
with larger sample size and longer study duration.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1 Govindan M, Mohney BG, Diehl NN, Burke JP. Incidence and types of
childhood exotropia: a population-based study. Ophthalmology 2005;
112:104–108.
2 Friedman DS, Repka MX, Katz J, Giordano L., Ibironke J., Hawse P.,
Tielsch J.M. Prevalence of amblyopia and strabismus in white and African
American children aged 6 through 71 months the Baltimore Pediatric Eye
Disease Study. Ophthalmology 2009; 116:2128–2134.
3 Alastair DKO, Philip MI. Strabismus. Oxford handbook of ophthalmology.
3rd ed. Oxford city UK: Oxford University Press 2014. 750–751
4 Wright KW, Ning SJY. Color Atlas of strabismus surgery; stratigies and
techniques. 4th ed. New York: Springer 2012. 29–31
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.
81
6 Pediatric Eye Disease Investigator, 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; 121:2299–2310.
7 Hatt S, Gnanaraj L. Interventions for intermittent exotropia. Cochrane
Database Syst Rev 2006; 3:003737.
8 Reynolds JD, Wackerhagen M, Olitsky SE. Overminus lens therapy for
intermittent exotropia. Am Orthopt J 1994; 44:86–91.
9 Kushner BJ. Does overcorrecting minus lens therapy for intermittent
exotropia cause myopia? Arch Ophthalmol 1999; 117:638–642.
10 Rowe FJ, Noonan CP, Freeman G, DeBell J. Intervention for intermittent
distance exotropia with overcorrecting minus lenses. Eye (London,
England) 2009; 23:320–325.
11 Kennedy JR. The correction of divergent strabisums with concave lenses.
Am J Optom Arch Am Acad Optom 1954; 31:605–614.
12 Goodacre H. Minus overcorrection: conservative treatment of intermittent
exotropia in the young children comparative study. Aust Orthop J 1985;
22:9–17.
13 AlKhamous LS, AlSaleh AA. Does occlusion therapy improve control in
intermitent exotropia? SJOPT 2016; 433:1–4.
14 Berg PH, Isenberg SJ. Treatment of unilateral exotropia by part-time
occlusion. Am Orthopt J 1991; 41:72–76.
15 Berg PH, Lozano MJ, Isenberg SJ. Long-term results of parttime occlusion
for intermittent exotropia. Am Orthopt J 1998; 48:85–89.
16 Chutter CP. Occlusion treatment of intermittent divergent strabismus. Am
Orthopt J 1977; 27:80–84.
17 Lee BJ, Kim SJ, Yu YS. The clinical course of intermittent exotropia with
small initial deviation. J Pediatr Ophthalmol Strabismus 2015; 52:206–212.
18 Pediatric Eye Disease Investigator, Mohney BG, Cotter SA, Chandler DL,
Holmes JM, et al. A randomized trial comparing part-time patching with
observation for intermittent exotropia in children 12 to 35 months of age.
Ophthalmology 2015; 122:1718–1725.
19 Pediatric Eye Disease Investigator, 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; 123:2127–2136.
20 Watts P, Tippings E, Al-Madfai H. Intermittent exotropia, overcorrecting
minus lenses, and the Newcastle scoring system. JAAPOS 2005;
9:460–464.
21 Huseyin B, Ayse GY, Unsal S, Remzi K. Overcorrecting minus lens therapy
in patients with intermittent exotropia. Int Ophthalmol 2016; 36:1–6.