DIVERGENT

STRABISMUS
EXODEVIATION
PSEUDOEXOTROPIA
EXOPHORIA
INTERMITTENT EXOTROPIA
CONSTANT EXOTROPIA
 PSEUDOEXOTROPIA

+ ve  pupillary
axis is nasal to
the visual axis
- ve  pupillary
axis is temporal
to the visual axis.

A, When the observer places his or her eye in line with the light located on the subject’s line
of sight, the reflection of that light appears displaced nasal ward on the cornea. B, When the
examiner brings his or her eye and the light into line with the patient’s pupillary axis, the
reflection of the light appears centered.
PSEUDOEXOTROPIA
Like psuedoesotropia, certain
morphological features of the face
can result in a false appearance of
eyes to be drifted outwards.
Hypertelorism, which is widely set eyes,
can result in pseudoexotropia.
Traction of the retina resulting in
pathologic ectopia of the macula
temporally can cause a positive
angle kappa resulting in nasal
displacement of the light reflex on
the cornea simulating a true
exotropia.
Pseudoexotropia from positive angle
kappa is mostly seen in retinopathy
of prematurity which results
in temporal dragging of the macula,
it can also be seen in ectopic
macula resulting from toxocara
retinal scars, high myopia or
congenital retinal folds.
ROP causing traction & ectopic macula
PSEUDOEXOTROPIA

Pseudoexotropia (positive angle A

kappa).
(A) The left eye appears slightly
exotropic, and the left corneal
B
light reflex is nasal to the center
of the cornea.
There is no change in the reflex and
the eyes do not move when (B)
the right eye is covered or (C) the C
left eye is covered.
This confirms the diagnosis of
pseudo strabismus.
CLASSIFICATION ACCORDING TO
FUSION STATUS
• Exophoria: X
• Intermittent Exotropia: X (T)
• Exotropia: XT
EXOPHORIA
Controlled by fusion.
Detected – Alternate cover test – BSV
interrupted.
Asthenopia on prolonged reading.
No treatment – unless – intermittent exotropia.
CLASSIFICATION OF EXOTROPIA
PRIMARY CONSECUTIVE SYMPTOMATIC
INTERMITTENT: 1. Spontaneous (secondary)
1. Distance exotropia 2. Postoperative 1. Early onset
(divergence excess)
a) True divergence 2. Late onset
excess
b) Simulated
divergence excess
2. Non-specific
exotropia
3. Near exotropia
CONSTANT:
1. Early onset
2. Decompensated
intermittent
exotropia
ABBREVATIONS

X’ - Exophoria
XT - Exotropia
X(T) - Intermittent Exotropia
CT – Cover Test
PD – Prism Dioptre
IOP – Intra Ocular Pressure
PACD – Peripheral Anterior Chamber Depth
RAPD – Relative Afferent Pupillary Defect
Sx – Surgery
RTC – Return To the Clinic
 PATIENTS DETAIL

Age : 10 Years/ Male

Profession - Student

Address- Lucknow, Uttar Pradesh, India

First visit - 05/07/2014

VISIT 1
 CHIEF COMPLAINTS

(OU) Gradual progressive painless blurring of

vision for near and distance since 5 years

Occasional outward deviation of eyeballs noticed

by parents since 4 years

Photophobia since 1 year

 HISTORY

Recent ophthalmic consultation locally - diagnosed Alternate

exotropia - referred to our hospital for further management

No h/o using glasses/contact lens/patching

No h/o head and ocular injury

No h/o seizures, Asthma and CAD

Normal pre, peri and postnatal birth history with normal physical ,
emotional and cognitive development
CONTD…

Family history- mother myopic

Not aware of any allergy

No h/o systemic diseases

No h/o past lasers, surgeries and medications

 REFRACTION
OD OS

Unaided Visual Acuity 20/60 20/100

With Pinhole 20/30 20/30

Near Vision N6 @ 30 cm with Snellens N6 @ 30 cm with Snellens

Chart in RI Chart in RI

Dry Retinoscopy -1.50/-0.75* 10 -2.00/-0.75 * 160

Dry Acceptance -1.50 DSph (20/30), N6 @ -2.00 DSph (20/30), N6

30 cm @30 cm

Cycloplegic Retinoscopy -1.50/-0.75 * 10 -1.50/-0.75*160

(cyclopentolate)
 EXTERNAL EXAMINATION
Facial Asymmetry nil

Abnormal head posture nil

Nystagmus nil

EOM Movement Full, Free and Painless

Hirschberg's Test LXT 10 Degree

Cover Test 25-30 PD X(T) ( Distance)

12 PD X(T (Near)

Stereo Acuity using Random Dot 80 sec of arc

Stereogram Test
 SLIT LAMP EXAMINATION

OD OS

Lids Flat Flat

Conjunctiva Quiet Quiet

Cornea Clear Clear

AC PACD > 1/2 CT, Quiet PACD > 1/2 CT, Quiet

Pupil R/R/R, No RAPD R/R/R

Iris Normal color and Normal color and

pattern pattern
Lens Clear Clear

IOP With GAT 13 mm of Hg @ 11:10am 14 mm of Hg @ 11:10am

 FUNDUS EXAMINATION

OD OS

Media Clear Clear

Retina On On

Macula Healthy Healthy

C/D 0.2 0.2

DIAGNOSIS ?
 DIAGNOSIS

(OU) Compound Myopic Astigmatism

Intermittent Exotropia
INTERMITTENT EXO
Onset < 5 yrs.
Manifest – inattention, fatigue, stress, distant visual
target.
Progress to
constant exo
Amblyopia –
rare
INTERMITTENT EXO

Good control : XT manifests only after cover test

& pt. resumes fusion rapidly.

Fair control: XT manifests only after cover test &

pt. resumes fusion only after blinking or
refixating.

Poor control: XT manifests spontaneously and

remains manifest for long time.
CLASSIFICATION OF INTERMITTENT EXOTROPIA
ACCORDING TO AC/A
Deviation AC/A Example

Convergence Insufficiency Low X= 0, X’= 12, or

X(T)= 20, XT’=40

Basic Normal XT= XT’= 20

Divergence Excess High XT= 35, XT’=10

 Divergence excess(XT DIST>NEAR)

 Convergence insufficiency (XT NEAR >DIST)
 Basic (XT NEAR=DIST)
DIVERGENCE EXCESS
The exotropia is manifest at distance and exophoria is present
for near.

True divergence excess Simulated or Pseudodivergence

excess

• True divergence excess is significantly greater angle of

deviation in the distance.

• Simulated is initially exotropia appears greater in the

distance, but increases on near fixation when
accommodative convergence is eliminated or when fusion
is suspended.
Charateristics of distance exotropia:
• Inattention
• Poor health or excessive fatigue.
• Alcohol
• Bright light
Symptoms & signs:
• Rarely complain of symptoms.
• Sometimes aware of when the deviation becomes manifest by
‘feeling’the eye diverge.
• Notices an enlarged visual field or more rarely by panaromic vision,
when the image seen by the deviating eye is projected from the fovea,
but is not seen superimposed on the fixation object as in confusion.
• Diplopia is rare.
• Does not appreciate the loss of stereopsis.
• Occassional blurred vision due to use of
accommodation to control the exotropia in the
distance.
• Though this is rare, it is followed by convergence
or accommodative spasm.
• Closure of the deviating the eye in bright light is an
almost invariable sign, strongly suggestive of
intermittent exotropia.
VISUAL ACUITY:
• VA is equal in nearly all cases.
• Some degree of anisometropia is present always.
OCULAR MOVEMENTS:
• Should be checked by combining cover test with
examination of ocular movements on Dextroversion and
Levoversion, comparing the deviation in the primary
position with the deviation on lateroversions.
• V patterns are commonly found in distance exotropia.
• The increase in up-gaze must be confirmed by cover test
and by PBCT on up-gaze and down-gaze for distance
fixation as well as near fixation.
• Many patients cannot control the deviation on up-gaze, thus
simulating a V pattern.
CONVERGENCE:
• Has good convergence.
• Detoriation of convergence is a sign of decompensation and requires
early treatment.
• The eyes appear straight when accommodation is exerted.
• When decompensated, eye position fluctuates and consistent
convergence is not maintained.
• These patients sometimes have DVD, which further indicates that BSV
is improbable.
BINOCULAR FUNCTION:
Patients with distance and Basic exotropia
responses are:
1. Hemiretinal suppression without NRC.
2. A less extensive suppression scotoma.
3. ARC when the deviation is manifest.
4. Occassionally with synaptophore both
images are seen seperately, clearly
and simultaneously, and not able to
superimpose.
NON-SPECIFIC EXOTROPIA: (BASIC)
• The exotropia is intermittently manifest at any
distance and there is no significant change in the
angle of deviation for near or distance fixation.
CONVERGENCE INSUFFICIENCY
• Exophoria is seen on distance fixation and an
exotropia is present for near fixation.
•
 DIFFERENTIAL DIAGNOSIS OF TRUE AND
SIMULATED DIVERGENCE EXCESS:
• Simulated divergence excess is usually associated
with a high AC/A ratio.
• Some has a strong fusion hold.
• The criteria for diagnosis of simulated divergence
excess is an increase in exotropia exceeding 10
prisms when accommodative convergence is
excluded or fusion suspended.
Differentiation is based on:
• Measurement of the AC/A ratio
• Diagnostic occlussion for 24-48 hrs to suspend
fusion and elicit maximum deviation.
NEAR EXTROPIA
• Diplopia can be elicited by colored filters.
• Asthenopic symptoms and headaches.
• Equal visual acuity
• Very poor or no binocular convergence.
• NRC and sensory and motor fusion present but poor
positive fusional amplitude.
• Low AC/A ratio.
DIFFERENTIAL DIAGNOSIS:
• Resembles a convergence palsy.
• But some fusional response is obtained with base-out
prisms which is absent in convergent palsy.
• Also differentiated from convergence insufficiency by
frequent presence of exotropia at near.
TREATMENT OF INT. EXOT
Non surgical
- Correction of mild myopia
- > 4D hyperopia
- > 1.5 D hyperopic anisometropia
Part time patching of dominant eye – 4-6 hrs
/day, or alternate daily patching when no
ocular preferance.- small/mod XT
CONSERVATIVE TREATMENT:
This comprises:
1. Orthoptic exercises
2. Optical treatment.
ORTHOPTIC EXERCISES:
• Aim is to make the patient aware of the deviation
and to gain control over it.
• Anti-suppression exercises only if NRC is present.
• Otherwise make the patient appreciate diplopia,
and then to gain control over it.
OPTICAL TREATMENT:
• Mainly concave lenses, prisms and tinted glasses
are used.
• Usually applicable to children rather than adults.
CONCAVE LENSES:
• Up to -3.00D are used to stimulate convergence by
inducing accommodation thus aiding control of the
exotropia.
• Treatment is continued for several months and
gradually the strength is reduced.
• It is contraindicated if the lenses result in
esotropia or large esophoria.
PRISMS:
• Base-in prisms can be used to compensate the
deviation in children to allow the continued use of
binocular single vision, if the angle of deviation is
not too great.
• PBCT is done to determine the strength of prisms.
It is worn constantly, aiming to reduce the strength
gradually over a period of several weeks.
TINTED GLASSES:
• It should be sufficiently dark to allow control of the
exotropia in strong light.
TREATMENT OF INT. EXOT
• Ultimately require surgery- manifestation of
the deviation >50% of the time.
• Before age of 7yrs – good sensory and motor.
• Recession of (BE) LR.
• Basic type – Recession of 1 LR +
Resection of ipsilateral MR
CASE CONT.…. PLAN OF RX

Glasses

Reassure

EOM Sx If Required

Patch Test next visit

RTC 3/12
 INTERMITTENT EXOTROPIA
Obstracles to development or maintenance of BSV

Defective action of MR Muscles

Defective fusional convergence (1)

New born infants with transient exodeviation (2)

Refractive Errors, Anisomyopia and Anisoastigmatism

(3)
Differs from Exophoria
1. Worth C. Squint, its causes, pathology and treatment ed. 6. London 1929, Bailliere, Tyndall and Cox
2. 2. Archer SM, Helveston EM: Strabismus and Eye Movement Disorders. In Isenberg SJ (ed) The eye in Infancy
1994 Mosby, pg 255.
3. Jampolsky A, Flom BC, Weymouth FS, Moster LE. Unequal corrected visual acuity as related to anisometropia
Arch Ophthalmol. 1955;54:893
 Tropia Phase of Intermittent exotropia observed when :

 In Child - Tired, sick or day dreaming

 In Adults - Also after imbibing alcoholic beverages or taking
sedatives
 PREVALENCE
Comprises 50-90% of cases of Exotropia

Affects 1 % of general population (1,2)

Nearer a country is to the equator the higher

the prevalence of exodeviations (3)

1.Govindan M, Mohney BG, Diehl NN, Burke JP. Incidence and types of childhood exotropia:
a population based study. Ophthalmology. 2005 Jan;112(1):104-8.

2. Noorden GK von. Exodeviations. In: Binocular Vision and Ocular Motility 5 th ed., 1996
Mosby, pg 343

3. Jenkins R. Demograhics: geographic variations in the prevalence and management of

exotropia. Am. Orthopt. J.
1992,42:82.
 NATURAL HISTORY

Remains obscure

Intermittent
Exophoria constant
Some cases exotropia

First at distance and then at near

Not all the cases are progressive, may be constant or even improve

Noorden GK von. Exodeviations. In: Binocular Vision and Ocular Motility 5 th ed., 1996 Mosby, pg 343
FACTORS TO BE RECORDED FOR PROGRESSION

• Amount of Loss of fusional control with increasing

strabismus

• Development of a secondary convergence insufficiency

• Increase in size of basic deviation

• Development of Suppression
 SYMPTOMS OF INT. XT
Transient Diplopia

Asthenopic symptoms

Photophobia (1)

Micropsia (2)

1. Manley DR. Classification of the exodeviations. In: Manley D ed.: Symposium on

horizontal ocular deviations. St. Louis. 1971. Mosby-Year Book Inc. p128
2. Noorden GK von. Exodeviations. In: Binocular Vision and Ocular Motility 5 th ed., 1996
Mosby, pg 361
 PATCH TEST

Noorden GK von: Atlas of Strabismus, ed 4. St Louis, Mosby–Year Book, 1983

Visit 2nd
 OD OS

20/30 – NI with PH 20/25 – NI with PH

N6 @ 30 cm with N6 @ 30 cm with
VA with PGP
chart chart

60 Seconds of Arc With Random Dot

Stereopsis with PGP

Dist. – 18 PD X(T)
CT with PGP Near - 6 PD X(T)
1ST FOLLOW UP 10/09/2014
WNL
Slit Lamp Examination
PROVISIONAL DIAGNOSIS
Basic Intermittent Exotropia

Divergence Excess

Convergence Insufficiency

Simulated or Pseudo-divergence Excess

 BASIC INTERMITTENT EXOTROPIA - DEVIATION FOR
DISTANCE AND NEAR WITHIN 10∆
- NORMAL ACCOMMODATIVE,
FUSIONAL AND PROXIMAL
CONVERGENCE
• Divergence Excess - Deviation for distance > 10∆ than near even after patch test
- High AC/A Ratio

Convergence Insufficiency - Near deviation > 10∆ than distance deviation

Simulated / Pseudo divergence Excess - Larger exotropia for distance than near but
near deviation increases within 10 PD
of distance deviation after Patch Test

Burian HM: Exodeviations: Their classification, diagnosis, and treatment. Am J Ophthalmol

62:1161, 1966
COVER TEST AFTER 1 HOUR
PATCHING ( WITH PGP)

Distance = 20-25 PD X(T)

Near = 20-25 PD X(T)
FINAL DIAGNOSIS

(OU) Compound Myopic Astigmatism

Intermittent Exotropia
(Pseudo divergence Type)
PLAN OF RX

Continue same glass

RTC 6-8 months

• Patch Test is the main criterion for
differentiating true and pseudo
divergence exotropia

• Nevertheless, not all intermittent

exotropia are progressive nor do they
need surgical interventions

• Proper clinical history with relation to

classical symptoms plays vital role for
the diagnosis
CONSTANT EARLY ONSET EXO
• Is constant from the time of onset, usually in
the first year of life.
• May be alternating or unilateral.
• Amblyopia will be severe in unilateral
exotropia.
• Binocular vision is absent or very weak.
• DVD is a common finding.
• Associated with severe craniofacial
abnormalities, including crouzon’s syndrome
& Hypertelorism.
 DECOMPENSATED INTERMITTENT
EXOTROPIA
• Decompensation of distance or non-specific exotropia,
resulting in a constant strabismus, can occur in adult life,
when a diminishing amplitude of accommodation can be a
contributory factor.

• Marked suppression, diplopia cannot be elicited and

impossible to demonstrate any retinal correspondence.

• Prognosis for the restoration of binocular single vision is

quite good, if exotropia had remained intermittent for some
years before becoming constant.
 DIFFERENTIAL DIAGNOSIS
• Should be differentiated from early onset exotropia and
decompensated intermittent exotropia, by the history.

• Early photographs should be examined, preferably those

taken by a professional photographer, as opposed to family
photographs taken in sunlight often show the patient closing
one eye.

• A decompensated intermittent exotropia should be expected

if there is a constant unilateral exotropia and no amblyopia.
PRINCIPLES OF SURGERY
• Cosmetic: proper alignment
• Functional: restore and maintain binocular
single vision
TREATMENT

• Surgery is the main form of treatment in constant

exotropia.

• Unless the deviation is very unsightly, surgery for

an early onset exo is deferred until late childhood
to allow for facial development and a possible
increase in the angle of deviation.

• Surgery on the affected eye is usually preferred in

cosmetic cases, especially if there is amblyopia –
resection of MR and recession of the LR.
TREATMENT
• If the angle of deviation is more than 45-50
prisms, involving the MR or the LR in the
fixing eye is done.

• If a functional result is hoped for, account of

variation in the angle of deviation on
lateroversions and on up-gaze and down-
gaze.

• If BSV is achieved post-operatively, it can be

consolidated by orthoptic treatment.
 SENSORY EXO

• MONOCULAR/BINOCULAR VISUAL IMPAIRMENT –

CATARACT
• EXO- OLDER CHILDREN OR ADULTS
• ESO- INFANCY
• TREATMENT – CORRECTION OF THE VISUAL
DEFICIT , FOLLOWED BY SURGERY
CONSECUTIVE EXO
• Develops spontaneously in an amblyopic eye or foll. Surgical
correction of an eso.

SPONTANEOUS COSECUTIVE EXOTROPIA:

• This occurs when there is weak or absent sensory and motor
fusion.
• The onset is gradual and diplopia does not usually occur.

FACTORS:
• Early onset of esotropia.
• Hypermetropia of 5D or more
• Amblyopia
• Consecutive exotropia can develop in childhood or much later in
adult life as the amplitude of accommodation decreases.
• Sometimes even by late correction of hypermetropia.
TREATMENT
• If there is low degree of hypermetropia,
spectacles can be discontinued.

• Reduction in moderate to high hypermetropic

correction is not advisable.

• Surgery is indicated if the deviation is

unacceptable.
 POSTOPERATIVE CONSECUTIVE
EXOTROPIA
• Immediate consecutive exotropia may be planned occasionally as a
deliberate overcorrection of esotropia with a good prognosis for a
functional result.
• Diplopia is probable.

• Patients with restricted adduction may use a face turn to the unaffected
side in an effort to fuse the diplopia or may use a suppression scotoma
to overcome it.

• Many times this occurs after some considerable time post surgery, even
after several years.

• These types are attributed to lack of fusion rather than to the surgery
itself, especially when there is high degree of hypermetropia.
 TREATMENT
• Patients with this type of exo is treated in the same way as
spontaneous consecutive exotropia.
• When the exotropia is immediate consequence of surgery,
treatment depends on whether functional or cosmetic.

FUNCTIONAL:
1. Reducing the strength of the hyperopic correction as a
temporary measure.
2. Fresnel prisms placed base-in.
3. Orthoptic exercises to increase the positive fusional
vergence.
4. If all of the above fails and the exotropia persists for a
period of 2 or 3 months then re-surgery is considered.
COSMETIC:
• Is indicated only if the deviation warrants it, or unsuppersable
diplopia persists.
• If the appearance is satisfactory and patient is comfortable, the
patient should be kept under observation.

PERSISTENT DIPLOPIA:
• Is encouraged to ignore the diplopia.
• If very distressing then the refractive correction is slightly
modified.
• More satisfactory method is using fresnel prisms to place the
image back into the suppression scotoma.
• Re-surgery is considered if conservative method of treatment is
not helpful.