Intermittent Exotropia: When Nonsurgical Therapy Has Not Achieved Adequate Fusional Control
Intermittent exotropia is the most common presentation of childhood-onset exotropia. When conservative measures fail to adequately improve fusional control or sufficiently reduce the angle of deviation, a structured next-line approach is indicated.
Childhood-onset exotropia is typically intermittent and usually appears before age 3, though it may be first detected later in childhood. In this scenario, the exodeviation remains frequent enough, large enough, or symptomatic enough that the initial nonsurgical strategy has been insufficient.
Nonsurgical therapy — including optical correction strategies to modulate accommodative convergence, and/or part-time patching — did not achieve adequate fusional control or a sufficiently reduced angle of strabismus. This failure of the first line is the trigger for escalation.
Good binocular alignment of the eyes at 6 months postoperatively.
References
DOI: 10.1016/j.ophtha.2022.11.002
Childhood-onset exotropia is typically intermittent and usually appears before 3 years of age, but it may be first detected later in childhood.
Surgical intervention is considered if the exodeviation is constant, if it occurs so frequently or is so large as to be unacceptable to the child or parent/caregiver, or if symptoms are not relieved by corrective lenses and nonsurgical treatment.
Surgery consists of bilateral-lateral rectus-muscle recessions or unilateral-lateral rectus-muscle recession and medial rectus-muscle strengthening.
Chemodenervation by injection of botulinum toxin into one or more extraocular muscles has been used as initial, secondary, and adjunctive treatment for exotropia.
Although approximately 80% of patients have good alignment 6 months postoperatively after bilateral-lateral rectus-muscle recession, long-term results are less favorable and recurrence is common over time.
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