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Kopmann S, Grenzebach U, Ehrt O, Biermann J. Effectiveness of Strabismus Surgery in Intermittent Exotropia and Factors Influencing Outcome. J Clin Med 2024; 13:1031. [PMID: 38398344 PMCID: PMC10889094 DOI: 10.3390/jcm13041031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Intermittent exotropia (IXT) is known to relapse after surgery. No factors to predict or prevent recurrence are known with certainty. This study investigated surgical outcome, potential influencing factors, and reoperation rate in patients with IXT. Medical records of 537 patients who underwent surgery for IXT from 2000 to 2022 with preoperative angles of exodeviation of 6 to 50 prism diopters (PD) were retrospectively studied. Multivariate regression analyses of factors influencing surgical outcome on postoperative day 1 (POD1) and reoperation rate were performed. A Kaplan-Meier analysis was performed to illustrate the reoperation rate. After the first surgery, 83.8% of patients had a successful surgical outcome on POD1 (esodeviation ≤ 5 PD or exodeviation ≤ 10 PD). Logistic regression analysis revealed that small preoperative angles of exodeviation increased the probability for surgical success. Follow-up data at different times (4 days-20 years) after surgery were available for 176 patients: 40 patients were still in the range of surgical success, 133 patients had exotropia > 10 PD. Of the follow-up patients, 65 (12.1%) underwent reoperation. A total of 8.5% had their reoperation within one year after the first surgery, 52.9% within five years. Cox regression analysis revealed that large preoperative angles of exodeviation, far/near incomitance and alphabet pattern strabismus increased the risk of reoperation. Most patients achieved surgical success on POD1, yet the squint angles often increased after surgery, resulting in reoperation in some patients. Prospective studies are needed for a better assessment of pre-, peri- and postoperative factors for surgical success in IXT.
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Affiliation(s)
- Svenja Kopmann
- Department of Ophthalmology, University of Muenster Medical Center, 48149 Muenster, Germany
| | - Ulrike Grenzebach
- Department of Ophthalmology, University of Muenster Medical Center, 48149 Muenster, Germany
| | - Oliver Ehrt
- Department of Ophthalmology, LMU University Hospital, Ludwig-Maximilians Universität Muenchen, 80539 Muenchen, Germany
| | - Julia Biermann
- Department of Ophthalmology, University of Muenster Medical Center, 48149 Muenster, Germany
- Department of Ophthalmology, Klinikum Bielefeld Gem. GmbH, 33604 Bielefeld, Germany
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Gore J, Rath S, Ganesh S. Clinical profile of childhood exotropia in a tertiary eye care center in North India. Indian J Ophthalmol 2023; 71:3637-3641. [PMID: 37991296 PMCID: PMC10788762 DOI: 10.4103/ijo.ijo_29_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 06/21/2023] [Accepted: 07/17/2023] [Indexed: 11/23/2023] Open
Abstract
PURPOSE To identify different types of exotropia in children less than 16 years and their clinical presentation. The secondary objective is to identify the age of onset, age of presentation, birth history, and ocular and systemic associations as well as to evaluate their motor and sensory status. METHODS This hospital-based descriptive observational study was conducted from September 2018 to December 2019. Patients with a clinical diagnosis of exotropia of age less than 16 years, and exotropia of ≥ 10 PD were included in the study. Data were collected using a structured proforma. All statistical calculations were performed using Microsoft Excel Office version 2016 and R version 4.0.2. RESULTS Two hundred eighty-six (286) consecutive children with exotropia were analyzed. Intermittent exotropia (72%) was the most common form of exotropia, followed by exotropia with a neurological association (11%), infantile (8%), sensory (6%), restrictive (2%), and paralytic (1%) types. Exotropia with neurological association had a significantly earlier age of presentation (median = 42months) as compared to other types (P = 0.039). CONCLUSION We recorded a huge amount of cases of exotropia associated with neurological abnormalities and this group of patients had significantly more number of preterm and low birth weight children. This study has its limitations as it is not a population-based study and prevalence rates could not be calculated.
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Affiliation(s)
- Jinal Gore
- Department of Pediatric Ophthalmology and Strabismus and Neuro-ophthalmology, Dr. Shroff's Charity Eye Hospital, New Delhi, India
| | - Soveeta Rath
- Department of Pediatric Ophthalmology and Strabismus and Neuro-ophthalmology, Dr. Shroff's Charity Eye Hospital, New Delhi, India
| | - Suma Ganesh
- Department of Pediatric Ophthalmology and Strabismus and Neuro-ophthalmology, Dr. Shroff's Charity Eye Hospital, New Delhi, India
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Han M, Shen T, Wang X, Yu X, Zhu B, Wen Y, Yan J. Surgical outcomes of bilateral lateral rectus recession versus unilateral recession and resection for the divergence excess type of intermittent exotropia. Indian J Ophthalmol 2023; 71:3558-3562. [PMID: 37870024 PMCID: PMC10752302 DOI: 10.4103/ijo.ijo_2977_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 04/24/2023] [Accepted: 06/27/2023] [Indexed: 10/24/2023] Open
Abstract
Purpose To compare bilateral lateral rectus recession (BLR) with unilateral recession and resection (RR) for divergence excess intermittent exotropia (IXT). Methods Retrospective analysis of 66 patients with divergence excess IXT who underwent either BLR or RR from January 2013 to December 2020 was conducted. Data on demographics, pre- and postoperative deviations, fusion, stereopsis, control, and accommodative convergence/accommodation ratio were collected. Success was defined as esodeviation ≤5 PD (prism diopter) to exodeviation ≤10 PD with a follow-up time of at least 8.0 ± 2.0 weeks. Results BLR (42 cases) and RR (24 cases) groups had the same success rate (83.3%, P = 0.688) and similar reduced postoperative deviations both in distance and at near (P > 0.05). Near-distance disparity decreased significantly in both groups (P = 0.000) with no intergroup difference (P = 0.193). Conclusion BLR and RR were equally effective for divergence excess IXT with comparable outcomes of both distance and near deviations.
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Affiliation(s)
- Mengya Han
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Tao Shen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Xiangjun Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Xinping Yu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Binbin Zhu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Yun Wen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Jianhua Yan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
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Ale Magar JB, Shah S, Sleep M, Dai S. Assessment of distance-near control disparity in basic and divergence excess paediatric intermittent exotropia. Clin Exp Optom 2023; 106:901-904. [PMID: 36122577 DOI: 10.1080/08164622.2022.2122703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/05/2022] [Indexed: 10/14/2022] Open
Abstract
CLINICAL RELEVANCE In intermittent exotropia (IXT), deviation is better controlled at near fixation. Understanding of the mechanism responsible for this common observation may improve clinical management of IXT. BACKGROUND The physiological basis for the distance-near difference in control of deviation in IXT is vastly undetermined. A new parameter, 'control score disparity (CSD)', defined as the difference between distance and near control scores, is introduced. Association of CSD with positive fusional amplitude (PFA), accommodative convergence to accommodation (AC/A) ratio and distance angle of deviation was investigated to further understand the mechanisms. METHOD Patients aged between four and fifteen years with basic and divergence excess IXT were included. Subjects with previous strabismus surgery, amblyopia and inability to perform clinical tests were excluded. A standardized office-based scoring system was used to assess IXT controls. Subjects were sub-divided into group 1 (CSD <2) and group 2 (CSD ≥2). Pearson's univariate and regression analysis were used to determine relationships between CSD and other independent variables. RESULTS Mean age of the total 141 subjects (57.6% female) was 6.8 ± 2.5 years. Basic IXT was more common (60%) and 60% had CSD ≥2. The mean±SD distance angle of deviation, AC/A ratio, PFA and CSD were 22.1 ± 6.6 prism dioptres, 5.0 ± 1.0, 28.6 ± 6.3 prism dioptre and 2.0 ± 0.5, respectively. CSD was significantly correlated to PFA (r = 0.64, p < 0.001) and AC/A ratio (r = 0.27, p < 0.001) in overall samples and Group 2 subjects (r = 0.41, p = 0.001). CONCLUSIONS PFA is a major factor associated with the distance/near difference of IXT control. Individuals with a higher PFA demonstrated greater CSD. While AC/A ratio was associated in better control at near in divergence excess IXT, magnitude of angle appears irrelevant.
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Affiliation(s)
- Jit B Ale Magar
- Ophthalmology Department, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Shaheen Shah
- Ophthalmology Department, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Michael Sleep
- Ophthalmology Department, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Shuan Dai
- Ophthalmology Department, Queensland Children's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
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Zhang W, Fei N, Wang Y, Yang B, Liu Z, Cheng L, Li J, Xian J, Fu T. Functional changes in fusional vergence-related brain areas and correlation with clinical features in intermittent exotropia using functional magnetic resonance imaging. Hum Brain Mapp 2023; 44:5002-5012. [PMID: 37539805 PMCID: PMC10502682 DOI: 10.1002/hbm.26427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/02/2023] [Accepted: 07/07/2023] [Indexed: 08/05/2023] Open
Abstract
To explore the functional changes of the frontal eye field (FEF) and relevant brain regions and its role in the pathogenesis of intermittent exotropia (IXT) children via functional magnetic resonance imaging (fMRI). Twenty-four IXT children (mean age, 11.83 ± 1.93 years) and 28 normal control (NC) subjects (mean age, 11.11 ± 1.50 years) were recruited. During fMRI scans, the IXT children and NCs were provided with static visual stimuli (to evoke sensory fusion) and dynamic visual stimuli (to evoke motor fusion and vergence eye movements) with binocular disparity. Brain activation in the relevant brain regions and clinical characteristics were evaluated. Group differences of brain activation and brain-behavior correlations were investigated. For dynamic and static visual disparity relative to no visual disparity, reduced brain activation in the right FEF and right inferior occipital gyrus (IOG), and increased brain activation in the left middle temporal gyrus complex (MT+) were found in the IXT children compared with NCs. Significant positive correlations between the fusional vergence amplitude and the brain activation values were found in the right FEF, right IPL, and left cerebellum in the NC group. Positive correlations between brain activation values and Newcastle Control Scores (NCS) were found in the left MT+ in the IXT group. For dynamic visual disparity relative to static visual disparity, reduced brain activation in the right middle occipital gyrus, left cerebellum, and bilateral IPL was found in the IXT children compared with NCs. Significant positive correlations between brain activation values and the fusional vergence amplitude were found in the right FEF and right cerebellum in the NC group. Negative correlations between brain activation values and NCS were found in the right middle occipital gyrus, right cerebellum, left IPL, and right FEF in the IXT group. These results suggest that the reduced brain activation in the right FEF, left IPL, and cerebellum may play an important role in the pathogenesis of IXT by influencing fusional vergence function. While the increased brain activation in the left MT+ may compensate for this dysfunction in IXT children.
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Affiliation(s)
- Weijia Zhang
- Department of Ophthalmology, Beijing Tongren Eye Centre, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
- Beijing Ophthalmology & Visual Sciences Key LaboratoryCapital Medical UniversityBeijingChina
| | - Nanxi Fei
- Department of Radiology, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Yachen Wang
- Department of Ophthalmology, Beijing Tongren Eye Centre, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
- Beijing Ophthalmology & Visual Sciences Key LaboratoryCapital Medical UniversityBeijingChina
| | - Bingbing Yang
- Department of Radiology, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Zhihan Liu
- Department of Ophthalmology, Beijing Tongren Eye Centre, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
- Beijing Ophthalmology & Visual Sciences Key LaboratoryCapital Medical UniversityBeijingChina
| | - Luyao Cheng
- Department of Ophthalmology, Beijing Tongren Eye Centre, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
- Beijing Ophthalmology & Visual Sciences Key LaboratoryCapital Medical UniversityBeijingChina
| | - Junfa Li
- Department of Neurobiology, School of Basic Medical SciencesCapital Medical UniversityBeijingChina
| | - Junfang Xian
- Department of Radiology, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
| | - Tao Fu
- Department of Ophthalmology, Beijing Tongren Eye Centre, Beijing Tongren HospitalCapital Medical UniversityBeijingChina
- Beijing Ophthalmology & Visual Sciences Key LaboratoryCapital Medical UniversityBeijingChina
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Lyubasyuk V, Jones KL, Caesar MA, Chambers C. Vision outcomes in children with fetal alcohol spectrum disorders. Birth Defects Res 2023; 115:1208-1215. [PMID: 37461259 PMCID: PMC10862690 DOI: 10.1002/bdr2.2223] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/29/2023] [Accepted: 06/30/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Previous studies demonstrated that children with Fetal Alcohol Spectrum Disorders (FASD) are more likely to have vision impairments. However, existing human clinical and epidemiological investigations are few and include limited sample sizes. This study aimed to explore the association between ophthalmologic abnormalities and FASD in a sample of 5-7 year old children in the general population. METHODS This was a cross-sectional study nested in a larger study intended to estimate the prevalence of FASD in San Diego, California, conducted between 2012 and 2014. Prenatal exposure to alcohol, dysmorphology examinations, and a neurobehavioral testing battery were collected for each child and an FASD diagnosis was assigned. Parents of participating children were asked to release their child's vision screening or diagnostic records. RESULTS Vision records were obtained for 424 participants in the larger prevalence study. Of these, 53 children were classified as having FASD. A statistically significant association was found between FASD and a diagnosis of strabismus; 5/42 (11.9%) of children who were classified as having FASD had strabismus compared to 6/290 (2.1%) of children who were not classified as having FASD (p = .01). All five cases of strabismus in the FASD group occurred in 19 children classified as having partial fetal alcohol syndrome (pFAS). No association was found between FASD and vision impairment (p = .23), refractive errors (p = .66), glasses/contact lens prescription (p = .30), or having one or more ophthalmological abnormalities (p = .97). CONCLUSIONS An association between strabismus and FASD, specifically partial FAS, suggests that the effect of alcohol exposure on risk of strabismus must be severe enough to result in facial features consistent with FASD. This emphasizes the importance of vision screening in children with FASD.
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Affiliation(s)
| | - Kenneth Lyons Jones
- Department of Pediatrics, School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Michelle Ann Caesar
- Department of Pediatrics, School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Christina Chambers
- Department of Pediatrics, School of Medicine, University of California San Diego, La Jolla, California, USA
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, USA
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Varrone E, Lenhart P, Peragallo J, Hutchinson A, Weil N. Surgical outcomes in sensory exotropia. J AAPOS 2023; 27:147.e1-147.e5. [PMID: 37182651 DOI: 10.1016/j.jaapos.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 04/15/2023] [Accepted: 04/16/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE To determine success rates over time for strabismus surgery for sensory exotropia and to determine factors associated with successful outcomes. METHODS We retrospectively reviewed medical records of patients with sensory exotropia (best-corrected visual acuity ≤20/200 in the affected eye) who underwent strabismus surgery between May 2009 and December 2019. Patients with paralytic/restrictive exotropia and patients who did not follow up postoperatively were excluded. Surgical success was defined as exotropia of ≤10Δ or esotropia of ≤6Δ. Cox-proportional hazard models were used to evaluate covariate relationships with surgical outcome (α = 0.05). RESULTS A total of 94 patients (64% female) were included. Mean patient age was 27.2 years (range, 3-69). Mean follow-up was 2.35 ± 2.77 years. The mean preoperative near deviation was 39Δ ± 14.8Δ of manifest or intermittent exotropia. Successful alignment was achieved in 51 of 83 patients (61%) at 1 month, 19 of 32 (59%) at 1 year, and 8 of 16 (50%) at 5 years. We found a significant correlation (P value = 0.0476) between success and smaller surgical doses in patients that underwent one- and two-muscle surgeries. CONCLUSIONS In our study cohort of 94 patients, 50% of patients still had satisfactory ocular alignment at 5 years.
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Affiliation(s)
- Emilia Varrone
- Department of Ophthalmology, Virginia Commonwealth University, Richmond, Virginia
| | - Phoebe Lenhart
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Jason Peragallo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Amy Hutchinson
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Natalie Weil
- Department of Ophthalmology, Children's Hospital of New Orleans, New Orleans, Louisiana; Department of Ophthalmology, Louisiana State University Health Sciences Center, New Orleans; Department of Ophthalmology, Tulane University School of Medicine, New Orleans, Louisiana.
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Ma MML, Scheiman M. Divergence excess and basic exotropia types of intermittent exotropia: a major review. Part 1: prevalence, classification, risk factors, natural history and clinical characteristics. Strabismus 2023; 31:97-128. [PMID: 37489263 DOI: 10.1080/09273972.2023.2227681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Intermittent exotropia (IXT) is a common form of strabismus. It is an outward deviation of one eye typically when viewing at distance. Symptoms include, but are not limited to double vision, eyes feeling tired, excessive blinking, and reduced quality of life. Its clinical characteristics are distinctive from other types of strabismus. This paper provides a comprehensive review of prevalence, classification, risk factors, natural history and clinical characteristics of the divergence excess and basic exotropia types of IXT. METHODS Search strategies involving combination of keywords including intermittent exotropia, exotropia, divergences excess, basic exotropia, prevalence, incidence, classification, terminology, risk factor, natural history, observation, angle of deviation, control, control score, symptom, quality of life, suppression, anomalous retinal correspondence, AC/A, accommodative convergence/accommodation, accommodative convergence, convergence, accommodation, vergence, incomitance and vertical were used in Medline. All English articles from 1900/01/01 to 2020/09/01 were reviewed. The reference list of the identified article was also checked for additional relevant article. Studies focused on animal model or strabismus associated with neurologic disorder or injury were excluded. RESULTS The estimated prevalence of IXT in children ranges from 0.1% to 3.7%. Hypoxia at birth and being female are potential risk factors of IXT. Using validated measures of control, multicenter prospective studies showed that the rate of conversion from IXT to constant exotropia is low. The angle of deviation is the most reported outcome measure in studies of IXT. It is often used to represent the severity of the condition and has been suggested as one of the four core outcomes for studies of the surgical management of IXT. Control of exodeviation is one of the four suggested core outcomes for study of surgery of IXT and is considered the main parameter of disease severity. Several validated tools for quality of life score are available to evaluate the subjective severity of IXT. DISCUSSION We reviewed the prevalence, classification, risk factors, natural history and clinical characteristics of the divergence excess and basic exotropia types of IXT. Further research into these areas, especially its clinical characteristics (e.g. suppression, dual retinal correspondence), will increase our understanding of this condition and potentially lead to better management of this common form of strabismus.
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Affiliation(s)
- Martin Ming-Leung Ma
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou
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Mestre C, Neupane S, Manh V, Tarczy-Hornoch K, Candy TR. Vergence and accommodation responses in the control of intermittent exotropia. Ophthalmic Physiol Opt 2023. [PMID: 36692334 DOI: 10.1111/opo.13093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/25/2023]
Abstract
PURPOSE Individuals with different types of intermittent exotropia (IXT) may use neurally coupled accommodation and vergence responses differently from those without exotropia to achieve eye alignment. This study examined the relationship between simultaneously recorded accommodation and vergence responses in children and young adults with a range of types of IXT while aligned and deviated. METHODS Responses of 29 participants with IXT (4-31 years) and 24 age-matched controls were recorded using simultaneous eye-tracking and eccentric photorefraction while they watched a movie in binocular or monocular viewing at varying viewing distances. Gradient response AC/A ratios and fusional vergence ranges were also assessed. Eight participants had divergence or pseudo-divergence excess type IXT, 5 had convergence insufficiency and 16 had basic IXT. RESULTS Control and IXT participants accommodated similarly both in monocular and binocular-aligned conditions to visual targets at 80 and 33 cm. When deviated in binocular viewing, most participants with IXT exhibited changes in accommodation <0.5D relative to alignment. Gradient response AC/A ratios were similar for control [0.56 MA/D (IQR: 0.51 MA/D)] and IXT participants [0.42 MA/D (0.54 MA/D); p = 0.60]. IXT participants showed larger vergence to accommodation ratios with changes from distance to near fixation [1.19 MA/D (1.45 MA/D)] than control participants [0.78 MA/D (0.60 MA/D); p = 0.02], especially among IXT participants with divergence or pseudo-divergence excess. Participants with IXT exhibited typical fusional divergence ranges beyond their dissociated position [8.86 Δ (7.10 Δ)] and typical fusional convergence ranges from alignment [18 Δ (15.75 Δ)]. CONCLUSIONS This study suggests that control of IXT is typically neither driven by accommodative convergence alone nor associated with over-accommodation secondary to fusional convergence efforts. These simultaneous measurements confirmed that proximal vergence contributed significantly to IXT control, particularly for divergence or pseudo-divergence excess type IXT. For IXT participants in this study, achieving eye alignment did not conflict with having clear vision.
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Affiliation(s)
- Clara Mestre
- School of Optometry, Indiana University, Bloomington, Indiana, USA
| | - Sonisha Neupane
- Department of Psychology, Northeastern University, Boston, Massachusetts, USA
| | - Vivian Manh
- Division of Ophthalmology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kristina Tarczy-Hornoch
- Division of Ophthalmology, Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington, Seattle, Washington, USA
| | - T Rowan Candy
- School of Optometry, Indiana University, Bloomington, Indiana, USA
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Economides JR, Dilbeck MD, Gentry TN, Horton JC. Ambulatory Monitoring With Eye Tracking Glasses to Assess the Severity of Intermittent Exotropia. Am J Ophthalmol 2023; 250:120-129. [PMID: 36681174 DOI: 10.1016/j.ajo.2023.01.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/19/2023]
Abstract
PURPOSE To explore the utility of eye tracking glasses in patients with intermittent exotropia as a means for quantifying the occurrence of exotropia, defined as the percentage of time that the eyes are misaligned. DESIGN Prospective observational study. METHODS Eye tracking glasses were used to obtain 68 recordings in 44 ambulatory patients with a history of intermittent exotropia. Vergence angle was monitored for up to 12 hours to document the occurrence of exotropia. RESULTS Intermittent exotropia was present in 31 of 44 patients. They had a mean exotropia of 19.3 ± 5.3° and a mean occurrence of 40% (range 3-99%). There was a moderate correlation between the magnitude of exotropia and its occurrence (r = 0.59). In 13 patients the occurrence of exotropia was <1%; they were deemed to have an exophoria only. In 35 of 44 cases, families reported an occurrence of intermittent exotropia greater than that measured by the eye tracking glasses. CONCLUSIONS Eye tracking glasses may be a useful tool for quantifying the severity of intermittent exotropia and for defining more precisely its clinical features.
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Affiliation(s)
- John R Economides
- From the Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
| | - Mikayla D Dilbeck
- From the Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
| | - Thomas N Gentry
- From the Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
| | - Jonathan C Horton
- From the Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA..
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Shafik HM, Eldesouky MA, Elbakary MA, Elbedewy HA. Unilateral surgery for pediatric sensory exotropia: clinical characteristics and surgical results. BMC Ophthalmol 2022; 22:507. [PMID: 36550417 PMCID: PMC9773499 DOI: 10.1186/s12886-022-02722-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND To delineate the clinical characteristics and surgical outcomes of large angle sensory exotropia in pediatric patients. METHODS The medical records of 54 large angle exotropia ≥40 PD patients aged from 1 to 18 years who were operated on between 2018 and 2021 and were followed up for 1 year were reviewed and contacted. Clinical characteristics and surgical outcomes were analyzed retrospectively. Patients were divided into two groups, group S patients had supermaximum recession resection and group E had augmented recession by lateral rectus muscle elongation with an autograft from the resected medial rectus muscle in the same eye. The clinical characteristics and results of both groups were compared. RESULTS The mean age of the studied patients with sensory exodeviation at the time of surgery was 8.3 ± 4.2 years. Mean of the duration of exotropia was 6.9 ± 2.2 years, and the mean of postoperative follow-up was 14.3 ± 4.2 months. Surgical success was achieved in 73.07% of group S and 82.14% of group E. Recurrence was more common with anterior segment pathology. Larger post-operative distant angles were strongly related to poorer visual acuities P = 0.001 and not related to the age of onset or the duration. Narrowing of the palpebral fissure improved in both groups at the last follow up P = 0.336. The limitation of abduction in both groups improved in the last follow up P = 0.145. CONCLUSION The outcome of monocular surgery for sensory exotropia in children is satisfactory with no significant differences in results between lateral rectus muscle tendon autograft elongation technique and supermaximum recession resection. Recurrence is more common with anterior segment pathology. Larger post-operative distant angle of deviation is strongly related to poorer visual acuity. CLINICAL TRIAL REGISTRATION This study was retrospectively registered at clinicaltrials.gov (ID: NCT04286945) on 25-2-2020.
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Affiliation(s)
- Heba M. Shafik
- grid.412258.80000 0000 9477 7793Department of Ophthalmology, Faculty of Medicine, Tanta University, El Geish Street, Tanta, Gharbeya Governorate Egypt
| | - Mohamed Ashraf Eldesouky
- grid.412258.80000 0000 9477 7793Department of Ophthalmology, Faculty of Medicine, Tanta University, El Geish Street, Tanta, Gharbeya Governorate Egypt
| | - Molham A. Elbakary
- grid.412258.80000 0000 9477 7793Department of Ophthalmology, Faculty of Medicine, Tanta University, El Geish Street, Tanta, Gharbeya Governorate Egypt
| | - Hazem A. Elbedewy
- grid.412258.80000 0000 9477 7793Department of Ophthalmology, Faculty of Medicine, Tanta University, El Geish Street, Tanta, Gharbeya Governorate Egypt
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Moradi F, Mirzajani A, Akbari MR, Khorrami-Nejad M, Abolghasemi J, Masoomian B. Binocular contrast sensitivity in patients with intermittent exotropia in relation to angle of strabismus and level of compensation. Strabismus 2022; 31:1-8. [PMID: 36415944 DOI: 10.1080/09273972.2022.2141272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Intermittent exotropia (IXT) causes photophobia, and photophobia has been studied by measurement of contrast sensitivity (CS). CS was reduced in children with IXT. We compared binocular CS (BCS) in patients with IXT and normal subjects in relation to the angle of strabismus and control of IXT. This case-control study was performed on 40 patients with IXT and 40 normal subjects who were examined with the CSV1000 CS device in mesopic (3 cd/m2) and photopic (85 cd/m2) conditions with and without a glare stimulus at 3, 6, 12, and 18 cycle/degree (cpd) spatial frequencies. The angle of strabismus and near stereoacuity were also measured. The patient's IXT compensation was graded based on the office control scale. The mean age for IXT and normal participants were 12.30 ± 0.60 (range, 6-18) and 11.00 ± 0.78 (range, 6-18) years, respectively (P = .34). The IXT patients had lower binocular CS than controls at all spatial frequencies (P < .001). The largest decrease in CS occurred at 6 cpd spatial frequency under mesopic condition (1.61 ± 0.07 vs 1.38 ± 0.15, P < .001) and photopic condition with glare (2.03 ± 0.06 vs 1.77 ± 0.13, P < .001). Patients with better control scores had higher levels of BCS; also, the score of BCS showed a significant decrease in patients with a deviation of 25 prism diopter or more, compared to those with less deviation. BCS correlated at 3 and 6 cpd with near stereoacuity (r = -0.652, P < .001 and r = -0.613, P < .001). Binocular CS in patients with IXT correlates with the angle of strabismus and level of compensation.
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Affiliation(s)
- Fatemeh Moradi
- Rehabilitation Research Center, Department of Optometry, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran
| | - Ali Mirzajani
- Rehabilitation Research Center, Department of Optometry, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran
| | - Mohammad Reza Akbari
- Translational research center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran
| | - Masoud Khorrami-Nejad
- Translational research center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran
- School of Rehabilitation, Tehran University of Medical Sciences, Tehran
| | - Jamileh Abolghasemi
- Biostatistics Department, School of Public Health, Iran University of Medical Sciences, Tehran
| | - Babak Masoomian
- Translational research center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran
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Fang C, Wu Y, peng T, Wang C, Lou J, Xu M, Bao J, Chen C, Yu X. Reading speed in school-age children with intermittent exotropia. Sci Rep 2022; 12:9423. [PMID: 35676393 PMCID: PMC9177830 DOI: 10.1038/s41598-022-13293-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/23/2022] [Indexed: 11/29/2022] Open
Abstract
Reading speed in intermittent exotropia (IXT) children has been minimally examined. This study assessed reading speed in school-age children with IXT and determined clinical characteristics of IXT that impacted their reading ability. We compared the reading speed of 63 school-age (10–14 years) children with IXT to 44 age-matched normal counterparts. In addition, the correlation between reading speed and clinical characteristics of IXT were evaluated. The reading speed in children with IXT was 231 ± 51 CPM, while reading speed in normal counterparts was 257 ± 33 CPM. Age, gender were found to be factors associated with reading speed in children with IXT. After adjusting for the age and gender, we found a significant correlation between the LogTNO and reading speed in IXT group based on a generalized linear model (p = 0.014). These data show that reading speed was slower in school-age children with IXT assessed with the International Reading Speed Texts. When age and gender were adjusted, poor stereo function at near was found to be related with a slower reading speed.
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Cai X, Chen Z, Liu Y, Deng D, Yu M. A Dichoptic Optokinetic Nystagmus Paradigm for Interocular Suppression Quantification in Intermittent Exotropia. Front Neurosci 2021; 15:772341. [PMID: 34924941 PMCID: PMC8678071 DOI: 10.3389/fnins.2021.772341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 11/04/2021] [Indexed: 11/13/2022] Open
Abstract
Purposes: To investigate the effectiveness of a dichoptic optokinetic nystagmus (dOKN) test to objectively quantify interocular suppression in intermittent exotropia (IXT) patients during the states of orthotropia and exodeviation. Methods: The OKN motion in subjects (15 controls and 59 IXT subjects) who viewed dichoptic oppositely moving gratings with different contrast ratios was monitored and recorded by an eye tracker. Interocular suppression in control subjects was induced using neutral density (ND) filters. The OKN direction ratios were fitted to examine the changes of interocular suppression in subjects under different viewing states. Two established interocular suppression tests (phase and motion) were conducted for a comparative study. Results: The dOKN test, which requires a minimal response from subjects, could accurately quantify the interocular suppression in both IXT and control subjects, which is in line with the established interocular suppression tests. Overall, although comparative, the strength of interocular suppression detected by the dOKN test (0.171 ± 0.088) was stronger than those of the phase (0.293 ± 0.081) and the motion tests (0.212 ± 0.068) in the control subjects with 1.5 ND filters. In IXT patients, when their eyes kept aligned, the dOKN test (0.58 ± 0.09) measured deeper visual suppression compared with the phase (0.73 ± 0.17) or the motion test (0.65 ± 0.14). Interestingly, strong interocular suppression (dOKN: 0.15 ± 0.12) was observed in IXT subjects during the periods of exodeviation, irrespective of their binocular visual function as measured by synoptophore. Conclusion: The dOKN test provides efficient and objective quantification of interocular suppression in IXT, and demonstrates how it fluctuates under different eye positions.
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Affiliation(s)
- Xiaoxiao Cai
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Zidong Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Yanping Liu
- Guangdong Provincial Key Laboratory of Social Cognitive Neuroscience and Mental Health, Department of Psychology, Sun Yat-sen University, Guangzhou, China
| | - Daming Deng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Minbin Yu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
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15
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Abstract
BACKGROUND The clinical management of intermittent exotropia (X(T)) has been discussed extensively in the literature, yet there remains a lack of clarity regarding indications for intervention, the most effective form of treatment, and whether there is an optimal time in the evolution of the disease at which any given treatment should be carried out. OBJECTIVES The objective of this review was to analyze the effects of various surgical and non-surgical treatments in randomized controlled trials (RCTs) of participants with intermittent exotropia, and to report intervention criteria and determine whether the treatment effect varies by age and subtype of X(T). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2021, Issue 1), which contains the Cochrane Eyes and Vision Trials Register; Ovid MEDLINE; Ovid Embase; Latin American and Caribbean Health Science Information database (LILACS); the ISRCTN registry; ClinicalTrials.gov, and the WHO ICTRP. The date of the search was 20 January 2021. We performed manual searches of the British Orthoptic Journal up to 2002, and the proceedings of the European Strabismological Association (ESA), International Strabismological Association (ISA), and American Association for Pediatric Ophthalmology and Strabismus meeting (AAPOS) up to 2001. SELECTION CRITERIA We included RCTs of any surgical or non-surgical treatment for intermittent exotropia. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. MAIN RESULTS We included six RCTs, four of which took place in the United States, and the remaining two in Asia (Turkey, India). A total of 890 participants with basic or distance X(T) were included, most of whom were children aged 12 months to 10 years. Three of these six studies were from the 2013 version of this review. Overall, the included studies had a high risk of performance bias as masking of participants and personnel administering treatment was not possible. Two RCTs compared bilateral lateral rectus recession versus unilateral lateral rectus recession with medial rectus resection, but only one RCT (n = 197) reported on the primary outcomes of this review. Bilateral lateral rectus recession likely results in little difference in motor alignment at near (MD 1.00, 95% CI -2.69 to 4.69) and distance (MD 2.00, 95% CI -1.22 to 5.22) fixation as measured in pupillary distance using PACT (moderate-certainty evidence). Bilateral lateral rectus recession may result in little to no difference in stereoacuity at near fixation (risk ratio (RR) 0.77, 95% CI 0.35 to 1.71), adverse events (RR 7.36, 95% CI 0.39 to 140.65), or quality of life measures (low-certainty evidence). We conducted a meta-analysis of two RCTs comparing patching (n = 249) with active observation (n = 252), but were unable to conduct further meta-analyses due to the clinical and methodological heterogeneity in the remaining trials. We found evidence that patching was clinically more effective than active observation in improving motor alignment at near (mean difference (MD) -2.23, 95% confidence interval (CI) -4.02 to -0.44) and distance (MD -2.00, 95% CI -3.40 to -0.61) fixation as measured by prism and alternate cover test (PACT) at six months (high-certainty evidence). The evidence suggests that patching results in little to no difference in stereoacuity at near fixation (MD 0.00, 95% CI -0.07 to 0.07) (low-certainty evidence). Stereoacuity at distance, motor fusion test, and quality of life measures were not reported. Adverse events were also not reported, but study authors explained that they were not anticipated due to the non-surgical nature of patching. One RCT (n = 38) compared prism adaptation test with eye muscle surgery versus eye muscle surgery alone. No review outcomes were reported. One RCT (n = 60) compared lateral rectus recession and medial rectus plication versus lateral rectus recession and medial rectus resection. Lateral rectus recession and medial rectus plication may not improve motor alignment at distance (MD 0.66, 95% CI -1.06 to 2.38) (low-certainty evidence). The evidence for the effect of lateral rectus recession and medial rectus plication on motor fusion test performance is very uncertain (RR 0.92, 95% CI 0.48 to 1.74) (very low-certainty evidence). AUTHORS' CONCLUSIONS Patching confers a clinical benefit in children aged 12 months to 10 years of age with basic- or distance-type X(T) compared with active observation. There is insufficient evidence to determine whether interventions such as bilateral lateral rectus recession versus unilateral lateral rectus recession with medial rectus resection; lateral rectus recession and medial rectus plication versus lateral rectus recession and medial rectus resection; and prism adaptation test prior to eye muscle surgery versus eye muscle surgery alone may confer any benefit.
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Affiliation(s)
- Yi Pang
- Optometry, Illinois College of Optometry, Chicago, IL, USA
| | | | - Jessica Gayleard
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, Maryland, USA
| | - Genie Han
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Sarah R Hatt
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA
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16
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Mao D, Lin J, Chen L, Luo J, Yan J. Health-related quality of life and anxiety associated with childhood intermittent exotropia before and after surgical correction. BMC Ophthalmol 2021; 21:270. [PMID: 34193079 PMCID: PMC8247233 DOI: 10.1186/s12886-021-02027-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 06/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intermittent exotropia (IXT) is the most common form of exotropia in children. In addition to cosmetic effects and loss of stereoscopic function, IXT may negatively impact the psychological well-being of children and their parents. The purpose of this study was to assess the patient-reported outcomes of Chinese children with IXT before and after strabismus surgery. METHODS The records of children with IXT who underwent strabismus surgery at the Zhongshan Ophthalmic Center of Sun Yat-sen University, China over the period from January 1, 2016 to December 31, 2018 were prospectively recruited. All children underwent ophthalmic and orthoptic examinations, including the prism and alternate cover test, fusion function by synoptophore, stereoacuity and Newcastle control score. Two patient-reported outcome measures were used: the intermittent Exotropia Questionnaire (IXTQ) to measure disease-specific health-related quality of life (HRQOL) and the Hospital Anxiety and Depression Scale (HADS) to measure anxiety and depression. Patient-reported outcome measurements were made before and after surgery with responses from children and their parents. RESULTS A total of 389 children were eligible for inclusion (47.8% male, 52.2% female, mean + SD age = 8.17 ± 2.81). Preoperative IXTQ scores in both children (48.21 ± 26.2) and their parents (44.6 ± 25.68) were significantly correlated with near stereoacuity (P = 0.029 and P = 0.015, respectively). The angle of deviation at near vision showed a negative linear relationship with visual function (P = 0.026) and psychological (P = 0.019) scores as well as opinions regarding surgery (P = 0.024). HADS scores (anxiety scale score: 11 ± 2.92, depression scale score: 10.44 ± 2.9) were also related to near stereoacuity (P < 0.05). After surgery, both children's (74.83 ± 16.59) and parents' (68.57 ± 17.06) IXTQ scores significantly improved (p<0.01). Children's IXTQ scores were related to the angle of deviation at distance, and their psychological and visual function scores showed a negative relationship with the angle of deviation at near vision (P < 0.05). CONCLUSION Children and parents' HRQOL and HADS were associated with near stereoacuity. Parents usually attend more readily to the angle of deviation at near in their IXT children. HRQOL improved significantly after surgery and can be used as one of the indices for preoperative evaluation but is not recommended as a criterion for surgical intervention.
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Affiliation(s)
- Danyi Mao
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Jing Lin
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Lina Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Jiying Luo
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China
| | - Jianhua Yan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, 510080, Guangdong, China.
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Preoperative Variables Associated with Surgical Outcome for the Correction of Exodeviation. Vision (Basel) 2021; 5:vision5020019. [PMID: 33922815 PMCID: PMC8167507 DOI: 10.3390/vision5020019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/17/2022] Open
Abstract
The success rate of exodeviation surgery in existing literature has been shown to be variable. This study sought to determine the success rate of surgery for exodeviation in Atlantic Canada and determine variables associated with surgical outcome. A retrospective chart review was performed, considering patients who had been assessed and surgically treated for exodeviation at the IWK Health Centre between 2011–2018. This study included 176 subjects, aged 1–75 years. Preoperative variables were compared between subjects with successful versus unsuccessful surgical outcomes, using the chi square, Fischer’s exact test and binary logistic regression. A success rate of 43% was determined. Smaller preoperative deviation size at near and distance fixation, as well as the basic type classification were associated with successful operative outcome. Left eye acuity showed a statistically significant association with surgical success outcome. In conclusion, these findings compliment those of previous groups, suggesting exodeviation surgery outcome is variable. Our results add to a growing list of variables implicated in outcomes for these subjects. A smaller deviation preoperatively was associated with success in existing data and in this study, and these findings may suggest a potential role for basic subtype into future exodeviation literature.
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Abstract
BACKGROUND Accommodative esotropia is the most common form of childhood strabismus presenting to optometric practice. Functional and cosmetic outcomes are often excellent but depend on accurate diagnosis, urgent and correct initial management and careful follow-up. CASE REPORTS We present several cases that highlight important aspects of the clinical care of accommodative esotropia. The first patient was mismanaged by undercorrection of hypermetropia, but was later accurately diagnosed to have accommodative esotropia and was subsequently managed successfully with full hypermetropic correction alone. The second patient had an accommodative esotropia with amblyopia. The third patient used a near addition to correct a residual near esotropia. CONCLUSIONS The published evidence and these cases make several points regarding assessment, diagnosis and management of esotropia. Assessment must aim to reach a diagnosis based on aetiology, as the aetiology of esotropia has a significant impact on management decisions and prognosis.
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Affiliation(s)
- Steffanie L-H Liang
- Victorian College of Optometry, The University of Melbourne, Carlton, Australia
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Abri Aghdam K, Zand A, Soltan Sanjari M, Khorramdel S, Asadi R. Overminus Lens Therapy in the Management of Children with Intermittent Exotropia. J Curr Ophthalmol 2021; 33:36-40. [PMID: 34084955 PMCID: PMC8102942 DOI: 10.4103/joco.joco_17_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/10/2020] [Accepted: 08/05/2020] [Indexed: 11/18/2022] Open
Abstract
Purpose: To evaluate the results of overminus lens therapy in the management of children with intermittent exotropia or X(T). Methods: In this retrospective study, 163 consecutive patients with X(T) who were treated with overminus spectacles with at least 12 months of follow-up were included in the study. The outcome measures were the level of X(T) control evaluated using the Jampolsky's qualitative assessment method and refractive error changes under overminus lens treatment. Results: The mean angle of deviation at the initial visit was 24.7 ± 15.1 prism diopters (PD) that improved to 10.6 ± 4.2 PD with overminus glasses with a median follow-up of 38 months (P = 0.02). One hundred and nine patients (66.8%) achieved good controlled X(T) or orthotropia by overminus lens therapy after 1 year. Three patients progressed to esotropia, which disappeared after discontinuing overminus lens therapy. Overminus lens therapy did not have a statistically significant effect on the mean spherical equivalent of cycloplegic refraction in each eye (right eye: P = 0.13; left eye: P = 0.15). Conclusions: Overminus lens therapy can be effective for improving the control of X(T) in young children. It can defer the requirement for surgery or decrease the rate of surgical intervention.
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Affiliation(s)
- Kaveh Abri Aghdam
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Amin Zand
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Soltan Sanjari
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shabnam Khorramdel
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Asadi
- Eye Research Center, The Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Schielen oder nicht Schielen? – Strabismus divergens intermittens, eine besondere Schielform. SPEKTRUM DER AUGENHEILKUNDE 2021. [DOI: 10.1007/s00717-020-00478-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Zusammenfassung
Hintergrund
Schielen tritt bei ca. 5–7 % der gesunden Kinder auf. Außenschielen ist mit 1,24 % weltweit seltener als Innenschielen. Der Strabismus divergens intermittens stellt mit 40–90 % die häufigste divergente Schielform dar. Das klinische Bild wurde von vielen AutorInnen beschrieben. Dennoch stellt es durch die Variabilität der Befunde eine therapeutische Herausforderung dar.
Material und Methode
Es wurden im Rahmen einer Literaturrecherche die Ergebnisse von Studien zum Strabismus divergens intermittens mit Fokus auf klinisches Bild, Untersuchungskriterien und Therapieansätze gesammelt und die Ergebnisse dargestellt.
Resultate
Der Strabismus divergens intermittens zeichnet sich durch eine besondere Binokularsituation und bisher ursächlich nicht vollends geklärte Symptome (Photophobie, Kneifen) aus. Konservative Therapien dienen der Entlastung des visuellen Systems, in vielen Fällen ist aber eine Schieloperation nötig. In der präoperativen Beurteilung ist der Stabilität des Schielwinkels besonderes Augenmerk zu schenken, als Entscheidungshilfe hinsichtlich Schieloperation hat sich der New Castle Control Score bewährt.
Schlussfolgerung
Die klinischen Charakteristika des Strabismus divergens intermittens sind klar beschrieben. Hinsichtlich therapeutischer Ansätze zeigen sich im internationalen Vergleich Unterschiede. Die Bedeutung der Einbeziehung der Eltern („shared decision making“) bei der Beurteilung der Schielhäufigkeit und bei der Operationsentscheidung ist zu betonen.
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Yun YI, Kim SJ, Jung JH. Clinical Characteristics of Patients with Intermittent Exotropia According to the Response to Short-term Prism Adaptation Test. KOREAN JOURNAL OF OPHTHALMOLOGY 2020; 34:375-382. [PMID: 33099559 PMCID: PMC7597609 DOI: 10.3341/kjo.2020.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/26/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose To evaluate the prevalence of the prism adaptation response in patients with intermittent exotropia (IXT) using the short-term prism adaptation test (PAT) and to assess factors associated with prism adaptation response in IXT patients. Methods A case-controlled retrospective analysis was performed on 113 patients with IXT without prior surgical treatment. Age, sex, visual acuity, refraction, stereoacuity, control scale, type of exotropia, history of occlusion, and presence of accompanying visual symptoms were recorded. Prism alternate cover test (PACT) was performed with fixation targets at 6 m and 1/3 m. All patients underwent short-term PAT wearing prism glasses that offset the exodeviation previously measured by PACT. After 30 minutes, angle deviation was measured, and patients were classified into either an increase group, which had an increase in deviation ≥5 prism diopters after short-term PAT, or a no-change group. Analysis was performed to investigate the clinical factors influencing the increase in exodeviation after short-term PAT. Results Fifty patients (44.2%) showed an increase ≥5 prism diopters during distance or near fixation after short-term PAT compared to the previous PACT: 12 patients (10.6%) showed an increment at distance fixation, and 45 patients (39.8%) showed an increase at near fixation. At distance fixation, the increase-group had a significantly smaller maximum angle measured by PACT. At near distance, age at PAT, maximum distance angle, minimum distance angle, maximum near angle, minimum near angle, angle fluctuation at near, and IXT type showed significant associations with positive short-term PAT response. In the multivariate analysis, older age and smaller maximum near angle were significantly associated with positive short-term PAT response at near fixation. Conclusions Short-term PAT could be helpful in older IXT patients with a small maximum angle of deviation at near fixation to mitigate the vergence aftereffect and show the maximum angle of deviation.
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Affiliation(s)
- Young In Yun
- Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea
| | - Seong-Joon Kim
- Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea.,Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Ho Jung
- Department of Ophthalmology, Seoul National University Hospital, Seoul, Korea.,Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea
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Heydarian S, Hashemi H, Jafarzadehpour E, Ostadi A, Yekta A, Aghamirsalim M, Dadbin N, Ostadimoghaddam H, Khoshhal F, Khabazkhoob M. Non-surgical Management Options of Intermittent Exotropia: A Literature Review. J Curr Ophthalmol 2020; 32:217-225. [PMID: 32775794 PMCID: PMC7382517 DOI: 10.4103/joco.joco_81_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 03/24/2020] [Accepted: 04/01/2020] [Indexed: 11/04/2022] Open
Abstract
Purpose To review current non-surgical management methods of intermittent exotropia (IXT) which is one of the most common types of childhood-onset exotropia. Methods A search strategy was developed using a combination of the words IXT, divergence excess, non-surgical management, observation, overcorrecting minus lens therapy, patch/occlusion therapy, orthoptics/binocular vision therapy, and prism therapy to identify all articles in four electronic databases (PubMed, Web of Science, Google Scholar, and Scopus). To find more articles and to ensure that the databases were thoroughly searched, the reference lists of the selected articles were also reviewed from inception to June 2018 with no restrictions and filters. Results IXT is treated when binocular vision is impaired, or the patient is symptomatic. There are different surgical and non-surgical management strategies. Non-surgical treatment of IXT includes patch therapy, prism therapy, orthoptic sessions, and overcorrecting minus lens therapy. The objective of these treatments is to reduce the symptoms and the frequency of manifest deviation by decreasing the angle of deviation or enhancing the ability to control it. Conclusions Evidence of the efficacy of non-surgical management options for IXT is not compelling. More comprehensive randomized controlled trial studies are required to evaluate the effectiveness of these procedures and detect the most effective strategy.
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Affiliation(s)
- Samira Heydarian
- Department of Rehabilitation Sciences, School of Allied Medical Sciences, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hassan Hashemi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | | | - Amin Ostadi
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Abbasali Yekta
- Department of Optometry, School of Paramedical Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Nooshin Dadbin
- Noor Research Center for Ophthalmic Epidemiology, Noor Eye Hospital, Tehran, Iran
| | - Hadi Ostadimoghaddam
- Refractive Errors Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Mehdi Khabazkhoob
- Department of Medical Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Hirota M, Yada K, Morimoto T, Endo T, Miyoshi T, Miyagawa S, Hirohara Y, Yamaguchi T, Saika M, Fujikado T. Objective evaluation of visual fatigue in patients with intermittent exotropia. PLoS One 2020; 15:e0230788. [PMID: 32214343 PMCID: PMC7098610 DOI: 10.1371/journal.pone.0230788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 03/08/2020] [Indexed: 11/18/2022] Open
Abstract
Purpose The purpose of this study was to evaluate the degree of visual fatigue in patients with intermittent exotropia (IXT) using the binocular fusion maintenance (BFM) test. Methods Fourteen patients with IXT (32.1 ± 16.4 years) and 15 age-matched healthy volunteers (31.2 ± 9.3 years) participated in the study. BFM was assessed by measuring the transmittance of liquid crystals placed in front of the subject's nondominant eye at the instance when binocular fusion was broken and vergence eye movement was induced. A questionnaire on subjective symptoms was administered to the subjects before and after the visual task. The visual task consisted of a reciprocal movement between 67 and 40 cm. Results The change [post–pre] of BFM was significantly lower in the IXT group (−0.185 ± 0.187) than in the control group (−0.030 ± 0.070) (P = 0.010). The change of total subjective eye symptom score was significantly greater in the IXT group (2.28 ± 1.43) than in the control group (0.93 ± 1.27) (P = 0.018). The reduction in BFM rate with increasing total subjective eye symptom score was significantly greater in the IXT group (−0.106 ± 0.017) than in the control group (−0.030 ± 0.013) (P = 0.006). Conclusion The present findings objectively showed that patients with IXT are at a greater risk of visual fatigue in comparison with healthy individuals.
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Affiliation(s)
- Masakazu Hirota
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Orthoptics, Teikyo University Faculty of Medical Technology, Itabashi, Tokyo, Japan
| | - Kozue Yada
- Department of Ophthalmology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takeshi Morimoto
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Department of Advanced Visual Neuroscience, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takao Endo
- Department of Ophthalmology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tomomitsu Miyoshi
- Department of Integrative Physiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Suguru Miyagawa
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Special Research Promotion Group, Osaka University Graduate School of Frontier Biosciences, Suita, Osaka, Japan
- Topcon Corporation, Tokyo, Japan
| | - Yoko Hirohara
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Special Research Promotion Group, Osaka University Graduate School of Frontier Biosciences, Suita, Osaka, Japan
- Topcon Corporation, Tokyo, Japan
| | | | | | - Takashi Fujikado
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Special Research Promotion Group, Osaka University Graduate School of Frontier Biosciences, Suita, Osaka, Japan
- * E-mail:
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Comparison of surgery versus observation for small angle intermittent exotropia. Sci Rep 2020; 10:4631. [PMID: 32170126 PMCID: PMC7070054 DOI: 10.1038/s41598-020-61568-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/10/2019] [Indexed: 11/16/2022] Open
Abstract
In young children with small angle exotropia, making decisions for the individual patient whether to perform surgery or not, and choosing the optimal time for surgical intervention are quite difficult. We aimed to compare the long-term outcomes of small angle intermittent exotropia of 20 prism diopters (PD) or less after observation versus strabismus surgery. A retrospective study was performed on 164 patients aged 3 to 13 who underwent surgical intervention or observation with or without conservative management for intermittent exotropia of 14 to 20 PD. The minimum follow-up period was 2 years. The average follow-up period was 3.9 ± 2.2 years in the observation group and 4.5 ± 2.3 years in the surgery group. At the final examination, the mean angle of deviation at distance was 11.1 ± 8.9 PD in the observation group and 9.0 ± 7.5 PD in the surgery group, which was not significantly different (P = 0.121). Changes in sensory outcome and fusional control were not significantly different between both groups (P = 0.748 and P = 0.968). Subgroup analysis including patients with poor fusional control also showed similar results. By multivariate analysis, the type of surgery, unilateral recess-resect procedure, was the only predictive factor of good motor outcome in the surgery group. In conclusion, long-term surgical outcomes in small angle exotropia did not appear to be more satisfying than observation in terms of motor and sensory outcomes.
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Hemispherotomy can cause post-operative strabismus. Brain Dev 2020; 42:41-47. [PMID: 31521421 DOI: 10.1016/j.braindev.2019.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 08/19/2019] [Accepted: 08/26/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hemispherotomy, which involves disconnecting hemispherical fibers, is a treatment option for medically intractable epilepsy. As various neurological disorders can cause strabismus, we hypothesized that hemispherotomy can cause post-operative strabismus in patients with medically intractable epilepsy. METHODS Nineteen patients underwent the Hirschberg test before and after hemispherical disconnection surgery. Among the 19 patients, 16 patients (six females and 10 males; mean age, 12.2 years; range, 0.17-43 years) who underwent hemispherotomy were included in this study. RESULTS The difference in the angle between the left and right eyes was significantly widened (p = 0.025). Nine (56%) of 16 patients exhibited post-operative chronic strabismus as evaluated with the Hirschberg test. Intermittent strabismus was noticed by family members or caregivers in 10 (63%) of 16 patients. Patients older than 12 years did not show post-operative strabismus as evaluated by the Hirschberg test. CONCLUSION Hemispherotomy can cause or worsen post-operative strabismus in pediatric patients.
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Yoo G, Ha SG, Kim SH. Distance Suppression as a Predictive Factor in Progression of Intermittent Exotropia. KOREAN JOURNAL OF OPHTHALMOLOGY 2019; 33:446-450. [PMID: 31612655 PMCID: PMC6791956 DOI: 10.3341/kjo.2019.0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/27/2019] [Accepted: 07/08/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose To address the natural course of intermittent exotropia with small exodeviations (less than 20 prism diopters [PD]) according to the status of suppression, and to evaluate whether suppression testing at the initial visit can assist in predicting the progression of intermittent exotropia. Methods Clinical records of patients at the Korea University Anam Hospital, Seoul, Korea diagnosed between January 2014 and December 2018 with basic-type intermittent exotropia and initial distance deviations of less than 20 PD, older than four years of age and a minimum of three follow-up visits within a 6-month span were retrospectively reviewed. The participants were divided into two groups, the suppression group and the non-suppression group, based on the Vectogram results at the initial visit. Clinical characteristics, rate of surgery, and rate of progression were compared between the two groups. Results A total of 71 patients were included. Among them, 16 patients (22.5%) had visual suppression at the initial visit, while 55 patients (77.5%) had no suppression. At the initial visit, the mean distant angle of deviation was 13.7 ± 3.2 PD (range, 4 to 18 PD) in the suppression group and 12.7 ± 3.4 PD (range, 10 to 18 PD) in the non-suppression group. Ten patients (62.5%) underwent surgery in the suppression group and 12 patients (21.8%) underwent surgery in the non-suppression group (p < 0.01). Eleven patients (68.8%) in the suppression group and 13 (23.6%) in the non-suppression group developed progression (p < 0.01). Conclusions Suppression testing was important to predict the progression of intermittent exotropia, in patients with exodeviation angles less than 20 PD at the initial visit.
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Affiliation(s)
- Gyeongmin Yoo
- Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea
| | - Suk Gyu Ha
- Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea
| | - Seung Hyun Kim
- Department of Ophthalmology, Korea University College of Medicine, Seoul, Korea.
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Insufficient accommodation during binocular near viewing in eyes with intermittent exotropia. Jpn J Ophthalmol 2019; 64:77-85. [PMID: 31707606 DOI: 10.1007/s10384-019-00695-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE To investigate the changes in spherical equivalent and pupil response during near viewing in patients with intermittent exotropia (IXT) who have complaints of blurred vision or asthenopia from near viewing in daily life using a novel binocular wavefront aberrometer. STUDY DESIGN A cross-sectional study. METHODS Ten IXT patients and ten healthy subjects wearing full-correction lenses at far sight (5 m) were instructed to fixate on a near target at 67 cm, which was then moved to 40 cm three times. Serial changes in the spherical equivalent (SE) refractive error (SE) were measured during this task using a laboratory-made open-field binocular Hartmann-Shack wavefront aberrometer and compared between patients and healthy subjects. In the IXT patients, regression analysis was performed between ∆SE and exodeviation angles, as measured by an alternate prism and cover test. Pupil-diameter and pupil-constriction ratios were also compared between patients and healthy subjects, and the correlation of constriction ratio with ∆SE was calculated for both groups. RESULTS Compared to healthy subjects, IXT patients demonstrated significantly lower ∆SE of convergence (mean ± SD, 0.91 ± 0.26 D vs. 1.15 ± 0.19 D; P < 0.05) and divergence (0.93 ± 0.28 D vs. 1.16 ± 0.20 D; P < 0.05). Angle of exotropia was negatively correlated with ∆SE during far-sight and near-sight convergence and divergence (P < 0.05). Pupil-constriction ratio was also reduced in patients compared to healthy subjects (6.67% ± 3.31% vs. 11.9% ± 5.96%; P<0.05). Pupil-constriction ratio was positively correlated with ∆SE during convergence in both groups (P < 0.05). CONCLUSION Insufficient accommodation and pupil constriction during near viewing were observed in patients with IXT who had complaints of blurred vision or asthenopia from near viewing. These conditions might contribute to symptoms, such as fatigue, eye strain and impaired visual performance.
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Algee K, Walsh L, Hahn E. A Comparison of the Maximum Deviation Measured in Intermittent Exotropia Using Various Clinical Conditions. J Binocul Vis Ocul Motil 2019; 69:73-81. [PMID: 31157609 DOI: 10.1080/2576117x.2019.1607428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background and Purpose: In the Intermittent Exotropia (IXT) population determining the largest deviation for surgical planning has been suggested for desired surgical outcomes Throughout the literature, the clinical tests that elicit largest deviation remains unclear. Patients and Methods: 24 IXT subjects were measured at the customary 1/3 m and 6 m fixation, with +3D lenses at 1/3 m, at far distance (20 m), 1/3 m and 6 m after PMO, with +3D lenses at 1/3 m after PMO, and far distance (20 m) after PMO, in an attempt to determine which of these conditions elicit the largest exodeviation. Results: At near, all subjects had clinically significant increases with at least one condition. In 87.5%, clinical and statistical increases occurred with +3D lenses and/or with +3D after PMO. There was no statistically significant difference between those conditions. At distance, 16.7% demonstrated clinically significant increases. Two increased at 20 m and 6 m after PMO similarly, and all increased at 20 m fixation with or without PMO, without a significant difference between measurements at 20 m and 20 m after PMO. All increases at 20m, with and without PMO were statistically significant. Conclusion: This research indicates that measurements with +3D lenses and at 20 m are the most efficient for the maximum deviation in IXT patients.
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Affiliation(s)
- Kailee Algee
- a Faculty of Health, Clinical Vision Science , Dalhousie University , Halifax , Nova Scotia , Canada
| | - Leah Walsh
- a Faculty of Health, Clinical Vision Science , Dalhousie University , Halifax , Nova Scotia , Canada
| | - Erik Hahn
- a Faculty of Health, Clinical Vision Science , Dalhousie University , Halifax , Nova Scotia , Canada
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Long-term outcomes of bilateral lateral rectus recession versus unilateral lateral rectus recession-medial rectus plication in children with basic type intermittent exotropia. Eye (Lond) 2019; 33:1402-1410. [PMID: 30944460 DOI: 10.1038/s41433-019-0422-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 02/08/2019] [Accepted: 03/08/2019] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To compare the long-term surgical outcomes between bilateral lateral rectus recession (BLR) and unilateral lateral rectus recession-medial rectus plication (RP) in intermittent exotropia. METHODS Children who underwent BLR or RP for basic type intermittent exotropia between 2015 and 2016 with a minimum follow-up period of 2 years were retrospectively reviewed. Surgical outcomes were classified based on postoperative angle of deviation as follows: success (esodeviation ≤ 5 prism diopters [PD] to exodeviation ≤ 10 PD), and failure (overcorrection [esodeviation > 5 PD] and undercorrection or recurrence [exodeviation > 10 PD]). RESULTS Of 144 patients, 90 underwent BLR and 54 underwent RP. The angle of exodeviation of the RP group steadily increased over time after the surgery. The BLR group showed an earlier exodrift and a more stable course compared to the RP group. Kaplan-Meier survival analysis showed a better survival in the BLR group, with final success rates of 48.9% in the BLR group and 25.9% in the RP group after a mean follow-up of 2.2 years. Patients with a successful outcome had greater esodeviation at 1 week postoperatively (at distance 7.6 PD in the BLR group, 11.4 in the RP group). CONCLUSIONS Surgical outcomes were better in the BLR group than in the RP group. The RP group showed higher rates of recurrence of exodeviation, while the BLR group presented a more stable course. Establishing more esodeviation at postoperative week 1 in the RP group compared to the BLR group would be required to achieve successful results.
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Chougule P, Kekunnaya R. Surgical management of intermittent exotropia: do we have an answer for all? BMJ Open Ophthalmol 2019; 4:e000243. [PMID: 30997406 PMCID: PMC6440598 DOI: 10.1136/bmjophth-2018-000243] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 12/20/2018] [Accepted: 12/28/2018] [Indexed: 12/11/2022] Open
Abstract
Intermittent exotropia (X(T)) is one of the most common form of strabismus with surgery being the mainstay of treatment. The main goal of surgery is to preserve binocular vision and stereopsis and to prevent its further loss. The decision to operate is mainly based on four aspects: increasing angle of exodeviation, deteriorating control of X(T), decrease in stereopsis for near or distance and quality of life. Bilateral lateral rectus muscle recession and unilateral lateral rectus recession with medial rectus resection, are the two most common surgical procedures performed and have been studied extensively in basic, divergence excess and convergence insufficiency types of X(T). However, there is no consensus over the relative efficacy of the two procedures in terms of postoperative alignment, residual or recurrent exotropia and consecutive esotropia with widely variable results, which can be attributed to poor understanding of the natural course of the disease. Multiple demographic, clinical and anatomic features that may influence the surgical outcomes have been studied to explain this variability. Moreover, most of the evidence regarding surgical outcomes of X(T) is from retrospective studies and the ongoing randomised prospective trials can shed light on long-term efficacy of these procedures. The goal of this review is to give a comprehensive overview of the outcomes of various surgical techniques in the management of different types of X(T), the preoperative and postoperative factors that may affect the surgical outcomes and to discuss the dilemmas faced by the treating surgeons including the effective management of overcorrection and undercorrection.
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Affiliation(s)
- Pratik Chougule
- Child Sight Institute, Jasti V Ramanamma Children's Eye Care Centre, L V Prasad Eye Institute, Hyderabad, India
| | - Ramesh Kekunnaya
- Child Sight Institute, Jasti V Ramanamma Children's Eye Care Centre, L V Prasad Eye Institute, Hyderabad, India
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Incomitant Strabismus and Principles of Its Management. Strabismus 2019. [DOI: 10.1007/978-981-13-1126-0_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Hirota M, Kanda H, Endo T, Morimoto T, Miyoshi T, Fujikado T. Binocular coordination and reading performance during smartphone reading in intermittent exotropia. Clin Ophthalmol 2018; 12:2069-2078. [PMID: 30425446 PMCID: PMC6200431 DOI: 10.2147/opth.s177899] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This study aimed to evaluate binocular coordination using video-oculography during smartphone reading in patients with intermittent exotropia compared to individuals with normal vision. Patients and methods Eleven youth and adult patients with intermittent exotropia (21.9±9.3 years) and 15 control subjects (26.6±4.3 years) were examined. Eye movements were recorded during smartphone reading at 50, 30, and 20 cm using video-oculography. The loss of binocular coordination was tentatively defined as a horizontal disparity greater than 2°. The proportion of monocular viewing was the percentage of time for which binocularity was lost during smartphone reading. The proportion of monocular viewing, the reading speed, and the correlation between proportion of monocular viewing and reading speed were analyzed. Results The proportion of monocular viewing during smartphone reading was significantly higher in the intermittent exotropia group than in the control group (P<0.001). It was significantly more frequent at 20 cm than at 50 cm in the intermittent exotropia group (P<0.05). The reading speed was significantly negatively correlated with the proportion of monocular viewing at 30 and 20 cm in the intermittent exotropia group (P<0.05). Conclusion A significant increase in the proportion of monocular viewing in the intermittent exotropia group suggests that an appropriate viewing distance should be advised so that users can maintain binocular coordination when viewing a smartphone.
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Affiliation(s)
- Masakazu Hirota
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,
| | - Hiroyuki Kanda
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,
| | - Takao Endo
- Department of Ophthalmology, Osaka University Graduate School of Medicine, Izumi, Osaka, Japan
| | - Takeshi Morimoto
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,
| | - Tomomitsu Miyoshi
- Department of Integrative Physiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takashi Fujikado
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,
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Kwon JM, Jung JH. Subnormal Binocular Contrast Sensitivity Summation in Patients with Intermittent Exotropia. J Korean Med Sci 2018; 33:e222. [PMID: 30079006 PMCID: PMC6070470 DOI: 10.3346/jkms.2018.33.e222] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 06/14/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND To evaluate binocular summation ratio using contrast sensitivity (CS) testing and correlation between binocular summation and stereoacuity, and control scale in intermittent exotropia (IXT). METHODS We conducted a prospective case-control study. Thirty-seven IXT and 41 controls were evaluated with both monocular and binocular CS testing. We compared the binocular summation ratio of IXT to that of controls. Near and distance stereoacuity was assessed and office-based control scale was evaluated. We investigated correlation between binocular CS summation ratio and stereoacuity, and control scale in IXT, respectively. RESULTS IXT had lower binocular CS summation ratio than controls at 1.5 and 3.0 cycles/degree (1.01 ± 1.02 vs. 1.62 ± 1.88 and 1.17 ± 0.96 vs. 1.86 ± 1.75, Both P < 0.05). We found significant correlation between binocular CS summation ratio at 3.0 cycles/degree and both near and distance stereoacuity (r = -0.411, P = 0.012 and r = -0.624, P = 0.005), and ratio at 1.5 cycles/degree also correlated significantly with distance stereoacuity (r = -0.397, P = 0.034) in the IXT. Binocular CS summation ratio was correlated to control scale at 1.5 and 3.0 cycles/degree (r = -0.327, P = 0.041 and r = -0.418, P = 0.028), and the ratio significantly differed in control scale groupings analysis at the same frequencies (Both P < 0.05). CONCLUSION Our findings of subnormal binocular CS summation ratio in IXT had correlation with stereoacuity and control scale suggest that binocular CS testing may be a useful method in assessing binocular visual function in IXT.
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Affiliation(s)
- Jeong Min Kwon
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jae Ho Jung
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
- Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Bilateral lateral rectus recession versus unilateral recession resection for basic intermittent exotropia: a meta-analysis. Graefes Arch Clin Exp Ophthalmol 2018; 256:451-458. [DOI: 10.1007/s00417-018-3912-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/23/2017] [Accepted: 01/16/2018] [Indexed: 10/18/2022] Open
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Wallace DK, Christiansen SP, Sprunger DT, Melia M, Lee KA, Morse CL, Repka MX. Esotropia and Exotropia Preferred Practice Pattern®. Ophthalmology 2017; 125:P143-P183. [PMID: 29108746 DOI: 10.1016/j.ophtha.2017.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 10/03/2017] [Indexed: 11/27/2022] Open
Affiliation(s)
- David K Wallace
- Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephen P Christiansen
- Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts
| | - Derek T Sprunger
- Indiana University Health Physicians, Midwest Eye Institute, Indianapolis, Indiana
| | | | - Katherine A Lee
- Pediatric Ophthalmology, St. Luke's Health System, Boise, Idaho
| | | | - Michael X Repka
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland
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Torp-Pedersen T, Boyd HA, Skotte L, Haargaard B, Wohlfahrt J, Holmes JM, Melbye M. Strabismus Incidence in a Danish Population-Based Cohort of Children. JAMA Ophthalmol 2017; 135:1047-1053. [PMID: 28859196 DOI: 10.1001/jamaophthalmol.2017.3158] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance To our knowledge, there have been few population-based studies of strabismus incidence conducted. Our population-based study provides valuable data for health services planning and identifying research needs. Objective To determine the incidence and age distribution of strabismus, overall and by subtype, among children 7 years or younger. Design, Setting, and Participants This population-based cohort study was conducted with data from 96 842 children enrolled in the Danish National Birth Cohort. Main Outcomes and Measures Age-specific incidence and cumulative incidence and median age at the detection of strabismus, overall and by subtype. Results The study cohort included 96 842 children born between 1996 and 2008 who are predominantly Caucasian and is composed of approximately 30% of births in Denmark, with a boy-girl ratio of 51:49. Overall, 1309 cases of strabismus were identified in the cohort. We found an overall cumulative strabismus incidence of 2.56% (95% CI, 2.42-2.69) at 7 years. The overall incidence was similar among boys and girls. Two hundred sixteen participants (16.5%) (95% CI, 14.5-18.6) had congenital esotropia, 177 (13.5%) (95% CI, 11.7-15.5) had fully accommodative esotropia, 252 (19.3%) (95% CI, 17.1-21.5) had partially accommodative esotropia, and 181 (13.8%) (95% CI, 12.0-15.8) had exotropia. The esotropia:exotropia ratio was 5.4:1 (95% CI, 3.4:1 to 7.5:1). Age-specific incidence curves for congenital esotropia, fully accommodative esotropia, partially accommodative esotropia, and all exotropia revealed interactions between strabismus subtype and age, suggesting that the different subtypes had different age-specific patterns of incidence (P < .001 for all comparisons between pairs of curves). The median age at detection for the 4 subtypes was 0, 32.0, 26.1, and 16.6 months, respectively. Conclusions and Relevance In a national, population-based cohort study, we found a cumulative incidence of strabismus consistent with those reported in smaller European and American cohorts, but a somewhat higher esotropia:exotropia ratio than those that, to our knowledge, are typically reported by English and American studies. Patterns of incidence by age differed for different strabismus subtypes, indicating differences in age at onset and thereby implying differences in the underlying etiology.
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Affiliation(s)
| | - Heather A Boyd
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen S, Denmark
| | - Line Skotte
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen S, Denmark
| | | | - Jan Wohlfahrt
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen S, Denmark
| | | | - Mads Melbye
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen S, Denmark
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Wang C, Wang L, Ren M, Wang Q. Far distance control scores for assessing intermittent exotropia. J AAPOS 2017; 21:278-281. [PMID: 28673866 DOI: 10.1016/j.jaapos.2017.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 04/04/2017] [Accepted: 04/19/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the level of control in intermittent exotropia by applying the office-based 6-point control scale to far-distance testing. METHODS Fifty-two children with intermittent exotropia were enrolled in this prospective, noninterventional case series. Control of exodeviation was assessed at indoor distance (ID) of 3 m and near distance of 33 cm using the office-based 6-point control scale, which was additionally applied to indoor far distance (IFD) fixation of 30 m and outdoor far distance (OFD) fixation of 50 m. RESULTS In all 52 patients, the level of control at OFD fixation was either worse than (31%) or the same as (70%) the level of control at IFD fixation and the level of control at IFD fixation was worse than (64%) or the same as (35%) the level of control at ID fixation. The level of control at OFD fixation was worse than (69%) or the same as (31%) the level of control at ID fixation for all 52 patients. The differences between mean control scores of OFD and IFD fixation (P = 0.002), IFD and ID fixation (P < 0.001), OFD and ID fixation (P < 0.001) were statistically significant. CONCLUSIONS The outdoor and indoor far distance control scores can increase the sensitivity of the office-based 6-point control scale. The office control scale for assessing control in patients with intermittent exotropia could have application for the management of intermittent exotropia.
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Affiliation(s)
- Cuiqing Wang
- Department of Ophthalmology, Shandong Provincial Hospital affiliated to Shandong University, Shandong Province, P.R. China
| | - Lihua Wang
- Department of Ophthalmology, Shandong Provincial Hospital affiliated to Shandong University, Shandong Province, P.R. China.
| | - Meiyu Ren
- Department of Ophthalmology, Shandong Provincial Hospital affiliated to Shandong University, Shandong Province, P.R. China
| | - Qi Wang
- Department of Ophthalmology, Shandong Provincial Hospital affiliated to Shandong University, Shandong Province, P.R. China
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Comment on "Exotropia Is the Main Pattern of Childhood Strabismus Surgery in the South of China: A Six-Year Clinical Review". J Ophthalmol 2016; 2016:8251629. [PMID: 27523160 PMCID: PMC4976143 DOI: 10.1155/2016/8251629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/29/2016] [Indexed: 11/20/2022] Open
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Lee JY, Lee EJ, Park KA, Oh SY. Correlation between the Limbus-Insertion Distance of the Lateral Rectus Muscle and Lateral Rectus Recession Surgery in Intermittent Exotropia. PLoS One 2016; 11:e0160263. [PMID: 27463100 PMCID: PMC4962984 DOI: 10.1371/journal.pone.0160263] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 07/16/2016] [Indexed: 11/19/2022] Open
Abstract
The aim of this study was to investigate whether the limbus-insertion distance (LID) of the lateral rectus (LR) muscle can be a useful indicator for predicting the surgical effect of recession surgery in intermittent exotropia (IXT). Patients who underwent unilateral or bilateral LR recession for the basic type of IXT were included. The distance between the corneal limbus and the posterior edge of the insertion of LR muscle (limbus-insertion distance) was measured intraoperatively using surgical calipers (graded with 0.25 mm precision). We calculated the actual dose-response effect as the difference between the angle of preoperative deviation and the angle of postoperative deviation, and then divided the figure by the total amount of recession at postoperative months 1, 3, and 6. The correlation between the limbus-insertion distance (LID) of LR muscle and each dose-response effect was statistically analyzed. A total of 60 subjects were enrolled in this study. The mean LID of LR muscle was 5.8±0.7 mm. The dose-response effect was 3.2±1.0 prism diopters (PD)/mm at postoperative month 1, 3.4±1.0 PD/mm at postoperative month 3, and 3.4±1.1 PD/mm at postoperative month 6. The LID of the LR muscle was significantly correlated with dose-response effects in cases of unilateral and bilateral LR recession at postoperative months 3 and 6 (P = 0.01, <0.01, 0.04 and <0.01 respectively). As the LID of the LR muscle increased by 1 mm, the dose-response effect increased by 0.2PD/mm in unilateral LR recession, and by 0.4 PD/mm in bilateral LR recession at postoperative month 6. In conclusion, the LID of the LR muscle can be used as one predictor of the recession effect to assist in surgical planning for IXT. Moreover, undercorrection at the time of LR recession might be considered in patients with long LID of the LR muscle.
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Affiliation(s)
- Ju-Yeun Lee
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Jung Lee
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung-Ah Park
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sei Yeul Oh
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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Ha SG, Jang SM, Cho YA, Kim SH, Song JS, Suh YW. Clinical exhibition of increased accommodative loads for binocular fusion in patients with basic intermittent exotropia. BMC Ophthalmol 2016; 16:77. [PMID: 27266700 PMCID: PMC4896026 DOI: 10.1186/s12886-016-0260-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the accommodative loads change needed to maintain binocular fusion in patients with intermittent exotropia (IXT). METHODS Seventeen consecutive patients with basic IXT and 15 normal controls were recruited. The WAM-5500 autorefractor (GrandSeiko, Fukuyama, Japan) was used to measure refractive error (D) under binocular and monocular viewing conditions at 6 m, 50 cm, 33 cm and 20 cm. The difference between binocular and monocular refractive error (D) at each distance defined the change in the accommodative load. The changes in accommodative load were compared between IXT patients and normal controls. We also investigated the change in accommodative loads according to the fixing preference in patients with IXT. RESULTS In IXT patients, the mean angles of deviation were 20.2 ± 7.19 and 21.0 ± 8.02 prism diopters at 6 m and 33 cm, respectively. Under binocular viewing, the changes in accommodative loads of each eye in IXT patients were significantly higher at 50, 33 and 20 cm than those of normal controls (p < 0.05, all). The changes in accommodative loads of fixating and deviating eyes at 6 m were not significantly different between IXT patients and normal controls (p = 0.193, 0.155, respectively). The changes in accommodative loads of the fixating eye at each distance were not significantly different from those of the deviating eye in IXT patients (p > 0.05). CONCLUSION The changes of accommodative loads at near fixation increased more in IXT patients than they did in normal controls while maintaining binocular fusion.
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Affiliation(s)
- Suk-Gyu Ha
- Department of Ophthalmology, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Sung-Min Jang
- Department of Ophthalmology, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, South Korea
| | - Yoonae A Cho
- Nune Eye Hospital, 404, Seolleung-ro, Gangnam-gu, Seoul, 06198, South Korea
| | - Seung-Hyun Kim
- Department of Ophthalmology, Korea University Anam Hospital, 73, Inchon-ro, Seongbuk-gu, Seoul, 02841, South Korea
| | - Jong-Suk Song
- Department of Ophthalmology, Korea University Guro Hospital, 148, Gurodong-ro, Guro-gu, Seoul, 08308, South Korea
| | - Young-Woo Suh
- Department of Ophthalmology, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do, 15355, South Korea.
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Abstract
PURPOSE To determine the prevalence, subtypes, and associated risk factors for intermittent exotropia (IXT) in preschool children aged 3 to 6 years in eastern China. METHODS A population-based study including 5831 preschool children aged 3 to 6 years was conducted from 2011 to 2012 in Yuhua District, Nanjing, China, using an age-stratified random sampling procedure. Clinical examinations including ocular alignment, ocular motility, visual acuity, prism cover test, cycloplegia refraction, stereopsis screening, slitlamp examination, and fundus examination were performed by trained ophthalmologists and optometrists. Intermittent exotropia was defined as an acquired intermittent exodeviation of at least 10 prism diopters in an otherwise healthy child following the classification recommended by the National Eye Institute. RESULTS The overall prevalence of IXT in this population was 3.24% (95% confidence interval, 2.79 to 3.69%), with no age (p = 0.19) and sex (p = 0.89) differences. Among 166 children with IXT, the "basic type" was the most common type of IXT (74.7%), the "divergence excess" was the second (19.9%), whereas the "convergence weakness" was the rarest (5.4%). In multivariate analysis adjusting for age, sex, and other confounders, the presence of IXT was only associated with a history of hypoxia at birth (odds ratio, 4.41; 95% confidence interval, 2.47 to 7.86). CONCLUSIONS Intermittent exotropia affected approximately 1 in 30 Chinese preschool-aged children in eastern China, indicating a relatively higher burden of this pediatric eye condition in the world's most populous country. The presence of IXT was strongly associated with a history of hypoxia at birth.
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Hirota M, Kanda H, Endo T, Lohmann TK, Miyoshi T, Morimoto T, Fujikado T. Relationship between reading performance and saccadic disconjugacy in patients with convergence insufficiency type intermittent exotropia. Jpn J Ophthalmol 2016; 60:326-32. [PMID: 27112342 DOI: 10.1007/s10384-016-0444-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 02/18/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine the relationship between re-reading the same line and saccadic disconjugacy in patients with convergence insufficiency-type intermittent exotropia [CI-type X(T)]. METHODS Eight patients with CI-type X(T) and ten healthy orthophoric individuals were studied. Video-oculography was used to assess the eye movements during the reading of a Japanese novel displayed on a 23-in. liquid crystal monitor placed 60 cm from the eyes. The sentences were displayed horizontally and read from left to right. The number of unintentional re-readings of the same line was counted, and the disconjugacy at the median of the saccade between the end of a line and the next line was determined. RESULTS The number of re-readings of the same line in patients with CI-type X(T) was 4.9 ± 2.3 times which was significantly higher than that in the controls at 0.2 ± 0.4 times (P < 0.001). The saccadic disconjugacy was significantly larger in patients with CI-type X(T) at -1.70° ± 0.72° than that in the controls at -0.40°± 0.30° (P < 0.001). The number of re-readings of the same line was significantly and positively correlated with the saccadic disconjugacy (R = 0.84, R (2) = 0.71, P < 0.01). CONCLUSIONS The results of our study indicate that saccadic disconjugacy is associated with re-reading the same line in patients with CI-type X(T).
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Affiliation(s)
- Masakazu Hirota
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Hiroyuki Kanda
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Takao Endo
- Department of Ophthalmology, Osaka University Graduate School of Medicine, Suita-shi, Osaka, Japan
| | - Tibor Karl Lohmann
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan.,Department of Ophthalmology, University Hospital Aachen RWTH Aachen University, Aachen, Nordrhein-Westfalen, Germany
| | - Tomomitsu Miyoshi
- Department of Integrative Physiology, Osaka University Graduate School of Medicine, Suita-shi, Osaka, Japan
| | - Takeshi Morimoto
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Takashi Fujikado
- Department of Applied Visual Science, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan.
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Clarke M, Hogan V, Buck D, Shen J, Powell C, Speed C, Tiffin P, Sloper J, Taylor R, Nassar M, Joyce K, Beyer F, Thomson R, Vale L, McColl E, Steen N. An external pilot study to test the feasibility of a randomised controlled trial comparing eye muscle surgery against active monitoring for childhood intermittent exotropia [X(T)]. Health Technol Assess 2016; 19:1-144. [PMID: 26005878 DOI: 10.3310/hta19390] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION The evidence base for the treatment of strabismus (squint) is poor. Our main aim is to improve this evidence base for the treatment of a common type of childhood squint {intermittent exotropia, [X(T)]}. We conducted an external pilot study in order to inform the design and conduct of a future full randomised controlled trial (RCT). METHODS Children of between 6 months and 16 years with a recent diagnosis of X(T) were eligible for recruitment. Participants were recruited from secondary care at the ophthalmology departments at four UK NHS foundation trusts. Participants were randomised to either active monitoring or surgery. This report describes the findings of the Pilot Rehearsal Trial and Qualitative Study, and assesses the success against the objectives proposed. RECRUITMENT AND RETENTION The experience gained during the Pilot Rehearsal Trial demonstrates the ability to recruit and retain sites that are willing to randomise children to both trial arms, and for parents to agree to randomisation of their children to such a study. One child declined the group allocation. A total of 231 children were screened (expected 240), of whom 138 (60%) were eligible (expected 228: 95%) and 49 (35% of eligible) children were recruited (expected 144: 63% of eligible). Strategies that improved recruitment over the course of the trial are discussed, together with the reasons why fewer children were eligible for recruitment than initially anticipated. Attrition was low. Outcome data were obtained for 47 of 49 randomised children. TRIAL PROCESSES AND DATA COLLECTION The Trial Management processes proved effective. There were high levels of completion on all of the data collection forms. However, the feedback from the treatment orthoptists revealed that some modifications should be made to the length and frequency of the health service assessment and travel assessment questionnaires, thus reducing the burden on participants in the main trial. Modifications to the wording of the questions also need to be made. MONITORING OF BIAS Children who recruited to the trial were older and had more severe strabismus than those children eligible but declining participation. Strategies to account for this in a full trial are proposed. REASONS FOR PARTICIPATION OR DECLINING STUDY These were identified using qualitative interviews. The principal reasons for declining entry into the study were strong preferences for and against surgical treatment. HARMS There were no serious unexpected adverse events. Two children had overcorrection of their X(T) with reduction in binocular vision following surgery, which is in line with previous studies. No children in the active monitoring arm developed a constant strabismus although two showed some reduction in control. CONCLUSIONS The SamExo study has demonstrated that it is possible to recruit and retain participants to a randomised trial of surgery compared with active monitoring for X(T). For longer-term full RCTs, in order to maximise the generalisability of future studies, consideration needs to be given to planning more time and clinic appointments to assess eligibility and to allow consideration of participation; the greater use of research nurses for recruitment; and accommodating the strong preferences of some parents both for and against surgical intervention. TRIAL REGISTRATION Current Controlled Trials ISRCTN44114892. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 39. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Michael Clarke
- Department of Ophthalmology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Vanessa Hogan
- Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Deborah Buck
- Institute of Neuroscience, Newcastle University, Newcastle, UK
| | - Jing Shen
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Christine Powell
- Department of Ophthalmology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Chris Speed
- Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Peter Tiffin
- Sunderland Eye Infirmary, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - John Sloper
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Robert Taylor
- Department of Ophthalmology, York Hospitals NHS Foundation Trust, York, UK
| | - Mahmoud Nassar
- Ophthalmology Department, Faculty of Medicine, Minia University, Al-Mini, Egypt
| | - Kerry Joyce
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Fiona Beyer
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Elaine McColl
- Newcastle Clinical Trials Unit, Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Nick Steen
- Institute of Health and Society, Newcastle University, Newcastle, UK
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Transient Exotropia after Open Reduction of a Naso-Ethmoidal-Orbital Fracture. Arch Plast Surg 2016; 43:99-102. [PMID: 26848456 PMCID: PMC4738139 DOI: 10.5999/aps.2016.43.1.99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 10/12/2015] [Accepted: 11/04/2015] [Indexed: 12/01/2022] Open
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Yang M, Chen J, Shen T, Kang Y, Deng D, Lin X, Wu H, Chen Q, Ye X, Li J, Yan J. Clinical Characteristics and Surgical Outcomes in Patients With Intermittent Exotropia: A Large Sample Study in South China. Medicine (Baltimore) 2016; 95:e2590. [PMID: 26844467 PMCID: PMC4748884 DOI: 10.1097/md.0000000000002590] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The clinical characteristics and surgical outcomes in a large sample of patients with intermittent exotropia (IXT) as well as an analysis of risk factors associated with surgical failures are presented in this article. Data from IXT patients who received surgical management at the Eye Hospital, in the Zhongshan Ophthalmic Center, of Sun Yat-Sen University, China from January 2009 to December 2013 were reviewed retrospectively. Included within this analysis were data from pre- and postoperative ocular motility, primary alignment, and binocular vision.A total of 1228 patients with IXT were reviewed. Males (50.4%) and females (49.6%) were nearly equally represented in this sample. Thirty-two patients (2.6%) had a family history of strabismus. The mean age at onset was 6.77 ± 6.43 years (range 7 months -48.5 years), mean duration at presentation was 7.35 ± 6.68 years (range 6 months-47 years), and mean age at surgery was 13.7 ± 8.8 years (range 3-49 years). The mean refractive error was -0.84 ± 2.69 diopter in the right eye and -0.72 ± 2.58 diopter in the left eye. Amblyopia (4.2%), oblique muscle dysfunction (7.0%), and dissociated vertical deviation (4.7%) were also present in these patients. The most common subtype of IXT was the basic type (88.1%). Orthophoria was observed in 80.5% of patients and the ratios of surgical undercorrection and overcorrection were 14.7% and 4.8%, respectively, as determined with a mean follow-up time of 7.8 ± 3.7 months. When combining ocular alignment with binocular vision as the success criteria, the success rate decreased to 35.6%. Multivariate risk factor analysis showed that only the loss of stereoacuity (P = 0.002) was associated with a poor outcome. There were no differences in the long-term results between bilateral lateral rectus recession and unilateral lateral rectus recession with medial rectus resection.Most IXT patients displayed normal vision, with few having positive family histories, amblyopia, oblique muscle dysfunction, and dissociated vertical deviation. The most common subtype of IXT was the basic type. Long-term surgical results were less favorable when sensory status was included in the criteria for success. Patients with stereoacuity loss were at an increased risk for poor outcomes.
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Affiliation(s)
- Min Yang
- From the State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, The People's Republic of China
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Ha SG, Kim SH. Clinical Preoperative and Postoperative Symptoms of Exotropia. J Pediatr Ophthalmol Strabismus 2016; 53:44-51. [PMID: 26836003 DOI: 10.3928/01913913-20160113-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 12/07/2015] [Indexed: 11/20/2022]
Abstract
PURPOSE To examine clinical preoperative and postoperative symptoms and changes in exotropia according to constancy and age. METHODS A survey was conducted of 50 patients on the day before and 1 month after exotropia surgery. Survey results were analyzed by type of exotropia at presentation and age. Changes in subjective symptoms from preoperatively to postoperatively were examined for stereopsis (5 items), asthenopia (5 items), and appearance (5 items). Each item was rated on a 5-point scale ranging from 0 to 4. RESULTS The mean age of the 50 patients was 10.6 ± 7.75 years, and there were 21 (41.2%) males and 29 (56.9%) females. Thirty-two patients with intermittent exotropia had no significant improvement in the stereopsis or asthenopia symptoms. However, they showed significant (P < .05) improvement in the appearance symptoms of squint and out of focus. Eighteen patients with constant exotropia showed significant improvements in the symptoms of tripping over objects or running into a wall in stereopsis and of squint and out of focus in appearance (P < .05). Postoperatively, all patients had significant improvement in appearance-related symptoms regardless of age (P < .05). CONCLUSIONS Patients with constant exotropia had improved symptoms in stereopsis, asthenopia, and appearance after surgery. Appearance was improved regardless of the type of exotropia or age.
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Adams DL, Economides JR, Horton JC. Contrasting effects of strabismic amblyopia on metabolic activity in superficial and deep layers of striate cortex. J Neurophysiol 2015; 113:3337-44. [PMID: 25810480 DOI: 10.1152/jn.00159.2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/23/2015] [Indexed: 11/22/2022] Open
Abstract
To probe the mechanism of visual suppression, we have raised macaques with strabismus by disinserting the medial rectus muscle in each eye at 1 mo of age. Typically, this operation produces a comitant, alternating exotropia with normal acuity in each eye. Here we describe an unusual occurrence: the development of severe amblyopia in one eye of a monkey after induction of exotropia. Shortly after surgery, the animal demonstrated a strong fixation preference for the left eye, with apparent suppression of the right eye. Later, behavioral testing showed inability to track or to saccade to targets with the right eye. With the left eye occluded, the animal demonstrated no visually guided behavior. Optokinetic nystagmus was absent in the right eye. Metabolic activity in striate cortex was assessed by processing the tissue for cytochrome oxidase (CO). Amblyopia caused loss of CO in one eye's rows of patches, presumably those serving the blind eye. Layers 4A and 4B showed columns of reduced CO, in register with pale rows of patches in layer 2/3. Layers 4C, 5, and 6 also showed columns of CO activity, but remarkably, comparison with more superficial layers showed a reversal in contrast. In other words, pale CO staining in layers 2/3, 4A, and 4B was aligned with dark CO staining in layers 4C, 5, and 6. No experimental intervention or deprivation paradigm has been reported previously to produce opposite effects on metabolic activity in layers 2/3, 4A, and 4B vs. layers 4C, 5, and 6 within a given eye's columns.
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Affiliation(s)
- Daniel L Adams
- Beckman Vision Center, University of California, San Francisco, California; and Center for Mind/Brain Sciences, The University of Trento, Trento, Italy
| | - John R Economides
- Beckman Vision Center, University of California, San Francisco, California; and
| | - Jonathan C Horton
- Beckman Vision Center, University of California, San Francisco, California; and
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Feng X, Zhang X, Jia Y. Improvement in fusion and stereopsis following surgery for intermittent exotropia. J Pediatr Ophthalmol Strabismus 2015; 52:52-7. [PMID: 25643371 DOI: 10.3928/01913913-20141230-08] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 11/12/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate fusion stereopsis in patients with intermittent exotropia before and after strabismus surgery. METHODS Fifty-three patients (mean age: 11.8 years, range: 5 to 25 years) with intermittent exotropia were enrolled. Fusion was measured with the Worth 4-dot test. Near stereopsis was examined with Titmus and stereoscopic test charts (created in China by Shao-Ming Yan). Distance stereopsis was tested with random-dot stereograms produced by Tianjin Eye Hospital. All patients completed the tests preoperatively and 2 and 6 weeks postoperatively. RESULTS There were no statistically significant differences in stereoscopic test charts among groups preoperatively (P > .05) and postoperatively (P > .05) or on Titmus tests preoperatively (P > .05) and postoperatively (P > .05). Among 53 patients, the percentage of distance stereoscopic improvement was 49% after 2 weeks and 77% after 6 weeks compared to 13% preoperatively. Six weeks postoperatively, random-dot stereograms were significantly different in those younger than 7 years and older than 13 years (P < .05), as well as those 7 to 13 years and older than 13 years (P < .05). Fifty (94%) demonstrated peripheral fusion and only 21 (40%) demonstrated central fusion preoperatively. Six weeks postoperatively, all patients exhibited peripheral fusion and 52 (98%) demonstrated central fusion. Central fusion in patients with intermittent exotropia significantly increased after 6 weeks (chi-square = 42.29, P < .01). CONCLUSIONS Patients with intermittent exotropia have good near stereoacuity preoperatively and postoperatively. Even if surgery is postponed until adolescence, distance stereopsis can still be recovered. Surgical intervention can restore central fusion and stereoacuity in patients with intermittent exotropia.
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Korah S, Philip S, Jasper S, Antonio-Santos A, Braganza A. Strabismus surgery before versus after completion of amblyopia therapy in children. Cochrane Database Syst Rev 2014; 10:CD009272. [PMID: 25315969 PMCID: PMC4438561 DOI: 10.1002/14651858.cd009272.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Normal visual development occurs when the brain is able to integrate the visual input from each of the two eyes to form a single three-dimensional image. The process of development of complete three-dimensional vision begins at birth and is almost complete by 24 months of age. The development of this binocular vision is hindered by any abnormality that prevents the brain from receiving a clear, similar image from each eye, due to decreased vision (e.g. amblyopia), or due to misalignment of the two eyes (strabismus or squint) in infancy and early childhood. Currently, practice patterns for management of a child with both strabismus and amblyopia are not standardized. OBJECTIVES To study the functional and anatomic (ocular alignment) outcomes of strabismus surgery before completion of amblyopia therapy as compared with surgery after completion of amblyopia therapy in children under seven years of age. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2014), EMBASE (January 1980 to July 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to July 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 24 July 2014. A manual search for articles from a review of the references of the selected publications and conference abstracts was completed to identify any additional relevant studies. SELECTION CRITERIA We searched for randomized controlled trials (RCTs) that provided data on strabismus surgery in children less than seven years of age, performed after initiation of, but before completion of amblyopia therapy, as compared with strabismus surgery after completion of amblyopia therapy. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies identified from the electronic and manual searches. MAIN RESULTS There were no RCTs that fit our inclusion criteria and so no analysis was possible. AUTHORS' CONCLUSIONS As there are no RCTs currently available and the best existing evidence is only from non-randomized studies, there is a need for prospective RCTs to investigate strabismus surgery in the presence of strabismic amblyopia. The optimal timing of when to perform strabismus surgery in children with amblyopia is unknown.
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Affiliation(s)
- Sanita Korah
- Department of Ophthalmology, Christian Medical College, Vellore, Tamil Nadu, India, 632001
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