Pearls in the management of exotropia

Editors' note: This roundtable was taken from the 2003 New Orleans Academy of Ophthalmology meeting. Burton Kushner, M.D.: Let's say you have a very young child, in this case a 1year-old, and the child has a poorly controlled intermittent exotropia. Presume their refractive error is not at issue; there is no amblyopia, there is no pattern. What do you do with a young child with intermittent exotropia whose control is very poor. When do you operate, and do you operate? Arthur Jampolsky, M.D.: Intermittent exotropia in small infants may get better, and I would certainly take that path if it were my child. Minus lenses are great. Some 1-year-olds will wear glasses. And I am for minus lenses, -3.00, and you would be surprised over time, some of these people have ortho without the glasses after a long time of wearing such glasses. Certainly, if this child were older and could wear glasses more, I would really push that one. But the main thing is that I would not operate at this age. I would observe. Gunter von Noorden, M.D.: I agree. I would also plead for watchful waiting here. Not because I don't think you could cure such a child surgically. I am quite sure this is possible. But I am afraid of converting such a patient who eventually may have a very good potential for recovery of good binocular vision into a small angle esotropia with amblyopia, anomalous correspondence, and suppression. Edward G. Buckley, M.D.: I certainly agree with that. This is an unusual situation for a 1-year-old. I worry about the fact that we are already out of control at this age, but you are still better off being slightly exotropic than esotropic in this situation. I probably would be a little bit more aggressive and consider surgical intervention sooner rather than later because of the poor control at such a young age. Von Noorden: Very little visual activity takes place in a child of that age at distance fixation. If fusional control of intermittent exotropia is good at near fixation, normal binocular vision is reinforced constantly, which will give us more time to observe such a patient rather than rush him to surgery. Kenneth Wright, M.D.: I would watch very carefully. If the deviation increased in the tropia phase, I would operate early. In the meantime, I would do alternate patching. I have not had success with myopic spectacles, but alternate patching maybe four hours a day, patch one eye, patch the other eye, tends to act as anti-suppression and may help control it. But if it was breaking down, I would operate. David Guyton, M.D.: I'd watch the child and if deterioration occurred from one visit to the next Id operate. I use adjustable sutures in all children, and that

gives me a little safety factor. I am more prone to go onto surgery because I can do that. Forrest D. Ellis, M.D.: Despite the observations that have been made regarding loss of stereopsis at distance and poor control at distance, my experience with children with intermittent exotropia is that if they are straight somewhere, usually at near, most of the time they are ultimately going to end up with good fusion as long as they continue to be followed and intervention can be undertaken if things look worse. Marshall Parks, M.D.: Intermittent exotropia is a surgical disease. It is not really an orthoptic disease. It is not going to be cured by minus lenses or by intermittent occlusion. These children have problems. Imagine living with a 30 D of deviation at your age. A child has that same problem. I think early surgery is the thing to do for strabismus, regardless of whether it is esotropia or exotropia. I would not operate at the first visit. I would see this child and make sure of the deviation, and if the child is 1 year old, having as much of a problem as you have outlined in this case, I wouldn't hesitate at all to take this child to surgery. The big objection is that you may have an overcorrection, have an esotropia. Hence, that would be constant. Now, it is an intermittent problem and most of these children are bifixaters. They have excellent stereoacuity. They have both macular and extramacular fusion. And you don't want to then create a problem where you have eliminated this patient's macular binocular vision. One of the things that is underappreciated in this loss of macular binocular vision is that if the patient is unable to align the eyes and obtain macular binocular vision, and hence avoid that scotoma that is always in the non-fixating eye, three months of that will forever eliminate that patient's capability to have macular binocular vision. They can have extramacular binocular vision. Hence, all reports of the outcomes of exotropia surgery then should have what the final state is in the stereoacuity, which measures your presence or absence of macular binocular vision. If you do then have an overcorrection a constant tropia after eliminating the intermittent tropia, then you have done the wrong thing if you haven't followed this patient carefully, and within that three-month period of when they can convert from having capability from macular to having no capability in the future for macular binocular vision, you have done them a disservice. Kushner: When we see a patient, we can measure them, they're 30, they're 40, but then you want to make the judgment whether they need surgery, not how much to do, but whether, based on whether their control is good or bad. Is this just objective or subjective? Do people use criteria like control though a blink? What is your criteria? Guyton: In my experience, the first binocular function to disappear or to be altered is the alternate letter vectographic test for suppression in the distance. I love that test. It is an old American Optical test. Reichert still sells the slides. Stereo Optical has the slides. You project them. The alternate letters are seen with the vectographic Polaroid glasses in the distance. And that's the first thing that drops out, in my experience

Later, the distance stereoacuity drops out. I have found that if I wait for the distance stereoacuity to drop out, I don't always recover that. At least, however, I have usually been able to recover binocular motor fusion in these patients. If they still have good stereo, but they are starting to suppress, then I can often reverse that suppression with timely surgery. But once they lose the distance stereo, they don't always recover the stereoacuity. Ellis: I usually rely on near stereo tests for my confidence in conservative treatment. I think the distance stereo tests are an objective way to measure no control at distance, but I have yet to see a single patient who had good stereopsis at near, poor control, or poor stereopsis at distance, who didn't recover stereopsis if he was properly aligned. At 20 feet, I'm not sure how important stereopsis is that we measure in that way. I have yet to see anybody lose that ability if they never lost it all, or if they never lost it at near. You do have to make a decision on somewhat subjective grounds, I think, in all of these patients. That is an objective measurement, but I do have parents sort of keep a mental diary as to how much of the time this patient has deviated, and I try to keep my own assessment of that and use my best judgment. Wright: I am an advocate for early surgery as long as there is a constant tropia. However, if the patient is fusing consistently at near and has excellent stereo at near, that's recoverable, and that will be maintained because they do have excellent stereo at near. My biggest indication for older children with intermittent exotropia is number one, progression. If it is breaking down and getting worse. I think that is very important. The most important factor to me is the history. Is it getting worse and it's breaking down. The other thing is what the parents think. If the parents think everything is great, I am hard-pressed to operate. Buckley: There are a lot of things you can follow. I follow the vision in a deviating eye, especially in young children. If it starts to drop a little bit, I become concerned. You can follow the sensory status, especially stereoacuity. I measure the angle looking to see if its increasing. One real important factor for me is how easily the child breaks down into a constant tropia. If I can just sort of hold my hand two to three feet away from that eye and the eye goes zipping out, I am much more concerned about it than if I have to completely cover the eye to get it to go out. I also look at how easily they bring the eye back in after I force it out. The kid just sits there with the eye out for the next 10 minutes, I am much more concerned than if he makes a quick refusion effort right away. Kushner: Those are subjective criteria, really. Buckley: The subjective criteria is the sensory status. Objective criteria are: How easily I can break the child, and how quickly the child refuses.

Von Noorden: Intermittent exotropia does not progress in all patients. Years ago, when I was still working at Wilmer Eye Institute, we followed a group of such patients with this condition for several years rather than operating on them. To our surprise, one-third improved spontaneously without treatment. I would like to make another point that is nearly always neglected in studies reporting the results of surgery in intermittent exotropia: The stability of fusional control at far distance fixation, that is fixation beyond six meters. Many patients that no longer have a manifest residual deviation at distance while being examined in the office after surgery do so when stepping out into the street, or looking from the office through a window at a distant object, tower, or chimney, for instance. Jampolsky: I follow mainly what Buckley has said. I use objective tests almost always in young people and couldn't care less about some of the subjective tests, because they can be inferred. I am not inferring that the sensory apparatus is unimportant. It is terribly important. But you can find it out by different ways. There are three things: Number one is the degree of deviation increasing; number two are there oblique muscles that are now becoming overactive, as it does in exotropia, if it's a unilateral intermittent exo; and most importantly, though, is how well the patient refused. You can cover the eye and the eye stays out and you have them blink and if the eye still stays out, that's not better. If a blink brings it right back, fine. If you make them fix with the usually deviating eye and then uncover it and it goes back and fixes with the good eye, and refuses immediately, that's good. So it's the degree of recovery of refusion, oblique overactions and the degree.