Moreover unilateral lateral rectus recession with medial rectus resection may not show improved stereoacuity at near (lowcertainty evidence due to risk of bias and imprecision), and may result in more minor adverse events (lowcertainty evidence due to risk of bias and imprecision) when compared to bilateral lateral rectus recession. 1985 Winter. Caltrider N, Jampolsky A. Overcorrecting minus lens therapy for treatment of intermittent exotropia. Joyce 2015 included study designs other than RCTs (i.e. or/333840. A study of 666 cases, Binocular Vision and Strabismus Quarterly, The prevalence of strabismus and amblyopia in Japanese elementary school children. Ocular misalignment (strabismus) develops in approximately 5% of developmentally normal children (Graham 1974). Anand 2020 compared lateral rectus recession and medial rectus plication versus lateral rectus recession and medial rectus resection. Nonsurgical treatments, such as alternate-day occlusion, orthoptics, minus lens therapy and prisms, may be tried as a prelude or 1. exp randomized controlled trial/2. A unilateral recess-resect procedure can also be performed in children with exotropia of the convergence insufficiency type where the exodeviation is more at near and less or absent at distance. 25(4):53-68. The objective of this review was to analyze the effects of various surgical and nonsurgical treatments in randomized trials of participants with intermittent exotropia, and to report intervention criteria and determine whether the treatment effect varies by age and subtype of X(T). Exotropia is a type ofstrabismus(misaligned eyes) in which one or both of the eyes turn outward. Treatment of Intermittent Exotropia. We will conduct a sensitivity analysis in future updates to assess the robustness of findings by excluding trials assessed as inadequate with regard to concealment of randomization or those with missing data. In exotropia, one eye turns outward while the other eye remains straight ahead. The condition can begin as early as the first few months of life or any time during childhood. Parents recorded the number of patching hours completed per day on calendar logs that were brought to the 6month visit for review", Primary outcomes: "whether the participants condition had deteriorated within 6 months after randomization. Studies were also excluded if other types of exotropia were included, and data on X(T) could not be extracted, or if participants had received prior treatment. In: Rosenbaum AL, Santiago AP, editors(s). Neither IXT2 2014 nor IXT2 2015 reported motor fusion test at near or distance. The results section of the Kushner 1998a manuscript reported that 99 participants were operated on during the study enrollment period, some of whom were excluded because they were recruited for another study (Kushner 1998b). Surgical correction is difficult because of the varying nature of this alignment. Exodeviations: Their classifications, diagnosis, and treatment. Intermittent exotropia is sometimes subdivided into 'basic' and 'distance' subtypes, but the clinical characteristics for these subtypes of X(T) are very similar, and, as investigation is also essentially the same (Cooper 1977), they are considered together in this review and jointly referred to as 'intermittent exotropia,' or X(T). How long will it take for my child's eyes to heal? Glasses might be recommended to correct refractive error and help improve the alignment of the eyes. (animal or animal experiment).sh.8. In the 'true' type of distance X(T), the angle remains smaller at near despite manipulation of focusing and fusing mechanisms. "The authors have no proprietary or commercial interest in any materials discussed in this article". 62:1161. Figueira EC, Hing S. Intermittent exotropia: comparison of treatments. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). In Asian populations there is a preponderance of myopia (43%) in children with X(T) compared with children with esotropia (inwardturning strabismus) (22%) (Chia 2007). We excluded 979 reports, and assessed 22 fulltexts (22 studies) for eligibility; two of these studies were eligible for inclusion (IXT2 2014; Kiyak Yilmaz 2015). The mean difference in motor alignment was 2.23 PD lower (4.02 to 0.44 lower). The distance type (or 'divergence excess') was originally described as an exodeviation measuring at least 10 greater at distance than near (Burian 1965). Eye. 1990 Jan-Feb. 27(1):16-20; discussion 21-2. 1998 Feb. 116(2):189-94. Comparison 2: Patching versus observation, Outcome 1: Motor alignment at near at 6 months measured by PACT, Comparison 2: Patching versus observation, Outcome 2: Motor alignment at distance at 6 months measured by PACT. Acquired exotropia has three types: Exotropia, especially the intermittent type, often has no known cause. Kiyak Yilmaz 2015 did not report motor alignment at near and distance fixation. Study authors reported "cosmetic outcomes" (i.e. Angle of deviation: there is no clearly defined threshold at which the angle of exodeviation is recognized as more severe. 68:730-822. As there is often poor classification of X(T), and differing nomenclature, any study that did not clearly describe inclusion of basic or distance types of X(T) was excluded. The date of the search was 20 January 2021. Holmes JM, Leske DA, Hatt SR, Brodsky MC, Mohney BG. Exotropia Kushner 1998a and IXT1 2019 randomized participants with basic type X(T) to receive bilateral lateral rectus recession surgery (n = 120) or unilateral lateral rectus recession with medial rectus resection (n = 113). Onemuscle unilateral surgery: one lateral rectus muscle is weakened. The overall methodological quality of the included trials was good, in particular with regard to IXT1 2019, IXT2 2014, and IXT2 2015, which were all conducted by the Pediatric Eye Disease Investigator Group. Any degree of tropia, phoria greater than that stated above (by implication), or any additional treatment was considered an unsatisfactory outcome. Binocular facilitation of discomfort with high luminances. Dallas, TX 75390, 2023 The University of Texas Southwestern Medical Center, 600 South Main Street, Additional measurement of the exodeviation with the individual fixing on a far distance target has been recommended to uncover the maximum misalignment (Burian 1971b; Knapp 1960; Kushner 1998c). 1988. See the Characteristics of included studies table for additional details on included studies. Treatment may also be indicated if or when there is evidence of loss of stereoacuity, but this appears to be extremely rare. 12 and 19. Some cases of exotropia occur without any apparent health problems or family medical history. Arthur L Rosenbaum, MD Choi DG, Rosenbaum AL. The two RCTs followed similar surgical protocol and had comparable risk of bias, but varied in followup (one year in Kushner 1998a and three years in IXT1 2019). The mean change in distance alignment was 10.13 PD. Bilateral MR advancement and/or WebOverview What is exotropia? A systematic review of the effectiveness of treatments in altering the natural history of intermittent exotropia, The surgical overcorrection of intermittent exotropia, Clinical study for the undercorrection factor in intermittent exotropia, The distance angle to target in surgery for intermittent exotropia, Distance/near differences in intermittent exotropia. Exotropia with neurologic causes and field defects. Success rate (RR 1.67, 95% CI 0.63 to 1.20): We judged the evidence for success rate to be of low certainty due to performance bias and imprecision. Exotropia | Condition | UT Southwestern Medical Center The influence of alternate part-time patching on control of intermittent exotropia: a randomized clinical trial, Graefe's Archive for Clinical and Experimental Ophthalmology. Although in Kushner 1998a most risk of bias domains were assessed as low risk, the author did not perform masked assessment of the outcome; the outcomes were assessed by the surgeon, which could have led to detection bias. The short-term follow-up could be considered the possible cause of the difference in reported success rate. We are unaware of any potential biases in the review process. Reports of this complication range from 1.5%, Beneish 1994, to 27%, Edelman 1988. Distance alignment (MD 0.66, 95% CI 1.06 to 2.38): We judged the evidence for motor alignment for distance fixation to be of low certainty due to imprecision (2). Treatment of Intermittent Exotropia Treatment options consist of Vision Therapy, patching, eyeglasses and/or, very rarely, surgery. The most successful form of treatment is in-office supervised Vision Therapy with home reinforcement. Therapy changes the brain and is directed at the cause and cure of the problem. WebTreatment Eye muscle surgery to improve ocular alignment is generally recommended if one or more of the following criteria are present: If the exotropia is present for more than 50% of each day. A 'constant' tropia was defined as a manifest tropia present 100% of the time during the examination, determined by cover/uncover tests performed at least 3 different times during the exam, including one before any dissociation. [QxMD MEDLINE Link]. The search filter for trials at the beginning of the MEDLINE strategy is from the published paper by Glanville (Glanville 2006). IXT2 2014 and IXT2 2015 used the same protocol to compare patching (n = 190) versus observation (n = 188) on participants with basic X(T). Exotropia symptoms can occur frequently or infrequently. Stereoacuity at near using any ageappropriate test. Various studies have reported not only an improvement in quality of fusion but also a quantitative decrease in the angle of deviation. UT Southwestern eye specialists offer treatment options such as: In children with congenital/infantile exotropia, surgery is almost always the recommended treatment. This condition can occur Coffey B, Wick B, Cotter S, Scharre J, Horner D. Treatment options in intermittent exotropia: a critical appraisal, The management of intermittent exotropia. Yildirim C, Mutulu FM, Chen Y, Altinsoy HI. Near point exercises, prism convergence exercises, and red glass convergence exercises are recommended. If the deviation is large, a reoperation is the procedure of choice. or/122123. 1Downgraded due to performance bias and imprecision. 2. Strabismus in adults can be treated in a variety of ways, including observation, patching, prism glasses and/or strabismus surgery According to the Academy's recently published Adult Strabismus Preferred Practice Pattern, strabismus is common among adults, with an estimated incidence of 4%. 1 A matter of age. Overcorrections in horizontal strabismus surgery. There was probably no difference between groups with regard to distance alignment (lowcertainty evidence due to imprecision) or motor fusion (very lowcertainty evidence due to imprecision and risk of bias). 1992. Eye turning only happens occasionally, as a result of one of these circumstances: Most bouts of intermittent exotropia are infrequent, but they can happen so often that it becomes a permanent problem. "visible hump/scar, foreignbody sensation, and persistence of congestion"); however, these outcomes were not considered severe or minor adverse events according to the review protocol. Treatment may be either surgical, nonsurgical, or a combination of both. randomly.ab,ti.6. intermittent [4], Since undercorrection is a frequent sequela to surgery for intermittent exotropia, it is recommended that the largest angle ever measured be taken as the target angle for surgery and that the surgical dose be based on this angle. IXT1 2019 reported a loss of two or more octaves near stereoacuity at three years using the Preschool Randot test (n = 163). This was not spelled out in the manuscript, but has more implications for the generalizability of the results than for conclusions regarding treatment effect. bilateral surgery (n = 86), mean (standard deviation (SD)): 15, unilateral surgery (n = 77), mean (SD): 16, bilateral surgery (n = 86), mean (SD): 16, unilateral surgery (n = 77), mean (SD): 18. bilateral surgery 9/19 (48%), 2/19 (11%) overcorrected and 7/19 (37%) undercorrected; unilateral surgery 3/17 (18%), 1/17 (6%) overcorrected and 2/17 (12%) undercorrected. Am Ophthalmol Otolaryngol. Prisms and botulinum toxin injections do not play a significant role in the treatment of sensory deviation. Neither Kushner 1998a nor IXT1 2019 reported distance stereoacuity. WebEyeglasses Used to stimulate convergence (movement of the eyes toward the nose) by prescribing glasses that are too strong (called "over minus" lenses) Eye muscle surgery Used to loosen or tighten eye muscles in one or both eyes to improve eye alignment. Botulinum toxin management of childhood intermittent exotropia, Occlusion therapy for exodeviations occurring in infants and young children. Early and late postoperative alignments, The utilization of prisms in the treatment of divergent strabismus, Orthoptics. Three of the included studies were multicenter (IXT1 2019; IXT2 2014; IXT2 2015), with the number of sites ranging from 35 to 60. Note the outward deviation of the right eye. Patient is fixing with the left eye. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMTE5OTAwNC10cmVhdG1lbnQ=. When assessed in this way, true distance X(T) appears to be relatively uncommon (Kushner 1998c; Walklate 1998). With the exception of Kiyak Yilmaz 2015, the included studies were at low risk of selection bias. Kiyak Yilmaz 2015 did not report adverse events. Treatment will vary depending on the severity of exotropia. Joyce 2015 included two RCTs, one of which was included in this update (Kushner 1998a). Outcomes were reported as specified in the study protocol. Int Ophthalmol Clin. We judged the evidence for stereoacuity at near fixation to be of low certainty due to performance and attrition bias and imprecision. Study authors did not specify whether the assessment was for near or distance. Am Orthopt J. Nonsurgical versus nonsurgical intervention. Contact an eye doctor if you need medical attention. Strabismus (misaligned eyes) is a condition in which your eyes dont line up with one another. Anand 2020 used computergenerated assignments for randomization, and allocation was concealed using opaque, sealed envelopes. Most current teaching texts describe X(T) as generally being progressive (Mitchell 2000; Santiago 1999; von Noorden 2002), but in the absence of rigorous studies, the true natural history of X(T) remains uncertain. Kushner BJ. Selective surgery for intermittent exotropia based on distance/near differences. The six randomized studies eligible for inclusion in this review reviewed four interventions for intermittent exotropia (X(T)): two surgical (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), nonsurgical (patching versus observation), and surgical adjunct (prism adaptation test with surgery versus surgery alone). Systemic associations with X(T) include mental illness, with a recent study reporting a higher incidence of mental illnesses in individuals with X(T) compared to those with esotropia and the general population (Mohney 2008). Moreover, followup varied from one year to three years. All studies used a dichotomous primary outcome of success or suboptimal performance, variously defined by study authors. Management of Consecutive Exotropia - PMC - National Center patching (n = 159) (mean, SD): 1.84 log arcsec (0.31); observation (n = 165) (mean, SD): 1.84 log arcsec (0.33). We followed the guidelines for data analyses in Chapter 9 of the Cochrane Handbook for Systematic Reviews of Interventions (Deeks 2017). Intermittent exotropia. Were one of the worlds top academic medical centers, with a unique legacy of innovation in patient care and scientific discovery. Kiyak Yilmaz 2015 did not report stereoacuity at near. Duane A. Patching of the good eye, to improve Baseline characteristics were similar between groups. For the majority of children with X(T) who are asymptomatic, criteria for intervention are poorly defined. The updated version of this review includes a broader spectrum of intermittent exotropia; we initially restricted inclusion to studies specifying intermittent distance exotropia. Its making treatment decisions difficult for doctors and patients. Ohtsuki H, Hasebe S, Kono R, Yamane T, Fujiwara H, Shiraga F. Prism adaptation response is useful for surgical outcome in selected types of intermittent exotropia. The Convergence Insufficiency Neuro-mechanism in Adult Population Study (CINAPS) randomized clinical trial: design, methods, and clinical data, Comparison of surgical outcomes of slanted procedure for exotropia with convergence insufficiency according to their response to preoperative monocular occlusion. IXT2 2014 lost 16 participants in the patching group and 18 participants in the observation group at 6 months due to followup, uncompleted masked primary outcome exams, treatmentrelated withdrawal, and other. We created a summary of findings table and presented a summary of evidence, which provided key information about the best estimate of the magnitude of effect when possible, in relative terms and as absolute differences, for comparisons of alternative management strategies, numbers of participants, and trials. Measurement of the exodeviation using the prism cover test at distance and near provides information regarding the degree of misalignment and subtype of X(T). 2001 Feb. 5(1):13-7. This weakens the credibility of the results. Parks MM. Surgery should result in a complete correction of the exotropia and restoration of normal binocular alignment at distance and near fixation. 75(5):683-8. The distance angle to target in surgery for intermittent exotropia. In another retrospective analysis by Figueira 43 that aimed to identify the best treatment option for intermittent exotropia, it was reported that surgery combined with preoperative orthoptic/occlusion therapy achieved the highest successful treatment rate at the 5 year follow-up (84.6%) when compared to surgery alone (25%). Abroms AD, Mohney BG, Rush DP, Parks MM, Tong PY. The two RCTs comparing nonsurgical treatment of X(T) (patching versus observation; IXT2 2014 and IXT2 2015) were conducted by the same investigator group, therefore they followed identical protocols and reported the same outcomes. Hatt SR, Liebermann L, Leske DA, Mohney BG, Holmes JM. Kiyak Yilmaz 2015 and Kushner 1998a did not report conflicts of interest, and the study authors did not respond to our emails requesting additional information. lateral rectus recession and medial rectus plication versus lateral rectus recession and medial rectus resection (1 study, 60 participants). We judged the evidence for stereoacuity at near to be of low certainty due to performance bias and imprecision. Sensory exotropia happens when there is vision loss or blindness in one eye. This review was supported by the NIHR via Cochrane Infrastructure funding to the CEV UK editorial base. ((excess$ or strabism$) adj10 diverge$).tw.16. 1986. These tests are performed with the individual fixing on an accommodative target at distance fixation and then at near fixation. Treatments Other studies report a higher prevalence of myopia in children with X(T) compared with the general population (Caltrider 1983). It will often disappear when the child is focusing on close objects, as when talking to you, making discovery difficult. We judged the evidence for exotropia control to be of high certainty. Barrel cards. Six weeks into treatment, the average pain score was 2.78 in the opioid group and 2.25 in the placebo group, a difference that increased over time. A pincer forceps was applied to the muscle beyond the sutures placed, and an iris sweep was placed temporarily between the tendon and the sutures forming a fulcrum over which the anterior tendon was folded flat between the muscle and globe. Patient is fixing with the left eye. Exotropia may be seen in children with very poor vision in one eye (sensory exotropia) or in association with certain genetic disorders that affect the eyes. Michael J Bartiss, OD, MD Medical Director, Ophthalmology, Family Eye Care of the Carolinas and Surgery Center of Pinehurst Concomitant exodeviations. The two studies included in this comparison varied with regard to outcome reporting and followup times. Masking of participants and personnel administering treatment was not possible for all of the included trials due to the nature of the interventions. Overcorrection of the deviation lasting beyond the initial postoperative period with or without symptoms of diplopia. A final update search in December 2019 identified 211 reports of new studies. Some cases of exotropia will require surgery to realign the eye muscles. or/157. Subjective and objective criteria for recommending surgery on intermittent exotropia. Primary outcome: comparison between 2 techniques for intermittent exotropia. National Library of Medicine In: Duane TD, editors(s). Adjustable sutures may be used, but results tend to be unstable because of the absence of fusion. Symptoms include: UT Southwestern ophthalmologists perform a comprehensive medical eye exam to confirm a diagnosis of exotropia and rule out other conditions. Introduction. New Patient Appointment, Appointment Treatment Surgery remains the mainstay of treatment for intermittent exotropia and most commonly consists of either a bilateral lateral rectus recession or a unilateral recess resect procedure. Holmes JM, Birch EE, Leske DA, Fu VL, Mohney BG. For example, they often did not investigate adverse effects or effects on sharpness of vision at a distance and quality of life. Rajavi Z, Sabbaghi H, Kheiri B, Sheibani K. Lateral rectus resection versus lateral rectus plication in patients with residual esotropia. The majority of participants were children (younger than 18 years of age). One study found that certain people had a higher risk for developing consecutive exotropia after a procedure than others. 7 not 911. If you dont have the chance to make it to the spa or the esthetician, you can still get that type of treatment at home. Mental illness in young adults who had strabismus as children, The prognostic value of lateral gaze measurements in intermittent exotropia, Female predominance in intermittent exotropia. Only medians were reported for IXTQ scores. Prism adaptation test: "prism adaptation test was performed using Fresnel PressOn prisms (Health Care Specialties Division/3M, St. Paul, Minnesota, USA), while the patients were wearing full corrective lenses without cycloplegia. Appointment The age at surgery is thought by some to influence success; some authorities advocate early intervention to avoid entrenched suppression and achieve an optimal result (Abroms 2001; AsjesTydeman 2006; PrattJohnson 1977; PrattJohnson 1994); others suggest that surgery should be delayed until the child is older (Edelman 1988; Richardson 2001; von Noorden 2002; Wickens 1984); and still others have concluded that age at surgery makes no difference to the outcome (Beneish 1994; Folk 1956; Ing 1999; Richard 1983; Stoller 1994). Each risk of bias domain was described and summarized in the text of the Results and also in a risk of bias table. All other included participants had complete outcome data. Eye. Participants could not be masked due to the nature of the surgery (bilateral or unilateral). Two review authors independently recorded data from study reports related to study methods, participants, interventions, and outcomes. The unit for randomization and analysis was the individual in all included trials. The six studies randomized a total of 890 participants (range per study: 36 to 358), 463 of whom had basic or distance X(T) (range per study: 36 to 246). 2nd Floor, Suite P2200, to Pediatric Ophthalmology, for What Is Exotropia? - Optometrists.org The study is not yet recruiting participants.
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