Acta Ophthalmologica 2016

Clinical analysis of childhood intermittent

exotropia with surgical success at postoperative
2 years
Hae Jin Kim and Dong Gyu Choi
Department of Ophthalmology, Hallym University College of Medicine, Kangnam Sacred Heart Hospital, Seoul, Korea

ABSTRACT. within 2 years of surgery of 19%, but

Purpose: To analyse the characteristics of children who had maintained the an overall recurrence rate of exodevia-
successful outcome at 2 years after surgery for intermittent exotropia. tion during the entire follow-up period
Methods: A retrospective study was performed in 216 patients who had of mean 51 months was 49%.
undergone intermittent exotropia surgery and had had at least 2 years of Most of the previous studies on the
follow-up. Surgical outcomes were grouped, according to the angle of deviation success of intermittent exotropia sur-
at postoperative 2 years, as success (esophoria/tropia ≤ 5 prism dioptres (PD) to gery included patients with diverse
exophoria/tropia ≤ 10PD), recurrence (exotropia > 10PD or reoperation within postoperative follow-up periods rang-
2 years) or overcorrection (esophoria/tropia > 5PD). We investigated various ing between 6 and 12 months or more
(Keenan & Willshaw 1994; Abbasoglu
clinical factors for their possible associations with the surgical outcomes.
et al. 1996; Gezer et al. 2004; Jeoung
Results: Of the 216 patients, 128 (59%) were assigned to the success group, and
et al. 2006; Lim et al. 2012). A more
84 (39%) to the recurrence group. According to a univariate analysis, surgical reasonable approach would be to anal-
method and the angle of deviation at the postoperative day 1 showed statistically yse surgical results among patients at a
significant associations with the surgical outcome for intermittent exotropia. certain postoperative time-point. This
However, in the results of a logistic regression test, the angle of deviation at study, accordingly, investigated the
distance at postoperative day 1 was the only factor showing a significant characteristics of patients who had
association (p = 0.023). maintained successful surgical results
Conclusions: Early postoperative overcorrection was significantly associated for childhood intermittent exotropia to
with the maintenance of successful surgical outcome of intermittent exotropia at postoperative 2 years and analysed the
postoperative 2 years. factors associated with those outcomes.

Key words: early postoperative overcorrection – intermittent exotropia surgery – postoperative

2 years – surgical success
Patients and Methods
The medical records of 216 children
Acta Ophthalmol. 2016: 94: e85–e89 who had undergone surgery for inter-
ª 2015 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd mittent exotropia between May 1989
and November 2011 and had had at
doi: 10.1111/aos.12849
least 2 years of follow-up were ret-
rospectively reviewed. Patients who
timing of surgery, preoperative angle of had a history of prior strabismus
Introduction deviation, A and V pattern and visual surgery, simultaneous vertical and/or
The reported surgical outcomes of acuity (Keenan & Willshaw 1994; oblique muscle surgery and/or other
intermittent exotropia have varied Abbasoglu et al. 1996; Gezer et al. ocular abnormalities were excluded.
widely according to both the definition 2004). However, other long-term Patients who had paralytic or
of surgical success and the length of studies have shown that because there restrictive exotropia or a systemic
follow-up (Clarke & Noel 1981; Scott is an exotropic drift following surgery anomaly such as a neurologic disor-
et al. 1981; Ekdawi et al. 2009; Pineles for exotropia, follow-up length might der or developmental delay also were
et al. 2010; Choi et al. 2011, 2012). be the most important factor related to excluded. This study was approved
Numerous studies have suggested exotropia recurrence (Ekdawi et al. by the Institutional Review Board of
various factors possibly related to sur- 2009; Leow et al. 2010). Choi et al. the Hallym University Medical
gical success, including age at onset, (2011) reported a recurrence rate Center.

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Acta Ophthalmologica 2016

Preoperative examinations lateral rectus recession and medial Table 2. Preoperative and postoperative inde-
rectus resection (RR). Patients with pendent variables in surgical outcomes.
The patients’ age at onset of deviation
exotropia of <25 PD both at distant
was revealed by their medical histories, Variables
and near fixation usually underwent
which were provided by their parents.
unilateral lateral rectus muscle reces- Gender
Visual acuity was assessed on the
sion (ULR). Patients with the conver- Visual acuity
Snellen chart. Refractive errors were
gence insufficiency type of exotropia Refractive errors in spherical equivalent
determined using streak retinoscopy Amblyopia
underwent RR based on the angle of
after topical administration of 1% Anisometropia
near deviation.
cyclopentolate hydrochloride (Cyclo- Age at onset, at diagnosis and at surgery
gyl, Alcon Lab. Inc., Fort Worth, Type of exotropia
TX, USA) and 1% tropicamide (My- Postoperative management Vertical deviation
driacyl, Alcon Lab. Inc.). The angle of AV pattern
Full-time alternate patching was pre- Lateral incomitance
deviation was primarily determined by
scribed from postoperative day 1 for Oblique dysfunction and dissociated vertical
the prism and alternating-cover test
patients who complained of diplopia or deviation (DVD)
with accommodative targets, both at Fixation dominance
who developed esodeviation and was
distance (6 m) and near (33 cm). For a Stereopsis
continued until the diplopia or esode-
few unco-operative patients, a modified Surgical method
viation was resolved. If the esodevia-
Krimsky method was used. All of the Duration from onset to surgery and from
tion was not resolved by postoperative diagnosis to surgery
recorded deviations were determined
1 month, cycloplegic refraction was Angle of deviation preoperatively and at
using appropriate spectacle correction.
performed and the residual hyperopia postoperative day 1
Ocular movements in the form of
was corrected. If the esotropia persisted
ductions and versions were examined.
with alternate patching for 2 months,
Sensory status was evaluated by the
base-out Fresnel press-on prisms (3M
Titmus stereo test (Stereo Optical Co.,
Press-On OpticsTM; 3M Health Care, St 40. Lack of alternate fixation in the
Inc, Chicago, IL, USA) in co-operative
Paul, MN, USA) were prescribed. cover–uncover test was also considered
patients.
amblyopia in younger patients. Ani-
sometropia was defined as difference of
Outcome measures
Strabismus surgery hyperopia > +1.50 dioptres (D),
The surgical outcomes were grouped myopia > 1.50 D and/or astigma-
The surgeries were performed under
according to the angle of deviation at tism > +1.50 D. Patients were classified
general anaesthesia by a single surgeon
postoperative 2 years as follows: suc- as having basic type intermittent exo-
(DGC) using the modified surgical
cess (esophoria/tropia ≤ 5 prism diop- tropia if the deviation at distance was
formula suggested by Parks based on
tres (PD) to exophoria/tropia ≤ 10 within 15 PD of that at near. The
the angle of distant deviation (Parks
PD), recurrence (exotropia > 10 PD divergence excess type of exotropia was
2000) (Table 1). For the convergence
or reoperation within 2 years) and defined as a deviation at distance at
insufficiency type of exotropia, how-
overcorrection (esophoria/tropia > 5 least 15 PD greater than that at near.
ever, the surgery was performed based
PD). The convergence insufficiency type was
on the angle of near deviation. Part-
defined as exotropia at near at least 15
time occlusion therapy was attempted
PD greater than that at distance.
in patients with fixation dominance or Factors associated with outcomes after the
Among the patients who were initially
whose parents desired postponement of surgery for intermittent exotropia
considered to have the divergence
surgical intervention. The selection of
We investigated various clinical factors excess type of exotropia, if the devia-
the surgical procedure was made ran-
possibly associated with surgical out- tion at distance was increased close to
domly by the operating surgeon, who
comes, including gender, visual acuity, that at near after a 1 hr occlusion test,
had no preference for bilateral lateral
refractive errors, the presence of it was considered to be the pseudodi-
rectus recession (BLR) or unilateral
amblyopia and anisometropia age at vergence excess type. Lateral incomi-
onset, age at diagnosis, age at surgery, tance was defined as a 5 PD decrease in
Table 1. Surgical dosage for intermittent exo- type of exotropia, associated strabis- the lateral gaze.
tropia patients. mus (A and V pattern, vertical devia-
tion, oblique dysfunction and
Lateral rectus Statistical analysis
dissociated vertical deviation [DVD]),
Bilateral lateral recession/medial
presence of lateral incomitance and Statistical analyses were performed
Prism rectus recession rectus resection
fixation dominance, stereopsis, surgical with SPSS software for Windows (ver-
dioptres (mm) (mm)
method, duration from onset to sur- sion 20.0; SPSS Inc, Chicago, IL,
15 4.0 4.0/3.0 gery and from diagnosis to surgery, USA). Chi-square test and Fisher’s
20 5.0 5.0/4.0 angle of deviation preoperatively and exact test were used to compare the
25 6.0 6.0/5.0 at postoperative day 1 (Table 2). surgical outcomes by gender, type of
30 7.0 7.0/5.5 Amblyopia was defined as 2 or more exotropia, associated strabismus (A
35 7.5 7.5/6.0
Snellen lines difference between eyes and V pattern, vertical deviation,
40 8.0 8.0/6.5
with visual acuity <20/30 in the worse oblique dysfunction and DVD),
50 9.0 9.0/7.0
eye, or visual acuity in both eyes <20/ surgical method, presence of lateral

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 Acta Ophthalmologica 2016

incomitance and fixation dominance. A Table 3. Demographics of exotropia patients: analysis for association with surgical outcomes.
t-test was used to analyse the surgical
Success group Recurrence group
outcomes according to age at onset,
Variables (n = 128) (n = 84) p-Value
age at diagnosis, age at surgery, stere-
opsis, duration from onset to surgery Gender (female:male) 49:79 41:43 0.156*
and from diagnosis to surgery, and Best-corrected visual acuity (logMAR)
angle of deviation preoperatively and Dominant eye 0.043  0.07 0.040  0.07 0.838†
at postoperative day 1. A multivariate Non-dominant eye 0.067  0.11 0.088  0.13 0.271†
logistic regression analysis additionally Refractive errors in spherical
equivalent (Dioptre)
was performed to control for con-
Dominant eye 0.05  2.09 0.05  1.15 0.992†
founding variables, using, as indepen- Non-dominant eye 0.10  2.16 0.02  1.38 0.766†
dent variables, the previously reported Amblyopia 14 9 1.000*
risk factors and factors determined by Anisometropia 5 3 1.000‡
univariate analysis to be statistically Age at onset (months) 42.22  32.30 38.64  52.69 0.541†
significant. A probability value <0.05 Age at diagnosis (months) 62.84  44.10 62.99  55.30 0.983†
was considered statistically significant. Age at surgery (months) 70.13  43.10 70.08  53.04 0.995†
Exotropia type 0.334‡
Basic 109 66
Results Pseudodivergence 13 14
Convergence insufficiency 2 3
Of the 216 children who had undergone Divergence excess 4 1
surgery for intermittent exotropia, 128 Vertical deviation 34 (26.6%) 19 (22.6%) 0.627*
(59%) were assigned to the success AV pattern 14 (10.9%) 5 (6%) 0.488‡
group at postoperative 2 years, and 84 Lateral incomitance 7 (5.5%) 2 (2.4%) 0.488‡
(39%) were assigned to the recurrence Oblique dysfunction 43 (33.6%) 24 (28.6%) 0.829*
group. Four patients (2%) who were DVD 12 (9.4%) 6 (7.1%) 0.624*
Fixation dominance 86 (67.2%) 61 (72.6%) 0.448*
overcorrected were excluded from this
Stereopsis (second) 288.59  766.20 515.09  1271.91 0.223†
study to compare the success and Surgical method 0.042*
recurrence group and analyse factors RR 92 (71.9%) 63 (75.0%)
with surgical outcome at postoperative BLR 19 (14.8%) 4 (4.8%)
2 years. The overcorrected patients ULR 17 (13.3%) 17 (20.2%)
were treated with full-time patching Duration from onset to 20.54  32.82 24.29  24.96 0.374†
and Fresnel prism glasses. Three of surgery (months)
them began the glasses 4–5 months Duration from diagnosis to 7.52  14.05 6.39  9.64 0.520†
surgery (months)
after the onset of consecutive esotro-
Stereopsis (second) 288.59  766.20 515.09  1271.91 0.223†
pia, as it persisted with full-time patch- Preoperative angle of deviation (PD)
ing only, and continued wearing the At distance 27.76  7.33 29.63  9.54 0.109†
glasses for 22–26 months, thus effect- At near 28.03  8.47 29.76  10.63 0.197†
ing a gradual decrease of PD and, Angle of deviation on postoperative day 1 (PD)
finally, orthotropia. And 1 patient was At distance 5.34  5.92 2.55  4.81 <0.001†
lost to follow-up. So, a total of 212 At near 3.96  5.87 1.80  5.87 0.006†
patients were enrolled for the statistical
DVD = dissociated vertical deviation, RR = unilateral lateral rectus recession and medial rectus
analysis. resection, BLR = bilateral lateral rectus recession, ULR = unilateral lateral rectus recession,
Of these 212 patients, 90 (42.5%) PD = prism dioptres.
were female and 122 (57.5%) were Success group = esophoria/tropia ≤ 5 prism dioptres (PD) to exophoria/tropia ≤ 10 PD at
male. Forty-nine (54.4%) female and postoperative 2 years.
79 (64.8%) male patients maintained Recurrence group = exotropia >10 PD at postoperative 2 years or reoperation within 2 years.
successful alignment at postoperative For the angle of deviation, the plus numbers represent exodeviation; the minus numbers represent
2 years. There was no significant dif- esodeviation.
P < 0.05 shown in boldface.
ference in the surgical outcomes
* Chi-square test.
according to gender (p = 0.156, chi- †
t-test.
square test) (Table 3). The best-cor- ‡
Fisher’s exact test.
rected visual acuity, refractive errors in
spherical equivalent and the presence in the success group and two patients the 84 patients in the recurrence
of amblyopia and anisometropia did (2.4%) in the recurrence group. Asso- group. No statistically significant dif-
not show statistically significant differ- ciated strabismus including A and V ferences were observed in fixation
ences between success and recurrence pattern, vertical deviation, oblique dominance, lateral incomitance or
group (Table 3). dysfunction and DVD were, respec- associated strabismus (p > 0.05, chi-
Fixation dominance was observed tively, observed in 14 (10.9%), 34 square test and Fisher’s exact test)
in 86 patients (67.2%) in the success (26.6%), 12 (9.4%) and 43 (33.6%) (Table 3). Also, an intergroup com-
group and 61 patients (72.6%) in the of the 128 patients in the success parison revealed no difference in the
recurrence group. Lateral incomitance group, as well as in 5 (6%), 19 exotropia-type distribution (p = 0.334,
was observed in seven patients (5.5%) (22.6%), 6 (7.1%) and 24 (28.6%) of Fisher’s exact test) (Table 3).

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Acta Ophthalmologica 2016

BLR was performed on 19 (14.8%) icant difference, either (p = 0.223, t-test) in a RR group. Koklanis & Geor-
patients in the success group and 4 (Table 3). gievski (2009) also reported the recur-
(4.8%) in the recurrence group. ULR The mean preoperative deviation did rence of exodeviation occurred within
was performed on 17 (13.3%) in the not show any statistically significant 1 month to 2 years of the surgery.
success group and 17 (20.2%) in recur- difference between the groups Therefore, we considered that an anal-
rence group. RR was performed on (p > 0.05, t-test) (Table 3). By con- ysis of surgical outcomes at 2 years
similar proportions of patients in the trast, the mean deviation angle at after exotropia surgery would carry
two groups. By univariate analysis, the postoperative day 1 in the success clinical significance.
surgical method showed statistically group was 5.34 (esodeviation)  5.92 To date, the factors possibly influ-
significant associations with surgical PD at distance and 3.96  5.87 PD encing surgical outcomes have been
outcomes for intermittent exotropia at near, and in the recurrence group, well studied. Keenan & Willshaw
(p = 0.022, chi-square test): BLR was 2.55  4.81 PD at distance and (1994) determined that exotropia type,
performed more in the success group, 1.80  5.87 PD at near; that is, the age at onset and postoperative ocular
and ULR was performed more in the angle of deviation at distance and near alignment can affect final outcomes.
recurrence group (Table 3), but a logis- on postoperative day 1 was more Koklanis & Georgievski (2009), how-
tic regression analysis found no signif- esotropic in the success group than in ever, found no single factor influencing
icant difference (p > 0.05) (Table 4). the recurrence group and was statisti- patients’ response to intermittent exo-
The mean ages at onset, diagnosis cally significant (p = 0.000, p = 0.006) tropia surgery.
and surgery were 42.22  32.30 (Table 3). However, the multivariate Of the factors possibly associated
months, 62.84  44.10 months and logistic regression analysis, considering with positive surgical outcomes for
70.13  43.10 months, respectively, in confounding factors, demonstrated intermittent exotropia, initial overcor-
the success group, and 38.64  52.69 that the angle of deviation at distance rection has been shown to provide the
months, 62.99  55.30 months and on postoperative day 1 was the only best long-term result. Many authors,
70.08  53.04 months, respectively, in statistically significant factor indeed, have emphasized that initial
the recurrence group. The mean dura- (p = 0.023) (Table 4). overcorrection is necessary for satisfac-
tion from onset to surgery was tory correction (Raab & Parks 1969;
20.54  32.82 months in the success Clarke & Noel 1981; Scott et al. 1981;
group and 24.29  24.96 months in
Discussion Oh & Hwang 2006). Several have
the recurrence group. The mean dura- There have been many studies on proposed overcorrection of 8–10 PD
tion from diagnosis to surgery was recurrence after surgery for exotropia. (Park & Kim 1989; Paik & Cho 1990;
7.52  14.05 months in the success In a previous study conducted at our Santiago et al. 1999). Lee & Lee (2001)
group and 6.39  9.64 months in the clinic (Lee & Choi 2002), a survival reported that a postoperative day 1
recurrence group. No statistically signif- analysis showed that the mean dura- overcorrection of 11-20 PD following
icant differences in mean age at onset, tion from surgery to recurrence was BLR surgery, and of 1-10 PD following
diagnosis or surgery or in mean duration 21.3 months (range: 1–65 months). RR, can lead to good results. Further,
from onset to surgery or from diagnosis Correspondingly, Jeoung et al. (2006), they concluded, consistently with our
to surgery were observed between after a Kaplan–Meier survival analysis, present results, that alignment at
the groups (p > 0.05, t-test) (Table 3). reported an estimated mean time to postoperative day 1 can be a factor
Stereopsis which was evaluated by the surgical failure of 23.0  1.9 months predictive of positive surgical outcomes
Titmus stereo test did not show signif- in a BLR group and 28.3  2.1 months for exotropia. However, Pineles et al.
(2011) found that the results of over-
Table 4. Logistic regression analysis for prediction of intermittent exotropia recurrence. correction for exotropia were variable
and unpredictable; consequently, they
Odds 95% confidence
were unable to uncover any associa-
ratio interval p-Value
tions with recurrence of exotropia or
Age at onset 0.994 0.986, 1.001 0.315 secondary esotropia. Leow et al. (2010)
Duration from 0.980 0.953, 1.009 0.647 likewise reported that surgical success
onset to surgery rate appears to be unaffected by initial
Duration from 0.996 0.984, 1.008 0.526 ocular alignment, a finding that dif-
diagnosis to fered from our results. Choi et al.
surgery
(2011) reported that whereas initial
Surgical method
RR 3.350 0.650, 17.266 0.148
overcorrection after intermittent exo-
BLR 0.720 0.100, 5.020 0.745 tropia surgery might be associated with
ULR 5.399 0.898, 32.453 0.065 lower probability of recurrence within
Preoperative angle of deviation 2 years of surgery, it cannot predict
At distance 1.035 0.967, 1.108 0.592 long-term motor outcomes. These
At near 1.007 0.947, 1.070 0.697 study-result disparities might be attri-
Angle of deviation on postoperative day 1 butable to differences in the time of
At distance 1.116 1.015, 1.226 0.023
assessment of early postoperative devi-
At near 0.990 0.903, 1.085 0.832
ation, the surgical procedure utilized,
RR = unilateral lateral rectus recession and medial rectus resection, BLR = bilateral lateral rectus the definition of recurrence and the
recession, ULR = unilateral lateral rectus recession. follow-up period.

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 Acta Ophthalmologica 2016

Although exotropia can be sensory outcomes when the alignment Lee JY & Choi DG (2002): The clinical analysis of
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analyse the sensory outcome because intermittent exotropia: factors associated with Fax: 82-2-848-4638
we often omitted the evaluation of surgical outcomes. Strabismus 17: 37–40. Email: eyechoi602@gmail.com

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