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Exotropia

What is exotropia?

Exotropia refers to eyes that turn outward. It is the opposite of crossed eyes, or esotropia. Exotropia may occur from time to time (intermittent exotropia) or may be constant, and is found in every age group [See figures 1 and 2].

What are the different types of exotropia?

Exotropia may be congenital (present at birth) or acquired. The acquired forms of exotropia include intermittent exotropia, sensory exotropia, and consecutive exotropia.

What is congenital exotropia?

Newborn babies commonly have difficulty keeping their eyes straight. While this tendency for the eyes to wander at times is normal until four months of age, any constant eye misalignment during the newborn period should be evaluated by an ophthalmologist.

Congenital, or infantile, exotropia, is an outward turning of the eyes from birth or early infancy. Esotropia (crossing of the eyes) is much more common than exotropia in newborns. In fact, constant exotropia is so uncommon in infants that pediatric ophthalmologists generally will investigate the cause to be sure that no additional problem is present.

Fig. 1 Eyes Aligned

What is intermittent exotropia?

Many people normally have a tendency for the eyes to drift outward when their eyes are completely relaxed, such as when they are “staring off into space” while daydreaming. This outward drift, which occurs only in those moments when the eyes are not paying attention to each other, is called exophoria, and is controlled effortlessly by refocusing our visual attention.

At first, the exotropia may occur rarely. Over time, it may become more frequent, even to the point of becoming constant. However, the length of time it takes for intermittent exotropia to become constant varies from a few months or years to lasting an entire lifetime without ever becoming more than an occasional nuisance.

Fig. 2 Right eye deviated outward, exotropic.

Does exotropia run in families?

Strabismus, or misalignment of the eyes, does run in families. All affected family members will not necessarily share exactly the same type of strabismus, meaning that exotropia may not be the only kind of misalignment possible. In some relatives, the strabismus may be obvious, while others may have a milder form. Many family members will not have strabismus at all. A family history of strabismus is a very good reason to have a child evaluated by a pediatric ophthalmologist

What are the signs of intermittent exotropia?

People with intermittent exotropia may experience that outward drift only occasionally, such as when they are very tired, feeling sick, or after drinking alcohol, despite their efforts to refocus. Children may squint one eye in bright sunlight, or may rub one of their eyes. Their vision may become blurry or they may experience double vision when their eyes are misaligned. Some patients say that they can feel that an eye is misaligned, even though they do not see anything unusual. Others are unaware that an eye is turning unless it is mentioned by another person.

Why does my child, who has intermittent exotropia, close one eye frequently?

Children with intermittent exotropia commonly close or squint one eye at times, especially when they are exposed to bright sunlight. We used to think that the bright light caused the eye to turn out, and that the child was closing one eye to avoid double vision. Now, we believe that the child is reacting directly to the sunlight itself by closing one eye. In any case, when the eye is closed, the child cannot use both eyes together. Small children who won't wear sunglasses may be offered a hat with a brim, such as a baseball cap, to shield the eyes from the sun, thereby limiting the need to squint.

Will my child outgrow the intermittent exotropia?

Most exotropia does not resolve spontaneously (without treatment), but occasionally it may be adequately controlled with glasses.

How can I keep my child’s intermittent exotropia from getting worse?

Common sense approaches to caring for your child will help to control intermittent exotropia as much as possible. For example, be sure that your child gets the recommended amount of sleep for age—many children don’t! Do your best to help her stay healthy, and understand that when she gets sick, the intermittent exotropia is likely to temporarily occur more frequently. See your ophthalmologist as often as recommended, in order to keep your child’s visual system fine-tuned. Otherwise, the progression of intermittent exotropia is not something that we can predictably control.

Does watching too much television or playing too many video games make exotropia worse? Or can video games help?

Normal visual activities have no effect on exotropia. However, for other health reasons, parents are encouraged to limit the time their children spend watching TV, playing video games, and sitting at their computers.

What is sensory exotropia?

Exotropia in an eye with very poor vision is called sensory exotropia. In this case, the eye with low vision is unable to work together with the other eye, and therefore, the natural tendency for our eyes to drift outward takes over. Sensory exotropia may occur from an early age in a child with poor vision, or may be acquired later in life due to loss of vision. Of course, if the visual problem is treatable, it should be addressed as soon as possible. In cases of permanent visual loss, surgery to straighten the eye is often an option.

What is consecutive exotropia?

Exotropia occurring after strabismus surgery to correct esotropia is referred to as consecutive exotropia. This may occur near the time of the original surgery, or may develop many years later.

How is exotropia treated?

Nonsurgical treatment may include glasses or eye exercises. Occasionally, patching therapy may be recommended. Once the eyes have become misaligned more often than they are straight, surgery on the eye muscles may be recommended in order to realign the eyes. Your pediatric ophthalmologist will discuss the ideal timing of surgery for your situation.

When is surgery for exotropia indicated?

Criteria for surgery may vary somewhat, but generally surgery is indicated when the exotropia is frequently present, when the patient is experiencing significant symptoms (eyestrain, double vision, squinting), or when there is evidence that the patient is losing "binocular vision". Surgery may not be recommended if the exotropia is adequately controlled with nonsurgical means, such as glasses.

What is binocular vision?

Binocular vision refers to the brain's ability to see objects with both eyes simultaneously. Among other benefits, binocular vision is necessary for normal depth perception, or "3-D vision".

What age is best for exotropia surgery?

Age is not the main determining factor for exotropia surgery. The surgery is appropriate when exotropia is present for the majority of the time, at any age.

Can exotropia be treated with patching?

In a small child, part-time patching of the preferred eye is useful, if the child has a preference for one eye over the other, or amblyopia. This helps to protect the vision in the non-preferred eye, but rarely cures the intermittent exotropia. In fact, too much patching can actually make exotropia worse by preventing the eyes from working with each other for prolonged periods of time.

Can exotropia be treated with glasses?

If a patient is nearsighted, keeping the glasses prescription up-to-date helps control the alignment.

Can exotropia be treated with prisms in the glasses?

Prisms are not usually used for children with strabismus, at least on a permanent basis. In a minority of adult cases, prisms may play a role in treatment. Prism glasses may occasionally be used on a temporary basis, however.

What about exercises or vision therapy for the eyes?

Exercises have been proven to help with only one type of exotropia, convergence insufficiency. In other cases of intermittent exotropia, the goal of eye exercises is to teach patients to become aware that they are seeing two images when their eyes are misaligned. Theoretically, once a patient learns to recognize this double vision, he may then learn to realign his eyes. Unfortunately, many patients who are taught this technique accomplish the first goal, recognizing the double vision, but then cannot make it stop, resulting in permanent double vision. For this reason, these exercises are not prescribed by ophthalmologists except for convergence insufficiency.