University of Gondar

College of medicine and health science

  department of Optometry
seminar presentation on
exodeviations
By Gizachew T.
July17,2015
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 Outline
Introduction
Definition
Classification
Causes
Differentialdiagnosis
Clinical evaluation
Management
Reference

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 Introduction
• Strabismus is an ocular misalignment,
whether caused by abnormalities in binocular
vision or by anomalies of neuromuscular
control of ocular motility.
• It can be heterophoria w/c is an ocular
deviation kept latent by the fusional
mechanism (latent strabismus) or
heterotropia a deviation that is manifest and
not kept under control by the fusional
mechanism (manifest strabismus).
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Exodeviation
• Exodeviation: It is horizontal ocular deviations
in which the visual axis deviates outward or 
• divergent strabismus that can be latent
(controlled by fusion) or manifest that can’t be
control by the fusional mechanism.
• Although the exact etiology of most
exodeviations is unknown, proposed causes
include anatomical and mechanical factors within
the orbit as well as abnormalities of innervation
such as excessive tonic divergence.

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 Causes
The most common cause of exodeviation are:
• Disruption of fusion - intermittent exotropia
• type II Duane syndrome
• Oculomotor nerve palsy( paresis/palsies)
• congenital fibrosis of the EOMs,
• Deprivation of visual stimulus- sensory
exotropia (related to decreased visual acuity in
one eye)
• Surgery /change in refractive status-
consecutive exotropia (exotropia after surgery
to correct esotropia)
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pseudo exotropia /DDx
wide interpupillary distance
positive angle kappa without other ocular
abnormalities
positive angle kappa together with ocular
abnormalities such as temporal dragging
of the macula in retinopathy of
prematurity

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 Classification
Based on the underlying fusional
reserve/control exodeviation can be
broadly categorized in to:
1)Exophoria----XP
2)intermittent exotropia----X(T)
3)exotropia-----XT

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 1) Exophoria
Exophoria is an exodeviation controlled
by fusion under usual conditions of
vision.
An exophoria is detected when binocular
vision is interrupted, as during cover test.
 Exophoria is usually asymptomatic if the
angle of deviation is small and fusional
convergence amplitudes are adequate.

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 cont…
It may be:
 i) Convergence weakness type (exophoria
greater for near than distance).
 ii ) Divergence excess type (exophoria
greater on distant fixation than the near).
 Iii) Non-specific/basic type (exophoria
which does not vary significantly in degree
for any distance).

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 cont….
Prolonged, detailed visual work may
bring about asthenopic symptoms of
exophoria.
Treatment is usually not necessary
unless an exophoria progresses to an
intermittent exotropia or it causes
asthenopic symptoms

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 2) Exotropia
A manifest divergent/outward deviation
that can’t be control by the fusion
mechanism.
It is usually occurs as a result of certain
obstacle to the development or
maintenance of BV/ defective action of
MR muscle.

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 Classification of XT
Based on comitancy:
a)concomitant-- # of deviation is constant
in all directions and there is no associated
limitation of ocular movements.
I)primary
 Infantile XT
 Intermittent X(T)
II) Secondary
 Sensory XT
 Consecutive XT

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 cont…
b) Incomitant
 Paralytic(III N,MR palsy)
 Restrictive
 Musculofacial anomalies (DRS-2)
 DHD

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 Duane's classification exotropia
1)divergent excess(D>N~15pd)
2)convergence insufficient(N>D~15pd)
3)basic(D=N or with in 10 pd d/ce)
4)simulated divergent excess-a basic
deviation presenting as divergent excess
due to part compensation of the near
deviation by fusional or accommodative
convergence.

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Phases of XT & clinical presentation

Calhounz’s phase of progression:

I) XT@ D, ORTO @N-asymptomatic
II) X(T)@D,ORTO/XT @N-symptomatic @
D , no suppression
III) XT@ D,X(T)/XT@ N -BV may be for
near and suppression for distance IV)
XT@ D&N-lack of binocularity

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 Intermittent exotropia
With the possible exception of exophoria
at near, it is the most common type of
exodeviation, which is latent at times and
manifest at others.
The onset of intermittent exotropia
usually occurs early, before age 5, but it
may be detected for the first time even
later in childhood.

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 cont…
Because proper eye alignment with intermittent
exotropia requires compensatory fusional factors
to be active, the deviation often becomes manifest
during times of visual inattention, fatigue, or
stress.
 Parents of affected children often report the
exotropia occurs late in the day with fatigue or
during illness, daydreaming, or drowsiness upon
awakening.
Exposure to bright light often causes a reflex
closure of one eye.
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 cont…
In the early stages the deviation is usually
larger at distance than near, and the exotropia
is seen more frequently when the visual target
is remote.
 Later, the near and distance deviations tend
to be more equal in magnitude even if
fusional control remains good.
It can also be associated with small
hypertropias, A and V patterns, and oblique
muscle dysfunction.
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 clinical evaluation
The most important question in the diagnosis of this
deviation is how often and under what circumstances the
deviation is manifested.
A qualitative measurement of the control of the
exodeviation is an important component of the evaluation
and can be categorized as:

Good control: manifests only after cover testing, and the

fusion is rapidly without blinking or refixating.
Fair control: manifests after fusion is disrupted by cover
testing, and the fusion is only after blinking or refixating.
Poor control: manifests spontaneously and may remain
manifest for an extended time.

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 symptoms
Headache
Eye strain
Blurred vision
Double vision
Discomfort to strong light(diplopia-
phobia)
Abnormal stereopsis-X(T) to XT
Micropsia??? AC to maintain BSV

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 cont…
In many patients, untreated intermittent
exotropia progresses toward constant
exotropia.
During this progression, tropic episodes
occur at lower levels of fatigue and last for
longer periods.
Amblyopia is uncommon unless the
intermittent exotropia progresses to constant
or another amblyogenic factor, such as
anisometropia, is present.
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Infantile exotropia
Infantile exotropia presents before the age of
6 months with a large-angle(35pd or more)
constant deviation.
It has been reported that some children with
infantile exotropia have associated neurologic
impairment or craniofacial disorders.
Usually it is constant in nature & if operated
in early life of the patients w/c can lead to
gross binocular vision, but perfect binocular
function is rare.
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secondary XT
Sensory Exotropia
 Any condition that severely reduces visual
acuity in 1 eye can cause sensory
exotropia.
 The causes include anisometropia, corneal
or lens opacities, optic atrophy or
hypoplasia, macular lesions, and
amblyopia.

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 cont…
It predominates in infants younger than I
year, older children, and adults.
If the disadvantaged eye can be visually
rehabilitated, peripheral fusion may
sometimes be reestablished after surgical
realignment, provided the sensory
exotropia has not been present for an
extended period

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Consecutive exotropia
An exotropia that follows previous surgery
for esotropia/other refractive corrections.
Treatment of consecutive exotropia
depends on many factors, including the size
of the deviation, the type and amount of
surgery that preceded its development, the
presence of duction limitations, lateral
incomitance, and the level of visual acuity
in each eye

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 cont…
central fusional disruption lead to
constant and permanent diplopia when
adult-onset sensory exotropia has been
present for several years prior to vision
rehabilitation and realignment.
In these patients, intractable diplopia may
persist, even with well -aligned eyes.

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 Treatment
Non surgical
It
 doesn’t actually alter the angle of deviation rather
restores control
Orthoptic treatment- improve control(<20 pd)


a)anti suppression-directed to diplopia recog.

e.g bar reading ,synoptophore ,cheiroscope

b)relative convergence exercise

strengthen and improves fusional control

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optical spectacle correction
improve retinal image clarity and help control
the exodeviation.
concave lenses are effective to stimulus
convergence by inducing accom. (esp. High
AC/A ratio)
Correction of even mild myopia may improve
control of the exodeviation.
Mild to moderate degrees of hyperopia are
not routinely corrected in children with
intermittent exotropia for fear of worsening
the deviation but >4.00D or 1.5D of aniso????
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Prism correction
BI prisms
compensate strabismus
 enforce bifoveal stimulation
preoperatively
but this treatment option is seldom chosen
for long-term management because it can
cause a reduction in fusional vergence
amplitudes.

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 surgical
Indications
• Intermittent deviation (if >50%)
• If progress from phase II to III of calhounz
phasing
• If diplopia is present
• Suppression in the early childhood
 recession of lateral rectus muscles is the most
common
 Recession of lateral rectus muscle combined
with resection of the ipsilateral medial rectus
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 Reference
1. Strabismus simplified, Sharma prandeep

2. 3

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THANK YOU
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