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A case of intermittent exotropia by Krishna Banjade

The document presents a case study of a 10-year-old boy diagnosed with intermittent exotropia and compound myopic astigmatism, detailing his symptoms, clinical findings, and assessments over two visits. It discusses the potential for pseudo divergence excess and provides a treatment plan that includes glasses, patch testing, and possibly surgery if required. The importance of careful clinical history and assessment in differentiating types of exotropia and evaluating progression is emphasized.

Education◦
Intermittent Exotropia - A Case Of Pseudo divergence Excess Krishna Banjade Consultant optometrist in pediatrics and strabismus
ABBREVIATIONS  X’ - Exophoria  XT - Exotropia  X(T) - Intermittent Exotropia  CT – Cover Test  PD – Prism Dioptre  IOP – Intra Ocular Pressure  PACD – Peripheral Anterior Chamber Depth  RAPD – Relative Afferent Pupillary Defect  Sx – Surgery  RTC – Return To the Clinic
PATIENTS DETAIL Age : 10 Years/ Male Profession - Student Address- Lucknow, Uttar Pradesh, India First visit - 05/07/2014
VISIT 1 Visit 1
CHIEF COMPLAINTS  (OU) Gradual progressive painless blurring of vision for near and distance since 5 years  Occasional outward deviation of eyeballs noticed by parents since 4 years  Photophobia since 1 year
HISTORY  Recent ophthalmic consultation locally - diagnosed Alternate exotropia - referred to our hospital for further management  No h/o using glasses/contact lens/patching  No h/o head and ocular injury  No h/o seizures, Asthma and CAD  Normal pre, peri and postnatal birth history with normal physical , emotional and cognitive development
CONTD…  Family history- mother myopic  Not aware of any allergy  No h/o systemic diseases  No h/o past lasers, surgeries and medications
OD OS Unaided Visual Acuity 20/60 20/100 With Pinhole 20/30 20/30 Near Vision N6 @ 30 cm with Snellens Chart in RI N6 @ 30 cm with Snellens Chart in RI Dry Retinoscopy -1.50/-0.75* 10 -2.00/-0.75 * 160 Dry Acceptance -1.50 DSph (20/30), N6 @ 30 cm -2.00 DSph (20/30), N6 @30 cm Cycloplegic Retinoscopy (cyclopentolate) -1.50/-0.75 * 10 -1.50/-0.75*160 Refraction
Facial Asymmetry nil Abnormal head posture nil Nystagmus nil EOM Movement Full, Free and Painless Hirschberg's Test LXT 10 Degree Cover Test 25-30 PD X(T) ( Distance) 12 PD X(T (Near) Stereo Acuity using Random Dot Stereogram Test 80 sec of arc External Examination
OD OS Lids Flat Flat Conjunctiva Quiet Quiet Cornea Clear Clear AC PACD > 1/2 CT, Quiet PACD > 1/2 CT, Quiet Pupil R/R/R, No RAPD R/R/R Iris Normal color and pattern Normal color and pattern Lens Clear Clear IOP With GAT 13 mm of Hg @ 11:10am 14 mm of Hg @ 11:10am Slit Lamp Examination
OD OS Media Clear Clear Retina On On Macula Healthy Healthy C/D 0.2 0.2 Fundus examination
DIAGNOSIS ?
DIAGNOSIS (OU) Compound Myopic Astigmatism Intermittent Exotropia
PLAN OF RX  Glasses  Reassure  EOM Sx If Required  Patch Test next visit  RTC 3/12
INTERMITTENT EXOTROPIA  Obstracles to development or maintenance of BSV  Defective action of MR Muscles  Defective fusional convergence (1)  New born infants with transient exodeviation (2)  Refractive Errors, Anisomyopia and Anisoastigmatism (3)  Differs from Exophoria 1. Worth C. Squint, its causes, pathology and treatment ed. 6. London 1929, Bailliere, Tyndall and Cox 2. 2. Archer SM, Helveston EM: Strabismus and Eye Movement Disorders. In Isenberg SJ (ed) The eye in Infancy 1994 Mosby, pg 255. 3. Jampolsky A, Flom BC, Weymouth FS, Moster LE. Unequal corrected visual acuity as related to anisometropia Arch Ophthalmol. 1955;54:893
 Tropia Phase of Intermittent exotropia observed when :  In Child - Tired, sick or day dreaming  In Adults - Also after imbibing alcoholic beverages or taking sedatives
PREVALENCE  Comprises 50-90% of cases of Exotropia  Affects 1 % of general population (1,2)  Nearer a country is to the equator the higher the prevalence of exodeviations (3) 1.Govindan M, Mohney BG, Diehl NN, Burke JP. Incidence and types of childhood exotropia: a population based study. Ophthalmology. 2005 Jan;112(1):104-8. 2. Noorden GK von. Exodeviations. In: Binocular Vision and Ocular Motility 5 th ed., 1996 Mosby, pg 343 3. Jenkins R. Demograhics: geographic variations in the prevalence and management of exotropia. Am. Orthopt. J. 1992,42:82.
NATURAL HISTORY  Remains obscure  Some cases  First at distance and then at near  Not all the cases are progressive, may be constant or even improve Exophoria Intermittent exotropia constant Noorden GK von. Exodeviations. In: Binocular Vision and Ocular Motility 5 th ed., 1996 Mosby, pg 343
FACTORS TO BE RECORDED FOR PROGRESSION  Amount of Loss of fusional control with increasing strabismus  Development of a secondary convergence insufficiency  Increase in size of basic deviation  Development of Suppression
SYMPTOMS OF INT. XT  Transient Diplopia  Asthenopic symptoms  Photophobia (1)  Micropsia (2) 1. Manley DR. Classification of the exodeviations. In: Manley D ed.: Symposium on horizontal ocular deviations. St. Louis. 1971. Mosby-Year Book Inc. p128 2. Noorden GK von. Exodeviations. In: Binocular Vision and Ocular Motility 5 th ed., 1996 Mosby, pg 361
PATCH TEST Noorden GK von: Atlas of Strabismus, ed 4. St Louis, Mosby–Year Book, 1983
Visit 2nd
1ST FOLLOW UP 10/09/2014 OD OS VA with PGP 20/30 – NI with PH N6 @ 30 cm with Reduced Snellens chart 20/25 – NI with PH N6 @ 30 cm with Reduced Snellens chart Stereopsis with PGP 60 Seconds of Arc With Random Dot Stereo Card CT with PGP Dist. – 18 PD X(T) Near - 6 PD X(T) Slit Lamp Examination WNL
PROVISIONAL DIAGNOSIS  Basic Intermittent Exotropia  Divergence Excess  Convergence Insufficiency  Simulated or Pseudo-divergence Excess
 Basic Intermittent Exotropia - Deviation for distance and near within 10∆ - Normal Accommodative, Fusional and Proximal convergence • Divergence Excess - Deviation for distance > 10∆ than near even after patch test - High AC/A Ratio  Convergence Insufficiency - Near deviation > 10∆ than distance deviation  Simulated / Pseudo divergence Excess - Larger exotropia for distance than near but near deviation increases within 10 PD of distance deviation after Patch Test Burian HM: Exodeviations: Their classification, diagnosis, and treatment. Am J Ophthalmol 62:1161, 1966
COVER TEST AFTER 1 HOUR PATCHING ( WITH PGP) Distance = 20-25 PD X(T) Near = 20-25 PD X(T)
FINAL DIAGNOSIS  (OU) Compound Myopic Astigmatism  Intermittent Exotropia (Pseudo divergence Type)
PLAN OF RX  Continue same glass  RTC 6-8 months
• Patch Test is the main criterion for differentiating true and pseudo divergence exotropia • Nevertheless, not all intermittent exotropia are progressive nor do they need surgical interventions • Proper clinical history with relation to classical symptoms plays vital role for the diagnosis
Thank you…