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Treatment for a type of childhood strabismus where one or both eyes intermittently turn outwards

Strabismus is a condition in which the eyes are not normally aligned, that is one eye looks straight ahead whilst the other eye turns inwards, outwards, up or down. Most cases of childhood onset strabismus are present constantly, but some types are intermittent that is only present sometimes. In intermittent exotropia (X(T)) an eye intermittently turns outwards (exotropia), typically more when looking into the distance, when tired or day‐dreaming. When the child focuses on something close, the eye usually moves back to the centre. The eyes typically work together normally when the exotropia is controlled. When the exotropia occurs, the image from one eye is usually switched off or 'suppressed'. Treatment for X(T) may be sought to improve the appearance of misalignment or if there is concern that it is affecting the ability of the eyes to work together. Treatment typically consists of surgery on the muscles around the eye, either on the outside muscle of both eyes or on the inside and outside muscle of one eye. Exercises to strengthen the muscles may sometimes be used; sometimes patching or glasses for short or near sightedness can be tried. There is currently not a clear understanding of which treatments work most effectively and at what point any treatment should be given. We searched for studies where participants with X(T) had been randomised to receive treatment. The aim was to understand which treatments are most effective at correcting the exotropia without causing any harm. The one study included in this review was conducted by a single surgeon in the USA and compared surgery on one eye to surgery on both eyes in 36 children with the basic type of X(T). Success was defined as no exotropia (or other strabismus) one year following surgery. The study found that surgery on one eye was more effective (82% success) than surgery on both eyes (52% success). There are many studies of X(T) in the current literature but the methods used make it difficult to reliably interpret the results. Furthermore, there is a worrying lack of evidence regarding the natural history of X(T) and poor validation of measures of severity. There is a clear need for further randomised studies to provide more reliable evidence for the management of this condition.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2013

A systematic review of the effectiveness of treatments in altering the natural history of intermittent exotropia

Evidence of effectiveness of interventions for treatment of childhood intermittent exotropia, X(T), is unclear. We conducted a systematic review to locate, appraise and synthesise evidence of effectiveness, including twelve electronic databases, supplemented with hand searches and expert contact. We included randomised controlled trials, quasi-experimental and cohort studies with a comparison group examining interventions for divergence excess, simulated divergence excess or basic type X(T) in children, up to and including 18 years of age, followed for at least 6 months. Dual data extraction and critical appraisal were conducted and a narrative synthesis undertaken. Eleven studies satisfied the eligibility criteria. Seven examined the comparative effectiveness of two surgical procedures; four compared surgery with other interventions, including botulinum toxin A therapy, orthoptic exercises, occlusion, binocular vision training and watchful waiting. The evidence retrieved was of limited extent and quality with differences across studies in terms of outcome assessment and most appropriate time-point for measuring long-term outcomes. There were mixed outcomes when comparing unilateral recession/resection (R&R) with bilateral lateral rectus recession (BLR) on improving angle of deviation, which makes it difficult to recommend either surgical option with confidence. While non-surgical interventions appear less effective in terms of improving angle of deviation, they are rarely associated with adverse outcomes. Given the limited evidence base, better designed studies are required to address the question of the most effective management for treatment of childhood X(T). Importantly, consensus is required on what constitutes a successful outcome as well as agreement on how this should be measured.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2014

Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires: A Systematic Review [Internet]

The VA National Center for Patient Safety has requested an evidence review to examine the prevalence and the root causes of wrong site surgery, retained surgical items, and surgical fires. The evidence review also evaluates current guidelines and the effectiveness of interventions for the prevention of these events. Studies examining VA-specific data were of special interest. The evidence synthesis will be used to develop a standardized, single, strong recommendation to VA facilities in the effort to eliminate these events.

Evidence-Based Synthesis Program - Department of Veterans Affairs.

Version: September 2013
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Screening for Visual Impairment in Children Ages 1-5 Years: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation [Internet]

Impaired visual acuity is common in preschool-aged children. Screening for impaired visual acuity in primary care settings could identify children with vision problems at a critical period of visual development and lead to interventions to improve vision, function, and quality of life.

Evidence Syntheses - Agency for Healthcare Research and Quality (US).

Version: February 2011
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