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Ophthalmology. 2019 Jan 26. pii: S0161-6420(18)32817-3. doi: 10.1016/j.ophtha.2019.01.015. [Epub ahead of print]

Three-Year Observation of Children 3 to 10 Years of Age with Untreated Intermittent Exotropia.

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Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota. Electronic address:
Southern California College of Optometry at Marshall B. Ketchum University, Fullerton, California.
Jaeb Center for Health Research, Tampa, Florida.
Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota.
Department of Ophthalmology, Indiana University, Indianapolis, Indiana.
Rocky Mountain Eye Care Associates, Salt Lake City, Utah.
Concord Eye Center, Concord, New Hampshire.



To describe the course of intermittent exotropia (IXT) in children followed up without treatment for 3 years.


Observation arm from randomized trial of short-term occlusion versus observation.


One hundred eighty-three children 3 to 10 years of age with previously untreated IXT and 400 seconds of arc (arcsec) or better near stereoacuity.


Participants were to receive no treatment unless deterioration criteria were met at a follow-up visit occurring at 3 months, 6 months, or 6-month intervals thereafter for 3 years.


The primary outcome was deterioration by 3 years, defined as meeting motor criterion (constant exotropia ≥10 prism diopters [Δ] at distance and near) or near stereoacuity criterion (≥2-octave decrease from best previous measure). For the primary analysis, participants also were considered to have deteriorated if treatment was prescribed without meeting either deterioration criterion.


The cumulative probability of protocol-specified deterioration by 3 years was 15% (95% confidence interval, 10%-22%), but that was likely an overestimate, partly because of misclassification. Among 25 deteriorations, 2 met motor deterioration, 11 met stereoacuity deterioration, and 12 started treatment without meeting either criteria (7 for social concern, 1 for diplopia, 4 for other reasons). Among the 132 participants who completed the 3-year visit and had not been treated during the study, only 1 (<1%) met motor or stereoacuity deterioration criteria at 3 years. Of the 4 participants completing the 3-year visit who met deterioration criteria previously and had not started treatment, none still met deterioration criteria. Between the baseline and 3-year examination for these 132 patients, improvement occurred in distance and near stereoacuity (mean improvement, 0.14 and 0.14 logarithm of arcsec; P ≤ 0.001 and P ≤ 0.001, respectively), distance exotropia control (mean improvement, 0.6 points; P ≤ 0.001), and distance exodeviation magnitude (mean improvement, 2.2 Δ; P = 0.002).


Among children 3 to 10 years of age with IXT for whom surgery was not considered to be the immediately necessary treatment, stereoacuity deterioration or progression to constant exotropia over 3 years was uncommon, and exotropia control, stereoacuity, and magnitude of deviation remained stable or improved slightly.

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