It’s been a long time since the Amboy Dukes came out with this song, but it is mindful of the unique conundrum presented by the patient with consecutive exotropia. First, let’s define the condition: a patient with infantile or early onset esotropia has eye muscle surgery at a relatively young age, and ultimately the eyes turn outward excessively rather than inward. How does this happen? Our best understanding is that as far as the brain is concerned, its adaptive mindset is still of one eye turning inward relative to the other. But because of the surgical re-arrangement of the eye muscles, they are physically pre-disposed to turn outward. In eye doctor parlance, a sensory status of esotropia is now linked with a motor status of exotropia.
Let me walk you through John’s status, which is a paradox of sorts. When I first saw John his right eye drifted constantly outward by a similar amount at distance and near. Covering his left eye with a frosted occluder that made the acuity worse in the left eye than the right eye was not a strong enough signal to have him look straight ahead with the right eye. in order to do that we had to cover the left eye with an opaque occluder. When removing the cover the left eye was outward briefly but within seconds John reverted to fixing with the left eye and right eye drifted back outward.
We took John on for an intensive VT program, having him in the office for two hours each day, four days per week – one of a number of patients we did this kind of “immersion therapy” this summer because they had to return to college or lived out of the country. I’ll let you know how things turned out in a second part of this series.