Consecutive Exotropia: Journey to the Center of the Mind


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.

John - 2 (far)

John - 1 (near)John - 3 (frosted occluder)John - 4 (opaque occluder)John - 5 (post occluder)

4 thoughts on “Consecutive Exotropia: Journey to the Center of the Mind

  1. Dr. Press, would you mind clarifying this statement, it sounds like occluding the right eye makes the left eye acuity worse: “Covering his right 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. ”

    Compelling piece. Looking forward to the conclusion.

    Dr. B

  2. Thanks for the careful reading, Dr. B. There was a typo that confused you, which I’ve gone back in and corrected. The photo is correct – in that we covered the left eye with a translucent or frosted occluder, and even though this degraded acuity in the left eye to a level worse than the right eye, this was not a strong enough stimulus for the brain to switch fixation to the exotropic right eye. In order for that to occur we had to cover the left eye with an opaque occlude. This shows that at the outset the patient appeared to have a dogged constant right exotropia. I’ve just posted the conclusion to this.

  3. Dr. Press:

    I read this post Sunday morning actually after midnight. I work in a clinic in Monroe,NY. In a clear example of “Divine Providence”, my very 1st patient at 9 o’clock Sunday morning manifested a consecutive exotropia secondary to esotropia surgery utilizing a Botox injection at age 12! He is now 22 years old. He manifests an approximately 25-30 ^ exotropia/approximately 10 ^ hypertropia. He also complains about diplopia but the secondary image is not very intense. He also manifests a significant anisometropia of approximately 4 dpt. He has had vision training in Israel. He has also had “prism glasses” from doctors in New Jersey and in London. Those treatments have been not very successful to this date. He is looking for new options. I was not really able to achieve satisfactory binocular fusion with simple prism neutralization. His best corrected vision is 20/25 OD and 20/20 OS. RX is OD +4.50-1.75 CX 175/OS-0.50 sphere.

    What would you suggest? And thank you for your very timely blog on the subject!

    On Sat, Aug 16, 2014 at 11:03 PM, The VisionHelp Blog wrote:

    > Leonard J. Press, O.D., FAAO, FCOVD posted: ” 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 “

    • You’re welcome, Joel. What has been most successful in our experience has been a parallel approach of MFBF therapy (in this case for the R eye) and lustre to combine the two images in a non-complex field that would allow for relaxation. At some point, if efforts to combine the two eyes fail, there is obviously the option of going in the other direction. This would involve leaving the Rx of the R eye as plano, and doing some MFBF for the left eye to reinforce central suppression the R eye in a progressively complex and enlarged field.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s