Here is the abstract of a significant paper just published in Eye – the scientific journal of the Royal College of Ophthalmologists in the U.K. Although I can’t reproduce the entire article for you, here is some important background information. The health-related quality of life questionnaire (HRQOL) used in the study is the IXTQ (Intermittent Exotropia Questionnaire). There are 12 questions posed to children, with responses on a three point Likert scale (not at all/sometimes/alot), and they are as follows:
1) Are you worried about your eyes?
2) Does it bother you that people ask what is wrong with your eyes?
3) Does it bother you because you have to wait for your eyes to clear up?
4) Do kids tease you because of your eyes?
5) Does it bother you when grownups say things about your eyes?
6) Does it bother you when your dad or mom say things about your eyes?
7) Does it bother you that you have to shut one eye when it is sunny?
8) Do you feel different from other kids because of your eyes?
9) Are you worried what other people think of you because of your eyes?
10) Do you find it hard to look at people because of your eyes?
11) Is it hard for you to concentrate because of your eyes?
12) Do your eyes make it hard to make friends?
There are 12 identical proxy questions posed to the parent or legal guardian, with responses on a five point Likert scale (never/almost never/sometimes/often/almost always) to cross-check the correlation between the child’s self-perception and the parent’s impressions. This is followed by a 17 item questionnaire indicative of the parents’ feelings (with the same five point Likert scale), the questions being as follows:
1) I worry about my child’s eyes
2) I worry that my child will be less independent because of his/her eyes
3) I worry that my child will have permanent damage to his/her eyes
4) I worry that my child doesn’t see well
5) I worry about how my child’s eyes will affect him/her socially
6) I worry that my child will get hurt physically because of his/her eyes
7) I worry about the possibility of surgery
8) I worry about my child becoming self-conscious because of his/her eyes
9) I worry that my child will not be able to see the board at school
10) I worry about other kids teasing my child because of his/her eyes
11) It worries me what others will think about my child because of his/her eyes
12) I worry that my child’s eye condition will affect his/her personality
13) I worry that my child’s eyes will affect his/her social life if nothing is done
14) I worry about my child’s eyesight long term
15) I worry about my child’s depth perception
16) I worry about whether or not my child should have surgery
17) I worry about my child’s ability to make friends
The study concludes that children with intermittent exotropia generally experience a negative impact on their health-related quality of life (HRQOL). The HRQOL of children and their parents correlate well with each other, and can be predicted based on the clinical evaluation of the intermittent exotropia. Poorer outcomes on the HRQOL are linked to higher angle of IXT, poorer control of IXT, and reduced stereopsis.o have.
But what I want to emphasize here is the following set of observations by the authors. I’ll quote it directly, and then comment on its significance: “According to previous studies, there might be some deficits in visual processing at the cortical level in patients with intermittent exotropia. For example, cortical activity dysfunction has been observed in several regions, including the middle occipital gyrus, fusiform gyrus, and lingual gyrus, in patients with intermittent exotropia. In addition, voxel-based morphometry indicated impairment of the primary visual cortex in intermittent exotropia. All these results, together with the tight link between stereopsis and HRQOL observed here, indicated that in addition to abnormal deviations, we should pay close attention to deficits in visual cortical processing. In fact, a recent study in surgically corrected intermittent exotropia found that the sensory eye balance in binocular phase combination remains abnormal.”
The reference for the last statement is a paper by Feng, Zhou, Cheng and Hess in Scientific Reports showing that even patients having stereopsis within normal range have sensory imbalances between the two eyes following surgery for IXT that motorically aligns the eyes. This provides the impetus for prism and other active vision therapy that attains normal sensory balance to attain the highest quality outcome, as well as to safeguard against regression.