The Relationship of Age and Other Baseline Factors to Outcome of Initial Surgery for Intermittent Exotropia.
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ABSTRACT: Purpose
To determine whether age at surgery is associated with surgical outcome of intermittent exotropia (IXT) at 3 years.Design
Secondary analysis of pooled data from a randomized trial.Methods
A total of 197 children 3 to <11 years of age with basic-type IXT of 15-40 prism diopters (Δ) were randomly assigned to 1 of 2 surgical procedures for treatment of intermittent exotropia. Masked examinations were conducted every 6 months for 3 years. The primary outcome was suboptimal surgical outcome by 3 years, defined as constant or intermittent exotropia of ≥10 Δ at distance or near by simultaneous prism and cover test (SPCT); constant esotropia of ≥6 Δ at distance or near by SPCT; or decrease in near stereoacuity of ≥2 octaves, at any masked examination; or reoperation without meeting any of these criteria.Results
The cumulative probability of a suboptimal surgical outcome by 3 years was 28% (19 of 72) for children 3 to <5 years of age, compared with 50% (57 of 125) for children 5 to <11 years of age (adjusted hazard ratio = 2.05; 95% confidence interval = 1.16 to 3.60). No statistically significant associations were found between suboptimal outcome and other baseline factors (magnitude of deviation, control score, fixation preference, or near stereoacuity) (P values ≥ .20).Conclusions
This analysis suggests that in children with IXT, younger age at surgery (3 to <5 years) is associated with better surgical outcomes; however, further evidence from a randomized trial comparing immediate with delayed surgery is needed for confirmation.
SUBMITTER: Repka MX
PROVIDER: S-EPMC7137095 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:PURPOSE: To study the relationship between age and response to surgery in patients with intermittent exotropia and to identify change points in response to surgery. METHODS: A retrospective analysis was conducted on 311 patients with intermittent exotropia who had bilateral lateral rectus recession using standard tables with minimum follow-up of 6 months. Data were analyzed using the change-point analysis software to identify cutoff points. A prospective pilot study was then performed on 171 consecutive patients with intermittent exotropia with the same clinical characteristics, in whom amount of recession was modified according to the identified cutoff points. In angles with two change points, 1-mm recession was reduced from patients younger than the lower change point and 1.5-mm recession was added to those older than the upper change point. In angles with one change point, 1.5-mm recession was added to those older than the change point. Satisfactory alignment was defined as esophoria/tropia ? 5? to exophoria/tropia ? 8?. RESULTS: There was a negative correlation (P<0.01) between response to surgery and age at surgery for all angles. In younger patients (<7 years) in whom surgical dose was reduced, there was no significant change in success rate (77%), compared with those who had surgery using standard tables (75%). In older patients (>12 years) in whom surgical dose was increased, there was a statistically significant increase in success rate (80% vs 41%). CONCLUSIONS: Modifying the surgical dose according to age can improve the success in patients with intermittent exotropia.
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Project description:To evaluate whether distance stereoacuity improves following surgery for intermittent exotropia using the Frisby Davis Distance (FD2) and Distance Randot stereotests.Eighteen patients (median age, 24 years; range, 5 to 68 years) with intermittent exotropia were prospectively enrolled. Stereoacuity was measured pre- and 6 weeks postoperatively using the FD2 and Frisby near tests (real depth tests) and Preschool Randot and Distance Randot tests (polaroid vectographs).Distance stereoacuity measured with the FD2 improved from a median preoperative value of 80 to 40 arcsec postoperatively (p = 0.04) and stereoacuity measured with the Distance Randot improved from a median of nil to 200 arcsec (p = 0.06). In those that had subnormal stereoacuity preoperatively, there was even more marked improvement in distance stereoacuity (FD2 median nil vs 40 arcsec, p = 0.002; Distance Randot median nil vs 200 arcsec, p = 0.004). Near stereoacuity measured with Frisby and Preschool Randot remained unchanged pre- to postoperatively (median, 60 and 80 arcsec, respectively).There was improvement in distance stereoacuity measured with both the FD2 and the Distance Randot stereotests in patients who underwent surgery for intermittent exotropia. The FD2 and Distance Randot may be useful outcome measures in future clinical trials of interventions for intermittent exotropia.
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Project description:Reading speed in intermittent exotropia (IXT) children has been minimally examined. This study assessed reading speed in school-age children with IXT and determined clinical characteristics of IXT that impacted their reading ability. We compared the reading speed of 63 school-age (10-14 years) children with IXT to 44 age-matched normal counterparts. In addition, the correlation between reading speed and clinical characteristics of IXT were evaluated. The reading speed in children with IXT was 231 ± 51 CPM, while reading speed in normal counterparts was 257 ± 33 CPM. Age, gender were found to be factors associated with reading speed in children with IXT. After adjusting for the age and gender, we found a significant correlation between the LogTNO and reading speed in IXT group based on a generalized linear model (p = 0.014). These data show that reading speed was slower in school-age children with IXT assessed with the International Reading Speed Texts. When age and gender were adjusted, poor stereo function at near was found to be related with a slower reading speed.
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Project description:In young children with small angle exotropia, making decisions for the individual patient whether to perform surgery or not, and choosing the optimal time for surgical intervention are quite difficult. We aimed to compare the long-term outcomes of small angle intermittent exotropia of 20 prism diopters (PD) or less after observation versus strabismus surgery. A retrospective study was performed on 164 patients aged 3 to 13 who underwent surgical intervention or observation with or without conservative management for intermittent exotropia of 14 to 20 PD. The minimum follow-up period was 2 years. The average follow-up period was 3.9?±?2.2 years in the observation group and 4.5?±?2.3 years in the surgery group. At the final examination, the mean angle of deviation at distance was 11.1?±?8.9 PD in the observation group and 9.0?±?7.5 PD in the surgery group, which was not significantly different (P?=?0.121). Changes in sensory outcome and fusional control were not significantly different between both groups (P?=?0.748 and P?=?0.968). Subgroup analysis including patients with poor fusional control also showed similar results. By multivariate analysis, the type of surgery, unilateral recess-resect procedure, was the only predictive factor of good motor outcome in the surgery group. In conclusion, long-term surgical outcomes in small angle exotropia did not appear to be more satisfying than observation in terms of motor and sensory outcomes.
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Project description:ObjectivesTo evaluate the long-term refractive changes after horizontal muscle surgery in patients with intermittent exotropia and investigate the correlation between changes in the postoperative refractive error and clinical factors.MethodsWe retrospectively reviewed the clinical data of patients aged < 15 years who underwent unilateral strabismus surgery (lateral rectus recession and medial rectus resection [RR, n = 47], lateral rectus recession and medial rectus plication [RP, n = 81], or lateral rectus recession [LRc, n = 68]). Preoperative and postoperative refractive errors up to four years after surgery were recorded. A mixed model was applied to compare the refractive error between the operated and fellow eyes and identify the factors associated with postoperative refractive changes.ResultsThe mean age at surgery was 7.5±2.4years, and girls accounted for 56.1% of the study population. There was no significant difference in the change in the spherical equivalent of refractive error between both eyes throughout the postoperative period. In contrast, the operated eyes consistently and significantly showed higher cylindrical power in with-the-rule astigmatism by 0.25D than in fellow eyes. Age, sex, and preoperative refractive error were not correlated with changes in postoperative astigmatism. Meanwhile, the type of surgery showed a significant interaction with the astigmatism changes. RP had less effect on the changes in astigmatism than RR and LRc (p = 0.001 and p = 0.022, respectively).ConclusionsHorizontal muscle surgery has no long-term effect on the change in the spherical equivalent. However, mild with-the-rule astigmatism is induced and sustained after surgery, and the type of surgery affects the postoperative change of astigmatism.
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Project description:PurposeThe development and initial validation of patient-derived, health-related quality-of-life (HRQOL) questionnaires for intermittent exotropia (IXT).DesignCross-sectional study.ParticipantsIn a development phase, 27 children (age, 2-17 years) with IXT and 1 of their parents. In an initial validation phase, 33 children with IXT and 49 control children (age, 5-17 years), along with 1 parent for each child. Children in the control group had no strabismus or amblyopia.MethodsIndividual patient interviews generated 35 items for child and proxy (parental assessment of child's HRQOL) questionnaires and 46 items for a parent questionnaire. To reduce to a feasible number of items, questionnaires were administered to 5- to 17-year-old children with IXT (n = 15) and parents of 2- to 17-year-old children with IXT (n = 27). Responses were analyzed using standard item reduction methodology. Three final derived IXT questionnaires (IXTQ): child, proxy, and parent (12, 12, and 17 items, respectively) were administered to children with IXT and control children and to parents of IXT and control children. Likert-type scales ranging from never (100, best HRQOL) to almost always (0, worst HRQOL) were used.Main outcome measuresMedian scores for IXT and control groups, compared using Wilcoxon tests.ResultsMedian child scores were significantly lower (worse HRQOL) in the IXT group compared with the control group: 85 (quartiles, 73-92) versus 92 (quartiles, 79-96; P = 0.04). Median proxy IXTQ scores were significantly lower for IXT children than controls: 83 (quartiles, 75-94) versus 98 (quartiles, 92-100; P<0.0001). Median parent IXTQ scores also were significantly lower in the IXT group compared with the control group: 68 (quartiles, 56-79) versus 93 (quartiles, 87-99; P<0.0001).ConclusionsA new 3-part patient-derived HRQOL questionnaire for children with IXT and their parents has been developed and validated, comprising child, proxy, and parent questionnaires. These questionnaires detect reduced HRQOL in children with IXT as reported by the children themselves and perceived by their parents (proxy report). Childhood IXT also seems to affect parent HRQOL. The IXTQ HRQOL questionnaires may prove useful in the clinical assessment of IXT and for clinical trials.Financial disclosure(s)The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Project description: Not available
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Project description:BackgroundThe clinical management of intermittent exotropia has been discussed extensively in the literature, yet there remains a lack of clarity regarding indications for intervention, the most effective form of treatment and whether or not there is an optimal time in the evolution of the disease at which any treatment should be carried out.ObjectivesThe objective of this review was to analyse the effects of various surgical and non-surgical treatments in randomised trials of participants with intermittent exotropia, and to report intervention criteria and determine the significance of factors such as age with respect to outcome.Search methodsWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library, Issue 4, 2012), MEDLINE (January 1966 to May 2012), EMBASE (January 1980 to May 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to May 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 May 2012. We are no longer searching the UK Clinical Trials Gateway (UKCTG) for this review. We manually searched the British Orthoptic Journal up to 2002, and the proceedings of the European Strabismological Association (ESA), International Strabismological Association (ISA) and American Academy of Paediatric Ophthalmology and Strabismus meeting (AAPOS) up to 2001. We contacted researchers who are active in the field for information about further published or unpublished studies.Selection criteriaWe included randomised controlled trials of any surgical or non-surgical treatment for intermittent exotropia.Data collection and analysisEach review author independently assessed study abstracts identified from the electronic and manual searches. Author analysis was then compared and full papers for appropriate studies were obtained.Main resultsWe found one randomised trial that was eligible for inclusion. This trial showed that unilateral surgery was more effective than bilateral surgery for correcting the basic type of intermittent exotropia.Authors' conclusionsThe available literature consists mainly of retrospective case reviews, which are difficult to reliably interpret and analyse. The one randomised trial included found unilateral surgery more effective than bilateral surgery for basic intermittent exotropia. However, across all identified studies, measures of severity and thus criteria for intervention are poorly validated, and there appear to be no reliable natural history data. There is therefore a pressing need for improved measures of severity, a better understanding of the natural history and carefully planned clinical trials of treatment to improve the evidence base for the management of this condition.
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Project description:The aim of this study was to determine whether objective ocular torsion in intermittent exotropia (IXT) changes after recession surgery, and to evaluate the relationship between change in ocular torsion and clinical parameters in IXT. Sixty patients between 3 and 14 years of age underwent lateral rectus (LR) recession for IXT. Digital fundus photographs were obtained from both eyes of each subject and the disc-foveal angle (ocular torsion) was calculated using image software. We compared the preoperative and postoperative amount of ocular torsion, and analyzed the correlation between the difference in ocular torsion (DOC) and clinical parameters including age, duration of strabismus, stereoacuity, amount of preoperative exodeviation, and mean dose response. We categorized the patients according to DOC value: positive DOC value as group 1, and negative DOC value as group 2. A correlation between ocular torsion dominance and fixation preference was also investigated using the Kappa test. The mean ocular torsion was 15.8 ± 4.6 degrees preoperatively and 13.7 ± 5.1 degrees postoperatively. Compared with preoperative values, the mean ocular torsion showed a significant decrease after LR recession (p<0.001), and a greater preoperative ocular torsion was significantly associated with the amount of DOC (r = 0.37, p<0.001). Degree of stereopsis, mean dose-response, and postoperative exodeviation were significantly different between group 1 (positive DOC) and group 2 (negative DOC) (p<0.001, 0.030, and 0.001 respectively). The Kappa test showed that there was a significant correlation between the dominance of ocular torsion and fixation preference (p = 0.020). Therefore, change in ocular torsion after LR recession can be a useful supplementary indicator for evaluating the degree of fusional control and for predicting postoperative surgical response in IXT.
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