- Acute disease. When a divergent strabismus develops suddenly in an older patient who previously had normal binocular vision, it is classified as acute exotropia. This condition can result from an underlying disease process or a decompensating disease.
- Mechanical exotropia. Mechanical exotropia is a divergent strabismus caused by a mechanical restriction or tightness (e.g., fibrosis of muscle tissue, thyroid myopathy) or a physical obstruction of the extraocular muscles (orbital fracture), causing increasing exotropia. Tightness of the lateral rectus muscle may develop secondary to the primary innervational miswiring in a rare type of Duane syndrome. With this type of strabismus, an absence of adduction results in increasing disease accompanied by narrowing of the palpebral fissure and retraction of the globe.
- Sensory disease. A divergent strabismus resulting from a unilateral decrease in vision that disrupts fusion, sensory disease may be due to a sensory deficit such as uncorrected anisometropia, unilateral cataract, or other unilateral visual impairment. Sensory exotropia and sensory esotropia occur with equal frequency in children under age 5; however, sensory disease predominates in persons older than 5 years. Sensory disease occurs in less than 3 percent of all strabismic children.
- Consecutive exotropia. Exotropia that occurs following surgical or optical correction of an esotropia is referred to as consecutive disease. This form of a disease can also occur spontaneously in a formerly esotropic patient. A spontaneous change from esotropia to exotropia over time may be related to amblyopia of the deviating eye, weak binocular function, underaction of the medial rectus, or excessive hyperopic refractive error. When followed long term, the prevalence of consecutive disease is reported to be as high as 20 percent for esotropic patients treated with surgery.
- Ocular alignment and motility at distance and near.
- Extraocular muscle function (ductions and versions including incomitance, such as A and V patterns).
- Detection of nystagmus.
- Sensory testing.
- Cycloplegic retinoscopy/refraction.
- Funduscopic examination.
- If the frequency of the exotropia is definitely increasing over time although it is not yet apparent for 50% of each day.
- If there is a significant exotropia when your child intently views objects at near.
- If there is evidence that your child is losing "binocular vision." This refers to the brain's ability to use both eyes together as a single unit. Among other benefits, binocular vision affords optimal depth perception.
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