From the Guidelines
The initial treatment for a toddler with right eye exotropia typically involves patching therapy of the unaffected (left) eye for 2 hours each day, as this approach has been shown to improve fusional control and reduce the angle of strabismus 1. This treatment, also called occlusion therapy, involves covering the normal eye with an adhesive patch, forcing the brain to use visual input from the deviating eye. The exact patching schedule should be determined by a pediatric ophthalmologist based on the severity of the exotropia and the child's age. Some key points to consider in the treatment of exotropia include:
- Before starting patching, a comprehensive eye examination is essential to rule out refractive errors that might require glasses correction 1.
- If significant refractive errors exist, prescription glasses should be worn before or alongside patching.
- Regular follow-up appointments every 4-8 weeks are necessary to monitor progress and adjust treatment.
- Patching works by strengthening the eye muscles and improving the brain's ability to use both eyes together, potentially preventing amblyopia (lazy eye) development.
- If patching therapy doesn't show improvement after 3-6 months, or if the exotropia is large-angle or constant, surgical intervention might be considered, but non-surgical approaches are typically tried first in young children 1. It is also important to note that childhood exotropia is a long-term problem that requires commitment from the patient and/or family/caregiver and ophthalmologist to achieve the best possible outcome, and that parents/caregivers who understand the diagnosis and rationale for treatment are more likely to adhere to treatment recommendations 1.
From the Research
Treatment Options for Exotropia
The initial treatment for a toddler with exotropia (turning out) of the right eye may involve several options, including:
- Patching of the unaffected eye to improve control and reduce the deviation angle
- Occluding the affected eye to strengthen fusional amplitudes
- Botulinum toxin injection as an adjunct to surgery
- Corrective lenses to improve vision and reduce symptoms
Patching Therapy
Patching the unaffected eye for a certain period each day has been shown to be effective in improving control and reducing the deviation angle in patients with intermittent exotropia 2, 3. A study published in the European Journal of Ophthalmology found that part-time patching for 2 hours a day improved control and reduced the magnitude of exo-deviation in 31.6% of patients with intermittent exotropia 3.
Occlusion Therapy
Occlusion therapy, which involves patching the affected eye, has also been shown to be effective in improving control and reducing the deviation angle in patients with intermittent exotropia 2, 4. A study published in the Journal of AAPOS found that part-time alternate occlusion and overminus spectacles with prism delayed or avoided surgery in a large percentage of patients with intermittent exotropia 4.
Botulinum Toxin Injection
Botulinum toxin injection has been used as an adjunct to surgery in patients with large-angle exotropia 5. A study published in the Journal of AAPOS found that intraoperative botulinum toxin A injection improved cosmetic repair and reduced the deviation angle in patients with large-angle sensory exotropia 5.
Corrective Lenses
Corrective lenses may also be used to improve vision and reduce symptoms in patients with exotropia. However, the effectiveness of corrective lenses in improving control and reducing the deviation angle is not well established 6.
Recommended Treatment
Based on the available evidence, patching of the unaffected eye for 2 hours each day (option a) may be a recommended initial treatment for a toddler with exotropia of the right eye 2, 3.