How should I manage a 2-year-old with 15 diopter (a unit of refractive power) alternating exotropia (a form of strabismus where one eye turns outward)?

Management of 15 Diopter Alternating Exotropia in a 2-Year-Old Child

A 2-year-old with 15 diopter alternating exotropia should be referred to a pediatric ophthalmologist for comprehensive evaluation and management, as early intervention may improve long-term visual outcomes. 1

Initial Assessment and Referral

• Alternating exotropia is a form of strabismus where one eye turns outward, and when it appears before 3 years of age, it typically requires specialist evaluation 1
• Children with intermittent exotropia are at risk for developing amblyopia, though severe amblyopia is uncommon with this condition 1
• Referral to an ophthalmologist who specializes in pediatric patients is recommended for proper diagnosis and treatment planning 1
• The specialist will perform a comprehensive evaluation including cycloplegic refraction to determine if there are any refractive components contributing to the strabismus 1

Treatment Options

Non-surgical Management

• For intermittent exotropia with good fusional control, observation may be appropriate as deterioration is uncommon in young children 1, 2
• Part-time patching has been shown to be more effective than observation alone in preventing deterioration of intermittent exotropia 2
  • Patching for 3 hours daily may be prescribed as initial management 2
• Correction of any significant refractive error should be the first step in management 3
• Follow-up evaluations should be scheduled every 6-12 months to monitor:
  • The magnitude and frequency of the deviation
  • Visual acuity development
  • Binocularity 1

Surgical Intervention

• Surgical intervention should be considered if:
  • The exodeviation is constant
  • The deviation occurs frequently or is large enough to be unacceptable
  • Non-surgical treatments fail to control the deviation 1
• For young children with alternating exotropia, some evidence suggests that earlier surgery (ages 3-5 years) may have better outcomes 1
• Surgical options include:
  • Bilateral lateral rectus muscle recessions
  • Unilateral lateral rectus recession with medial rectus resection 1
• The timing of surgery depends on the child's neurodevelopmental status and the frequency of the deviation 1

Decision-Making Algorithm

1. Refer to pediatric ophthalmologist for comprehensive evaluation 1
2. Correct any significant refractive error with appropriate glasses 3
3. Monitor or initiate non-surgical treatment:
   • If exotropia is intermittent with good control: consider observation with regular follow-up 1
   • If control is poor: consider part-time patching for 3 hours daily 2
4. Consider surgery if:
   • Deviation is constant or poorly controlled despite non-surgical management
   • Deviation is large enough to impact quality of life or social interactions 1

Important Considerations

• Childhood exotropia is a long-term problem requiring commitment from both the family and healthcare providers 1
• Parents who understand the diagnosis and treatment rationale are more likely to adhere to recommendations 1
• The risk of deterioration in untreated intermittent exotropia is relatively low (approximately 6% over 6 months), but patching can reduce this risk further (to approximately 0.6%) 2
• Regular follow-up is essential as children with exotropia remain at risk for developing amblyopia and losing binocular vision 1

Prognosis

• With appropriate management, most children with alternating exotropia can achieve good visual acuity in both eyes 4
• However, high-level binocular function (stereopsis) may be limited in some patients despite successful alignment 4
• Long-term results after surgical correction show that approximately 80% of patients have good alignment at 6 months, but recurrence is common over time 1