What is the management approach for a 6-year-old child with 15-degree exotropia, severely impaired visual acuity in the left eye, and a history of trauma at 1 year of age, in the absence of confirmed optic atrophy?

Management of 6-Year-Old with Exotropia and Severe Unilateral Visual Impairment Following Trauma

In a 6-year-old child with 15-degree exotropia and severely impaired visual acuity in the left eye from trauma at age 1, the primary goal is cosmetic alignment through surgical correction, as restoration of binocular function is not achievable at this age and duration of visual loss. 1

Diagnostic Workup Required

Before proceeding with treatment, complete the following evaluation:

• Cycloplegic refraction to rule out uncorrected refractive error contributing to poor vision, though improvement is unlikely given the trauma history and 5-year duration 1
• Funduscopic examination to assess for retinal or optic nerve damage from the childhood trauma, particularly since optic atrophy has not been confirmed 1
• Measurement of deviation magnitude at distance and near using cover-uncover test and prism measurements 1
• Visual acuity assessment in both eyes to confirm the severity of impairment and ensure the fellow eye has excellent vision 1

Key Diagnostic Consideration

The presence of reduced visual acuity without an obvious etiology should alert you to consider subtle optic nerve or retinal abnormalities, even if frank optic atrophy is not visible 2. Severe unilateral vision loss in early childhood typically causes exotropia rather than esotropia 1.

Treatment Algorithm

Step 1: Establish Realistic Goals

• Primary objective: Cosmetic alignment, NOT restoration of binocular vision or stereopsis 1
• Secondary objective: Maintain excellent vision in the unaffected right eye 1
• The potential for visual recovery or development of binocular function is essentially absent at age 6 with this history 1

Step 2: Surgical Planning

Unilateral surgery on the affected (left) eye is the preferred approach when poor vision is present in one eye 1:

• Surgical options: Lateral rectus recession with or without medial rectus resection on the left eye 1
• This approach avoids operating on the good eye and provides adequate cosmetic correction 1

Step 3: Preoperative Counseling

Set realistic expectations with the family:

• Surgery aims for cosmetic alignment only 1
• No improvement in vision or development of stereopsis is expected 1
• Good cosmetic alignment is achievable in most cases, though recurrence risk exists 1

Postoperative Management

Immediate Follow-up

• Monitor for consecutive esotropia, which can occur after exotropia surgery, though less likely to cause diplopia with poor vision in the affected eye 1
• Assess alignment stability at standard postoperative intervals 1

Long-term Monitoring

• Follow-up every 6-12 months to monitor alignment stability and vision in the good eye 1
• Continue surveillance even after successful surgery to detect late-onset complications including recurrent exotropia, vertical deviations, or changes in the good eye 1

Critical Pitfalls to Avoid

• Do not delay surgical intervention if the deviation is cosmetically unacceptable to the family, as the child is already past the critical period for binocular vision development 1
• Do not pursue aggressive amblyopia treatment in the affected eye, as severe amblyopia is uncommon with intermittent exotropia, and the presence of severely reduced visual acuity suggests structural damage rather than functional amblyopia 2
• Do not operate on the good eye when unilateral poor vision is present, as this unnecessarily risks the only functional eye 1
• Do not promise binocular function restoration, as this is not achievable given the age, duration of visual loss, and trauma history 1

Prognosis

Approximately 80% of patients achieve good alignment at 6 months postoperatively, though recurrence is common over time 3. No improvement in vision or development of stereopsis is expected in this case 1. The child will require ongoing monitoring throughout childhood and adolescence 1.