This document discusses multiple cases of spontaneous consecutive exotropia in children, detailing management strategies and outcomes. It highlights risk factors such as amblyopia, poor follow-up, and the importance of careful prescription adjustments. Additionally, it emphasizes the need for closer follow-up and monitoring to manage deviations effectively.

1. Spontaneous Consecutive Exotropia
Alvina Pauline Santiago, MD

2. Case 1: 3, Male
Sc MET 4PD, 30PD LE(T)’
Atropine +2.50 OU
With +2.50, small MXT noted
Given Plano A +1.50
cc 0-2 PD MET, ortho at near

3. Case 1: 3, Male
Managed with reduced
plus with Adds till age 7
Short-acting cycloplegia:
+2.00 OU
Given +1.00 OU

4. Case 1: 3 now 9
Lost to follow-up for 2 years
Wearing a +1.00 prescribed from 2 years prior
30PD X(T)
Subjective Refraction
•OD: -0.50 20/20
•OS: -0.75 20/40
Cyclorefraction: +0.50, OU
•Conservative
management
•Myopic Rx
•Convergence exercises
•Patching

5. Case 1: 3 now 17
Findings
• -1.00 OU
• Orthotropia w correction
• 14PD X(T) without Rx

6. Case 1: 3 now 17
Findings
• -1.00 OU
• Orthotropia w correction
• 14PD X(T) without Rx
Risk Factors
• Amblyopia
• Control of ET in 2 months
• IOOA
• Remote NPC
• High AC/A
• Lost to follow-up 2 years

7. Case 2: 9 mo, Male
• +3.00 OU, still w 30PD ET
• 40PD sc
• Atropine: +4.25 OU
• Age 1: Cycloplegic: +2.50 OU
• Reduced plus +1.50 OU
controlled

8. Case 2: 9 mos, now 5
•Cyclorefraction: +2.00
OU
•Reduced plus:
•+1.00 20/40
•+1.00 20/60

9. Case 2: 9mo, now 7
• Lost to follow-up for 2 years
• Wearing last known Rx +1.00
• Monofixation Exotropia w/sc
• Cycloplegic refraction: +1.00 OU
• Patching
• Overminus lenses: -0.50 OU
• VA at least 20/40

10. Case 2: 9mo, now 9
Current Management
• Tolerated overminus: -1.00 OU
• 20/30 OU
• X(T) = 14PD
• Cycloplegic: plano OU
• -1.50: 12PD X(T)
Risk Factors
• Amblyopia
• DVD
• Remote NPC
• Wrong glasses
• Lost to follow-up 2 years

11. Case 3: 1, Male
Clinical Features
• ET 35PD
• Right preferred
• Surgery advised
• Membrane prisms
• Cyclo: +1.50 OU
Risk Factors
• V pattern; IOOA
• DVD

12. Case 3: 1 now 5
•18-25PD X(T)
•Controlled w -1.50 OU
•Remote NPC

13. Case 3: 1, now 12
• 12-16PD X(T)
• Over minus lenses: 10-16 X(T)
• Orthoptics
Risk Factors
• Remote NPC
• Amblyopia
• DVD
• IOOA, V pattern
• Preterm

14. Case 4: 4 mo, F
• E(T) = 25PD
• SAC: +2.00 OU
• Controlled for 2 years
• Then MX(T)
• Between ages 5-8, sometime MET,
sometimes MXT

15. Case 4: 4 mo, now 8
• 20PD X(T) w DVD
• Best correction:
• OD: -0.25 20/25
• OS: -1.00 -0.50 x 180 20/20
Risk Factors
• Variable monofixation?
• Amblyopia
• DVD
• E(T) recurrence

16. Take home message
• Spontaneous consecutive exotropia can occur:
• Accommodative esotropia
• Infantile esotropia (managed with prisms)
• Nonrefractive Accommodative ET with or without
high AC/A
• Intermittent esotropia
• Recognize risk factors
• Taper earlier than we were taught
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bulb-idea-clipart-take-home-message.png

17. Possible Risk Factors
•Poor follow-up
•Wrong prescription
•High AC/A
•Prematurity
•Rapid control of deviation
•Rapid drop in refraction
•Amblyopia
•DVD
•IOOA
•Remote NPC

18. Management Pearls
• Full cycloplegic refraction
• 2 cycles good control: consider reduce plus 1-1.5D
from full cycloplegic refraction
• Intermediate or Short acting cycloplegic refraction
• If ET controlled, No need to run after latent
hyperopia if ET controlled with Rx
• Iff residual ET, proceed with atropine refraction
• Closer follow-up than we were used to
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19. References
1. Santiago AP (2022). Spontaneous Consecutive Exotropia After Accommodative Esotropia. Acta
Medica Philippina (Online) https://doi.org/10.47895/amp.vi0.4540.
2. Lembo A, Serafino M, Strologo MD, Saunders RA, Trivedi RH, Villani E, et al. Accommodative
esotropia: the state of the art. Int Ophthalmol. 2019 Feb; 39(2):497-505. doi:
10.1007/s10792-018-0821-6. PMID: 29332227.
3. Raab E. Accommodative Esotropia. Difficult Esotropia Entities: Principles of Management. In
Clinical Strabismus Management Principles and Technique. Rosenbaum AL, Santiago AP
(editors), Philadephia, WB Saunders, 1999, pp 140-143.
4. Shin DH, Choi CY, Han SY. Risk factors for spontaneous consecutive exotropia in children with
refractive and nonrefractive accommodative esotropia. Jpn J Ophthalmol. 2020 May;
64(3):292-7. doi: 10.1007/s10384-020-00724-5. PMID: 32108919.
5. Senior JD, Chandna A, O'Connor AR. Spontaneous consecutive exotropia in childhood.
Strabismus. 2009 Jan-Mar; 17(1):33-6. doi: 10.1080/09273970802678818. PMID: 19301191.

20. References
6. Weir CR, Cleary M, Dutton GN. Spontaneous consecutive exotropia in children with motor fusion. Br J
Ophthalmol. 2001 Feb; 85(2):242-3. doi: 10.1136/bjo.85.2.238e. PMID: 11225577; PMCID: PMC1723827.
7. Beneish R, Williams F, Polomeno RC, Little JM. Consecutive exotropia after correction of hyperopia. Can J
Ophthalmol. 1981 Jan; 16(1):16-8. PMID: 7470983.
8. Watanabe-Numata K, Hayasaka S, Watanabe K, Hayasaka Y, Kadoi C. Changes in deviation following
correction of hyperopia in children with fully refractive accommodative esotropia. Ophthalmologica. 2000
Sep-Oct; 214(5):309-11. doi: 10.1159/000027511. PMID: 10965242.
9. Yurdakul NS, Ugurlu S. Analysis of risk factors for consecutive exotropia and review of the literature. J Pediatr
Ophthalmol Strabismus. 2013 Sep-Oct; 50(5):268-73. doi: 10.3928/01913913-20130430-01. Epub 2013 May
7. PMID: 23641958.
10. Ha SG, Suh YW, Kim SH. Esodeviation without correction for tapering hyperopia in refractive accommodative
esotropia. Can J Ophthalmol. 2018 Oct; 53(5):453-7. doi: 10.1016/j.jcjo.2018.01.019. Epub 2018 Mar 16.
PMID: 30340709.