Major article
Dissociated vertical deviation in patients with intermittent exotropia

Presented at the 33rd Annual Meeting of the American Association for PediatricOphthalmology and Strabismus, Seattle, Washington, April 11-15, 2007
https://doi.org/10.1016/j.jaapos.2007.11.019Get rights and content

Purpose

To determine whether the age of strabismus onset and the degree of stereopsis are related to the development of dissociated vertical deviation (DVD) in patients with intermittent exotropia and to describe the characteristics of DVD in patients with intermittent exotropia and DVD.

Methods

Retrospective record review of patients with (1) intermittent exotropia with DVD; (2) infantile esotropia with DVD; and (3) intermittent exotropia without DVD. Age of strabismus onset, stereopsis, strabismus measurements, and the response of DVD to the Bielschowsky head-tilt test were compared among the three groups.

Results

Fifty-two children with intermittent exotropia and DVD were identified. In patients with intermittent exotropia with DVD and intermittent exotropia without DVD group, the mean age of strabismus onset was 12.7 months and 28.9 months, respectively (p = 0.03), and mean stereopsis was 147 arcsec and 65 arcsec (p = 0.02). In patients with intermittent exotropia with DVD and infantile esotropia with DVD, the mean amount of DVD was 9.7Δ and 17.2Δ, respectively (p < 0.01). Bielschowsky head-tilt test showed an increase of DVD on ipsilateral head tilt in 91% and 63.3%, respectively.

Conclusions

Intermittent exotropia with DVD is characterized by earlier onset of strabismus and worse stereopsis, suggesting that these factors may be related to the development of DVD in patients with intermittent exotropia. Unlike DVD in infantile esotropia, DVD in intermittent exotropia was smaller in amount and demonstrated a more uniform response to the Bielschowsky head-tilt test.

Section snippets

Subjects and Methods

We retrospectively reviewed the records of all patients diagnosed with exotropia and DVD from 1996 to 2005 in our pediatric ophthalmology practice at the Hospital for Sick Children, Toronto, Canada, and Asan Medical Center, Seoul, Korea. The study protocol was approved by the Research Ethics Board of both institutions. Inclusion criteria were as follows: (1) a diagnosis of intermittent exotropia accompanied by DVD; (2) age of at least 5 years—required for obtaining reliable stereopsis

Intermittent Exotropia with DVD Group

Fifty-two patients met our criteria. Mean age at the time of DVD diagnosis was 8.0 ± 2.5 years and ranged from 5 to 15 years. Thirty-one children (59.6%) were female.

The mean age of strabismus onset was 12.7 ± 6.0 months (range, 3-24 months). The mean size of exodeviation in the primary position was 25.4Δ ± 5.8Δ (range, 14Δ-40Δ). Regarding the type of exodeviation, 37 (77.1%) children had basic exotropia, 3 had true divergence excess, 7 had pseudodivergence excess, and only 1 had convergence

Discussion

The results presented here suggest that DVD may develop in patients with intermittent exotropia, especially in those who have early onset of strabismus and poor stereopsis.

Intermittent exotropia is a strabismus disorder that has aligned phases interspersed with tropic phases.8, 20 In general, patients with intermittent exotropia, especially when the eyes are aligned, may have relatively normal binocular function.21, 22, 23 When the Titmus stereo test was used to measure stereoacuity in patients

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      There is little data with which to compare these findings. One prior study of exotropic children with DVD reported subnormal stereopsis (mean, 147 arcsec by Titmus; range, 80–400 arcsec) and poor control (spontaneous tropia without fusion disruption) in all 52 patients with DVD.2 Their findings were thought to be consistent with early-onset strabismus and monofixation status.1,2

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    • Prevalence of dissociated strabismus in children with ocular misalignment: A population-based study

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      The prevalence of DVD among patients with intermittent exotropia has been reported by Lim and colleagues,5 who found that patients with intermittent exotropia and DVD developed strabismus at a younger age than those with intermittent exotropia without DVD. It was further demonstrated that, when compared to the infantile esotropia group with DVD, the amount of DVD measured in patients with intermittent exotropia was smaller.5 However, no prevalence rates were reported, whereas the present study found a rate of 1.8% in children with intermittent exotropia.

    • Comparison of clinical features between two different types of exotropia before 12 months of age based on stereopsis outcome

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      Both DVD and IOOA in exotropia are associated with disruption of normal binocular function. Lim et al12 reported that intermittent exotropia accompanied by DVD has a poor prognosis in stereopsis. In addition, the incidence of DVD or IOOA in infantile exotropia is 50%.1

    • Congenital superior oblique palsy and trochlear nerve absence: A clinical and radiological study

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      In this study, half the patients with DVD were bilateral and the rest had DVD on the ipsilateral side of SOP. Dissociated vertical deviation occurs when normal binocular visual development is disrupted and when it is associated with nystagmus and horizontal and vertical deviations.21,22 Dissociated vertical deviation alone may cause head tilts, without significant oblique muscle dysfunction.23

    • Can the preoperative fundus extorsion in infantile esotropia predict the development of postoperative inferior oblique overaction and dissociated vertical deviation?

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      Ocular alignment was measured and the development of IOOA and DVD was evaluated and compared between the 2 groups. The IOOA and DVD were determined with previously described methods.1,13 The patient was considered to have IOOA when elevation in adducted eye position was present.

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    The authors have no conflicts of interest to disclose

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