Tuesday, January 4, 2011

Exotropia Classification

99 comments:

  1. this post is in accordance to our last case

    'Basic intermittent AXT'

    is this the topic that we'll be discussed tomorrow?

    ReplyDelete
  2. wah banyak tu 20%.

    Let's start our discussion with defining each XT. Make sure we state the source/references.

    then,

    1) etiology
    2) diferential diagnosis
    3) symptoms
    4) clinical manifestation/signs
    5) management and prognosis

    at the end of the day, we can come out with simple related cases.

    is that ok to u guys?

    ReplyDelete
  3. salam sir,,
    regarding this topic, everybody need to discuss each aspect in XT classification that azwan mentioned above or we have different question to be answered like before?

    ReplyDelete
  4. @Nur Syazriena Bt Ghazali

    OPEN DISCUSSION..The topic is up to U..as long as related to Exotropia..
    azuwan just suggest a few of them

    ReplyDelete
  5. NOR ARIFAH BT ZAKARIAJanuary 8, 2011 at 4:13 PM

    dear opto frens, i am now doing the primary XT-interminttent- distance XT...in progress~~hee~~~i will email my part to kak ela to post it here~

    ReplyDelete
  6. Slm..ok,regarding the topic, since arifah was already done with primary XT, then I wish to share about consecutive XT.
    Consecutive XT is actually a condition where a patient manifests an XT that had originally been an ET before. It’s merely a result of Strabismic surgery. The majority cases is because f overcorrection of an ET. This may develop in childhood or later. There are several factors that contribute to this problem which are:
    • early onset of ET
    • a hyperopia more than 5.00 D is the strongest risk factor for nonsurgical consecutive XT.
    • Presence of amblyopia
    Patient with this type of XT will come out with a moderate to large vertical deviation and has history of infantile or partially accommodative ET .
    Guys,please do correct or add the above info.

    ReplyDelete
  7. Salam...I would like to add some more information regarding Izzah's comment about consecutive XT.I want to share about the symptoms and the differential diagnosis.
    Symptoms of consecutive XT:
    - a common reason for presentation is cosmesis
    -pt may report an exotropia increasing (in frequency &size) over time.
    diplopia is rare,but it may occur if the strabismic deviation changes in adulthood.

    Differential diagnosis:
    all types of XT can be included in the differential diagnosis.a history of ET, typically with surgical intervation,is the key finding in the proper diagnosis of consecutive XT.Even in light of positive hx of strabismus surgery,care should be taken to exclude any other possible coexisting prob (recent changes in vision,neurological condition)that may be leading to the strabismus.

    ReplyDelete
  8. Nurfadzillah Bt. ArifinJanuary 8, 2011 at 10:21 PM

    Dear friends, I would like to share about Exotropia of divergence excess type.

    Divergence excess (DE) is an intermittent exotropia whose angle of deviation at distance is at least 10 to 15 prism dioptre greater than near, and whose frequency of turn can vary from 1% to 99% of the time.

    The symptoms for exotropia of DE type is as follow:
    •Photophobia and squinting of one eye when outside.
    •Asthenopic symptoms are rare unless a secondary binocular or accommodative issue is manifest at near.
    •Diplopia is very rare. When reported, it is typically done so by a young child.
    While the sign for exotropia of DE is as follow:
    •A concomitant exotropia is greater at distance than at near.
    •An exotropia of v pattern may present.
    •Approximately 50% of patient may have vertical component, which seems due in about 2/3 of this cases to an overreaction of the inferior oblique muscle, and in the remainder to the fact that the medial rectus is simply a stronger elevator when the eye is abducted.
    •When the eye is align, the patient usually exhibit normal retinal correspondesce (NRC), good stereopsis, no strabismic amblyopia and a good near point of convergence.
    •When the deviation is present, these patients will exhibit either NRC with suppression or abnormal retinal correspondesce (ARC).
    •Stimulus response AC/A ratios may be higher than average, and distance-near AC/A ratio are high

    Btw, please correct me if I’m wrong...

    ReplyDelete
  9. nurulhuda abd latifJanuary 8, 2011 at 10:45 PM

    salam and good evening to everyone...
    here i would to share about general idea of intermitten exotropia..lets take a look..=)

    Intermittent exotropia is a large exophoria that intermittently breaks down to an exotropia. Occluding one eye will breaks fusion and will manifest the exotropia. When fusing, the eyes are straight and stereo acuity is excellent, usually 40 seconds of arc. When tropic, there is large hemi-retinal suppression of the deviated eye. It is common for patients to show a preference for one eye, however, resist the temptation to label the deviation as a right or left exotropia. You can easily change the deviated eye by covering the dominant eye. Patients with late onset exotropia during late childhood or adulthood may experience diplopia when tropic. The exotropia is typically manifest when the patient is fatigued, daydreaming or ill. Approximately 80% of intermittent exotropia patients will show progressive loss of fusion control and an increase in the exotropia over several months to years. Adult patients can have extremely large deviations.Despite the large angle exotropia sometimes they was able to fuse it intermittently.

    please add some more if u guys has extra info on this...tq..

    ReplyDelete
  10. As-slm everyone =)

    Next, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally,

    1. Classically defined as a large (30 to 80 PD) constant XT that develops during the first 6 to 12 months of life.
    2. The size of the angle may increase over time.
    3. XT have alternating/unilateral fixation but rare to find amblyopia.
    4. BV assessment is absent/very week
    5. Best treatment is surgery

    Sign and symptoms,

    1. May have coexisting ocular, craniofacial, or systemic abnormalities.
    2. Nearly symptom free (pt already adapt)

    Now I want to stress on how to workout such of this cases,

    1. History: Onset/frequency of deviation/ complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols, HOTV, or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruchner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation(sensory cause of the XT: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    guys please do add some more comment =))

    ReplyDelete
  11. Wowwww..everybody done a good JOB..
    Now,,its my turn..hehee..
    1st and foremost..

    Salam to all my beloved lecturer, seniors and friends..(hehehehe)
    Here, I’ll share about PRIMARY CONSTANT EXOTROPIA

    PRIMARY CONSTANT EXOTROPIA
    Can be divided into
    • Early onset
    • Decompensated intermittent
    Exotropia

    Definition : Constant Exotropia
    •A divergent deviation constitutes
    the initial defect, which is
    constantly present under all
    conditions.

    Anatomical causes:
    • Wide IPD
    • Exophthalmos
    • Orbital asymmetry
    • Muscle anomalies
    • Craniofacial anomalies.

    It can be hereditary and can be associated with myopia.

    Let us discuss each type of constant exotropia.

    1. Early Onset
    •Constant from time-time
    •Usually present in 1st year of
    life.
    •Can be either alternating (VA is
    equal)/ unilateral.
    •BV is absent / very weak
    •Common finding : DVD

    2. Decompensated Intermittent
    Exotropia
    •Often commence as an intermittent
    deviationconstant with time
    •Usually patient has marked
    suppression & no diplopia
    *Prognosis for restoration BSV:GOOD
    ( Providng XT remained
    intermittent for some year before
    becoming constant)

    REFERENCE : BV & ORTHOPTICS
    (Bruce Evan & Sandip Doshi)

    ReplyDelete
  12. As-slm everyone =)

    Next, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally,

    1. Classically defined as a large (30 to 80 PD) constant XT that develops during the first 6 to 12 months of life.
    2. The size of the angle may increase over time.
    3. XT have alternating/unilateral fixation but rare to find amblyopia.
    4. BV assessment is absent/very week
    5. Best treatment is surgery

    Sign and symptoms,

    1. May have coexisting ocular, craniofacial, or systemic abnormalities.
    2. Nearly symptom free (pt already adapt)

    Now I want to stress on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    guys please do add some more comment =))

    ReplyDelete
  13. 'which make u like cool!'.haha...

    Near XT.

    characteristics:
    -XT at N, XP at D
    -mainly in older children and adults
    -c/o asthenopic symptoms and HA with near work.
    -poor or little convergence
    -equal VA on each eye.
    -poor PFV at N and D

    Treatment
    -correct any significant ref. error(associated with acquired myopia).
    -Conservative treatment
    +in general, non surgical treatment only works well for near XT. it is only applicable for CI association, small angle X(T)(<20pd) and small XT after sugery. Other may not be usefulo for consercutive tx, surgery is necessary then.

    ReplyDelete
  14. As-slm everyone =)

    Next, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally,

    1. Classically defined as a large (30 to 80 PD) constant XT that develops during the first 6 to 12 months of life.
    2. The size of the angle may increase over time.
    3. XT have alternating/unilateral fixation but rare to find amblyopia.
    4. BV assessment is absent/very week
    5. Best treatment is surgery

    Sign and symptoms,

    1. May have coexisting ocular, craniofacial, or sys¬temic abnormalities.
    2. Nearly symptom free (pt already adapt)

    Now I want to stress on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    guys please do add some more comment =))

    ReplyDelete
  15. @The Traveler

    As-slm everyone =)

    Next, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally,

    1. Classically defined as a large (30 to 80 PD) constant XT that develops during the first 6 to 12 months of life.
    2. The size of the angle may increase over time.
    3. XT have alternating/unilateral fixation but rare to find amblyopia.
    4. BV assessment is absent/very week
    5. Best treatment is surgery

    Sign and symptoms,

    1. May have coexisting ocular, craniofacial, or systemic abnormalities.
    2. Nearly symptom free (pt already adapt)

    Now I want to stress on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sensory cause of the XT): ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    guys please do add some more comment =))

    ReplyDelete
  16. Salam to all of you... Here, I want to share some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
     Wide interpupillary distance
     Exophthalmos
     Orbital asymmetry
     Muscle anomalies
     Craniofacial anomalies
     Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into:
    1) Early onset exotropia:
    - constant from time onset
    - usually present in the first year of life
    - happen by alternaring or unilateral
    - binocular vision will absent or very weak.

    2) Decompensated intermittent exotropia
    - decompensation of distance or non-specific intermittent exotropia
    - become constant strabismus
    - patient has marked suppression and no diplopia
    - prognosis for restoration of BSV is good
    - providing exotropia remained intermittent for some years before becoming manifest

    ReplyDelete
  17. nurulhidayah mohamad nordinJanuary 9, 2011 at 10:52 PM

    I would like to share about PRIMARY CONSTANT XT

    It usually develops during the first 6 to 12 months of life.

    It is a large (30 to 80 PD) constant XT.

    Many pt have alternating fixation, therefore rare to find amblyopia.

    Binocular vision is absent or weak.

    The size angle of deviation may increase over time.

    SIGNS
    - A large constant XT, usually associated with alternating fixation is present.
    - Pt may have coexisting ocular (such as cataract or cloudy cornea), craniofacial, or systemic abnormalities.

    DIFFERENTIAL DIAGNOSIS
    - Sensory strabismus: there is an ocular pathology or an amblyogenic factor as the causative agent. Assessment of refractive error and external/internal ocular health assessment can usually rule out this condition.

    - Down syndrome has an associated XT that will result in a different natural history of the XT.

    - Divergence excess XT at young age usually not show strabismus during near testing and will show intermittent strabismus during distance testing.

    Treatment for this case is surgery

    ReplyDelete
  18. Salam to all of you... Here, I want to share some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
    - Wide interpupillary distance
    - Exophthalmos
    - Orbital asymmetry
    - Muscle anomalies
    - Craniofacial anomalies
    - Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into:
    1) Early onset exotropia:
    - constant from time onset
    - usually present in the first year of life
    - happen by alternaring or unilateral
    - binocular vision will absent or very weak.

    2) Decompensated intermittent exotropia
    - decompensation of distance or non-specific intermittent exotropia
    - become constant strabismus
    - patient has marked suppression and no diplopia
    - prognosis for restoration of BSV is good
    - providing exotropia remained intermittent for some years before becoming manifest

    ReplyDelete
  19. Salam to all of you... Here, I want to share some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
    - Wide interpupillary distance
    - Exophthalmos
    - Orbital asymmetry
    - Muscle anomalies
    - Craniofacial anomalies
    - Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into:
    1) Early onset exotropia:
    - constant from time onset
    - usually present in the first year of life
    - happen by alternaring or unilateral
    - binocular vision will absent or very weak.

    2) Decompensated intermittent exotropia
    - decompensation of distance or non-specific intermittent exotropia
    - become constant strabismus
    - patient has marked suppression and no diplopia
    - prognosis for restoration of BSV is good
    - providing exotropia remained intermittent for some years before becoming manifest

    ReplyDelete
  20. Salam to all of you... Here, I want to share some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
    - Wide interpupillary distance
    - Exophthalmos
    - Orbital asymmetry
    - Muscle anomalies
    - Craniofacial anomalies
    - Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into:
    1) Early onset exotropia:
    - constant from time onset
    - usually present in the first year of life
    - happen by alternaring or unilateral
    - binocular vision will absent or very weak.

    2) Decompensated intermittent exotropia
    - decompensation of distance or non-specific intermittent exotropia
    - become constant strabismus
    - patient has marked suppression and no diplopia
    - prognosis for restoration of BSV is good
    - providing exotropia remained intermittent for some years before becoming manifest

    ReplyDelete
  21. @nurulhidayah mohamad nordin

    Next, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    generally had been explained by hidayah

    so I want to add some info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    guys please do add some more comment =))

    ReplyDelete
  22. nurulhidayah mohamad nordinJanuary 10, 2011 at 1:18 AM

    my title more specific on early onset XT =)

    ReplyDelete
  23. Salam to all of you... Here, I want to share some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
    - Wide interpupillary distance
    - Exophthalmos
    - Orbital asymmetry
    - Muscle anomalies
    - Craniofacial anomalies
    - Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into:
    1) Early onset exotropia:
    - constant from time onset
    - usually present in the first year of life
    - happen by alternaring or unilateral
    - binocular vision will absent or very weak.

    2) Decompensated intermittent exotropia
    - decompensation of distance or non-specific intermittent exotropia
    - become constant strabismus
    - patient has marked suppression and no diplopia
    - prognosis for restoration of BSV is good
    - providing exotropia remained intermittent for some years before becoming manifest

    ReplyDelete
  24. Salam to all of you... Here, I want to share some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
    - Wide interpupillary distance
    - Exophthalmos
    - Orbital asymmetry
    - Muscle anomalies
    - Craniofacial anomalies
    - Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into:
    1) Early onset exotropia:
    - constant from time onset
    - usually present in the first year of life
    - happen by alternaring or unilateral
    - binocular vision will absent or very weak.

    2) Decompensated intermittent exotropia
    - decompensation of distance or non-specific intermittent exotropia
    - become constant strabismus
    - patient has marked suppression and no diplopia
    - prognosis for restoration of BSV is good
    - providing exotropia remained intermittent for some years before becoming manifest

    ReplyDelete
  25. the diagram given by Bro Muziman actually helping us alot

    As showed, PRIMARY EXO DEVIATION can be divided into 2 which are:

    * primary intermittent exo
    *primary constant exo

    primary intermittent exo devides into:

    *Distance
    *Near
    *Basic

    i would like to explain about PRIMARY INTERMITTENT DISTANCE EXOTROPIA.

    As the name imply, the degree of XT worse at distance and XP at near.

    pt with this type of exo deviation always complaint:

    *enlarge visual field
    *photophobia
    *closure of one eye in bright light
    *diplopia is uncommon

    PRIMARY INTERMITTENT DISTANCE EXOTROPIA can be further divided into:

    *TRUE DE
    *Pseudo DE (simulated)

    TRUE DE has degree D>N

    eg: (N) XP 15
    (D) RXT 45

    PSEUDO XT is a bit tricky. It mimic true DE but when we suspend the accommadative convergence element, angle for near become larger.


    Accommodative convergence is suspended using +3.00 DS while doing PCT at near.

    OR

    prior to PCT at near, one eye is occluded for at least 2 hours to elicit maximum deviation at near.

    AC/A ratio for PSEUDO XT is high whereas in TRUE DE, the AC/A ratio is normal.

    how to manage this type of patient??

    1) correct refractive error
    myope: Full RX
    hyperope: minimum plus lenses (controversial)

    2) exercise to increase PFV but usually not really effective and time consuming

    3) surgery in case of:

    *increasing angle of tropia (poor fusion)
    *XT manifest >50% of waking hours
    *XT > 20 PD

    ReplyDelete
  26. Salam to all of you... Here, I want to share some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
    - Wide interpupillary distance
    - Exophthalmos
    - Orbital asymmetry
    - Muscle anomalies
    - Craniofacial anomalies
    - Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into:
    1) Early onset exotropia:
    - constant from time onset
    - usually present in the first year of life
    - happen by alternaring or unilateral
    - binocular vision will absent or very weak.

    2) Decompensated intermittent exotropia
    - decompensation of distance or non-specific intermittent exotropia
    - become constant strabismus
    - patient has marked suppression and no diplopia
    - prognosis for restoration of BSV is good
    - providing exotropia remained intermittent for some years before becoming manifest

    ReplyDelete
  27. :) i would like to add some info to huda's topic which is the intermittent exotropia.

    Pros: Advantages of Intermittent Eye Turn
    When the eye turn is only occasional, the visual system (including the brain) still has many opportunities to develop. That is, as long as the eyes are straight some of the time, the brain and two eyes will develop some normal functioning (binocular vision and depth perception). Consequently, good possibilities for the development of improved vision in the future will still be present.

    Cons: Disadvantages of Intermittent Eye Turn
    When the eye turn happens some of the time, but not all the time, the outside observer(s) might conclude that there is no serious problem and fail to seek help. Or they might think the person is simply daydreaming, lazy, or not paying attention. Even worse, without knowing that there is a physical problem, the observer might feel uneasy or mistrustful of the person with intermittent exotropia who gives poor eye contact and comes off as distracted or "shifty-eyed."

    In regards to diagnosis, the intermittent exotropia can also be tough for the eye doctor to catch. For example, the parents might notice the child's occasional eye turn, bring the kid in for an exam, and then the eye doctor won't be able to find it or induce it. In that case, the eye turn is not showing up during the "command performance" of the eye exam because the child is making an extra effort to pay attention, be "on good behavior," please the adults, etc. This in not unlikely with the child who only has the eye turn when fatigued, ill, etc. Miscellaneous clue: children with intermittent exotropia often close their eye in bright sunlight.

    As for the treatment, treatment for intermittent exotropia does not have to occur immediately. Since the brain and eyes work properly some of the time, time is on your side. As a matter of fact, early surgery has the potential of disturbing the ability of the brain for fusion in the future and can cause a permanent reduction in vision (amblyopia).

    Treatment options consist of Vision Therapy, patching, eyeglasses and/or, very rarely, surgery. The most successful form of treatment is in-office supervised Vision Therapy with home reinforcement. Therapy changes the brain and is directed at the cause and cure of the problem. Surgery should be used as a last resort only for the large angle intermittent exotropes and only after in-office Vision Therapy not been as successful as expected. In those cases, surgery will probably only yield cosmetic benefits.

    ReplyDelete
  28. :) hehe. i would like to add to huda's topic which is the intermittent exotropia.

    Pros: Advantages of Intermittent Eye Turn
    - When the eye turn is only occasional, the visual system (including the brain) still has many opportunities to develop.
    - As long as the eyes are straight some of the time, the brain and two eyes will develop some normal functioning (binocular vision and depth perception).
    - Consequently, good possibilities for the development of improved vision in the future will still be present.

    Cons: Disadvantages of Intermittent Eye Turn
    - When the eye turn happens some of the time, but not all the time, the outside observer(s) might conclude that there is no serious problem and fail to seek help. Or they might think the person is simply daydreaming, lazy, or not paying attention.
    - Even worse, without knowing that there is a physical problem, the observer might feel uneasy or mistrustful of the person with intermittent exotropia who gives poor eye contact and comes off as distracted or "shifty-eyed."

    In regards to diagnosis, the intermittent exotropia can also be tough to catch. For example, the parents might notice the child's occasional eye turn, bring the kid in for an exam, and then the eye doctor won't be able to find it or induce it. In that case, the eye turn is not showing up during the "command performance" of the eye exam because the child is making an extra effort to pay attention, be "on good behavior," please the adults, etc. This in not unlikely with the child who only has the eye turn when fatigued, ill, etc. Miscellaneous clue: children with intermittent exotropia often close their eye in bright sunlight.

    ReplyDelete
  29. Nor Arifah ZakariaJanuary 10, 2011 at 3:34 PM

    dear frens!!
    i already done the explaination bout primary intermittent exotropia- Etiology & mechanism...

    hpefully, we will more understnd more bout this deviation...

    click on this link yaa~~~

    COMPULSORY!!..huhuhu


    http://syah916.blogspot.com/2011/01/exotropia.html

    ReplyDelete
  30. @Nor Arifah Zakaria

    baik la chu..

    http://syah916.blogspot.com/2011/01/exotropia.html

    atuk akan buka

    ReplyDelete
  31. y i had problem in posting this post??? =((

    As-slm everyone =)

    Next, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally it had been explained by HIDAYAH,

    It can be classified into 2:
    1. Primary infantile XT; constant and early onset
    2. Secondary infantile XT; ocular disease and sytemic disease


    So I want to add info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    guys please do add some more comment =))

    ReplyDelete
  32. y i can post comment here!! arrggghhh so many time i had try =((

    ReplyDelete
  33. At LAST…huhu

    Here everyone, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally it had been explained by HIDAYAH,

    It can be classified into 2:
    1. Primary infantile XT; constant and early onset
    2. Secondary infantile XT; ocular disease and sytemic disease


    So I want to add info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    guys please do add some more comment =))

    ReplyDelete
  34. At LAST…huhu

    Here everyone, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally it had been explained by HIDAYAH,

    It can be classified into 2:
    1. Primary infantile XT; constant and early onset
    2. Secondary infantile XT; ocular disease and sytemic disease


    So I want to add info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    ReplyDelete
  35. @The Traveler

    At LAST…huhu

    Here everyone, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally it had been explained by HIDAYAH,

    It can be classified into 2:
    1. Primary infantile XT; constant and early onset
    2. Secondary infantile XT; ocular disease and sytemic disease

    So I want to add info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    ReplyDelete
  36. At LAST…huhu

    Here everyone, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally it had been explained by HIDAYAH,

    It can be classified into 2:
    1. Primary infantile XT; constant and early onset
    2. Secondary infantile XT; ocular disease and sytemic disease

    So I want to add info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    ReplyDelete
  37. @The Traveler

    At LAST…huhu

    Here everyone, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally it had been explained by HIDAYAH,

    It can be classified into 2:
    1. Primary infantile XT; constant and early onset
    2. Secondary infantile XT; ocular disease and sytemic disease


    So I want to add info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    ReplyDelete
  38. At LAST…huhu

    Here everyone, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally it had been explained by HIDAYAH,

    It can be classified into 2:
    1. Primary infantile XT; constant and early onset
    2. Secondary infantile XT; ocular disease and sytemic disease

    ReplyDelete
  39. At LAST…huhu

    Here everyone, let’s have a look on INFANTILE/CONGENITAL XT a.k.a EARLY ONSET XT.

    In generally it had been explained by HIDAYAH,

    It can be classified into 2:
    1. Primary infantile XT; constant and early onset
    2. Secondary infantile XT; ocular disease and sytemic disease


    So I want to add info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    ReplyDelete
  40. continue........
    So I want to add info on how to workout such of this cases,

    1. History: Onset/frequency of deviation/complications during the pregnancy/perinatal/postnatal periods

    2. Measurement of visual acuity:
    a. Infants: Preferential Looking method (Teller Acuity cards)
    b. Preschool-aged children: Lea symbols or Broken Wheel cards.
    c. School-aged children: Snellen chart/Log MAR.
    d. For all ages: observing the patient's monocular/binocular fixation pattern

    3. Assessment of deviation: Measure magnitude at distance vs. near, laterality, concomitancy, and frequency:
    a. Infants and toddlers: Cover test, Hirshberg and Bruckner tests and versions.
    b. Older children/Adults: Cover test, Hirshberg test

    4. Cycloplegic refraction: Mandatory in all cases

    5. Slit-lamp evaluation (sen¬sory cause of the XT) : ex: Cataracts, vitreal opacity, RD, toxoplasmosis/ anomalous optic nerve (hypoplasia)

    ReplyDelete
  41. mohd naim bin rahimJanuary 10, 2011 at 7:14 PM

    salam'alaik..
    sir and fellow friend, i'm so sorry for the late response..
    just have a chance to read this post...
    erm, i'n not so sure what topic that i should post..

    ok, let's try...

    insyaallah, after 'isyak, i will touch a little bit about the treatment of CONSECUTIVE EXOTROPIA..

    ReplyDelete
  42. salam..:)

    Wou..so detail..good2..

    i juz wanna add some..for intermittent divergence excess(DE), it can be divided into True DE and Simulated..But how we gonna differentiate? there are 2 ways, either with +3.00DS or patching..

    The purpose of +3.00D to exclude the accommodation, because in simulated, the AC/A ratio is high..and it is done only at near..

    The 2nd is patching..the purpose is to suspend the fusion in order to have maximum deviation. so, in simulated, the deviation will increase..

    Some more..how to differentiate between near exo and Convergence Palsy Just put small amount of BO prism and look if the eye is response to the prism. If does, it is near exo, but if no response, it is convergence palsy.

    hmm..what else? for constant..the management usually depend on the BSV potential and the stereopsis as well..surgery is the last choice if the consecutive treatment does not work...usually the decompensated heterophoria can become constant..pt with this type usually still has BSV and the stereopsis..for early onset or infatile..the BSV is poor or maybe no BSV..

    Hope u guys understand..huhuk..

    ReplyDelete
  43. Huh... I'm so sorry i can't keep track of all the comments.. If I tend to repeat some, pliz ignore eh...

    1) Just wanna share on the prevalence of exodeviation cases. In cases of exodeviation it rarely occurs on those of young ages such as babies and toddlers except in deviation due to neurogenic cause.

    2) In terms of management, when surgery is needed to be done in young patients thet cannot be corrected with either Rx nor Orthoptics theraphy, surgeon usually consider surgery when they are a bit older and will make it become slightly eso considering that the eye will become slightly exo due to the development of the eye when the patient become older.

    I hope you'll understand my 'omongan'

    ReplyDelete
  44. Farah Nadianah JoharJanuary 10, 2011 at 8:03 PM

    Salam..i would like to add some information on huda and hanani's topic.

    In intermittent exotropia, three types may be seen.

    1) Divergence excess
    On cover/uncover test for near fixation, the eye is orthophoric but on alternating cover test, there is a large exophoria which recovers slowly. With distant fixation, the eye shows exotropia which becomes straight after one or two blinks. The exotropia increases on alternating cover test.

    2) Convergence weakness
    In this condition, the exotropia is worse with near fixation.

    3) Basic
    The magnitude of the exotropia is the same for near and distant fixation.


    Other examination:

    - mention that you would like to perform ocular motility. Patients usually has a V pattern ie. the exotropia increases on upgaze
    -if the patient has constant exotropia mention that you would like to test the visual acuity. The exotropia may be secondary to poor vision

    -in patients with evidence of DVD (dissociated vertical deviation) during the cover/uncover test consider the possibility of consecutive exotropia and examine the eye for previous squint surgery (conjunctival scar).

    ReplyDelete
  45. ahaa..impressive discussions u guys.. i will explain about SECONDARY EXOTROPIA :

    Certain conditions, such as third nerve palsy, thyroid ophthalmopathy, and iatrogenic trauma following retinal detachment surgery or endoscopic sinus surgery, could cause acquired/secondary exotropia.

    The most important aspect of the management is to find and/or eliminate and/or reverse a treatable cause of the exotropia. Prisms and botulinum toxin injections do not play a significant role in the treatment of sensory deviation.

    Exotropia with neurologic causes and field defects :

    Exotropia with bilateral homonymous visual field defects: Nonsurgical methods of treatment, such as patching, prisms, or botulinum toxin injections, should be tried before surgical realignment.

    Exotropia with bitemporal visual field defects: Nonsurgical treatment includes the use of prisms to increase the separation of images and to avoid diplopia without sacrificing the total visual field.

    ReplyDelete
  46. norhafizah abdul nasirJanuary 10, 2011 at 8:22 PM

    Exotropia is a condition in which one eye deviates outwards. It can be classified as primary, secondary and consecutive. I will expalain about primary exotropia. In primary type, it is divided into intermittent and constant.
    Intermittent exotropia occurs when the eyes may be diverged at times but aligned at others. It is divided into divided into distance exotropia, near exotropia and non specific(basic). In distance exotropia, exotropia is manifest at near and exophoria will present at near fixation. It can be subdivided into true divergence excess and simulated of pseudo divergence excess. True divergence excess occurs when the angle is significantly greater at distance. This type is associated with high AC/A ratio and anatomical anomalies. While simulated of pseudo divergence excess occurs when exotropia at first appear greater at distance fixation but increase on near fixation when accommodative convergence is eliminated or when fusion is suspended. Patient who demonstrates an increase in angle for near fixation on occlusion or with plus lenses are describes as simulated distances types and these are characterized by an increase in angle of greater than 10Δ for near fixation with +3.00D lens. The deviation may appear controlled initially for distance but decompensate quickly on dissociation. Management for this type of exotropia are full correction of any myopic refractive error, undercorrection of any hyperopia, orthoptics exercise for small deviations (<15Δ), base in prisms, tinted lenses and possibly surgery.
    In near exotropia, an exotropia is present on near fixation with binocular single vision on distance fixation although there may be exophoria at distance. Onset is usually late and may be associated with myopia or presbyopia. It is common among young people with decompensating exophoria who present with diplopia and asthenopic symptoms. Management for this type includes correction of refractive errors, orthoptics exercises, base in prisms and rarely surgery. The last type under primary exotropia is non-specific/basic type. This is characterized by a manifested divergent strabismus that occurs at any distance and at any time. The size of deviation does not change with fixation distance and causes can be any of those described for the near and distance types as well as poor fusional ability. Surgery is often the only management option.
    Constant exotropia is divided into early onset exotropia and decompensated intermittent exotropia. Early onset exotropia occurs when exotropia is constant from time of onset. It is usually present in first year of life. It may associated with absence of binocular vision or BV is very weak. In decompensated intermittent exotropia occurs when decompensation of distance or non specific exotropia. Patient is usually has marked suppression and no diplopia. The main treatment for this type of exotropia is surgery and use of Botulinum toxin A may be an alternative.

    ReplyDelete
  47. here i provide a link to an article about INCIDENCE AND TYPES OF CHILDHOOD EXOTROPIA. it might be useful to us.

    http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6VT2-4DW8TFM-H-3&_cdi=6278&_user=565570&_pii=S0161642004012965&_origin=search&_coverDate=01/01/2005&_sk=998879998&view=c&wchp=dGLbVlW-zSkWA&md5=56fef1be21441538a42989ab506da2e5&ie=/sdarticle.pdf

    mana 4th year yg lain ni?come on ;)

    ReplyDelete
  48. norhafizah abdul nasirJanuary 10, 2011 at 8:24 PM

    Exotropia is a condition in which one eye deviates outwards. It can be classified as primary, secondary and consecutive. I will expalain about primary exotropia. In primary type, it is divided into intermittent and constant.
    Intermittent exotropia occurs when the eyes may be diverged at times but aligned at others. It is divided into divided into distance exotropia, near exotropia and non specific(basic). In distance exotropia, exotropia is manifest at near and exophoria will present at near fixation. It can be subdivided into true divergence excess and simulated of pseudo divergence excess. True divergence excess occurs when the angle is significantly greater at distance. This type is associated with high AC/A ratio and anatomical anomalies. While simulated of pseudo divergence excess occurs when exotropia at first appear greater at distance fixation but increase on near fixation when accommodative convergence is eliminated or when fusion is suspended. Patient who demonstrates an increase in angle for near fixation on occlusion or with plus lenses are describes as simulated distances types and these are characterized by an increase in angle of greater than 10Δ for near fixation with +3.00D lens. The deviation may appear controlled initially for distance but decompensate quickly on dissociation. Management for this type of exotropia are full correction of any myopic refractive error, undercorrection of any hyperopia, orthoptics exercise for small deviations (<15Δ), base in prisms, tinted lenses and possibly surgery.
    In near exotropia, an exotropia is present on near fixation with binocular single vision on distance fixation although there may be exophoria at distance. Onset is usually late and may be associated with myopia or presbyopia. It is common among young people with decompensating exophoria who present with diplopia and asthenopic symptoms. Management for this type includes correction of refractive errors, orthoptics exercises, base in prisms and rarely surgery. The last type under primary exotropia is non-specific/basic type. This is characterized by a manifested divergent strabismus that occurs at any distance and at any time. The size of deviation does not change with fixation distance and causes can be any of those described for the near and distance types as well as poor fusional ability. Surgery is often the only management option.
    Constant exotropia is divided into early onset exotropia and decompensated intermittent exotropia. Early onset exotropia occurs when exotropia is constant from time of onset. It is usually present in first year of life. It may associated with absence of binocular vision or BV is very weak. In decompensated intermittent exotropia occurs when decompensation of distance or non specific exotropia. Patient is usually has marked suppression and no diplopia. The main treatment for this type of exotropia is surgery and use of Botulinum toxin A may be an alternative.

    ReplyDelete
  49. Salam to all of you...Since many of our friends above had shared about primary exotropia, so here, I want to add up some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
    - Wide interpupillary distance
    - Exophthalmos
    - Orbital asymmetry
    - Muscle anomalies
    - Craniofacial anomalies
    - Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into:
    1) Early onset exotropia:
    - constant from time onset
    - usually present in the first year of life
    - happen by alternaring or unilateral
    - binocular vision will absent or very weak.

    2) Decompensated intermittent exotropia
    - decompensation of distance or non-specific intermittent exotropia
    - become constant strabismus
    - patient has marked suppression and no diplopia
    - prognosis for restoration of BSV is good
    - providing exotropia remained intermittent for some years before becoming manifest

    ReplyDelete
  50. Salam to all of you...Since many of our friends above had shared about primary exotropia, so here, I want to add up some informations about primary constant exotropia. It is a divergent deviation that constitutes the initial defect, which is constantly present under all conditions. Anatomical causes include:
    - Wide interpupillary distance
    - Exophthalmos
    - Orbital asymmetry
    - Muscle anomalies
    - Craniofacial anomalies
    - Can be associated with myopia
    It often commences as an intermittent deviation, which then becomes constant with time. The deviation may increase in size when the patient is in bright sunlight, and presentation is with a history of closing one eye and photophobia. If the deviation is alternating, visual acuity can be equal. However, it is less common than intermittent exotropia. The primary constant exotropia can be divided into early onset exotropia and decompenasted intermittent exotropia like hafizah had explained above.

    ReplyDelete
  51. NOR ARIFAH BT ZAKARIAJanuary 10, 2011 at 10:17 PM

    @Nur Hanani Hamdan

    opto frens!

    if u guy notice, nani, huda and i did explained bout primary intermittent ET...

    huda has explained bout some CHARACTERISTIC..

    i did exlpained bout the why those characteristic huda's explained happen theoritically and based study research...

    while nani, besh nye...nani did discuss bout pro and cons of intermittent itself..(really interesting!)


    just to let our open discussion here organise little...since too many word here~~hee~~


    ENJOY READING!

    ReplyDelete
  52. @NOR ARIFAH BT ZAKARIA


    typing error--- above statement..not eso but XT actually..

    hee~ (^_^)v

    ReplyDelete
  53. @NOR ARIFAH BT ZAKARIA


    typing error--- above statement..not eso but XT actually..

    hee~ (^_^)v

    ReplyDelete
  54. Nurul Athirah HarunJanuary 10, 2011 at 11:01 PM

    Assalamualaikum… I would like to add some info from what kak che nur have said about True DE and Simulated. But I will only state about Simulated Divergence Excess.. it could be subdivided into 2 categories which are:

    a)High tonic convergence type
    Complete occlusion of one year for 30-40 minutes may reveal an increase of the near exodeviation to approximately equal the distance deviation. Before removing the occluding patch , cover the other eye with a hand-held orthoptic occlude. Remove the patch and replace it with a prism with a least strength of the distance deviation in place. Perform the prism cover test to measure the angle for near vision using an accommodative target at 33cm. equality of distance and near deviations indicate a different surgical approach: true divergence excess may require recession of both lateral rectus muscles. The high tonic convergence type of simulated divergence excess will be treated as a basic exotropia , by lateral rectus resection and medial rectus resection of the deviating eye.

    b)Hifh accommodative convergence type
    Measurement of the near angle through binocular +3.00DS lenses will markedly increase the exodeviation to the level of the distance angle in patients with a high AC/A ratio. In this case, opinion appears divided as to surgical management. For non-surgical both true and simulated divergence excess will present a better prognosis than basic exotropia as the patient is closer to good control at near fixation. Also, the variable angle of deviation precludes deep anomalous correspondence. In particular a high AC/A ratio enables considerable manipulation of the deviation with lenses.

    ReplyDelete
  55. Nurul Athirah HarunJanuary 10, 2011 at 11:01 PM

    Assalamualaikum… I would like to add some info from what kak che nur have said about True DE and Simulated. But I will only state about Simulated Divergence Excess.. it could be subdivided into 2 categories which are:

    a)High tonic convergence type
    Complete occlusion of one year for 30-40 minutes may reveal an increase of the near exodeviation to approximately equal the distance deviation. Before removing the occluding patch , cover the other eye with a hand-held orthoptic occlude. Remove the patch and replace it with a prism with a least strength of the distance deviation in place. Perform the prism cover test to measure the angle for near vision using an accommodative target at 33cm. equality of distance and near deviations indicate a different surgical approach: true divergence excess may require recession of both lateral rectus muscles. The high tonic convergence type of simulated divergence excess will be treated as a basic exotropia , by lateral rectus resection and medial rectus resection of the deviating eye.

    b)Hifh accommodative convergence type
    Measurement of the near angle through binocular +3.00DS lenses will markedly increase the exodeviation to the level of the distance angle in patients with a high AC/A ratio. In this case, opinion appears divided as to surgical management. For non-surgical both true and simulated divergence excess will present a better prognosis than basic exotropia as the patient is closer to good control at near fixation. Also, the variable angle of deviation precludes deep anomalous correspondence. In particular a high AC/A ratio enables considerable manipulation of the deviation with lenses.

    ReplyDelete
  56. Nurul Athirah HarunJanuary 10, 2011 at 11:01 PM

    Assalamualaikum… I would like to add some info from what kak che nur have said about True DE and Simulated. But I will only state about Simulated Divergence Excess.. it could be subdivided into 2 categories which are:

    a)High tonic convergence type
    Complete occlusion of one year for 30-40 minutes may reveal an increase of the near exodeviation to approximately equal the distance deviation. Before removing the occluding patch , cover the other eye with a hand-held orthoptic occlude. Remove the patch and replace it with a prism with a least strength of the distance deviation in place. Perform the prism cover test to measure the angle for near vision using an accommodative target at 33cm. equality of distance and near deviations indicate a different surgical approach: true divergence excess may require recession of both lateral rectus muscles. The high tonic convergence type of simulated divergence excess will be treated as a basic exotropia , by lateral rectus resection and medial rectus resection of the deviating eye.

    b)Hifh accommodative convergence type
    Measurement of the near angle through binocular +3.00DS lenses will markedly increase the exodeviation to the level of the distance angle in patients with a high AC/A ratio. In this case, opinion appears divided as to surgical management. For non-surgical both true and simulated divergence excess will present a better prognosis than basic exotropia as the patient is closer to good control at near fixation. Also, the variable angle of deviation precludes deep anomalous correspondence. In particular a high AC/A ratio enables considerable manipulation of the deviation with lenses.

    ReplyDelete
  57. wah, i think this is not a discussion but more to presentation. so i think i want add something in divergence excess. for this patient they may complain of occasional diplopia at distance. and they will learn how to supress, to avoid diplopia. divergence excess is a condition which there is a high AC/A ratio.
    for management, because of the high AC/A ratio, an over correction of minus power will reduce the exophoria at distance but will create an esophoria at near unless they use bifocals. base in prism also can be used at distance but also will give esophoria at near.

    wallahu alam..

    ReplyDelete
  58. @muhamad zulhusni ok. how about we discuss about this.

    a 13 year old child has 12 prism dioptres alternating exotropia for distance, and 6prism (compensated) exophoria for near with good streopsis.

    question:
    1) what will be the visual acuities
    2)does the child need treatment
    3)will the child have suppression or ARC for distance vision? how will this affect treatment
    4)how would you modify Rx to control the tropia?
    5) alternatively could prism be prescribed to control tropia?
    6)which of the following could be used to improve the positive fusional reserve: three card streocard, holmes streoscope and Bradford streocard?

    ReplyDelete
  59. i just want add some more...maybe related to the rectus muscle..as we know that exotropia can be cause by the defect on 3rd nerve palsy.. usually this will be unilateral,may be cause by birth injury,head injury,hypertension and compression by posterior communicating artery aneurysm..if the 3rd nerve palsy(oculomotor)is completely defect,it surely affects all extra and intra ocular muscle,so that the eye will not just become exotopia but also ptosis,mydriasis,loss of pupil reaction, accommodation and etc.

    ReplyDelete
  60. eh, where my other comments??? sir delete post sy ke.. haha..

    ReplyDelete
  61. zahirah said "surgeon usually consider surgery when they are a bit older"..is there any exact age which surgeon will perform surgery to the patients?..4?5?or 6 years old?.. anyone??

    ReplyDelete
  62. or maybe why surgeon need to wait until they are a bit older???huhu..

    ReplyDelete
  63. @shahril

    there is no specific age for a surgery to be done in exotropia case. but usually for children, the surgeon will wait until the patient is old enough to perform the surgery..this is because children facial's bone is still grow..thus, if the surgery is done now, the eye will still deviate out as the globe is getting bigger as the patient grow up...

    however, there is another opinion, the surgeon will over correct the exotropia to become more eso, so that later the eye will align in primary position..

    p/s: correct me if i'm wrong..anybody can add some more regarding this surgery procedure...teehee

    ReplyDelete
  64. @muhamad zulhusni

    haha...betu tu. masing kejar masa

    ReplyDelete
  65. i can't find any discussion among each of u..Do you understand word of 'discussion'..please discuss something la..I dun want everyone open your own topic...

    please raise a hot topic of exotropia n discuss..I extend deadline until next Tuesday..pls start discuss from now...not I day b4 deadline baru la terhegeh2 nak join...come on..you are Y3 n Y4 now..

    ReplyDelete
  66. Salam’alaik…

    ..continue with my short notice just now..

    Possible treatment for consecutive esotropia

    1) reduction of the hyperopic correction/ use overcorrecting minus lenses

    - as you already know, this technique will stimulate ACCOMODATION and can help CONTROL the consecutive XT.
    - it maybe successful in YOUNGER CHILDREN. in presbyopic patient, this treatment is not highly succeed due to acuity compromise
    - trial frame with reduced olus correction and an examination of the effect on distance/near acuity, along with a cover test, cab be a guide for determining the correct prescription.

    p/s: this method may be more successful in patient with high AC/A ratio

    2) vision therapy

    - practitioner may consider to do vision therapy when once it has been demonstrated that only the angle of turn has increased and that one is in fact dealing with a case of consecutive XT.
    - a primary-care optometrist who does little VT should not consider performing this therapy to the patients. it is because incorrect manner when performing the VT will result in interactable diplopia.
    - Most therapist, after thorough evaluation, will consider using techniques to develop and improve peripheral fusion.
    - As peripheral fusion skills improve, careful attention to improvement of monocular skills and further reduction (or increased control) of the angle will be considered.

    p/s : in this level, the goal of the treatment is most likely to be a small angle strabismus that is not cosmetically noticeable with excellent peripheral fusion and reasonable accommodative skills.

    ReplyDelete
  67. Hot topic on exotropia..hmm...

    I have one thing in mind regrading the treatment of exotropia, specifically true DE (divergence excess type).

    One of the option for treatment is overminus lens right?

    We know that this will stimulate accommodation and accommodative convergence component will help patient to overcome the DE, hence the eye will hopefully align.

    In other words, patients under overminus therapy 'extra-accommodate'.

    However, it is known that accommodation is a factor in the progression of myopia.


    Therefore should we worry on myopia progression for patients treated with overminus therapy?

    If it is true that overminus therapy cause myopia progression, surely patients or their guardian would resist this treatment.

    Just a thought and concern since we have been giving overminus therapy before.

    Lets discuss if this is appropriate for a discussion.

    ReplyDelete
  68. @nazaryna

    good topic nana..one of the conservative treatment for DE is overminus lens. Best resuts usually obtained with pt who has small deviation (<20 PD).

    based on Erik M. Weissberg, overminus tx mau not cause additional mypoia. Thus, we did not need to worry about the progression of myopia as our main concern now is pt's vision and their eyes alignment.

    ReplyDelete
  69. mohd faiz mohd haseriJanuary 11, 2011 at 11:06 AM

    Sorry for the late submission any comment here due to unhealthy condition in several days.. i would like to share about non-specific exotropia...
    1. This kind of exotropia shows intermittent binocular single vision not conforming to any pattern.
    2. The patient will have symptoms of headache, asthenopia, and intermittent diplopia usually by older patients.
    3. VA will show equal as the deviation is intermittent.
    4. Cover Test- the deviation is intermittently manifested at any fixation distance and there is no significant change in the angle of deviation for near or distance fixation.
    5. In term of management, surgery is main option involves unilateral lateral rectus recession and medial rectus resection procedure.

    ReplyDelete
  70. Exotropia is a condition on which one eye or the other eye deviates outward. Sign of exotropia include nasally displaced corneal reflection during Hirschberg test.
    XT are categorized into three; primary, consecutive following a primary ET and secondary to severe visual loss.
    Primary XT can either be intermittent or constant. Further classifications of intermittent XT are distance, basic and near XT. Intermittent X(T) commonly present in child after the age of 1 year. This usually started with large XP which become decompensated which later manifested into a tropia. Once XT become manifested, the condition could become constant.
    Patient with distance XT will be presented with XT at distance and XP at near. It is then further classified into true divergence excess whereby angle at distance greater than angle of near and stimulated or pseudo divergence excess. XT in stimulated divergence excess appear greater at distance initially. However the angle of deviation at near increases once accommodative convergence is suspended by means of +3.00D lens.
    Moving on, the basic XT occurs when the difference in deviation for distance and near are within 10 PD. Basic XT can be either intermittent or constant. As for the near XT, patient would have XT at near and XP in the distance.
    Secondary XT also known as sensory XT. This are usually associated with monocular blindness or dense amblyopia. Last but not least is the consecutive XT occurring after strabismus surgery. Patient had initially undergone surgery to correct ET, however postoperatively the eye become XT.

    Primary XT- Distance XT

    1) etiology
    Identified during first few year of life. XT become more apparent when pt is inattentive, have poor health, fatigue, alcohol intake and exposure to bright sunlight.

    2) diferential diagnosis
    -Basic XT
    -Pseudo divergence excess
    -Sensory strabismus
    -Sudden-onset XT

    3) symptoms
    -photophobia
    -asthenopic
    -diplopia (rarely)

    4) clinical manifestation/signs
    -XT greater at distance than at near
    -associated vertical phoria / tropia
    -XT of V pattern
    -have NRC when eyes are align
    -During deviation, pt would have NRC with suppression or ARC.
    -High AC/A ratio

    5) management and prognosis
    -Therapy
    -Surgery

    Primary XT-Infantile/ Congenital XT

    1) etiology
    Very rare and develop during 6 to 12 months of life. Pt would have alternating fixationg therefore amblyopia is rare.

    2) diferential diagnosis
    -Sensory strabismus
    -Related to genetic condition sucha s Down syndrome.
    -Divergence excess XT

    3) symptoms
    -parent address for the cosmetic concern.

    4) clinical manifestation/signs
    -Large constant XT (alternating fixation)
    -Coexisting ocular, craniofacial or systemic abnormalities

    5) management and prognosis
    -Surgery

    ReplyDelete
  71. mohd faiz mohd haseriJanuary 11, 2011 at 1:38 PM

    Sorry for the late submission any comment here due to unhealthy condition in several days...uhuk2.. i would like to share about non-specific exotropia...

    1. This kind of exotropia shows intermittent binocular single vision not conforming to any pattern.
    2. The patient will have symptoms of headache, asthenopia, and intermittent diplopia usually by older patients.
    3. VA will show equal as the deviation is intermittent.
    4. Cover Test- the deviation is intermittently manifested at any fixation distance and there is no significant change in the angle of deviation for near or distance fixation.
    5. In term of management, surgery is main option involves unilateral lateral rectus recession and medial rectus resection procedure.

    ReplyDelete
  72. mohd faiz mohd haseriJanuary 11, 2011 at 1:43 PM

    Sorry for the late submission any comment here due to unhealthy condition in several days...uhuk2.. i would like to share about non-specific exotropia...
    1. This kind of exotropia shows intermittent binocular single vision not conforming to any pattern.
    2. The patient will have symptoms of headache, asthenopia, and intermittent diplopia usually by older patients.
    3. VA will show equal as the deviation is intermittent.
    4. Cover Test- the deviation is intermittently manifested at any fixation distance and there is no significant change in the angle of deviation for near or distance fixation.
    5. In term of management, surgery is main option involves unilateral lateral rectus recession and medial rectus resection procedure.

    ReplyDelete
  73. @nurlizzz

    i forgot how to calculate the power using minus lens.we can use Sheard's criterion right?

    what do u guys think about my topic then? SECONDARY XT?

    ReplyDelete
  74. Exotropia is a condition on which one eye or the other eye deviates outward. Sign of exotropia include nasally displaced corneal reflection during Hirschberg test.
    XT are categorized into three; primary, consecutive following a primary ET and secondary to severe visual loss.
    Primary XT can either be intermittent or constant. Further classifications of intermittent XT are distance, basic and near XT. Intermittent X(T) commonly present in child after the age of 1 year. This usually started with large XP which become decompensated which later manifested into a tropia. Once XT become manifested, the condition could become constant.
    Patient with distance XT will be presented with XT at distance and XP at near. It is then further classified into true divergence excess whereby angle at distance greater than angle of near and stimulated or pseudo divergence excess. XT in stimulated divergence excess appear greater at distance initially. However the angle of deviation at near increases once accommodative convergence is suspended by means of +3.00D lens.
    Moving on, the basic XT occurs when the difference in deviation for distance and near are within 10 PD. Basic XT can be either intermittent or constant. As for the near XT, patient would have XT at near and XP in the distance.
    Secondary XT also known as sensory XT. This are usually associated with monocular blindness or dense amblyopia. Last but not least is the consecutive XT occurring after strabismus surgery. Patient had initially undergone surgery to correct ET, however postoperatively the eye become XT.

    Primary XT- Distance XT

    1) etiology
    Identified during first few year of life. XT become more apparent when pt is inattentive, have poor health, fatigue, alcohol intake and exposure to bright sunlight.

    2) diferential diagnosis
    -Basic XT
    -Pseudo divergence excess
    -Sensory strabismus
    -Sudden-onset XT

    3) symptoms
    -photophobia
    -asthenopic
    -diplopia (rarely)

    4) clinical manifestation/signs
    -XT greater at distance than at near
    -associated vertical phoria / tropia
    -XT of V pattern
    -have NRC when eyes are align
    -During deviation, pt would have NRC with suppression or ARC.
    -High AC/A ratio

    5) management and prognosis
    -Therapy
    -Surgery

    Primary XT-Infantile/ Congenital XT

    1) etiology
    Very rare and develop during 6 to 12 months of life. Pt would have alternating fixationg therefore amblyopia is rare.

    2) diferential diagnosis
    -Sensory strabismus
    -Related to genetic condition sucha s Down syndrome.
    -Divergence excess XT

    3) symptoms
    -parent address for the cosmetic concern.

    4) clinical manifestation/signs
    -Large constant XT (alternating fixation)
    -Coexisting ocular, craniofacial or systemic abnormalities

    5) management and prognosis
    -Surgery

    ReplyDelete
  75. interesting topic nana..overminusing therapy in DE patient..
    but worried if overminusing lead to stimulate more accommodation, thus lead to myopic progression...
    hmm...how about if we prescribe bifocal?

    as Prof Azrin said on last weekend, Carl Zeiss and Essilor come out with a lens that they claimed to be lens to control myopic progression.. that is actually PAL design.

    ReplyDelete
  76. @eli aimi

    Overminus? We do not apply calculation of Sheard (only for phoria case)..but we still apply his rules..he said, to overcome the Exo deviation, the PFV must at least double from Exo deviation magnitude

    ReplyDelete
  77. @hidayah

    DE: exo greater at distance than near..

    So, the PALs will give two benefits;

    1. Control the deviation
    2. Control myopia progression

    But be careful, please re-check pt's near exo b4 prescribe PALs Rx

    ReplyDelete
  78. sir muziman..sorry for the late response..uhh( sweating)...too many wordy..and i'm bit confius to choose a topic discuss on or to arise a hot topic one..

    so now i'm still reading/ annalyse ur blog and comment from the classmate and senior..hee~

    ReplyDelete
  79. NOR ARIFAH BT ZAKARIAJanuary 17, 2011 at 12:05 AM

    i just read some article bout exotropia...

    * cass 1937 :
    women develop exotropia more commonly than a men

    *eustace et al., 1973, romano, 1990, MacFarlane 1960:
    relationship b/n exotropia and sunlight exposure

    -intermittent exotropia is more common in latitudes where the higher levels of sunlight

    haha..in simpler,those researcher said so coz bright illumination forces patients t close one eyes~


    though, this already 2011..many year had pass by..but yet no new research against this study...


    sound intersting and logic too...

    hehe...

    ReplyDelete
  80. salam..
    Actually, I just come across with a case of V-pattern manifestation.Would somebody share with me in what case we can see V-exotropia?

    ReplyDelete
  81. @The Traveler

    tq sir, for sharing information..n reminding on near exo before prescribe PALs RX.

    ReplyDelete
  82. @nazaryna

    I'd love to share about the myopia control.

    from what I've learnt in a seminar given given by Prof Brien Holden, myopia progession is only occured in people in age of <15 yo.

    meaning to say, we just have to worry in prescribing over-minus on this group of people. Others will not get affected by over minus prescription.

    ReplyDelete
  83. @hidayah

    Bifocal is one of the option that has been used for myopia control. It needs a consistency of wearing. Of course full time use. Otherwise it'll not be helpful. i've been informed that the use of bifocal is not clinically significant in controlling myopia.

    Same goes to PALs. Patient with poor compliance is not a good candidate in such way.

    ReplyDelete
  84. @The Traveler

    sir muzi, if I may... em...why we need to be careful bout the near Exo in prescibing them with PALs?

    ReplyDelete
  85. @rohaila

    hey, V-pattern always remind me on Brown's syndrome!

    is there anyone want to add some info?

    ReplyDelete
  86. since you guys have come out with myopia control topic. I'd like to post/share with you some options that can be used in controlling myopia other that bifocal/PALs. It may be useful for us later.

    Sir, can I write it in new post?

    ReplyDelete
  87. NOR ARIFAH ZAKARIAJanuary 17, 2011 at 9:22 PM

    kak ela..hehe..V-exotropia tu same with divergent vertical deviation ke?

    DVD is result from the hyperfuction of superior Rectus muscle ea?

    then pt DVD x de specific symtoms kn? just sometimes patient aware the eye rotated up, esp when fatigue, illness or lack concentration.


    nut actually V-exotropia tu DVD ke?

    ReplyDelete
  88. NOR ARIFAH BT ZAKARIAJanuary 17, 2011 at 10:11 PM

    @rohaila

    cop2..or i'm may be worng (my previous statement)...huhu..


    V-exotropia could be inferior oblique(IO) over-action kn?

    but for DVD there will be no A or V pattern kn? but DVD will show eye torsion .....


    kak ela..reply yee~..heee~~what a confiusion..

    ReplyDelete
  89. salam..hye everyone..:)
    sorry i missed the train..
    br jumpe post ni..b4 ni just on kt case discussion je..huhuhu..

    wah, lot of thing hv been discuss here..but I can't follow all the post..soooo muuuch words yg tiada titik penghujung...pening2..huhu..but gud try, insyaallh ad ms i try digest..huhuhu

    here i want to share something regarding rohaila's question about V pattern (but not sure will help or not..enlighten me if i'm wrong) :

    v pattern much relates on relative divergence on up gaze(V-Exotropia)and relative convergence on down gaze (V-Esotropia).. but here, i just want to share regarding V-Exotropia..

    myb due to:
    -o/a MR -> more add on depression.
    -u/a LR -> more abd on elevation
    -o/a IO -> more add on dep.
    -u/a SR -> more abd on elev.

    describe by Neepa Thecker;2009, said that V-patterns are acquired after superior oblique muscle palsy and are a prominent feature of bilateral superior oblique muscle palsies.

    in US, research shows that: Although the exact prevalence of V-pattern strabismus in a given population is not known, 12.5-50% of patients with horizontal strabismus have an associated A- or V-pattern. V-pattern esotropia is not as commonly seen as V-pattern exotropia...

    ReplyDelete
  90. nurulhuda abd latifJanuary 18, 2011 at 10:40 AM

    @Zanariah Muda

    i would to add some info here. i'm come across about this, the experts said that treatment for this condition should be early and aggressive.
    If the eye turn is constant and simple things like patching, drops, and/or glasses (bifocal, prismatic, etc) do not eliminate the eye turn.
    or else we should consider for Vision Therapy, Orthoptics, or Surgery.

    ReplyDelete
  91. @rohaila

    Kak ela.. I have read about this cases who has V-pattern.

    Patients with CRANIOSYNOSTOSIS

    Mean that pt has shallow orbits, related to anatomical malposition of the rectus muscles.

    **angle between the visual axis and the insertion of IO muscle is increased.

    **So it will increases the abduction ability of the IO muscles in upgaze, resulting in a V-pattern.

    But, ada x pt mcmni kt Malaysia??


    And what about X-pattern?? How its look like? Rarely to be seen?

    ReplyDelete
  92. @azuwan

    nk share about

    Brown syndrome that much related to V-pattern

    is underaction of the SO and overaction of the IO.

    **that caused by a tight or inelastic SO muscle

    **Limited elevation in adduction

    **So pt has head-posturing, their chin up, contralateral face turn to avoid the hypotropia that increases in upgaze and gaze to the contralateral side of the affected eye.

    ReplyDelete
  93. salam'alaik..
    sory sir and guys..
    really cant catch up with all the discussion above..my understanding in the topic really under border line...in progress to understand the topic and all the discussion..

    ReplyDelete
  94. salam to all my frens n seniors..
    i got confused about how to diagnose 1 of my pt's case..
    -the details are below-
    EOM - pain at right, left and upward gaze.
    CT - ortho
    BUT..
    CT at R upper gaze :LE XT
    CT at L upper gaze :small XP

    Hess chart : looks like normal

    -what is the steps/tentative Dx towards this case?
    - tertanya2 why pt feel pain during EOM n avoided to look at those gaze.

    * Pt is high myopic (~-8.00)
    * current glasses overcorrected about 2.50D
    * C/O HA after prolonged reading and feel 'senak' around the eyeball.

    so..help me to manage this case..
    (always got pt who have EOM problem)--NerVous..hehehe

    ReplyDelete

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