How do you approach the timing of surgical intervention in intermittent exotropia?

If the child alternates fairly well and there is no amblyopia, I monitor the strabismus every six months. There is no urgency to operate in these cases, and multiple measurements of the angle over time are beneficial. The frequency helps with the decision. If the eyes are exotropic more than 40% of the day, surgery is indicated, in my opinion.

In training, I was advised to operate as soon as XT was identified to prevent suppression of vision in one eye. But it’s probably occurred by the time the...

Intermittent exotropia is typically a deteriorating condition due to deterioration of distance fusion. In order to follow binocular function at distance in these children, I relied on the distance vectograph. By the time they are exotropic for any significant percentage of time, binocularity has already deteriorated. Alternate patching was helpful if distance fusion showed some decline via the distance vectograph or by history of XT frequency worsening. With steady patching of 2 hours a day or s...

I trained with Ken Wright, and his rule of thumb was to try to wait until after four years old, the thinking being that the binocularity is pretty much matured and they will appreciate diplopia, thus stimulating them to pursue single vision. Generally, if you operate and get the desired small overcorrection, they are unlikely to develop a suppression scotoma and remain ET.

Parents very often want surgery prior to the first grade to avoid the inevitable comments by peers. Obviously, waiting as lo...