Interventions for intermittent exotropia

Abstract

Background The clinical management of intermittent exotropia has been discussed extensively in the literature, yet there remains a lack of clarity regarding indications for intervention, the most effective form of treatment and whether or not there is an optimal time in the evolution of the disease at which any treatment should be carried out. Objectives The objective of this review was to analyse the effects of various surgical and non-surgical treatments in randomised trials of participants with intermittent exotropia, and to report intervention criteria and determine the significance of factors such as age with respect to outcome. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library, Issue 4, 2012), MEDLINE (January 1966 to May 2012), EMBASE (January 1980 to May 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to May 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 4 May 2012. We are no longer searching the UK Clinical Trials Gateway (UKCTG) for this review. We manually searched the British Orthoptic Journal up to 2002, and the proceedings of the European Strabismological Association (ESA), International Strabismological Association (ISA) and American Academy of Paediatric Ophthalmology and Strabismus meeting (AAPOS) up to 2001. We contacted researchers who are active in the field for information about further published or unpublished studies. Selection criteria We included randomised controlled trials of any surgical or non-surgical treatment for intermittent exotropia. Data collection and analysis Each review author independently assessed study abstracts identified from the electronic and manual searches. Author analysis was then compared and full papers for appropriate studies were obtained. Main results We found one randomised trial that was eligible for inclusion. This trial showed that unilateral surgery was more effective than bilateral surgery for correcting the basic type of intermittent exotropia. Authors’ conclusions The available literature consists mainly of retrospective case reviews, which are difficult to reliably interpret and analyse. The one randomised trial included found unilateral surgery more effective than bilateral surgery for basic intermittent exotropia. However, across all identified studies, measures of severity and thus criteria for intervention are poorly validated, and there appear to be no reliable natural history data. There is therefore a pressing need for improved measures of severity, a better understanding of the natural history and carefully planned clinical trials of treatment to improve the e...

A systematic review of the effectiveness of treatments in altering the natural history of intermittent exotropia

“…Commensurate with the conclusions of the earlier Cochrane review,7 we found that there remains a need for further well designed RCTs to examine questions of effectiveness for different management options of childhood X(T). Given the absence of high-quality evidence, the authors argue for prudence when considering management options given the potential to ‘do harm by correcting the appearance of misalignment but disrupting the ability to maintain binocular stereo vision’ (ref.…”

“…Given the epidemiology of X(T)7 we did not exclude studies on the basis of language, country or publication date. We used Google Translate to translate abstracts in order to apply our eligibility criteria.…”

“…However, surgery is associated with important adverse effects including a risk of overcorrection, which may also adversely impact on stereoacuity. Evidence for the comparative effectiveness of treatment options is limited by the absence of randomised controlled trial data,7 but there is a much larger literature of observational studies for various interventions.…”

“…The updated Cochrane review of randomised trials of surgical and non-surgical interventions for X(T) found only one study which compared unilateral and bilateral surgery with results favouring unilateral surgery for basic type X(T) 7. Likewise, a review of conservative interventions concluded that there is a role for conservative management interventions, such as preoperative exercises and occlusion therapy post-surgery, but there is a need for further exploration of what works, for whom, and under what circumstances 8.…”

“…We conducted this review to synthesise the evidence base on the effectiveness of surgical and non-surgical interventions for X(T). Due to the epidemiology of X(T), with an increased prevalence in South East Asia and latitudes with greater exposure to sunlight,7 we included foreign language papers. In the absence of evidence from high-quality, randomised controlled trials, we considered comparative observational studies to provide a real-world, practice-ready perspective.…”