Today’s guest blogger is Dr. Kimberly Walker. Dr. Walker practices in New Jersey.  She is also a part-time member of the faculty at SUNY State College of Optometry.  She often travels to different schools in NYC providing eye examinations for young children.

I read a great journal article on the train into work this morning.  The paper is “Treatment Approaches to: Divergence Excess Intermittent Exotropia” and was written by the amazing behavioral optometrist, Dr. Nathan Flax.   Here is a copy of the article.   Flax discusses how this type of Exotropia (eye turned out) is treated differently than any other exotropia. While I have found this approach to treatment to be successful, I have also found myself struggling to clearly explain this treatment method to patients and parents who at first my see this approach as counterintuitive.

Most parents notice when one eye is turned out significantly especially at distance. The Divergence Excess Exotropia is quite easy to see in these kids, because usually the magnitude of the eye turn is quite large.  When their eye floats out when they look up, it really goes OUT!  As a parent,  this large eye turn can be quite disconcerting! While the eye turn or exotropia itself is quite obvious, what is not so obvious is the cause and the treatment.  Many times when a parent sees an eye turn, they talk to the pediatrician and then they are sent to a pediatric ophthalmologist.  In this scenario, the parent is usually given 2 treatment options: surgery or no treatment lets see if he or she “grows out of it”.  The sad part is many of these parents are never told about the 3rd option:  Vision Therapy.

Now, it is difficult to explain to a parent of a child with Divergence Excess Exotropia that not only does their child need vision therapy for the eye turn at distance, but they also need to wear reading glasses or a bifocal! The parent often time has trouble understanding that the key to Divergence Excess is that the eye turn at distance is really a response to near visual strain. What the eyes have to do to maintain single clear vision at near causes them to have an eye turn when they look out at distance. WHAT? I know confusing…. But I also try to explain it like this (while not technical at all) think of how a runner looks after they finish a marathon, their body is so exhausted, they practically fall to the ground.  When this child tries to read or do work at near, it is like “running a marathon” with their eyes… basically too much hard work. Then they look up and their eyes are so relieved… “Yahoo, time to relax”… and the eyes get floppy and wander off to the side. Reading glasses help the children relax their “eye focus” while doing near work. Once their eyes are not working so hard at near, this will help them to stay aligned at distance.  While this is not a technical account of what is going on in Divergence Excess Exotropia, it seems to help the parents of my patients understand my treatment approach and increases compliance.  Now we just need these patients to be referred to us first. Then we won’t be doing as much vision therapy with children with post-surgical eye turns and double vision!

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