We thank the author for his interest in our article.
The mean age of the patients was nearly 7 years, and in our cohort only six patients were <4 years of age.
There are controversies about the management of intermittent exotropia, especially in childhood because of its ambiguous natural history. The deviation may worsen or deteriorate into constant exotropia and may adversely affect stereo-vision and cause amblyopia. Social and/or psychological problems may also develop in children with intermittent exotropia. Such problems can impact into adult life with effects on self-image, work and personal relationships.
With regard to the age of the patient with consecutive esotropia; the mentioned patient was 6 years old. There were six patients <4 years of age in our study. Their ages and postoperative 1st week, 2nd month and 6th month deviations are indicated below:
- First patient: 3 years of age; orthotropic (1st week); orthotropic (2nd month); orthotropic (6th month)
- Second patient: 3 years of age; 20 PD esotropia (1st week), orthotropic (2nd month), orthotropic (6th month)
- Third patient: 3 years of age; orthotropic (1st week), 20 PD X(T) (2nd month), 25 PD XT (6th month)
- Fourth patient: 2 years of age; 10 PD esotropia (1st week), orthotropic (2nd month), orthotropic (6th month)
- Fifth patient: 2 years of age; 16 PD esotropia (1st week), 14 PD esotropia (2nd month), orthotropic (6th month)
- Sixth patient: 2 years of age; 18 PD esotropia (1st week), 4 PD esotropia (2nd month), orthotropic (6th month).
Although we see and follow high number of similar patients daily in our clinic, we only included patients who met deterioration criteria identical to what is mentioned by authors of the letter. Our primary approaches to such patients include refractive correction, patching and observation. We do pursue surgery only when the mentioned criteria are met.
To the best of our knowledge, none of the patients in our cohort were found to develop amblyopia. As we could not obtain formal vision in all the patients, we decided to focus the reporting only on the motor outcome. However, measures such as fixation preference, the rate of control and signs of diplopia were used to determine concerns on the loss of vision. Fresnel prisms and part-time patching treatments were used temporarily for a few patients who suffered from diplopia or showed the signs of dominant fixation at the early postoperative period. Patients with constant ET > 10 PD lasting for more than 6 months postoperatively and recurrent poor controlled X(T) underwent re-operation. None of the patients lost vision or developed amblyopia to our knowledge, and these results were seen possibly due to this close intervention.
With regard to three cases of recurrence exotropia, the extent of the operation performed was based on the largest angle ever measured at distance or near. In our cohort, none of the subjects were observed to have larger deviation at near. The distance deviation was observed to be either equal to the near deviation or the near deviation was <10 PD then the distance deviation. Thus after the operation both distance and near deviations were measured for all patients, and the largest angle was included before grouping the cases. Preoperative deviations and initial surgical amount of lateral rectus recessions of three cases with recurrence exotropia are indicated below:
- First patient; preoperative deviation was 45 PD, recession 9 mm
- Second patient; preoperative deviation was 25 PD, recession 6.5 mm
- Third patient; preoperative deviation was 30 PD, recession 7.5 mm.
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