Nonsurgical Consecutive Exotropia Following Childhood Esotropia: A Multicentered Study

center dot PURPOSE: Nonsurgical consecutive exotropia (NCX) occurs when an esotropia (ET) spontaneously converts to exotropia (XT) without surgical intervention. Although NCX is considered to occur in early-onset accommoda-tive ET with high hyperopia, consensus on causation is lacking. We report the clinical characteristics of NCX and assess the response to conservative management.center dot DESIGN: Retrospective, multicenter, observational case series. center dot METHODS: Patients aged 6 months and older with an initial diagnosis of ET who converted to XT with-out surgical intervention. Sensory strabismus was ex-cluded. Age, visual acuity, cycloplegic refraction, glasses prescriptions, deviation, and binocular vision were col-lected.center dot RESULTS: Forty-nine children were included with a mean age of 3.5 +/- 1.6 years and 8.4 +/- 3.6 years at the time of ET and NCX, respectively. Mean refractive er-ror was + 4.40 +/- 2.13 diopters (D) and + 4.05 +/- 2.74 D at the time of ET and NCX, respectively. Accommoda-tive ET occurred in 60% of cases, and only 35.7% were high hyperopes. All but 1 patient presented with XT at distance. In response to the XT, a mean decrease in hyper-opic prescription of 1.55 +/- 0.48 D was given (N = 17); only 1 case reverted to ET. Eventually, 43% underwent XT surgery, with similar rates between those who had refractive management and those who did not. center dot CONCLUSIONS: NCX occurs in both accommodative and nonaccommodative ET; high hyperopia is present in only one-third of cases. On average, drift to XT oc-curs within 5 years. Refractive management has a mod- est result. No predictive risk factors were identified. Our findings challenge hyperopia-linked theories of causation. Nonrefractive explanations, such as the role of the ver-gence system, deserve further study. (Am J Ophthal-mol 2024;258: 130-138. (c) 2023 Elsevier Inc. All rights reserved.)