EXODEVIATIONS: T H E I R CLASSIFICATION, DIAGNOSIS

AND T R E A T M E N T
HERMANN M. BURIAN, M.D.
Iowa City, Iowa
The direction of the deviation is not the groups, may complain of asthenopic symp­
only characteristic which distinguishes the toms, something which is rare in patients
exodeviations from the esodeviations. The with esodeviations.
two differ from each other in many respects.
Therefore, when exodeviations are treated on CLASSIFICATION
the principles valid for the esodeviations, 1. The exodeviations may be latent, inter­
they are not always cared for in the best pos­ mittent or manifest.
sible manner. In the latent exodeviations—as in all
One significant difference between these other latent deviations—the eyes are at all
two conditions is that the exodeviations times properly aligned. It is noteworthy that
occur much more frequently in a latent or latent exodeviations may be remarkably
intermittent form than do the esodeviations. large, reaching 30 A or more.
Consequently, amblyopia and anomalous In the intermittent exodeviations the pa­
correspondence are relatively rarely seen, tient keeps his eyes at times properly aligned;
and good and even excellent binocular co­ at other times he manifests a deviation.
operation is often encountered in the exo­ The deviation may become manifest when
deviations. the patient is tired, has a febrile illness,
The reason for the frequency of latent sustains a slight concussion, or the like.
and intermittent forms in exodeviations is Some patients have the ability to keep their
that the convergence mechanism is much eyes straight or to let them deviate at will
more powerful than the divergence mecha­ ("facultative" exodeviations). An intermit­
nism, both absolutely and relatively, and tent exodeviation may in time become con­
that it is particularly active in young indi­ stantly manifest.
viduals. Thus, if a person has any potential When the eyes of a patient with intermit­
at all for binocular cooperation, even re­ tent exotropia are aligned, he has, as a rule,
markably large exodeviations may be readily more or less secure binocular co-operation.
overcome by a convergence impulse. The When the deviation is manifest, he may ei­
urge for binocular single vision is so strong ther see double or may suppress the visual
that the patient calls into play all available stimuli coming from one eye. In rare in­
stimuli to convergence—voluntary conver­ stances the retinal correspondence may be
gence, tonic convergence, fusional conver­ anomalous only when the eyes are dissoci­
gence, accommodative convergence—and ated.1
that not only in near fixation but also in dis­ It is incorrect and confusing to restrict
tance fixation. the term "intermittent exotropia" to the di­
That this is so may be shown by the pu­ vergence excess type of exodeviation. Any
pillary constriction which patients with in­ one of the forms of exodeviations to be
termittent exotropia exhibit in distance fixa­ listed in the next paragraph may be latent,
tion when they keep their eyes straight. One intermittent or manifest.
result of this situation is that patients with 2. Three types of exodeviations may be
exodeviations, especially those in older age distinguished: a basic type, a divergence ex­
cess type and a convergence insufficiency
From the Strabismus Service, Department of type.
Ophthalmology, College of Medicine, University
of Iowa. The basic type of exodeviation is charac-
1161
1162 AMERICAN JOURNAL OF OPHTHALMOLOGY DECEMBER, 1966

terized by a deviation which varies only Since it is essential to obtain a full measure­
within physiologic limits in distance and ment of the deviation and since this is fre­
near fixation. Although convergence and di­ quently difficult to achieve with the routine
vergence mechanisms appear to function method, certain modifications must be made.
normally, there is often a more or less pro­ a. It has been repeatedly recommended
nounced weakness in the adductive function that in patients with exodeviations the angle
of the medial rectus muscles. of squint should be measured at a fixation
In the divergence excess type the devia­ distance of 75 to 200 feet. Using such a dis­
tion for distance is significantly greater than tance, one frequently elicits a larger devia­
the deviation for near. An excessive abduc­ tion than at the customary fixation distance
tion is also almost invariably present. In of six m. The reason for this recommenda­
general, the convergence function is normal. tion is that in patients with exodeviations
Patients with the convergence insufficien­ the convergence mechanism may be still
cy type of exodeviation show a greater devi­ quite active at a six-m fixation distance and
ation for near than for distance. The near prevents one from eliciting the full amount
point of convergence is outside the normal of the deviation.
range. The adductive action of the medial b. For the same reason it is necessary
rectus muscles is not impaired in patients when examining such a patient at six m to
with pure convergence insufficiency. choose a distinct small object which the pa­
A basic exodeviation may be combined tient must name (for example, a 20/30 acu­
with one of the other two forms, particular­ ity symbol) rather than a small fixation
ly with the convergence insufficiency type. It light. To recognize such a symbol the pa­
is important to determine in each case to tient must relax his accommodative conver­
what extent the deviation in a patient must gence and, as a result, the deviation mea­
be attributed to one or the other form, since sured is larger than when he fixates on a
each form requires different treatment. fixation light which he can see without re­
3. Exodeviations may be combined with laxing his accommodation (Costenbader 2 ).
vertical anomalies and may present A and V c. As has already been stated, the
patterns of deviation. In this regard, they do differentiation of the various types of exo­
not differ from the esodeviations; this as­ deviations rests primarily on a comparison
pect of the exodeviations will not be consid­ of the deviation in distance and near fixa­
ered in this paper. tion. Unless the correct amount of deviation
is elicited, a wrong diagnosis of the type of
DIAGNOSIS deviation is the result.
The diagnosis of the exodeviations is This is especially true—and frequently
made, in principle, on the basis of the same the case—in patients who appear to have a
criteria as those employed in the diagnosis of divergence excess type of deviation. In a
the esodeviations. However, the special cir­ large number of children one finds on first
cumstances obtaining in the exodeviations measurement that they have a much larger
make it mandatory that certain safeguards deviation in distance fixation than in near
be employed to avoid an incorrect diagnosis. fixation. In distance fixation there is often
1. As in all other forms of neuromuscu- an exotropia, or at least an intermittent exo-
lar anomalies, the presence or absence of a tropia, of rather sizable amount, whereas in
manifest deviation in near and distance fixa­ near fixation the patient would seem to have
tion is determined by the cover-uncover test. a relatively small exophoria, usually with
2. The amount of the deviation in dis­ satisfactory binocular co-operation.
tance and near fixation is best determined In the face of such measurements one is
with the alternate prism and cover test. tempted to make immediately the diagnosis
VOL. 62, NO. 6 EXODEVIATIONS 1163
of a divergence excess. This diagnosis may TABLE 1
or may not be correct. It can only be estab­ DIFFERENTIATION OF TRUE FROM
SIMULATED DIVERGENCE EXCESS
lished, on the basis of the measurement of
the deviations, if additional tests are made. Deviation in Dis­ Deviation in
These are, first, the occlusion of one eye tance Fixation Near Fixation
for one half to three fourths of an hour. If Case No. Before After Before After
the measurements are now repeated without
Occlusion of One Occlusion of One
allowing the patient to regain fusion, one of Eye for 30-45 Min Eye for 30-45 Min
two situations may arise:
1 30AXT 40AXT 10AX 56AXT
In the first, most frequent situation, the 2 18AX 20AXT 8AX 25AXT
measurements at near fixation are now very 3 20AXT 20AXT 6AX 18AXT
4 25AX(T) 20AXT 0 0
much larger than they were prior to occlu­ 5 26AX(T) 26AXT 4AX 4AX
sion. They may be as large, or even larger,
than the distance measurements. I have
termed the condition found in these patients Thus, if the deviation can be confidently
a simulated divergence excess.3 What, in considered to be greater for distance than
fact, occurs is that by occluding one eye fu­ for near, the patient may be assumed to
sion has been effectively interrupted and have an exodeviation of the divergence ex­
this has permitted the deviation at near to cess type; if it is greater for near than for
become fully manifest. distance, it is a convergence insufficiency
In the second, rarer situation, one finds type; if the amount is the same at the
no change in the deviation at near after oc­ different fixation distances, the patient has a
clusion. If this is the case, one is in all like­ basic exodeviation.
lihood dealing with a true divergence excess. d. As in all patients with neuromuscular
The differentiation of a true from a simulat­ anomalies, it is necessary to obtain measure­
ed divergence excess is essential for correct ments in the diagnostic positions of gaze in
diagnosis and proper treatment. the presence of an exodeviation of any type,
The two situations are very clearly shown especially if surgical treatment is contem­
in Table 1 which gives a few examples. plated.
Cases 1, 2 and 3 represent a simulated di­ 3. In addition to the measurements in the
vergence excess: Cases 4 and 5, a true di­ diagnostic positions, the versions should be
vergence excess. It must be pointed out that carefully studied. As has been pointed out,4
to make this differentiation a short-term oc­ a study of the versions does not necessarily
clusion should be employed. give the same information as the measure­
In addition to excluding fusion by occlud­ ments in the diagnostic positions. It is help­
ing one eye, one should, secondly, exclude ful to know, for instance, that there is an
accommodative convergence by the use of excess of abduction in a patient with a basic
plus lenses at near, say +3.0D if the devia­ exotropia. It helps in securing the diagnosis
tion is measured 33 cm. Accommodative and allows one to make one's surgical
convergence is one of the most powerful choice. On the other hand, if a patient who
means by which the patient overcomes his is believed to have a true divergence excess
exodeviation. If the exclusion of accommo­ does not show an excess of abduction, it is
dation increases the deviation materially, wise to recheck him carefully to make sure
this is an additional support for a diagnosis that the diagnosis was correct.
of a simulated divergence excess. If the 4. If the patient is heterophoric at any or
deviation at near is not materially affected, all fixation distances, one should determine
the patient most likely has a true divergence his fusional amplitudes. This is best done by
excess type of exodeviation. means of a rotary prism. In a patient with
1164 AMERICAN JOURNAL OF OPHTHALMOLOGY DECEMBER, 1966

true divergence excess it will be found that increase of the deviation; in time a progres­
the prism divergence, especially at distance, sively more pronounced convergence insuffi­
is abnormally large. In convergence insuffi­ ciency is frequently superimposed on the
ciency cases prism convergence is frequently basic exotropia.
abnormally low. 2. Nonsurgical treatment. Aside from the
5. If properly determined, the near-point rarely present amblyopia which requires the
of convergence may also provide useful di­ usual treatment, antisuppression training,
agnostic information. It is best to test for where indicated, is the most important non-
the so-called subjective near-point. This is surgical treatment in all forms of exodevia­
done by placing a red glass in front of one tions.
eye and ascertaining the distance from the Convergence treatment is definitely con-
eyes at which the patient perceives two traindicated in patients with true and simu­
lights, a red and a white one, when a pen- lated divergence excess. The former already
light is moved toward his nose. have a normally functioning convergence
6. The sensory behavior of patients with mechanism. In the latter the convergence
exodeviations is determined in the same mechanism is usually powerful. Conver­
fashion as in other patients with neuromus- gence training in such cases may lead to an
cular anomalies: by means of a major am- undesirable over-effect if operation follows
blyoscope, the Worth 4-dot test, stereoscopic such training.
devices, tests for retinal correspondence, etc. On the other hand, patients with a pure
convergence insufficiency should not be op­
TREATMENT erated upon. They represent a class of pa­
1. The natural history of untreated exo­ tients who particularly benefit from proper
deviations. On the basis of considerable ex­ orthoptic treatment.
perience with patients having untreated exo­ Patients with a basic exotropia are, as a
deviations observed over 10 to 20 years, the rule, unsuited for fusion training unless
following statements appear to be warrant­ they have been made heterophoric by sur­
ed: gery.
a. The condition appears more or less Some ophthalmologists avoid the pre­
stable—at least up to the presbyopic age—in scription of plus lenses and, indeed, advo­
patients with true divergence excess. cate the use of minus lenses—beyond the
b. In patients with simulated divergence actual refractive error of the patient—in the
excess, there is usually little change in the treatment of exodeviations. The rationale is
distance deviation, but the near deviation that the stimulation of accommodative con­
tends to increase and may approach the vergence will help the patient to overcome
amount of the distance deviation when the his deviation.
patient reaches the age of 17 to 20 years. Clearly, the prescription of +1.5D or
c. In patients with a convergence insuffi­ + 2.0D, O.U., in a young child with an exo­
ciency type of exodeviation, there is gen­ deviation is not warranted. However, with
erally a gradual deterioration of function higher spherical and with astigmatic errors
in near vision which may or may not lead to glasses may be required for better vision,
symptoms of asthenopia, according to and in older children and adults, to relieve
whether, or to what extent, there is suppres­ an accommodative asthenopia, for one can
sion of vision in one eye. The deterioration never be sure from the examination alone
becomes more rapidly progressive when the whether the patient's symptoms are due to
presbyopic age is reached. accommodative or muscular asthenopia.*
d. In patients with a basic exotropia at
* I vividly recall a student nurse who, upon en­
distance and near there is a trend toward an tering training, complained of asthenopia which
 VOL. 62, NO. 6 EXODEVIATIONS 1165

The judicious prescription of additional cosmetic factor which, when present, is a

minus corrections (— 2.0D or so) has a place good reason to intervene surgically.
if the ophthalmologist has a justified hope T h e choice of surgery will be only briefly
that with the use of such glasses a more se­ and schematically sketched. T h e complica­
cure binocularity may be encouraged in a tions arising from the presence of vertical
patient. T h e y are certainly not indicated in deviations, A or V patterns and other forms
the class designated in this paper as simulat­ of incomitance are disregarded.
ed divergence excess cases. Whenever they I n patients with true divergence excess a
are prescribed, especially in teenagers and bilateral lateral rectus muscle recession is
adults, one must carefully follow the patient the operation of choice. It is one of the most
to make sure that he does not trade an im­ reliable procedures in the whole field of sur­
provement in binocularity for accommoda­ gery on extraocular muscles. It is essential,
tive asthenopia. however, that the patient have a true diver­
3. Surgical treatment. T h e therapy of pa­ gence excess. Unsatisfactory results from
tients with exodeviations—except for those this type of operation are frequently due to
with pure convergence insufficiency—is a misdiagnosis. I n patients with basic exo-
essentially surgical. H e r e again, however, tropia recession-resection operations give
time of surgery and surgical indications the best result; they are also useful when
differ somewhat from those in patients with the deviation is of the convergence insuffi­
esodeviations. ciency type. I n the latter case one may also
If the patients have satisfactory binocular perform bilateral medial rectus resections.
co-operation at near, there is no urgency to Further details on the operative indications
operate. I t is sufficient to treat them when and of the results in 200 cases may be
required with nonsurgical techniques and to found in a previous paper. 4
watch them closely. If the binocular co-op­
SUMMARY
eration begins to deteriorate, one should not
procrastinate but advise surgery. Exodeviations are of three types: basic
O n the other hand, the very fact that the exodeviations, a divergence excess type and
patients have fusion should encourage one a convergence insufficiency type.
to operate. A reduction in the angle of In diagnosing the type of exodeviation it
squint is of great benefit to these patients. It is essential to exclude maximally the binocu­
is of major help in establishing more secure lar co-operation by interrupting fusion for
binocular co-operation and may save the one half to three fourths of an hour (occlu­
younger patients possible muscular astheno­ sion of one eye) and by reducing accommo­
pia in the future and reduce, or do away dative convergence (by using discrete acuity
with, a muscular asthenopia in older pa­ symbols at 6-m fixation distance and mea­
tients. There remains finally the additional suring the deviation for near by adding the
appropriate amount of plus lenses). In so
had started during the last two years of high doing one frequently finds that what origi­
school and had become increasingly severe. She nally impressed one as a divergence excess
had an uncorrected refractive error of +2.5D, case is in fact a simulated not a true case of
O.U., and a basic exophoria of 18-20A. She was
given a prescription for glasses and told that divergence excess.
these would undoubtedly make her symptoms Treatment of exodeviations, where re­
worse in which case other treatment would have
to be considered. Much to my surprise, the pa­ quired, is essentially surgical. T r u e diver­
tient was relieved of her symptoms and remained gence excess cases are best handled by
symptom free for three years of observation, al­ recession of both lateral rectus muscles;
though she was an assiduous student. Obviously,
the symptoms were due in this instance to an cases of basic exodeviations and of the con­
accommodative and not a muscular asthenopia. vergence insufficiency type, by recession-re-
1166 AMERICAN JOURNAL OF OPHTHALMOLOGY DECEMBER, 1966

section operations or resections of both REFERENCES

medial rectus muscles. However, cases of 1. Burian, H. M.: The sensorial retinal rela­
pure convergence insufficiency without an tionship in concomitant strabismus. Arch. Ophth.
37:336, 504, 648, 1947.
underlying basic exodeviation should never 2. Costenbader, F. D.: Personal communica­
be operated. They require nonsurgical (or­ tion.
thoptic) treatment. Nonsurgical (orthoptic) 3. Burian, H. M.: Selected problems in the di­
treatment should otherwise be directed agnosis and treatment of the neuromuscular
anomalies of the eyes. II 'Curso International de
against suppression and where indicated Oftalmologia 2:457. Barcelona, Publicaciones del
postoperatively to an increase in fusional Institute Baraquer, 1958.
vergences. 4. Burian, H. M., and Spivey, B. E.: The sur­
gical management of exodeviations. Am. J.
University Hospitals (52241) Ophth. 59:603, 1965.

T H E VISUAL-EVOKED CORTICAL R E S P O N S E IN N I G H T BLINDNESS

R O N A L D S. F I S H M A N , * M.D.
Washington, D.C.

Computer techniques have recently made I. METHODS

possible a clear recognition of the visual- A. Dark adaptation. Dark adaptation was
evoked response in the occipital electro­ evaluated after three minutes of light adap­
encephalogram. 1 " 3 This response produces tation to the preadaptation illumination of
such a minor change in the E E G that it the Goldmann-Weekers adaptometer (2800
is not readily evident upon simple inspec­ l u x ) , the subjects centrally fixating a test
tion of the E E G record. Earlier studies of stimulus 30 degrees in diameter for 30 min­
the evoked response 4 ' 5 relied largely upon utes during the course of dark adaptation.
demonstrating the effect of light stimuli in Central fixation of this stimulus produced
blocking the intrinsic cortical alpha rhythm normal biphasic dark-adaptation curves in
or in photically driving the alpha rhythm in three normal subjects, as illustrated in Fig­
time with the stimulus. However, computer ure 1.
analysis of the E E G during repetitive visual B. Electroretinography. A Grass photic
stimuli readily allows the evoked response stimulator strobe lamp faced with a white
itself to be detected above random back­ opal surface, emitting 10 [/.sec light pulses,
ground E E G activity and offers a new was housed behind a central aperture 14
means of evaluating the integrity of the degrees in diameter in a specially construct­
visual system. ed vertical hemisphere. T h e E R G of the sit­
In order to assess the relative contribu­ ting subject was detected by a Burian-Allen
tion of scotopic and photopic retinal recep­ contact lens electrode, amplified by a Grass
tors to the visual evoked cortical response P-511 amplifier and recorded on a Sanborn
( V E R ) , the following report describes the recorder at a paper speed of 20 mm/sec. A
V E R in two patients with severely impaired reference electrode was placed on the fore­
scotopic function. head above the test eye and a ground elec­
trode upon the ipsilateral earlobe. Light-
From the Department of Ophthalmology, Uni­ adapted E R G responses to the S4 stimulus
versity of Florida. This work was supported by intensity were elicited against a surround
grants NB 04896-03 and NB 05597-02 from the illumination of 12 foot-candles by single
National Institutes of Health.
* Special Research Fellow, National Institute flashes and by a 30 per sec flickering white
of Neurological Diseases and Blindness. stimulus. Dark-adapted responses to single