Kim et al.

BMC Ophthalmology (2023) 23:125 BMC Ophthalmology

https://doi.org/10.1186/s12886-023-02873-w

RESEARCH Open Access

The subjective controllability of exotropia

and its effect on surgical outcomes in patients
with intermittent exotropia
Mirae Kim1,2*, Hong Kyun Kim2,3† and Won Jae Kim4*†

Abstract
Background/aims We evaluate the clinical characteristics of intermittent exotropia with controllability and compare
surgical outcomes between patients with and without controllability.
Methods We reviewed the medical records of patients aged 6–18 years with intermittent exotropia who underwent
surgery between September 2015 and September 2021. Controllability was defined as the patient’s subjective
awareness of exotropia or diplopia associated with the presence of exotropia and ability to instinctively correct the
ocular exodeviation. Surgical outcomes were compared between patients with and without controllability, with a
favorable surgical outcome defined as an ocular deviation between ≤ 10 PD of exotropia and ≤ 4 PD of esotropia at
distance and near.
Results Among 521 patients, 130 (25%, 130/521) had controllability. The mean age of onset (7.7 years) and surgery
(9.9 years) were higher in patients with controllability than in those without controllability (p < 0.001). The mean
control scores of patients with controllability (distance: 1.9, near: 1.5) were lower compared with patients without
controllability (distance: 3.0, near: 2.2), reflecting a better level of control. Patients with controllability had a better
surgical outcome than those without controllability, as analyzed by log-rank test (p < 0.001). Larger preoperative
ocular exodeviation at distance (hazard ratio [HR] = 1.083, confidence interval [CI] = 1.018–1.151, p = 0.012) and near
(HR = 1.102, CI = 1.037–1.172, p = 0.002) were significantly related to recurrence in patients with controllability.
Conclusions Patients with controllability showed better surgical outcomes, later exotropia onset, and better level
of control than patients without controllability. Preoperative ocular exodeviation was a significant factor influencing
favorable outcomes in patients with controllable exotropia.
Keywords Control, Exotropia, Surgical outcomes

1
†
Hong Kyun Kim and Won Jae Kim contributed equally to this work. Nune Eye Hospital, Daegu, South Korea
2
Department of Medicine, The Graduate School, Kyungpook National
*Correspondence: University, Daegu, South Korea
Mirae Kim 3
Department of Ophthalmology, School of Medicine, Kyungpook
[email protected] National University, Daegu, South Korea
Won Jae Kim 4
Department of Ophthalmology, Yeungnam University College of
[email protected]; [email protected] Medicine, Daegu, South Korea

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,
sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and
the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this
article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included
in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The
Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available
in this article, unless otherwise stated in a credit line to the data.
Kim et al. BMC Ophthalmology (2023) 23:125 Page 2 of 7

Background and an ability to instinctively correct the ocular exodevia-

Intermittent exotropia is the most common type of stra- tion. Patients with any other type of strabismus, such as
bismus among Asians, particularly Koreans [1]. Exo- oblique muscle dysfunction, dissociated vertical devia-
drift and recurrence can occur after surgical treatment tion, A-V pattern, or nystagmus, were excluded from
in these patients [2–4]. Previous studies have evaluated this study. Patients with previous intraocular surgery,
the clinical factors associated with surgical outcomes to neurological impairment such as cerebral palsy, or uni-
predict the prognosis after surgical treatment [2–4]. The lateral amblyopia were also excluded. Controllability was
clinical factors mainly evaluated in patients with inter- assessed by asking the patient directly about the presence
mittent exotropia included the amount of ocular exode- of controllability at the initial visit and last examination
viation, level of control, and results of stereoacuity tests. before surgery. Patients with any disease such as autism
Patients with intermittent exotropia present both spectrum disorder that made it difficult for them to com-
objective findings and subjective symptoms associ- municate were also excluded as it was difficult to evalu-
ated with exotropia, such as light sensitivity, asthenopia, ate controllability. Patients with intermittent exotropia
blurred vision, headache, and diplopia [5–8]. Among were divided into two groups according to the presence
these subjective symptoms, some patients have a subjec- of controllability and the clinical characteristics and sur-
tive awareness of the ocular exodeviation and can correct gical outcomes were compared between the two groups.
it instinctively; however, this often leads to asthenopia, This study was approved by the institutional review board
diplopia, and headache [5, 8]. We defined these symp- of *** University Hospital (IRB file number: 2022-01-055),
toms and ability to control exotropia as controllabil- which waived the requirement for informed consent
ity and hypothesized that there might be an association owing to the retrospective nature of the study and the use
between binocularity and the controllability of exotro- of anonymized patient data.
pia. While previous studies have evaluated surgical out-
comes based on objective clinical factors, the association Preoperative evaluations
between surgical outcomes and subjective symptoms has Exotropia onset was assessed based on patient’s or paren-
rarely evaluated. This study evaluated the clinical charac- tal reports. The degree of deviation was measured using
teristics of intermittent exotropia with controllability and an alternate prism cover test at 6 m (distant fixation) and
compared surgical outcomes between patients with and 33 cm (near fixation). An occlusive patch was provided
without controllability. to all patients at the first visit. All patients were informed
that we planned to occlude the non-dominant eye for 1 h
Methods at the next visit to measure the largest exodeviation. The
We retrospectively reviewed the medical records of pedi- level of control was measured using the Look And Cover,
atric patients aged 6–18 years with intermittent exotro- then Ten seconds of Observation Scale for Exotropia
pia who underwent surgery between September 2015 (LACTOSE) control scoring system [9]. This control sys-
and September 2021. Patients with basic type of inter- tem was constructed by incorporating scales for both dis-
mittent exotropia with a distance deviation within 10 PD tance and near evaluations (5-point scales: 0–4 in each),
and near deviation were included. Controllability was yielding a total score ranging from 0 to 8. Higher and
defined as the patient’s subjective awareness of exotro- lower scores indicated poorer and better levels of control,
pia or diplopia associated with the presence of exotropia respectively. More than three preoperative examinations
were performed on each patient before the surgical treat-
Table 1 Surgical dose of bilateral lateral rectus recession and ment. Stereoacuity measurements were performed using
unilateral lateral rectus recession and medial rectus resection the Lang I (LANG-STEREOTEST AG, Küsnacht, Swit-
Prism diopters Bilateral LR Unilateral LR recession and zerland) and Stereo Fly Stereotest (Stereo Optical Co.,
recession MR resection Chicago, IL, USA) in patients able to cooperate and com-
Recession Recession Resection plete the test.
amount of LR amounts of LR amounts of
(millimeter) (millimeter) MR
(millimeter) Surgical treatment and postoperative evaluations
20 5/5 - - All surgeries were performed under general anesthe-
25 6/6 4 3 sia by a single surgeon (***). Conventional bilateral LR
30 - 4 4 recession or unilateral R&R procedures for exotropia
35 - 5 4 were performed using the surgical dose at the authors’
40 - 5 5 clinic (Table 1). In all patients, the operated muscles
45 - 7 5 were reattached directly to the sclera without an adjust-
50 - 8 5 able suture. The angle of deviation measured on the
LR, Lateral rectus muscle; MR, medial rectus muscle day of surgery or 1 day after surgery was defined as the
Kim et al. BMC Ophthalmology (2023) 23:125 Page 3 of 7

immediate postoperative deviation. All patients rou- exotropia > 10 PD at any time after surgery at distance or
tinely used Tobradex (tobramycin/dexamethasone) eye near deviation.
drops four times daily and Effexin (ofloxacin) eye oint-
ment once daily for 1 week postoperatively. The patients Statistical analysis
were followed up at 1, 3, 6, and 12 months after surgery Statistical analyses were performed using IBM SPSS Sta-
and every 6 months thereafter. The postoperative angle tistics for Windows, version 20.0 (IBM Corp., Armonk,
of deviation was measured at each visit. Patients with at NY, USA). Unpaired t- and chi-square tests were used
least 3 months of postoperative follow-up were included to evaluate differences between patients with and with-
in the analysis. Favorable or successful surgical outcomes out controllability. The cumulative probabilities of suc-
were defined as an ocular deviation in the primary posi- cess were assessed according to Kaplan–Meier life-table
tion between ≤ 10 PD of exotropia and ≤ 4 PD of eso- analysis. Log-rank tests were used to compare survival
tropia at distance and near. Recurrence was defined as rates between the two groups. Cox proportional hazards
regression analysis was used to identify the risk factors
Table 2 Comparison of basic characteristics between patients associated with recurrence after surgery in patients with
with and without controllability of exotropia controllability. Statistical significance was set at p < 0.05.
N = 521 With con- Without p-
trollability control- value Results
(N = 130) lability
This study included 521 patients (271 male, 250 female)
(N = 391)
with intermittent exotropia, 130 (25%, 130/521) of
Sex (Male: Female) 58: 72 213: 178 0.051
whom had controllability. The basic characteristics of
Mean onset of exotropia (range), 7.7 ± 2.8 5.6 ± 3.0 < 0.001
yr (107/130, (334/391, the patients with intermittent exotropia with and with-
2–17) 0–18) out controllability are shown in Table 2. Sex, amount of
Preoperative ocular exodeviation ocular exodeviation, surgical methods, and results of ste-
(range), PD reoacuity tests did not differ between patients with and
Distance 27.2 ± 7.2 26.8 ± 6.7 0.581 without controllability. The mean ages of exotropia onset
(16–50) (16–50) (7.7 years) and surgery (9.9 years) were higher in patients
Near 31.0 ± 7.4 30.0 ± 6.8 0.168 with controllability than in those without controllabil-
(16–55) (18–55)
ity (5.6 years and 8.3 years, respectively). The mean con-
Level of control, control score 109/130 282/391
trol scores at distance, near, and overall of patients with
Distance 1.9 ± 1.1 3.0 ± 0.9 < 0.001
controllability were 1.9, 1.5, and 3.4, respectively. The
Near 1.5 ± 0.8 2.2 ± 1.1 < 0.001
control scores for distance, near, and overall were lower
Overall 3.4 ± 1.7 5.2 ± 1.7 < 0.001
Spherical equivalent refractive
in patients with controllability, reflecting a better level
errors, D of control, compared to patients without controllability
Right eye -1.72 ± 1.60 -1.09 ± 1.55 < 0.001 (mean distance, near, and overall control scores were 3.0,
(-7.25 to (-7.00 to 2.2, and 5.2, respectively, all p < 0.001). Patients with con-
+ 1.00) + 4.50) trollability were more myopic than patients without con-
Left eye -1.80 ± 1.61 -1.08 ± 1.58 < 0.001 trollability, probably because patients often experience
(-8.00 to (-7.50 to
myopic changes with age.
+ 2.00) + 5.00)
Mean age of surgery (range), yr 9.9 ± 8.3 8.3 ± 2.4 < 0.001
(6–18) (6–18) Surgical outcomes in patients with and without
Surgical methods controllability of exotropia
Bilateral LR recession 73 232 The immediate postoperative ocular exodeviation was
Unilateral R&R 57 159 0.524 − 3.6 ± 1.9 PD at distance and − 0.3 ± 2.6 PD at near in
Results of stereotest patients with controllability, in which negative and posi-
Lang I test, passed, (%) 127 /128 353 /366 0.104 tive numbers indicate esodeviation and exodeviation,
(99.2) (96.4) respectively. Patients without controllability showed
Stereo Fly Stereotest (≤ 100 115 /128 311 /361 0.284 − 3.5 ± 2.4 PD at distance and − 0.3 ± 2.6 PD at near
arcsec, %) (89.8) (86.1) immediately after surgery, with no significant difference
PD: prism diopters; D: diopters; LR: lateral rectus; R&R: lateral rectus recession between the two groups (p = 0.594 at distance, p = 0.987
and medial rectus resection; arcsec: arcsecond
The level of control was measured using the Look And Cover, then Ten seconds
at near). Kaplan–Meier survival analysis showed cumula-
of Observation Scale for Exotropia (LACTOSE) control scoring system. This tive probability of success rates considering recurrence as
control system was constructed by incorporating scales for both distance and the event in patients with controllability of 94.4%, 86.4%,
near evaluations (5-point scales: 0–4 in each), yielding a total score ranging
from 0 to 8. Higher and lower scores indicated poorer and better levels of 82.1%, and 65.7% at 1, 2, 3, and 4 years after surgery,
control, respectively respectively. In contrast, the rates in patients without
Kim et al. BMC Ophthalmology (2023) 23:125 Page 4 of 7

controllability were 82.9%, 66.3%, 56.4%, and 51.1%, with recurrence in patients with exotropia and control-
respectively. The patients with controllability had a better lability (Table 3).
recurrence-free survival curve than patients without con-
trollability, as analyzed by log-rank test (p < 0.001, Fig. 1). Discussion
In this study, patients with controllability had a later
Factors associated with recurrence in patients with onset of exotropia and a better level of control than
controllability patients without controllability. Patients with control-
Among patients with controllability, the clinical factors lability had better surgical outcomes than patients with-
associated with recurrence were evaluated using Cox out controllability. Preoperative ocular exodeviation was
proportional hazards regression analysis. Larger pre- a significant factor influencing favorable outcomes in
operative ocular exodeviation at distance (HR = 1.083, patients with exotropia and controllability.
CI = 1.018–1.151, p = 0.012) and near (HR = 1.102, The subjective symptoms associated with exotropia
CI = 1.037–1.172, p = 0.002) were significantly associated may differ among patients with intermittent exotropia

Fig. 1 Comparison of Kaplan–Meier survival curves of surgical outcomes between patients with and without exotropia controllability. The recurrence-
free survival curve differs between the groups (p < 0.001, log-rank test). The cumulative probability of success considering recurrence as the event in
patients with controllability were 94.4%, 86.4%, 82.1%, and 65.7% at 1, 2, 3, and 4 years after surgery, respectively. In contrast, the probabilities of patients
without controllability were 82.9%, 66.3%, 56.4%, and 51.1%, respectively
Kim et al. BMC Ophthalmology (2023) 23:125 Page 5 of 7

Table 3 Cox proportional hazard regression analysis for patients with controllability may have better binocular-
recurrence of exotropia in patients with controllability ity than those without. These results may be consistent
N = 130 HR 95% CI p-value with previous study by Moon et al. that higher distance
Sex 1.092 0.344–3.472 0.881
and near LACTOSE scores representing worse control
Mean onset of exotropia 0.992 0.815–1.208 0.938
of deviation were associated with higher rates of surgical
Preoperative ocular exodeviation
failure in children with intermittent exotropia [10].
Distant 1.083 1.018–1.151 0.012
Patients with controllability showed a relatively later
Near 1.102 1.037–1.172 0.002
onset of exotropia than those without controllability,
Level of control, Control score
possibly because patients with better binocularity can
Distant 1.037 0.599–1.797 0.897
maintain normal ocular alignment for a longer time,
Near 1.701 0.914–3.166 0.094
leading to older mean ages of onset and surgery. Simi-
Overall 1.176 0.835–1.657 0.354
larly, patients with better binocularity may hide the total
Spherical equivalent refractive errors
Right eye 1.232 0.816–1.861 0.322
amount of ocular exodeviation, leading to variability in
Left eye 1.039 0.704–1.533 0.848
ocular exodeviation during follow-up [11–13]. Lim and
Mean age of surgery (range), yr 0.891 0.685–1.158 0.388
Kim showed a higher possibility of dramatic decreases
Immediate postoperative ocular in ocular alignment before impending surgery caused
deviation by anxiety in pediatric patients with controllability [12].
Distant 0.985 0.784–1.239 0.898 These patients had relatively better level of control [12].
Near 1.073 0.866–1.329 0.519 Lee et al. reported better surgical outcomes of exotro-
The level of control was measured using the Look And Cover, then Ten seconds pia in patients with increased ocular deviation after the
of Observation Scale for Exotropia (LACTOSE) control scoring system. This
monocular occlusion test [13]. They postulated that these
control system was constructed by incorporating scales for both distance and
near evaluations (5-point scales: 0–4 in each), yielding a total score ranging patients had a better preoperative fusion rate, which
from 0 to 8. Higher and lower scores indicated poorer and better levels of may have concealed the total amount of ocular deviation
control, respectively
before the occlusion test. Their better potential fusion
capacity may have influenced their response to surgery
[5–7]. The fusional potential and subjective symptoms of and facilitated stable surgical outcomes [13].
exotropia may be associated. von Nooden observed that The decision to agree to surgery in pediatric patients
the clinical course of exotropia differed depending on the with a large amount of exotropia but good control may be
state of the sensorimotor system [5]. For example, a child difficult for parents. Parental observations are more likely
with large exophoria without any symptoms may develop to correlate with the level of control than with the amount
exotropia in later life or stay exophoric and develop of ocular deviation in pediatric patients with intermittent
symptoms of eyestrain with sustained close work. We exotropia [14]. Patients with controllability usually have
were interested in the controllability of exotropia and a good level of control, with variable amounts of ocular
evaluated the association between surgical outcomes and deviation. Therefore, parents cannot easily notice ocular
controllability. deviation and may hesitate to agree to surgery in patients
In this study, 25% of patients reported exotropia con- with controllability. Not all patients with exotropia and
trollability. The degree of ocular exodeviation was vari- controllability require surgical treatment [6]. We recom-
able in these patients. Even patients with a large amount mended surgery in patients presenting with any symp-
of deviation (> 50 PD) showed controllability. A previous toms associated with difficulty on control of exotropia,
study reported that 42% of children expressed a general including asthenopia, diplopia, and headache, or if the
awareness of exodeviation and various ocular sensa- trend of these symptoms increases with age. The exo-
tions [9]. In their study, some children also demonstrated tropia gradually progresses with age [15–17]. Surgical
awareness of their ability to correct the exodeviation by outcomes are more favorable in patients with controlla-
blinking. bility than in those without. The results of this study sug-
The surgical outcomes in patients with controllability gest that surgical treatment may be more appropriate in
were better than those in patients without controllability. patients with exotropia and controllability.
Preoperative and immediate postoperative ocular align- Our results may help predict prognosis after surgery
ment did not differ significantly between patients with and may also provide data for the creation of a new clas-
and without controllability. Therefore, the differences in sification system for patients with intermittent exotropia.
surgical outcomes were not due to the immediate effects The current general classification system for exotropia is
of surgical treatment. The level of control using LAC- based on the main difference between ocular exodevia-
TOSE control scoring system is better in patients with tion and distant and near fixation or level of control [5,
controllability. The better surgical outcomes in patients 6]. While these systems are useful in the clinical setting,
with controllability may be due to better binocularity, as there may be limitations in predicting the surgical results.
Kim et al. BMC Ophthalmology (2023) 23:125 Page 6 of 7

Data Availability
Future classification systems that consider not only clini- All data generated or analysed during this study are included in the
cal findings, but also subjective symptoms may be appro- manuscript.
priate to better understand exotropia and predict surgical
outcomes. Declarations
In patients with controllability, a larger preoperative
Ethics approval and consent to participate
amount of deviation at distance and near was signifi- Approval to conduct this study was obtained from the Institutional Review
cantly associated with recurrence. These results are con- Board (IRB) of Yeungnam University Faculty of Medicine, and the study
sistent with those of previous studies on the prognostic adhered to the tenets of the Declaration of Helsinki (IRB file number: 2022-
01-055), which waived the requirement for informed consent owing to the
factors of surgical outcomes in patients with intermit- retrospective nature of the study and the use of anonymized patient data.
tent exotropia [2–4]. Although patients with control-
lability had relatively better binocularity, those with a Consent for publication
Not applicable.
large amount of exotropia were more likely to experience
recurrence after surgical treatment. Competing interests
This study had several limitations. First, we did not All authors (M.K., H.K.K., W.J.K.) declare no conflict of interests.

evaluate the changes in controllability and subjective

Received: 20 April 2022 / Accepted: 21 March 2023
awareness of exotropia after surgery. Ha and Kim showed
improved subjective symptoms including stereopsis and
asthenopia after surgery in patients with constant exo-
tropia [18]. We evaluated only the association between
surgical outcomes and the presence of controllability. References
The changes in controllability and awareness of exotro- 1. Kim DH, et al. An overview of the korean intermittent exotropia multicenter
pia require assessment in future studies. Second, this study by the korean association for pediatric ophthalmology and strabismus.
Korean J Ophthalmol. 2021;35:355–9.
study included only pediatric patients with intermit- 2. Kim WJ, Kim MM. The clinical course of recurrent intermittent exotropia
tent exotropia. The clinical characteristics of adult and following one or two surgeries over 24 months postoperatively. Eye (Lond).
pediatric patients with intermittent exotropia may differ 2014;28:819–24.
3. Kim S, Ha S, Suh Y, Kim S. Clinical factors affecting the rate of exodrift after
[19]. Third, the presence of controllability was assessed surgery in patients with basic intermittent exotropia. Sci Rep. 2021;11:6484.
by directly asking the patient and each patient’s spe- 4. Choi DD, Noh H, Park KA, Oh SY. Survival analysis of adult and children inter-
cific accompanying symptoms did not investigate in this mittent exotropia using a matched case-control design. Sci Rep. 2019;9:575.
5. von Noorden GK, Campos EC. Exodeviations. In: Binocular Vision and Ocular
study. Further study using questionnaire to evaluate the Motility. Mosby, 2002:356 – 76.
controllability and accompanying symptoms will be 6. Kushner BJ. Exotropia. Strabismus. Gewerbestrasse, Switzerland:Springer,
performed. 2017:pp. 73–95.
7. Hirota M, et al. Objective evaluation of visual fatigue in patients with intermit-
tent exotropia. PLoS ONE. 2020;15:e0230788.
Conclusion 8. Hatt SR, Leske DA, Holmes JM. Awareness of exodeviation in children with
In conclusion, about a quarter of pediatric patients with intermittent exotropia. Strabismus. 2009;17:101–6.
9. Kim H, Kim DH, Ahn H, Lim HT. Proposing a new scoring system in intermit-
intermittent exotropia had subjective controllability of tent exotropia: towards a better assessment of control. Can J Ophthalmol.
exotropia. Patients with controllability showed better 2017;52:235–9.
surgical outcomes, later exotropia onset, and better level 10. Moon Y, Kim H, Kim DH, Lim HT. LACTOSE control scoring helps predict
surgical outcomes for childhood intermittent exotropia. Can J Ophthalmol.
of control than patients without controllability. Preop- 2019;54:659–63.
erative ocular exodeviation was a significant factor influ- 11. Kim WJ, Kim MM. Variability of preoperative measurements in intermittent
encing favorable outcomes in patients with controllable exotropia and its effect on surgical outcome. J AAPOS. 2017;21:210–4.
12. Lim J, Kim WJ. Dramatic decrease in ocular deviation 1 day before surgery in
exotropia. patients with intermittent exotropia. Korean J Ophthalmol. 2020;34:361–6.
13. Lee JY, Song JE, Chang HR, Choi CY, Han SY. Surgical outcomes of patients
List of abbreviations with diagnostic preoperative monocular occlusion in intermittent exotropia.
PD prism diopters Sci Rep. 2020;10:7776.
LR lateral rectus muscle 14. Son W, Kim WJ. Comparison between parental observations and clinical
R&R lateral rectus muscle recession and medial rectus muscle resection evaluation findings in korean pediatric patients with intermittent exotropia. J
Pediatr Ophthalmol Strabismus. 2020;57:199–203.
Acknowledgements 15. Kwok JJ, Chong GS, Ko ST, Yam JCS. The natural course of intermittent exotro-
Not applicable. pia over a 3-year period and the factors predicting the control deterioration.
Sci Rep. 2016;6:27113.
Authors’ Contributions 16. Lee BJ, Kim SJ, Yu YS. The clinical course of intermittent exotropia with small
Involved in design of study (M.K., H.K.K., W.J.K.); Conduct of study (M.K., W.J.K.); initial deviation. J Pediatr Ophthalmol Strabismus. 2015;52:206–12.
Collection and management of data (M.K., W.J.K.); Analysis and interpretation 17. Nusz KJ, Mohney BG, Diehl NN. The course of intermittent exotropia in a
of data (M.K., H.K.K., W.J.K.); Preparation of manuscript (M.K., W.J.K.); and Review population-based cohort. Ophthalmology. 2006;113:1154–8.
or approval of manuscript (M.K., H.K.K., W.J.K.) 18. Ha SG, Kim SH. Clinical preoperative and postoperative symptoms of exotro-
pia. J Pediatr Ophthalmol Strabismus. 2016;53:44–51.
Funding
Not applicable.
Kim et al. BMC Ophthalmology (2023) 23:125 Page 7 of 7

19. Shin J, Kim WJ. Changes in exodeviation after the monocular occlusion test in
adult patients with intermittent exotropia and its association with the level of
control. Korean J Ophthalmol. 2020;34:485–90.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.