The management of exotropia (XT) in the presence of hyperopia is challenging, as these patients are at an increased risk of developing amblyopia and compromised binocular vision. This study aims to evaluate the management approaches and clinical outcomes in XT associated with hyperopia. A systematic review was conducted with a comprehensive search across PubMed, Web of Science, and Google Scholar, following PRISMA 2020 guidelines. The search strategy utilized a combination of free-text keywords and MeSH terms, including "Exodeviation," "Exotropia," "Intermittent Exotropia," and "Hyperopia." The search was restricted to articles published between 1991 and 2024 that examined various management modalities for XT. Four independent reviewers screened and assessed the eligibility of articles based on predefined guidelines. Excluded studies included animal research, case reports, narrative reviews, abstracts, conference proceedings, editorials, non-English publications, and other systematic reviews. A total of 10 studies from 6 countries with 1,090 participants with a mean age of 8.1 years, 194 of whom were hyperopic. Eight studies found that under-correcting hyperopia by 1.00 to 2.50 diopters was effective in treatment of XT. Three studies recommended full cycloplegic correction in cases with hyperopia exceeding 5.00 diopters. Surgical intervention was more effective and led to improvements in stereoacuity. Furthermore, postoperative correction of hyperopia resulted in favorable long-term outcomes. Notably, postoperative success rates were higher in hyperopic patients than in those with emmetropia. The management of XT associated with hyperopia should be individualized, accounting for the AC/A ratio, fusional status, control of XT, stereoacuity, the degree of hyperopia, and the refractive difference between the two eyes.
Alnasser et al. (Thu,) studied this question.