A toddler shows exotropia of the right eye on a cover-uncover test. What is the initial treatment?

• A. Botulinum toxin injection.
• B. Corrective lenses.
• C. Occluding the affected eye for 6 hours per day.
• D. Patching of the unaffected eye for 2 hours each day.

Answer: (D)

When a toddler shows exotropia on a cover-uncover test, the priority is to promote proper visual development in the affected eye and prevent amblyopia. The strongest initial approach is occlusion therapy: patch the normal eye so the weaker eye is forced to work, which reduces suppression and helps the brain develop binocular vision. Starting with about 2 hours of patching each day is a practical, toddler-friendly regimen that can be adjusted based on response. Corrective lenses may be helpful if there is a refractive error contributing to misalignment, but they don’t directly address the suppression of the affected eye. Botulinum toxin injections are usually considered after non-surgical measures, or in specific situations, and are not first-line. Patching the affected eye would deprive the good eye and is not appropriate. Therefore, patching the unaffected eye for 2 hours daily is the best initial treatment.