{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,27]],"date-time":"2026-02-27T05:08:50Z","timestamp":1772168930661,"version":"3.50.1"},"update-to":[{"DOI":"10.12688\/f1000research.156932.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,7,22]],"date-time":"2025-07-22T00:00:00Z","timestamp":1753142400000}},{"DOI":"10.12688\/f1000research.156932.2","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,7,22]],"date-time":"2025-07-22T00:00:00Z","timestamp":1753142400000}},{"DOI":"10.12688\/f1000research.156932.3","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,7,22]],"date-time":"2025-07-22T00:00:00Z","timestamp":1753142400000}},{"DOI":"10.12688\/f1000research.156932.4","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2025,7,22]],"date-time":"2025-07-22T00:00:00Z","timestamp":1753142400000}}],"reference-count":29,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2025,7,22]],"date-time":"2025-07-22T00:00:00Z","timestamp":1753142400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"<ns3:p>Background One of the most common strabismus types in children is intermittent exotropia (IXE), which predominantly occurs in children between the ages of 2-4 years. It may affect visual development and often coexists with refractive errors. Unlike esotropia, which is typically associated with hyperopia, IXE demonstrates a more complex relationship with refractive errors. Recent studies suggest a possible link with myopia; however, this relationship remains unclear. This study will investigate the prevalence and distribution of refractive errors in children with IXE, challenging the traditionally held relationship between strabismus and hyperopia and its possible contribution to the development of myopia. Methods In this cross-sectional retrospective study from August 2021 to December 2023, 179 patients diagnosed with IXE were recruited via an outpatient clinic in Najah Al-Quraishi, Baghdad, Iraq. The refractive errors were compared by autorefractometry and retinoscopy after cycloplegic dilation. Data analysis was conducted under the use of IBM SPSS V.26 for the determination of emmetropia, myopia, and hyperopia prevalence. Results Among the 179 patients, emmetropia was the most commonly observed refractive status, present in 68 patients (38%). Low hyperopia and low myopia were also common, with 64 and 40, respectively. A limited number of patients had moderate\/high myopia and moderate\/high hyperopia; in detail, the prevalence was as follows: 5% of patients had moderate myopia, while 0.5% of patients suffered from high myopia; symmetrically, 5% were moderate to high hyperopia. From the data collected, a trend emerged for a low refractive error and symmetric refractive error in both eyes. Conclusion Contrasted to prior conventional wisdom about refractive error in strabismus, it established the greater prevalence of emmetropia in patients with IXE. The findings call for specific management strategies to be applied in this population.<\/ns3:p>","DOI":"10.12688\/f1000research.156932.5","type":"journal-article","created":{"date-parts":[[2025,7,22]],"date-time":"2025-07-22T15:15:10Z","timestamp":1753197310000},"page":"1318","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Types of refractive errors in a sample of Iraqi children with Intermittent exotropia"],"prefix":"10.12688","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4396-9781","authenticated-orcid":false,"given":"Najah","family":"K. 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We hope that the following changes address your concerns. We have revised the abstract as follows:  Clarified the age group to &quot;predominantly in children aged 2 to 4 years.&quot; Replaced &quot;refractive mistakes&quot; with &quot;refractive errors.&quot; Rephrased &quot;The most expected refractive error&quot; to &quot;Emmetropia was the most commonly observed refractive status.&quot;   We have addressed your concerns in the introduction section as follows:  Revised the statement \u201cIt is insidious since this outward deviation of an eye happens only once in a while, hence disturbing binocular vision\u201d to reflect that this is not true for all patients with intermittent exotropia (IXT). Added appropriate citations for the statement regarding the relationship between intermittent exotropia and refractive errors.  We have addressed the concerns regarding the methodology as follows:  Added the dioptric definition of emmetropia (&plusmn;0.50 diopters). Updated the abstract and methods to explicitly state the study's retrospective nature. Clarified the consent process, specifying verbal consent for additional data collection and parental\/guardian consent for minors. Included normality testing using the Shapiro-Wilk test in the statistical analysis section.   We have made the following adjustments in the discussion section:  Discussed the high prevalence of emmetropia in the context of refractive error distribution in normal binocular vision. We acknowledged the retrospective nature of our study, which limits the inclusion of a control group. We have suggested that future prospective studies include such comparisons to further explore the relationship between refractive errors and intermittent exotropia.","URL":"https:\/\/f1000research.com\/articles\/13-1318\/v5#referee-comment-12901","order":1,"name":"referee-comment-12901","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.172316.r343840, Jiawei Zhou, Yiqiu Lu, School of Ophthalmology and Optometry, Eye Hospital, Wenzhou Medical University, Wenzhou, 10 Dec 2024, version 1, 2 not approved","URL":"https:\/\/f1000research.com\/articles\/13-1318\/v1#referee-response-343840","order":2,"name":"referee-response-343840","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Najah Mohammad<\/b>; \n<i>Posted: 15 Dec 2024<\/i>; We appreciate the time and effort you have taken to review our manuscript and for providing insightful comments and suggestions. We have carefully considered each point raised and have revised the manuscript accordingly. Below is a detailed response to your comments: &nbsp;  We have revised the abstract and background sections to explicitly state the purpose of the study. The purpose now highlights our aim to investigate the distribution of refractive errors in children with intermittent exotropia and its clinical implications. We have replaced &quot;incidence&quot; with &quot;prevalence&quot; throughout the manuscript, as this study reports proportions rather than the emergence of new cases. Additionally, we clarified that emmetropia is not classified as an illness. We carefully selected the cited literature to ensure it aligns with the focus and scope of the manuscript. While I aimed to include relevant and high-quality studies, I acknowledge that perspectives on what constitutes classic literature may vary. I did my best to include the most pertinent and available sources within the context of this work, and I hope the selection adequately supports the study's objectives.&nbsp; The introduction and discussion sections have been revised to adopt a less definitive tone. We now emphasize the need for longitudinal studies to establish causal relationships. We have restructured the background to clarify the study's primary focus on refractive error distribution and removed extraneous emphasis on treatment and prognosis. We have expanded the introduction and discussion sections to explicitly outline the gaps in prior studies, such as the lack of comprehensive data on refractive error profiles specific to intermittent exotropia and the absence of longitudinal analyses. We have replaced &quot;spherical equivalence&quot; with &quot;spherical equivalent refraction (SER)&quot; where appropriate and included refractive measurements to two decimal places with units. The overlapping content has been streamlined to remove duplication and improve clarity. Orthopia has been excluded from the myopia classification, and we clarified the myopia ranges in the data collection section. We have removed redundancy between Figures 1 and 2. The data is categorical in nature, histogram is not suitable for such issues Figure 2 has been removed Table 2 has been revised to include a column for &quot;Refractive Error OD&quot; and a footnote detailing the refractive error classification criteria. We have clarified in the methods and results sections that refractive errors are reported per patient, not per eye, to reflect the nature of the data. Figure 1 has been replaced by a confusion matrix to better visualize the data We have added a table to present the detailed refractive error analysis for better clarity. We have corrected all misplaced citations and ensured they align with the referenced studies. We have revised the statement to reflect the observational nature of the findings and removed unsupported causal implications. We have expanded the discussion to include specific examples of tailored therapeutic strategies based on the study's findings. The final paragraph has been revised to remove unsupported causal claims and emphasize the need for longitudinal studies.   We believe these revisions have strengthened the manuscript and addressed your concerns thoroughly. Thank you again for your valuable feedback. Sincerely,","URL":"https:\/\/f1000research.com\/articles\/13-1318\/v5#referee-comment-12968","order":3,"name":"referee-comment-12968","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.180118.r376737, Dr. Ankit Varshney, Shree Bharatimaiya College of Optometry and Physiotherapy, Veer Narmad South Gujarat University, Surat, Gujarat, 11 Apr 2025, version 4, 1 approved, 1 approved with reservations, 2 not approved","URL":"https:\/\/f1000research.com\/articles\/13-1318\/v4#referee-response-376737","order":4,"name":"referee-response-376737","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.180118.r382155, Janos Nemeth, Semmelweis University, Budapest, Budapest, 14 May 2025, version 4, 1 approved, 1 approved with reservations, 2 not approved","URL":"https:\/\/f1000research.com\/articles\/13-1318\/v4#referee-response-382155","order":5,"name":"referee-response-382155","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Najah Mohammad<\/b>; \n<i>Posted: 28 May 2025<\/i>; We sincerely thank the editorial team and reviewer for their time, constructive feedback, and commitment to improving the quality of our manuscript.  \n<b>In general, the study may be of interest to the scientific reader community because it is based on a large population cohort of individuals with intermittent exotropia (IXT) and studied the distribution of their refractive states. However, the analysis, presentation and discussion of the results would need further development and clarifications. The discussion needs to be far shortened and concentrated on the results. The manuscript needs language and logistic corrections by a native English expert, due to several unclear statements in the abstract and in the text of the article, like e.g. the last sentence of the results, or in the Introduction: \u201eWhereas esotropia can be associated with plus, \u2026\u201d \u2013 What \u201eplus\u201d means here?<\/b>   \n<b>Response: <\/b>Thank you for your constructive feedback. We will revise the manuscript thoroughly for clarity and conciseness, particularly in the Discussion section, and will seek assistance from an expert English speaker to improve language quality. The term &quot;plus&quot; in the Introduction will be replaced with &quot;hyperopia&quot; to avoid ambiguity.  \n<b>Detailed comments.<\/b> \n<b>I do not agree with the unsupported last two statements in the Background (that \u201e\u2026 intermittent exotropia might \u2026 lead to myopia\u201d). The mention of a causative relationship is too strong statement based on the literature list of the manuscript version 4. However, there are some new publications which might support the authors. Please, cite also these publications:&nbsp; (refer to 1 ); ( refer to 2 )<\/b> \n<b>Response: <\/b>Thank you for your valuable comment. We agree that the original statement may have implied causation too strongly. We have revised the wording to reflect an association rather than causality and have incorporated the suggested recent references to support the manuscript more appropriately.  \n<b>Please, show the age range of the study participants in the abstract.<\/b> \n<b>Response: <\/b>The study included patients based on predefined age groups, as outlined in the methodology section, without specifying their exact ages.  \n<b>In some places the authors mention only auto-refractometry and in some other places both auto-refractometry and retinoscopy for determination of the refraction. What is the reality? How the decision was made if auto-refractometry and retinoscopy presented different results?<\/b> \n<b>Response: <\/b>Thank you for highlighting this inconsistency. We confirm that both auto-refractometry and retinoscopy were performed for all participants. In cases of discrepancy, retinoscopy was considered the final and more accurate method for classification. We have revised the manuscript to reflect this clearly and consistently.  \n<b>Definitions of refractive errors are presented twice in Paragraph 1 of Data collection and slightly differently (see e.g. low myopia: &lt;-0.5D - -3.0D vs &lt;-0.75D - -3.0D).&nbsp; Where children with astigmatism in the studied groups? How did the authors classify them?<\/b> \n<b>Response: <\/b>Thank you for your careful observation. We have removed the duplicate and inconsistent definitions and unified the classification based on spherical equivalent refraction. Children with astigmatism were included in the analysis and classified according to their spherical equivalent values. The methodology section has been revised accordingly for clarity.   \n<b>Please, specify and describe definitely the ages (range, mean, SD) of the participants in the different groups at the date of the cross-sectional examination.<\/b> \n<b>Response: <\/b>The study included patients based on predefined age groups, as outlined in the methodology section, without specifying their exact ages.  \n<b>Figure 1. Due to the different number of participants in the two groups, it would be advisable to show their refractive status in two separate sub-figures (one for children and the other for young students) and in percentages instead of the number of persons.<\/b> \n<b>Response: <\/b>The figure was divided into two subfigures based on proportional distribution, as recommended.  \n<b>The mean spherical equivalents (in the text and also in Table 2) need to be shown with decimals, one or two decimals depending on the accuracy of the refraction measurements. E.g. if the refraction is determined by one decimal accuracy, two decimals need to be exhibited when showing the mean value.<\/b> \n<b>Response: <\/b>Two decimal places were used to present the mean spherical equivalent for greater precision.  \n<b>Table 1 and Table 3 shows age limits between the 2 subgroups. Less than 6 years of age or more than 6 years of age. What about those who were exactly 6 years old? Please, explain the definitions of age subgroups also in the text of the Methods. <\/b> \n<b>Response: &nbsp;&nbsp;<\/b>The exact definition of age groups was demonstrated in the methods.  \n<b><u>The<\/u> Count numbers are false in Table 3 and they are different than in Table 1. In Table 3 there are 99 females and 96 males for the right eye and 147 females and 146 males for the left eye! While in Table 1 only 83 females and 96 males are mentioned. In Table 3 there are 67 persons below the age of 6 years and 128 above for the right eye but for the left eye these numbers are quite higher: 191 and 102 respectively. Both are different than in Table 1.&nbsp;<\/b>  \n<b>Response: <\/b>The numbers and percentages in table 3 have been thoroughly rechecked, and the errors have been corrected accordingly.  \n<b>The percentage calculations are wrong in Table 3. because of the number of persons in the two gender groups and also in the two age groups are not equal (68 vs 128 persons), therefore the % calculations have to perform for the two subgroups independently.<\/b> \n<b>Response: <\/b>The numbers and percentage calculations have been reviewed, and the necessary corrections were made to reflect the correct subgroup proportions.\n<b> <\/b> \n<b>&nbsp;&nbsp; The authors missed to compare the distributions of the refraction states between the two age groups. They did not mention that in the older group, the percentage of emmetropia is higher (by 8.1%), myopia is far higher (by 74.5%) and hyperopia is far lower (by -34.1%) than in the younger age group (based on the data of the right eye in Table 3 which count numbers are close to the count numbers in Table 1).<\/b> \n<b>Response: <\/b>The authors compared the distribution of refractive states across different age groups and found no statistically significant differences between them. \n<b>&nbsp;<\/b> \n<b>Discussion First paragraph. Please, present the results, (the found percent of emmetropia,) in the context of the literature data of similar age groups of non-strabismus children and that of esotropia children and exotropia children. The best way would be if the authors would have own controls for children with non-strabismus and esotropia. However, as the authors have no such controls, the data might be compared to literature data of children with similar ages and ethnicity. Only after such comparisons might be made a supported statement that the found percentage of emmentropia is higher, similar or lower than in the corresponding literature. (It is scientifically not enough and acceptable to relate the findings only to \u201cprior conventional wisdom\u201d as the authors mentioned.)&nbsp;<\/b> \n<b>Response: <\/b>Thank you for this insightful comment. In response, we have added a comparative analysis of the emmetropia prevalence in our cohort against literature data to provide clearer context and highlight the distinct refractive error profile in intermittent exotropia.  \n<b>In the comparison with Robaei et al data, there might be mentioned some other important differences apart from myopia, namely: Robaei et al found far less emmetrops and hyperops among exotropia patients.&nbsp;<\/b> \n<b>Response: <\/b>Thank you for the valuable suggestion. We have revised the paragraph to include the lower prevalence of emmetropia and hyperopia among exotropia patients in the Robaei et al. study, providing a more comprehensive comparison.  \n<b>In Paragraph 4 in the Discussion, I do not agree with the authors statement that they observed a myopia prevalence which might suggest a possible association with IXT because their data presented in the manuscript do not support this. Among the refractive state, emmetropia and then phyperopia are the most prominent and myopia is only the last most frequent. However, I would agree that the prevalence of myopia in the older age group is far higher than in the younger age group which might be an indirect sign of a myopic shift with age in IXT children. As the authors presented no any longitudional data, it would be advisable not to present long discussion and conclusions on the existence of myopia in children with exotropia and on their relationship, as these are unsupported conclusions. Please, shorten this part of the discussion extensively.<\/b> \n<b>Response: <\/b>Thank you for your observation. We have revised the paragraph to clarify that while myopia was the least frequent overall, its increased prevalence in the older age group may reflect a potential age-related myopic shift in IXT, rather than a primary association.  \n<b>As author presented no data on the effect of therapy, the discussion about it is unsupported by the authors own data and therefore it is suggested to delete.<\/b> \n<b>Response: <\/b>Thank you for your comment. We agree that the original discussion extended beyond the data presented. We have now shortened this section to avoid unsupported conclusions   \n<b>The last sentence in the final conclusion is also unsupported, so need to modify the statement.<\/b> \n<b>Response: <\/b>Thank you for the comment. We have revised the conclusion to better reflect the descriptive nature of our results and to avoid unsupported causal inferences.","URL":"https:\/\/f1000research.com\/articles\/13-1318\/v5#referee-comment-13967","order":6,"name":"referee-comment-13967","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.183024.r407311, Hector Santiago, Inter American University of Puerto Rico, Bayam\u00f3n, 23 Sep 2025, version 5, indexed","URL":"https:\/\/f1000research.com\/articles\/13-1318\/v5#referee-response-407311","order":7,"name":"referee-response-407311","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The author(s) declared that no grants were involved in supporting this work","order":8,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}