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Purpose To simulate and check the plausibility of the proposed mechanisms of X-pattern exotropia and to determine the least invasive surgical method that can be used to treat the disorder. Design Computational supported analysis and retrospective study. Methods The oculomotor model SEE++ was used to simulate the effects of the different causes that have been proposed for the X-phenomenon. In addition, a retrospective study was conducted using preoperative and postoperative measurements of 10 patients with X-pattern exotropia. Eye movements and surgery of these patients were simulated and analyzed statistically. Results Our computer-based simulations showed that only 1 of the 4 proposed theories can account successfully for the observed X-patterns: an overaction of all 4 oblique muscles can induce divergent exotropia in upgaze and downgaze, and an alteration of horizontal muscles can cause the additional divergence in all gaze positions. The simulation of eye muscle surgery confirmed that a sufficient correction of the divergent deviation in all gazes already can be achieved by a recession and resection of 2 horizontal eye muscles. Conclusions In case of X-pattern exotropia, recession and resection of 2 horizontal muscles can be used as a first-line therapy, leading to a simplification of the therapy.