Orbital apex syndrome after trauma in a 6-year-old - a rare occurrence.

Orbital apex syndrome is rare, but can occur as a consequence of trauma from fracture of the medial orbit. This case report highlights the fact that a high index of suspicion is needed when a patient presents with a facial injury, especially in children who cannot give an account of the actual events that transpired. Radiological investigation should be done early when an underlying injury is suspected in a trauma patient. A low threshold for computed tomography should be maintained when proptosis and vision loss are present.

Botulinum toxin treatment for acute traumatic complete sixth nerve palsy.

AIMS: To investigate the benefits of botulinum toxin (BTX) injection for acute unilateral complete sixth nerve palsy caused by trauma. METHODS: We retrospectively reviewed patients treated for acute unilateral complete sixth nerve palsy caused by head injury during a 10-year period (between March 1993 and February 2003) in our hospital. The BTX treatment group was defined as patients who received BTX injection within 3 months of injury. Patients who presented within 3 months of trauma, and had no previous BTX injection or surgery were enrolled as the conservative treatment group. Comparison of the patient demographics, palsy characteristics, angle of deviations, and recovery rates were made between the two groups. RESULTS: In all, 33 patients were enrolled by our inclusion criteria. Of these, 19 patients were treated conservatively, and 14 patients were treated with BTX. A total of 79% of our patients presented with abduction deficit of grade -5. The results showed that there was no significant difference in the outcome for the two groups based on age, gender, time to presentation, severity, and initial angle of deviation. The BTX group had a higher recovery rate than the conservative treatment group (64.3 vs 26.3%, P=0.028). Among 26 patients with grade -5 abduction deficit, the recovery rate was higher in the BTX-treated patients than in the conservatively treated patients, which had no statistical significance (50 vs 18.8%, P=0.09). CONCLUSION: BTX facilitates recovery of acute traumatic complete sixth nerve palsy in severely injured patients.

Subtenon injection of botulinum toxin for treatment of traumatic sixth nerve palsy.

PURPOSE: Subtenon injection of botulinum toxin may produce results similar to intramuscular injection of the medial rectus muscle for the treatment of acute traumatic sixth nerve palsy. This study was designed to evaluate the clinical efficacy of subtenon injection and to compare our results with those in previously published reports. METHODS: During 3 years at a single institution, 13 patients with traumatic sixth nerve palsy of less than 6 months' duration were treated with subtenon injection of botulinum toxin. The deviation angles before and after injection were recorded. A distance esotropia of less than 10 prism diopters (PD) in the primary position or absence of diplopia at 3 months was defined as recovery. RESULTS: Of the 13 patients treated, 11 (84.5%) had unilateral palsy and 2 (15.4%) had bilateral palsy. The average pre-injection deviation was 39.5 PD of esotropia, and the average post-injection deviation was 17.0 PD. Seven patients experienced recovery and regained binocular single vision; the overall recovery rate was 53.8% (unilateral, 63.6%; bilateral, 0%). Six patients did not recover and subsequently underwent strabismus surgery. CONCLUSION: Patients with traumatic sixth nerve palsy treated with subtenon injection of botulinum toxin showed higher recovery rates than did most patients treated with conservative measures in published reports. The result of subtenon injection of botulinum toxin without electromyography (EMG) guidance was comparable to that obtained using EMG-guided intramuscular injection of botulinum toxin. Patients with unilateral palsy demonstrated a better recovery rate than did patients with bilateral palsy.

Predictors of nonrecovery in acute traumatic sixth nerve palsy and paresis.

PURPOSE: To evaluate whether nonrecovery from acute traumatic sixth nerve palsy could be predicted from demographic factors or palsy characteristics. DESIGN: Prospective, observational case series SETTING: Multicenter (academic and private practices). OUTCOME MEASURE: Nonrecovery, defined as the presence of diplopia in primary position or more than 10 prism diopters of distance esotropia in primary position at 6 months after onset. METHODS: Using data from a previously described cohort of 84 eligible patients with acute traumatic sixth nerve palsy, we performed multivariate analyses of demographic factors and palsy characteristics. RESULTS: Nonrecovery at 6 months after onset was associated with a complete palsy (adjusted risk ratio, 9.11; 95% confidence interval [CI], 2.77-14.84) and with a bilateral palsy or paresis (adjusted risk ratio, 2.53; 95% CI, 0.98-4.29). The choice of conservative management (observation, prism, or patch) versus acute injection of Botulinum toxin (within 3 months of injury) did not influence final recovery. CONCLUSIONS: In acute traumatic sixth nerve palsy or paresis, failure to recover by 6 months after onset was associated independently with inability to abduct past midline at presentation and bilaterality. Although the overall recovery rate is high in acute traumatic sixth nerve palsy or paresis, a complete or bilateral case has a poor prognosis and is more likely to need strabismus surgery.

Botulinum toxin treatment of the sixth nerve palsy: an experience of 5-year duration in Thailand.

Forty-five patients (48 eyes) with sixth nerve palsy were treated with botulinum toxin injection to antagonist medial rectus muscle at Siriraj Hospital from October 1995 to September 2000. The common causes of palsy were ischemia, trauma and inflammation. Thirty-eight patients (group I) had an interval to treatment of less than 24 weeks (average, 8.7 weeks) and seven patients (group II), longer than 24 weeks. The mean pre-injection esodeviation and extent of abduction in group I were 28.1 prism diopters (PD) and 28.4 per cent, and in group II were 38 PD and 8.1 per cent respectively. After a mean follow-up of 12.2 months, twenty-seven (71.1%) patients in group I recovered completely after the first injection and three (7.9%), after the second injection with a mean interval to recovery of 8.1 weeks. One (14.3%) of 7 patients of group II obtained complete recovery without fusion. Twenty-six (83.9%) of 31 patients with complete resolution achieved binocular function. We conclude that botulinum toxin treatment is a safe and effective alternative to traditional surgery of acute onset sixth nerve palsy.

Botulinum toxin treatment versus conservative management in acute traumatic sixth nerve palsy or paresis.

PURPOSE: Botulinum toxin (BTX), injected into the ipsilateral medial rectus muscle, has been advocated for the management of acute traumatic sixth nerve palsy or paresis. We conducted a multicenter, nonrandomized, data collection study to evaluate recovery rates of patients treated with either conservative measures or BTX. METHODS: All members of the American Association for Pediatric Ophthalmology and Strabismus and the North American Neuro-Ophthalmology Society were invited to enroll patients with acute traumatic sixth nerve palsy or paresis during a 2-year period (between March 1996 and February 1998). The BTX group was defined as patients who received a BTX injection within 3 months of injury. Recovery at 6 months from injury was defined as absence of diplopia in the primary position and a distance esotropia of no more than 10 PD in the primary position. Nonrecovered patients with less than 6 months of follow-up (n = 15) were excluded. RESULTS: Eighty-four eligible patients were enrolled by 46 investigators. Sixty-two patients (74%) were treated conservatively and 22 (26%) with BTX. Sixty-two patients (74%) had unilateral palsy, and 22 (26%) had bilateral palsy. Recovery rates were similar between BTX and conservatively treated patients (overall: 73% vs 71%, P = 1.0; unilateral: 81% vs 83%, P = 1.0; bilateral: 50% vs 38%, P = 0.66, respectively). CONCLUSIONS: In this prospective multicenter study of acute traumatic sixth nerve palsy or paresis, patients treated with either BTX or conservative measures had similar high recovery rates.

[Treatment of sixth nerve palsy of traumatic or tumor etiology using botulinum toxin]. / Tratamiento de las parálisis del VI par de etiología traumática y tumoral mediante toxina botulínica.

PURPOSE: To study the treatment of sixth nerve palsies of traumatic or tumoral etiologies using botulinum toxin. The factors and possible influences are analysed. METHODS: 35 patients with unilateral sixth nerve palsy are studied, 21 presenting traumatic (group I) and 14 with tumoral etiology (group II). They have been treated with botulinum toxin into the medial rectus muscle, using topical anesthesia. In group I the mean preoperative deviation was 59 diopters, in group II it was 37 diopters. The follow-up time, the initial deviation, the dose, the number of injections, the colateral effects and the final results are analyzed. RESULTS: In group I, the mean number of injections was 1.7, and the dose 10.23 international units, success was achieved in 38% of the patients, better results are obtained when treatment is injected within six months after traumatism, when less initial deviation and better initial lateral muscle function are present. In group II, the mean number of injections was 1.5 and the dose 8.21 international units, success was achieved in 57%, no influence among these factors was found. CONCLUSIONS: We consider useful to treat the traumatic palsy with botulinum toxin within six months after traumatism. The results depend on the initial deviation and the previous lateral muscle function. It is also useful as a chronic treatment and as a diagnosis procedure.