Effects of Short-Term Treatment of Rabbit Extraocular Muscle With Ciliary Neurotrophic Factor.

Purpose: Little is known about the effect of ciliary neurotrophic factor (CNTF) on extraocular muscles, but microarray studies suggested CNTF might play a role in the development and/or maintenance of strabismus. The effect of short-term treatment of adult rabbit extraocular muscle with injected CNTF was examined for its ability to alter muscle characteristics. Methods: Eight adult New Zealand white rabbits received an injection into one superior rectus muscle of 2 µg/100 µL CNTF on 3 consecutive days. One week after the first injection, the rabbits were euthanized, and the treated and contralateral superior rectus muscles were assessed for force generation capacity and contraction characteristics using an in vitro stimulation protocol and compared to naïve control superior rectus muscles. All muscles were analyzed to determine mean cross-sectional areas and expression of slow twitch myosin heavy chain isoform. Results: Short-term treatment of rabbit superior rectus muscles with CNTF resulted in a significant decrease in muscle force generation, but only at the higher stimulation frequencies. Significantly decreased myofiber cross-sectional areas of the treated muscles correlated with the decreased generated force. In addition, there were significant changes to contractile properties of the treated muscles, as well as a decrease in the number of myofibers expressing slow twitch myosin heavy chain. Conclusions: We show that short-term treatment of a single rabbit superior rectus muscle results in decreased myofiber size, decreased force, and altered contractile characteristics. Further studies are needed to determine if it can play a role in improving alignment in animal models of strabismus.

Botulinum Toxin A Injection in Horizontal Nystagmus: Effect on the Frequency of the Oscillation on a Pediatric Population.

PURPOSE: To evaluate the effect of botulinum toxin A injection on the frequency of horizontal nystagmus in children. METHODS: This was a non-randomized before-and-after clinical trial evaluating a cohort of children with horizontal nystagmus before and after treatment with botulinum toxin A. The toxin was injected under general anesthesia with spontaneous ventilation without intubation using the Mendonça forceps and the effect was evaluated by analyzing the frequency of the oscillation in Hertz (Hz) on video registrations before and after treatment. RESULTS: The current study found a statistically significant difference on the frequency of the nystagmus in children before and after the injection of botulinum toxin A, with the mean frequency decreasing from 1.55 ± 0.94 Hz before treatment to 1.04 ± 0.87 Hz at 1 month post-injection (P < .001) and to 1.27 ± 0.87 Hz at 6 months post-injection (P = .002). When comparing the data 1 and 6 months post-injection, this study found a significant increase (P = .001) in the frequency of the nystagmus. CONCLUSIONS: The injection of botulinum toxin A is effective in reducing the frequency of oscillations in children with horizontal nystagmus both 1 and 6 months after the procedure, and can be used as a first-line, less invasive treatment aiming to decrease the frequency of oscillation. [J Pediatr Ophthalmol Strabismus. 2024;61(5):365-370.].

Peribulbar Corticosteroids for Ocular Myasthenia Gravis.

BACKGROUND: Ocular myasthenia gravis is treated predominantly by oral medications, with the potential for systemic adverse effects. Successful treatment has been achieved using peribulbar dexamethasone. We assessed the effect of peribulbar dexamethasone or triamcinolone (40-mg Triesence), a longer-acting corticosteroid, targeting the peribulbar area as opposed to directly injecting the affected extraocular muscle. This more convenient and secure approach holds the potential for straightforward integration within clinical environments. METHODS: Retrospective chart review. RESULTS: Five patients were identified that were treated with peribulbar corticosteroids. In 4 of the 5 cases, ophthalmoparesis was unilateral. One case had isolated ptosis, and 4 had both ptosis and ophthalmoparesis. Three of these 4 cases reported complete resolution of symptoms within weeks of a single injection. Improvement lasted between 5 to 6 months, and all patients responded to repeated injections. CONCLUSIONS: Peribulbar corticosteroids can be effective in ocular myasthenia gravis. We suggest that longer-acting agents such as triamcinolone are preferable, to reduce injection frequency.

A novel hybrid BonT-A and hyaluronic acid cannula-based technique for eyelid ptosis and periorbital rejuvenation.

BACKGROUND: Eyelid ptosis is characterized by an inferior displacement of the upper eyelid when the eye assumes its primary position. Besides its aesthetic implications, ptosis can also adversely affect visual acuity. OBJECTIVE: This study aimed to evaluate the simultaneous administration of IncobotulinumtoxinA (IncoBonTA) and hyaluronic acid effect in eyelid ptosis and ocular rejuvenation. METHODS: A novel, non-surgical technique for eyelid ptosis management involving IncoBonTA and hyaluronic acid the co-administration within a single syringe, and applied using a cannula. RESULTS: The dual action of IncoBonTA and hyaluronic acid in conjunction with the exact injection sites approaches improves overall aesthetic outcomes but also optimizes the restoration of eyelid functionality in palpebral ptosis. CONCLUSIONS: The functional balance achieved among the contributory muscles-primarily the orbicularis oculi (OO) and its antagonists, the frontal muscle and levator palpebrae superioris (LPS), yields to both, cosmetic and functional.

Botulinum Toxin Injection for the Treatment of Third, Fourth, and Sixth Nerve Palsy: A Meta-Analysis.

The efficacy of botulinum toxin injection for the treatment of third, fourth, and sixth nerve palsy was evaluated. PubMed, Scopus, EMBASE, Web of Science, and Google Scholar databases were searched. Data about the duration of palsy (acute vs chronic), cause of the palsy, type of toxin used, mean dose, and other background characteristics were collected. Outcome variables were success rate (defined by alleviation of diplopia or reduction in eye deviation) and standardized mean difference of prism diopter and abduction deficit before and after injection. The Joanna Briggs Institute checklist was implemented for the risk of bias assessment. The analysis included 38 articles, comprising 643 patients. The overall treatment success rate in acute and chronic nerve palsy was 79% and 33%, respectively. The success rate was not significantly different between different subgroups of age, type of botulinum toxin, pre-injection prism diopter, etiology of the palsy, duration of follow-up, and mean dose of botulinum toxin injection. However, in both acute and chronic palsy, diabetes etiology was accompanied by the highest success rate. Overall symptomatic response to botulinum injection was 84% (95% CI: 67% to 96%), whereas functional response was observed in 64% (95% CI: 47% to 79%) of the patients. The odds ratio for the success rate of treatment of palsies with botulinum toxin versus expectant management was 2.67 (95% CI: 1.12 to 6.36) for acute palsy and 0.87 (95% CI: 0.17 to 4.42) for chronic palsy. Botulinum toxin can be used for the treatment of acute third, fourth, and sixth nerve palsy, especially in patients with acute palsy and more severe tropia. [J Pediatr Ophthalmol Strabismus. 2024;61(3):160-171.].

VEGF is an essential retrograde trophic factor for motoneurons.

VEGF was initially discovered due to its angiogenic activity and therefore named "vascular endothelial growth factor." However, its more recently discovered neurotrophic activity may be evolutionarily more ancient. Our previous work showed that all the changes produced by axotomy on the firing activity and synaptic inputs of abducens motoneurons were completely restored after VEGF administration. Therefore, we hypothesized that the lack of VEGF delivered by retrograde transport from the periphery should also affect the physiology of otherwise intact abducens motoneurons. For VEGF retrograde blockade, we chronically applied a neutralizing VEGF antibody to the lateral rectus muscle. Recordings of extracellular single-unit activity and eye movements were made in alert cats before and after the application of the neutralizing antibody. Our data revealed that intact, noninjured abducens motoneurons retrogradely deprived of VEGF exhibited noticeable changes in their firing pattern. There is a general decrease in firing rate and a significant reduction in eye position and eye velocity sensitivity (i.e., a decrease in the tonic and phasic components of their discharge, respectively). Moreover, by means of confocal immunocytochemistry, motoneurons under VEGF blockade showed a marked reduction in the density of afferent synaptic terminals contacting with their cell bodies. Altogether, the present findings demonstrate that the lack of retrogradely delivered VEGF renders abducens motoneurons into an axotomy-like state. This indicates that VEGF is an essential retrograde factor for motoneuronal synaptic drive and discharge activity.

Botulinum Toxin Injection for the Treatment of Strabismus: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the available evidence comparing the effectiveness of extraocular muscle botulinum toxin type A (BTXA) injection with eye muscle surgery for restoring ocular alignment in children and adults with nonparalytic, nonrestrictive horizontal strabismus. METHODS: Literature searches in the PubMed Cochrane Library, and clinical trial databases with no date restrictions, but limited to articles published in English, were conducted last on January 10, 2021. The searches yielded 515 citations, 40 of which were reviewed in full text by the first author. Fourteen articles met the criteria for inclusion (randomized or nonrandomized comparative studies, or case series with a minimum 50 patients; evaluating extraocular muscle BTXA injection for initial or repeat treatment of horizontal, nonparalytic, nonrestrictive strabismus; with at least 6 months of follow-up) and were graded by a methodologist. RESULTS: The 14 included studies consisted of 2 randomized clinical trials, 3 nonrandomized comparative studies, and 9 case series. All 5 comparative studies were graded level II evidence, and the 9 case series were graded level III evidence. Successful motor outcomes after BTXA injection were relatively consistent across 4 of the 5 comparative studies at 60%, when adjustment was made for differential selection bias in 1 of the studies. In the 4 studies, successful motor outcomes after surgery ranged from 66% to 77% with a mean follow-up of 23 to 75 months, and the outcomes were not significantly different from those after BTXA injection. In the fifth level II study, success was significantly higher with BTXA injection than with surgery (94% vs. 72%). The level III BTXA case series demonstrated higher motor success rates of 87% to 89% when children were treated in 2 muscles at a time; rates were lower in adults treated with single-muscle BTXA injection. CONCLUSIONS: Extraocular muscle injection of BTXA achieves a high rate of successful motor alignment, comparable with that achieved after eye muscle surgery for nonparalytic, nonrestrictive horizontal strabismus. Good alignment may require multiple BTXA injections, and it is not yet clear whether sensory outcomes are equivalent for BTXA injections versus eye muscle surgery in young children.

Diagnostic yields and clinical features of ocular myasthenia gravis.

ABSTRACT: To investigate clinical features and diagnosis process of ocular myasthenia gravis (OMG) in ophthalmology department.A total of 36 patients with ptosis or diplopia who had follow-up for at least 3 months between March 2016 and December 2019 were included in this study. Clinical symptoms of patients and the test results were analyzed. According to the positivity of serologic test, these patients were divided into 2 groups (confirmed OMG and possible OMG with relief of symptoms after antimyasthenic treatment) for comparison.Ptosis was present in 12 (33.33%) patients, diplopia was present in 14 (38.89%) patients, and both ptosis and diplopia were present in 10 (27.78%) patients. Acetylcholine receptor auto-antibody (AchR Ab) was positive in 14 (38.89%) of 36 patients and ice test was positive in 15 (71.43%) of 21 patients with ptosis. Unequivocal response to pyridostigmine was observed in 31 (86.11%) patients. For seropositive cases, AchR Ab titer was significantly higher in the group with 2 clinical symptoms than that in the 1 clinical symptom (P = .011).This study presents the usefulness and diagnostic validity of antimyasthenic treatment for OMG, especially seronegative OMG, with detailed symptom analysis.

Influence of 4-week or 12-week glucocorticoid treatment on metabolic changes in patients with active moderate-to-severe thyroid-associated ophthalmopathy.

Thyroid-associated ophthalmopathy (TAO) is a serious, progressive, vision-threatening and difficult-to-treat organ-specific autoimmune disease. The course, therapeutic effects and prognosis of moderate to severe TAO vary greatly. High-dose intravenous glucocorticoid (IVGC) therapy is considered a first-line treatment for active moderate-to-severe TAO, but there is still insufficient evidence regarding the treatment duration. Long-term IVGC therapy can influence the metabolism of glucose, lipids, and bone. This study was designed to compare changes in metabolic and immunological indexes as well as the magnetic resonance imaging apparent diffusion coefficient (ADC) of the extraocular muscles after 4 and 12 weeks of IVGC therapy. Forty-eight patients with active moderate-to-severe TAO were included in this retrospective cohort study. Metabolism and immunological indexes were measured before and after therapy. The ADC and clinical activity score (CAS) were used to evaluate the efficacy of treatment in these patients. We found that the patients in the 12-week group had increased fasting plasma glucose (p = 0.004), glycated hemoglobin (p = 0.028), total cholesterol (p < 0.001), and low-density lipoprotein (p < 0.001) after therapy. The patients in both groups had reduced bone metabolism markers after therapy. Thyroid peroxidase antibody and thyrotropin receptor antibody levels decreased after treatment in both groups (p < 0.001). A significant decrease in thyroglobulin antibody levels was found in the 4-week group (p = 0.006). The change in the ADC was higher in the 4-week group than in the 12-week group (p = 0.014). However, there were no significant differences in CAS values between the two groups. Therefore, 4-week IVGC therapy was recommended for patients with TAO with glucose and lipid disorders.

Flavonoids Sophoranone Promotes Differentiation of C2C12 and Extraocular Muscle Satellite Cells.

INTRODUCTION: Paralytic strabismus involves a functional loss of extraocular muscles resulting from muscular or neuronal disorders. Currently, only a limited number of drugs are available for functional repair of extraocular muscles. Here, we investigated the effects of a novel drug, flavonoids sophoranone, on the differentiation of extraocular muscles as assessed in bothin vivo and in vitro models. MATERIALS AND METHODS: The effect of flavonoids sophoranone on C2C12 cells was examinedin vitro as evaluated with use of apoptosis, reactive oxygen species (ROS), and cell viability assays. Then, both in vivo and in vitro effects of this drug were examined on the differentiation of C2C12 and satellite cells within extraocular muscles in rabbits. For these latter experiments, RT-PCR and Western blot assays were used to determine expression levels of markers for myogenic differentiation. RESULTS: With use of flavonoids sophoranone concentrations ranging from 0 to 10 µM, no effects were observed upon cell apoptosis, ROS, and cell cycle in C2C12 cells. Based on MTT assay results, flavonoids sophoranone was shown to increase C2C12 cell proliferation. Moreover, flavonoids sophoranone promoted the differentiation of C2C12 and satellite cells within extraocular muscles in rabbits, which were verified as based on cell morphology and expression levels of mRNA and protein markers of myogenic differentiation. Finally, flavonoids sophoranone treatment also increased gene expressions of Myh3, Myog, and MCK. CONCLUSION: The capacity for flavonoids sophoranone to upgrade the differentiation of both C2C12 and satellite cells within extraocular muscles in rabbits at concentrations producing no adverse effects suggest that this drug may provide a safe and effective means to promote repair of damaged extraocular muscles.

T2 mapping histogram at extraocular muscles for predicting the response to glucocorticoid therapy in patients with thyroid-associated ophthalmopathy.

AIM: To evaluate the performance of T2 mapping histograms at the extraocular muscles (EOMs) in predicting the response to glucocorticoid therapy in the patients with active and moderate-severe thyroid-associated ophthalmopathy (TAO). MATERIALS AND METHODS: Thirty active and moderate-severe TAO patients (responsive group, n=20; unresponsive group, n=10) were enrolled, and evaluated using T2 mapping before treatment. Histogram parameters (mean, median, max, min, 10th, 90th percentiles, skewness, and kurtosis) of T2 relaxation time (T2RT) at the EOMs for each orbit, and clinical variables (age, sex, disease duration, anti-thyroid treatment, smoking habit, pre-treatment thyroid function, thyrotrophin receptor antibody, diplopia presence, activity and severity scores) were collected and compared between groups. Logistic regression and receiver operating characteristic (ROC) curve analyses were used to assess the predictive value of identified independent variables for treatment response. RESULTS: The responsive group showed significantly shorter disease duration (p=0.003), while higher T2RTmin than unresponsive group (p<0.001). Multivariate analysis showed that T2RTmin and disease duration were independent predictors for responsive TAOs. ROC curve analyses indicated that setting a cut-off value of ≥54.3 for T2RTmin demonstrated the optimal predicting specificity for responsive TAOs (100%), while a combination of T2RTmin ≥54.3 and disease duration ≤4.5 showed optimal predicting efficiency and sensitivity (area under the curve, 0.820; sensitivity, 65%). CONCLUSIONS: Histogram analysis can help to exhibit the heterogeneity of T2RT at the EOMs. T2RTmin, together with disease duration may be the promising marker for predicting response to glucocorticoid therapy in the patients with active and moderate-severe TAO.

Quantification of Global Ocular Motility Impairment in Graves' Orbitopathy by Measuring Eye Muscle Ductions.

Background: The overall changes of ocular motility in Graves' orbitopathy (GO) are not easily quantifiable with the methods currently available, especially in clinical studies. The aim of the present study was to calculate parameters that quantify the changes of ocular motility in GO in relation to the Gorman score for diplopia. Methods: We studied 100 GO patients (Group 1) and 100 controls (Group 2). We also included 30 patients treated with intravenous methylprednisolone (iv-MP), assessed at baseline and after 12 and 24 weeks (Group 3), and 66 patients submitted to squint surgery, assessed at baseline and after 12 weeks (Group 4). Ocular ductions were measured in four gaze directions by a perimeter arc and were used to calculate a total motility score (TMS) as the sum of ductions in each direction; a biocular TMS (b-TMS) as the sum of the TMS of two eyes; and an asymmetry ratio (AR) as the sum of the differences of the corresponding ductions between the two fellow eyes divided by the mean difference found in controls. Quality of life was accessed by a specific questionnaire (Graves' orbitopathy quality of life [GO-QoL] questionnaire). Results: TMS and b-TMS were lower, while AR was higher, in Group 1 compared with controls (p < 0.001). In Group 1, TMS and b-TMS were inversely correlated with the Gorman score (p < 0.001) and AR was higher in patients with constant diplopia compared with the others (p < 0.001). In Group 3, TMS and b-TMS increased after treatment in responders to iv-MP (p < 0.001). In Group 4, TMS and b-TMS improved in all patients after surgery (p < 0.01), while AR and GO-QoL score improved only in those without residual constant diplopia (p < 0.001). Conclusion: We describe a quantitative method to assess eye motility dysfunction in any stage of GO to be used as an outcome measure in clinical studies.

Comparison of preseptal and pretarsal onabotulinum toxin an injection in patients with hemifacial spasm.

AIM: The aim of the present study was to evaluate the effects of different doses of onabotulinum toxin A on the amplitude and latency values of the blink reflex and facial nerve in the pretarsal and preseptal portions of the orbicularis oculi muscle in patients with hemifacial spasm. MATERIALS AND METHODS: Thirty patients with hemifacial spasm were assigned in two equal groups: Pretarsal Group: Five units of onabotulinum toxin A were injected into each of 2 points of the pretarsal portion; Preseptal Group: Five units of onabotulinum toxin A was injected into 4 points of the preseptal portion. We compared the electromyographic features of the patients before and 5 weeks after botulinum toxin (BTX) injection. RESULTS: In comparison of pre- and post-treatment measurements of blink reflex amplitude responses, the decreases in R1 (p = 0.003), R2 (p < 0.001), and R2C amplitudes (p = 0.031) were found to be significant in the BTX injected side in the pretarsal group. In the comparison of pre- and post-treatment measurements of facial nerve compound action potential amplitude changes, decreases in the amplitudes of the BTX injected (ipsilateral), and uninjected (contralateral) side in the pretarsal group were found to be significant (p < 0.001 for both groups). Decreases in the amplitudes of the BTX injected, and uninjected side in the preseptal group were found to be significant (p < 0.001, and p = 0.008, respectively). CONCLUSION: According to our hypothesis, the smaller amount of BTX applied to the pretarsal portion was found to be more effective than higher amount of BTX injected into the preseptal portion of the orbicularis oculi muscle.

Botulinum toxin injection without electromyographic guidance in consecutive esotropia.

PURPOSE: To investigate the efficacy of botulinum toxin injection without electromyographic guidance for the treatment of consecutive esotropia. METHODS: A retrospective study was performed on 49 subjects with consecutive esotropia who received botulinum toxin injection in the medial rectus muscles without the use of electromyographic guidance. Treatment was considered successful if the final ocular alignment was orthotropic or esodeviation was ≤10 prism diopters (PD) during distant fixation. RESULTS: The mean age was 15.2 ± 8.3 years. The mean esodeviation before injection was 21.8 ± 9.1 PD at distance and 21.3 ± 8.3 PD at near. The mean number of injections per patient was 1.3 ± 0.7, and 46 patients (93.9%) received two or fewer injections. At 6 months after the final injection, the mean angle of esodeviation was 7.3 ± 6.0 PD at distance and 7.5 ± 6.6 PD at near (all p<0.001), and 69.4% showed successful alignment. By multivariate analysis, an initial postoperative esodeviation of ≤18 PD at one month after exotropia surgery was considered to be a predictive factor for successful botulinum toxin injection (P = 0.007). Vertical deviation and/or ptosis occurred in 4 patients (8.2%) at two weeks after injection, which all resolved within three months. There was no recurrence of exotropia up to the final follow-up examination. CONCLUSION: Botulinum toxin injection without electromyographic guidance is safe and effective in the treatment of consecutive esotropia without causing recurrent exotropia. Successful botulinum toxin injection is likely in patients with an initial postoperative esodeviation of 18PD or less at one month after exotropia surgery.

Comparison of the Efficiency of the Botulinum Toxin for the Treatment of Esotropia in Children with and without Neurological Disease and/or Prematurity.

OBJECTIVE: To compare the effect of botulinum toxin injection for the management of esotropia in patients with and without neurological disease and/or prematurity. METHODS: A single-center, retrospective, nonrandomized controlled study was performed on botulinum toxin in 87 children divided into two groups: study group of esotropia in 56 children with neurological disease and/or prematurity and, control group of 31 healthy children with infantile esotropia. All patients were followed for at least 24 months after injection. Success was defined as motor alignment with 10Δ of orthotropia after single bilateral botulinum injection. RESULTS: Mean age at treatment was similar in both groups (15.5 vs 14.8 months; p = .555). Mean pretreatment deviation was similar in both groups (50.8Δ vs 50Δ; p = .855). The success rate was better in the control group (61.2% vs 51.7%, p = .265) at 24 months after injection, but the change in the mean angle of deviation was not statistically significant between the groups at 12 and 24 months after injection (p = .264 and p = .547, respectively). Multivariate regression analysis showed that pretreatment angle of deviation and presence of retinopathy of prematurity were significant predictors at 12 months after injection (p = .0001 and p = .004, respectively), while pretreatment angle of deviation was found to be a predictor at 24 months after injection (p = .0001). CONCLUSIONS: Decreased angle of deviation and absence of retinopathy of prematurity were associated with a better result. There was no difference in motor alignment of esotropia in children with and without neurological disease and/or prematurity. In these patients, botulinum injection may be used as an alternative to surgery.

Extraocular Muscle Palsy in Patients with Chronic Orbital Myositis.

BACKGROUND: Orbital myositis (OM) is a subgroup of idiopathic orbital inflammation. It can involve single or multiple extraocular muscles and result in restriction or paresis of extraocular muscles. METHOD: We reported two unusual cases of extraocular muscle paresis in the fibrotic stage of chronic OM and reviewed the literature related to this finding. RESULTS: The first case was of a 38-year-old woman with chronic OM with large-angle right eye exotropia and right medial rectus paresis. She received a botulinum A toxin injection into the right lateral rectus muscle as a first treatment, but it was unsuccessful in correcting her deviation. Subsequently, she underwent two strabismus surgeries, which successfully resolved her diplopia in primary gaze. The second case was of a 35-year-old woman with chronic OM and left lateral rectus palsy, which was managed with a botulinum A toxin injection. CONCLUSION: OM can cause extraocular muscle palsy in the chronic fibrotic stage of the disease.

Differences of a Single Injection of Botulinum Toxin A between Infantile and Nonaccommodative Esotropia.

PURPOSES: To compare the results of a single injection of botulinum toxin A (BTA) between children with infantile esotropia (IET) and nonaccommodative esotropia (NAET) during the first 2 years. METHODS: Retrospective study that included 23 children with IET and 25 with NAET. At 6 months, 1 and 2 years after treatment, the deviation and stereoacuity were evaluated. RESULTS: At 6 months and 1 year after treatment there was no difference in ocular alignment between the two groups (success criteria were achieved in 36.8% in IET group and 60.0% in NAET at 6 months p = .129, and 57.9% in IET group and 68.0% in NAET group at 1 year p = .352). Two years after treatment, there were statistical differences between motor alignment (IET group 21,1% and NAET group 60.0%, p = .007) and stereoacuity (IET group 40% and NAET group 90%, p = .004) between the two groups. Although side-effects affected most children during the first week (in the first week, overcorrection was present in 16 (84.2%) children with IET, and in 19 (76.0%) children with NAET; and ptosis affected 15 (78.9%) children with IET and 17 (68.0%) children with NAET), at 6 months all the effects have disappeared on both groups. CONCLUSIONS: We recommend BTA as an alternative, but not as definite treatment in IET if the surgeon/parents are not comfortable with an early strabismus surgery; but retreatment or surgery will have to be considered after 1 year. On the contrary, BTA may be a first-line treatment of NAET because it is an easy, safe and has a long-lasting effect.

Effect of topical Phenylephrine on the upper eyelid crease position.

PURPOSE: To investigate the effect of Phenylephrine test on the upper eyelid crease position. MATERIAL AND METHODS: This study follows a prospective and analytical design and included patients with unilateral acquired involutional ptosis recruited between January 2015 and January 2018. In the Phenylephrine test, 1 drop of Phenylephrine 10% was instilled on the inferior fornix of the ptotic eye and the eyelid crease position was evaluated 10 min after. RESULTS: A total of 60 patients were included in the final sample. The mean Margin-to-reflex distance 1 (MRD1) of the ptotic eye was 2.1 ± 1.0 and 3.8 ± 0.6 mm before and 10 min after the instillation of Phenylephrine, respectively. The difference between the means was statistically significant (p < 0.001). Ninety-five per cent of the eyes had a positive Phenylephrine test result. Of this, 100% showed a decrease in the height of eyelid crease after the drop. There was a statistically significant decrease in the height of eyelid crease from 10.3 ± 2.5 to 7.8 ± 2.0 mm (p < 0.001). CONCLUSION: Phenylephrine test not only affects the eyelid position but also the eyelid crease height. We show a significative decrease in eyelid crease height to a symmetrical level with the contralateral lid in all patients that had a positive Phenylephrine test result. This effect is probably due to a posterior lamella shortening secondary to Müller's muscle contraction and suggests that the eyelid crease is not only determined by the projections of levator aponeurosis, but also by the entire force vector of the upper eyelid retractors.

Ophthalmoplegia with skin necrosis after a hyaluronic acid filler injection.

Hyaluronic acid filler injection is commonly used for aesthetic purposes. However, many clinicians neglect the possibility of developing vascular occlusion and its devastating sequelae. Besides visual loss after iatrogenic ophthalmic artery occlusion, ophthalmoplegia without blindness is rare but may occur. Here, we report a 23-year-old woman with ptosis, lateral deviation of the right eye, and skin necrosis after hyaluronic acid filler injection. After hyaluronidase injection and steroid pulse therapy, ptosis and eye movement were completely restored. Skin necrosis was treated with a human epithelial growth factor ointment, followed by Nd:YAG laser. Complete healing with minimal scar was achieved.